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Oral Rehydration Therapy Protocol in Pediatric Dehydration

Aka: Oral Rehydration Therapy Protocol in Pediatric Dehydration, Dehydration Management in Children with Oral Replacement, Pediatric Diarrhea Fluid Replacement
  1. See Also
    1. Pediatric Dehydration Management
    2. Pediatric Diarrhea Management
  2. Indications
    1. Mild to moderate Pediatric Dehydration
    2. Mild to moderate Pediatric Diarrhea
  3. Precautions
    1. Use Oral Rehydration Solution (ORS) as this most closely mirrors Diarrhea related losses
      1. Sodium: 50 mEq/L
      2. Dextrose: 25 g/L
      3. Bicarbonate: 30 mEq/L
    2. In mild cases, half strength apple juice has been used safely and effectively
      1. Freedman (2016) JAMA 315(18): 1966-74 [PubMed]
    3. Avoid other solutions that do not adequately replace Sodium, bicarbonate, Potassium and Glucose
      1. Avoid hypoosmolar fluids (water, sodas, juices) due to Hyponatremia risk
      2. Avoid adult ORS solutions due to risk of Hypernatremia risk
  4. Protocol
    1. Uses Oral Rehydration Solution (e.g. Pedialyte, WHO-ORS)
    2. Consider a single dose of Ondansetron (Zofran) to aid starting Oral Rehydration Therapy (see below)
    3. Delivery of fluids
      1. Use a syringe (infants)
      2. Spoon or cup (children)
      3. Nasogastric Tube (if unable to take orally)
        1. Safe, effective, and less expensive than Intravenous Fluids
        2. Nager (2002) Pediatrics 109(4): 566-72 [PubMed]
    4. Conversions
      1. One teaspoon: 5 ml
      2. One ounce: 30 ml
  5. Management: Oral Protocol
    1. See Pediatric Dehydration
    2. Mild Dehydration (standard replacement)
      1. Total ORS: 50 ml/kg over 4 hours by syringe, spoon or cup
      2. Give 1 ml/kg of ORS by syringe every 5 minutes for 4 hours or
      3. Give 3 ml/kg of ORS every 15 minutes for 4 hours
    3. Moderate Dehydration (accelerated replacement)
      1. Total ORS: 100 ml/kg over 4 hours
      2. Infant: 1 ounce/hour
        1. Give 30 ml per hour of ORS
        2. Give 5-10 ml (1-2 tsp) every 15 minutes
      3. Toddler: 2 ounces/hour
        1. Give 60 ml per hour of ORS
        2. Give 15 ml (3 tsp) every 15 minutes
      4. Child: 3 ounces/hour
        1. Give 90 ml per hour of ORS
        2. Give 20-25 ml (1/2 to 1 oz) every 15 minutes
    4. Ongoing losses (added replacement per stool or Emesis)
      1. Method 1: Give an additional 10 ml/kg per stool or 2 ml/kg per Emesis or
      2. Method 2: Give an additional one-half to one cup ORS per stool (older children)
      3. Method 3: Replace for each episode of Diarrhea or Vomiting
        1. Weight <22 pounds: Give 60-120 ml (2-4 oz)
        2. Weight >22 pounds: Give 120-240 ml (4-8 oz)
        3. (2017) Presc Lett 24(1): 5
    5. Vomiting
      1. Pause feeding for 30-60 minutes if Vomiting occurs
      2. Give 5-10 ml every 5 minutes
      3. May resume above Diarrheal replacement after no Vomiting for 30-60 minutes
      4. Consider Ondansetron (Zofran) 4 mg ODT tablets
        1. See Ondansetron for dosing
        2. Weight 8-15 kg: Ondansetron 2mg (half tab)
        3. Weight 15-30 kg: Ondansetron 4 mg (one tab)
        4. Weight >30 kg: Ondansetron 8 mg (two tabs)
        5. Freedman (2006) N Engl J Med 354:1698-705 [PubMed]
  6. Management: Triage
    1. Emergency Department
      1. May be discharged home if initial replacement is successful and ongoing losses are not severe
    2. Home
      1. Parents reassess every 2 hours
      2. Indications to return to emergency department
        1. Losses (Diarrhea, Vomiting) exceed 25% of hourly fluid requirements
        2. Unable to maintain fluids orally
  7. Management: Severe Dehydration
    1. See Dehydration Management
  8. References
    1. Canavan (2009) Am Fam Physician 80(7): 692-6 [PubMed]
    2. Churgay (2012) Am Fam Physician 85(11): 1066-70 [PubMed]
    3. King (2003 MMWR Recomm Rep 52(RR-16):1-16 [PubMed]

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