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Fluid management

rehydration but again the difference was not statistically significant. No statistically significant
differences were seen for other outcomes studied – mean duration of diarrhoea, mean duration
of vomiting or mean volume of fluid therapy administered. No complications were reported in
either group.

Evidence summary
Neither of two RCTs [EL = 1−] comparing ORT with IVT in children with severe dehydration
found a statistically significant difference in the risk of failure to rehydrate. In one of these trials,
children receiving ORT had reduced duration of diarrhoea and reduced risk of vomiting during
rehydration compared with those given IVT. There were no differences in the incidences of
hypernatraemia, hyponatraemia or hyperkalaemia, or in the risk of complications such as peri-
orbital oedema and abdominal distension. The other was a relatively small trial, and it found no
statistically significant differences between the two groups for mean duration of diarrhoea or
vomiting or the volume of fluid administered.

5.2.3 ORT versus IVT for children with hypernatraemic dehydration

Evidence overview
Only one study was identified that was relevant to this question. This RCT was carried out in Iran
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and is described above under the evidence overview of ORT versus IVT in severe dehydration.
In this trial, of the 470 children randomised to ORT or IVT group, 34 who received ORT and 24
given IVT were hypernatraemic at the time of admission (serum sodium > 150 mmol/l). Overall,
only one child on ORT failed rehydration but the paper did not state whether this child was
among those with hypernatraemia. There were no rehydration failures in the IVT group. Two of
the 34 children with hypernatraemia in the ORT group and six of the 24 with hypernatraemia in
the IVT group had seizures but the evidence for statistical difference was not strong (6% versus
25%; P = 0.05). All who experienced seizures recovered without apparent sequelae. No other
outcomes were reported in relation to the children with hypernatraemia.

Evidence summary
There is a lack of high-quality evidence to compare the effectiveness and safety of ORT versus
IVT in hypernatraemic dehydration. One poorly conducted RCT [EL = 1−] reported that a larger
proportion of children treated with IVT experienced seizures compared with those given ORT.
However, the number of subjects was small and the difference was of borderline significance.
Moreover, this study did not report any other outcomes.

GDG translation from evidence to recommendation
Both ORT and IVT were shown to be effective in the treatment of dehydration. Although, overall,
IVT was shown to have a marginally higher success rate in terms of reduced risk of rehydration
failure, the difference was not statistically significant when a subgroup analysis was conducted
employing a uniform definition of rehydration failure. Moreover, IVT is associated with various
disadvantages such as the pain and distress associated with placement of an IV cannula and the
risk of complications such as phlebitis or cellulitis. In addition, the cost-effectiveness analysis
confirms significant benefits of ORT compared with IVT.
There was no difference in the effectiveness of IVT compared with ORT in children with severe
dehydration. As discussed in Chapter 3, a range of clinical symptoms and signs may be seen
in children with dehydration and these symptoms and signs may vary in degree. Although
clinicians have often attempted to make a global assessment of the degree of dehydration,
accurate determination of severity is probably unreliable. However, clinicians can recognise
the manifestations of shock and this requires a specific fluid management strategy as discussed
later in this chapter. For those children who are dehydrated to some degree but are not shocked,
treatment should normally be based on ORT. Some children may exhibit clinical features (red
flag symptoms and signs – see Table 4.6) that should cause special concern, suggesting that they
may be at risk of progression to shock. In such cases, close and continued observation is required
and if, despite ORT, there is evidence of deterioration, IVT should be commenced. Once the

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