Page 43 - 15Diarrhoeaandvomiting

Diarrhoea and vomiting caused by gastroenteritis in children under 5 years

vomiting. A well-conducted randomised controlled trial is needed to assess the cost effectiveness,
safety and acceptability of rehydration using nasogastric tube administration of ORS solution
compared with intravenous fluid therapy.

Fluid management (Chapter 5)
In children who require intravenous fluid therapy for the treatment of dehydration, is rapid
rehydration safe and cost-effective compared with the common practice of rehydration over
24 hours?

Why this is important
Most children with clinical dehydration should be treated with oral rehydration therapy, but some
require intravenous fluid therapy because they are shocked or they cannot tolerate oral rehydration
therapy. Rehydration with oral rehydration therapy is usually carried out over a period of 4 hours.
Rehydration with intravenous fluid therapy has traditionally been undertaken slowly – typically
over 24 hours. The National Patient Safety Agency has advised that intravenous fluid deficit
*
replacement should be over 24 hours or longer. Consequently, children will remain dehydrated
and in hospital for a prolonged period. The WHO recommends that intravenous rehydration should
†
be completed in 3–6 hours. Many experts now support rapid intravenous rehydration, suggesting
that it allows oral fluids to be starter earlier and can shorten the duration of hospital treatment.
Randomised controlled trials are needed urgently to examine the safety and cost-effectiveness of
rapid intravenous rehydration regimens compared with slow intravenous rehydration.

Other therapies: ondansetron (Chapter 8)
In children with persistent vomiting caused by gastroenteritis, is oral ondansetron cost-effective
and safe compared with placebo therapy?

Why this is important
Several randomised controlled trials have shown that in children with persistent vomiting during
oral rehydration therapy, administration of oral ondansetron, an anti-emetic agent, can increase
the likelihood of successful oral rehydration. However, in two of these there was evidence
suggesting that diarrhoea was more pronounced in those given ondansetron than in those in the
placebo groups. In one, in children given ondansetron, the number of stools passed during the
rehydration phase was significantly greater, and in the other the number of stools passed in the first
and second 24 hour period after rehydration was significantly greater. In those studies, diarrhoea
was not a primary outcome, and it was reported as an adverse event. The reliability of the finding
was therefore somewhat uncertain. If ondansetron does worsen diarrhoea it would be crucially
important to determine the clinical significance of this effect, for example in relation to the risk of
dehydration recurring or re-admission to hospital. If ondansetron is shown to be both effective and
safe in secondary care then studies should also be undertaken to evaluate its use in primary care.

Other therapies: probiotics (Chapter 8)
Are probiotics effective and safe compared with a placebo in the treatment of children with
gastroenteritis in the UK? Which specific probiotic is most effective and in what specific treatment
regimen?

Why this is important
The available studies of probiotic therapy frequently report benefits, particularly in terms of
reduced duration of diarrhoea or stool frequency. However, most of the published studies have
methodological limitations. Moreover, there is great variation in the specific probiotics evaluated
and in the treatment regimens used. Many of these studies were conducted in developing countries
where the response to probiotic therapy may differ. Good-quality randomised controlled trials
should be conducted in the UK to evaluate the effectiveness and safety of specific probiotics,
using clearly defined treatment regimens and outcome measures.

* National Patient Safety Agency. Alert no. 22, Ref: NPSA/2007/22. Issued: 28 March 2007.
† World Health Organization. The Treatment of Diarrhoea: a Manual for Physicians and Other Senior Health Workers. Geneva: WHO;
2005 [whqlibdoc.who.int/publications/2005/9241593180.pdf].

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