Page 80 - 15Diarrhoeaandvomiting

Fluid management

There were 285 cases and 728 controls. After controlling for confounding factors (lack of
maternal education, history of vomiting, high stool frequency, young age and infection with
Vibrio cholerae), the risk of dehydration was five times higher in infants whose mothers stopped
breastfeeding compared with infants whose mothers continued to breastfeed following the onset
of diarrhoea (OR 5.23; 95% CI 1.37 to 9.99; P = 0.016). Similarly, the risk of dehydration was
1.5 times higher in infants who did not receive any ORT at home compared with those who
received plentiful ORT (total volume ≥ 250 ml) (OR 1.57; 95% CI 1.08 to 2.29; P = 0.019).
Infants receiving smaller amounts of ORT (≤ 250 ml) before admission had an 18% higher risk
of dehydration compared with those receiving plentiful ORT, but the risk was not statistically
significant (OR 1.18; 95% CI 0.84 to 1.66; P = 0.343).

Evidence summary

Evidence from a case–control study [EL = 2+] indicated that cessation of breastfeeding in
children with gastroenteritis was associated with an increased risk of dehydration. This study
also suggested that oral fluid supplementation begun at home and given in good quantity was
associated with a reduced risk of dehydration.

GDG translation from evidence to recommendation

Evidence, though limited, suggests that continued breastfeeds and provision of oral fluid
supplementation to children with gastroenteritis reduces the risk of dehydration. The lack of
available evidence was not surprising, given the ethical difficulties with undertaking an RCT
comparing the administration and withholding of oral fluid supplementation. Given that oral
fluids are effective in the management of the dehydrated child, as discussed in Section 5.2, the
GDG considered that it was reasonable to assume that liberal fluid supplementation is effective
in the prevention of dehydration. While it was recognised that some children may prefer other
oral fluids, ORS solution has advantages (Section 5.3) and so should be used if possible for
children at increased risk of dehydration (Section 4.1).

Recommendation on primary prevention of dehydration

In children with gastroenteritis but without clinical dehydration:
• continue breastfeeding and other milk feeds
• encourage fluid intake
• discourage the drinking of fruit juices and carbonated drinks, especially in those at
increased risk of dehydration
• offer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk of
dehydration.

5.2 Treating dehydration

Clinical question
How do ORT and IVT compare in terms of safety and efficacy in the treatment of dehydration?
In order to address this question, a systematic literature search was undertaken that led to 363
articles and abstracts being identified. Of these, 27 articles were retrieved in hard copy for review.
Most of the retrieved studies were RCTs and their results had been pooled in a systematic review
83
discussed below. In addition to the systematic review, another RCT conducted in children with
84
severe dehydration was included. The evidence was considered in three categories:
• ORT versus IVT for children with all degrees and types of dehydration
• ORT versus IVT for children with severe dehydration
• ORT versus IVT for children with hypernatraemic dehydration.
Some of the trials included in the systematic review had compared the effectiveness of ORT with
IVT in children with severe dehydration and also hypernatraemic dehydration. Those trials were
considered separately under the relevant categories.

55