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Fluid management

risk of recurrence, for example very young infants, those with continuing severe diarrhoea and
those with persistent vomiting in whom oral fluids might not be tolerated.
There were therefore many variables to consider. The GDG considered that each individual child
should be assessed for risk and managed appropriately. No prescriptive recommendation could
be made regarding the exact volume or frequency of supplementary oral fluid that might be
required. However, the GDG agreed that in general the aim should be to offer the infant or
child plenty of their normal fluids. Supplementary ORS solution could be used if practical and
appropriate – particularly for those at increased risk of dehydration (Section 4.1). The WHO
previously advised giving 10 ml/kg of ORS solution after each diarrhoeal stool and more recently
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giving 50–100 ml if younger than 2 years and 100–200 ml if above 2 years. The post-rehydration
diarrhoeal losses in the WHO recommendations’ intended population (including children with
cholera) are probably greater than is often the case in children in the UK. The GDG considered
that specific fluid supplementation regimens are not necessary for most children. However, they
should be considered for children at increased risk of dehydration, and a pragmatic approach is
to give an additional 5 ml/kg of ORS solution for each large watery stool passed. It is important
to bear in mind that if, for some reason, a child remains on IVT following rehydration they too
might be at risk of dehydration recurrence, and they too might require fluid supplementation.
The GDG also agreed that if dehydration recurs, fluid management should be started again with
the ORT.

Recommendations on fluid management following rehydration

After rehydration:
• encourage breastfeeding and other milk feeds
• encourage fluid intake
• in children at increased risk of dehydration recurring, consider giving 5 ml/kg of ORS
solution after each large watery stool. These include:
– children younger than 1 year, particularly those younger than 6 months
– infants who were of low birthweight
– children who have had more than five diarrhoeal stools in the previous 24 hours
– children who have vomited more than twice in the previous 24 hours.
Restart oral rehydration therapy if dehydration recurs after rehydration.

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