Page 85 - 15Diarrhoeaandvomiting

Diarrhoea and vomiting caused by gastroenteritis in children under 5 years

circulation has been adequately restored and the child is clinically stable, management can
revert to ORT if tolerated.
Although it has often been suggested that ORT is safer than IVT for children with hypernatraemic
dehydration, no evidence was identified to support this view. Neither was any evidence found
to suggest that there is a risk of adverse outcomes with ORT in these cases. For that reason, the
GDG concluded that ORT is to be preferred in hypernatraemic dehydration.

Recommendation on treating dehydration
Use ORS solution to rehydrate children, including those with hypernatraemia, unless
intravenous fluid therapy is indicated.

5.3 Optimal composition and administration of oral fluids

While the properties of ORS solution promote its effective absorption, other fluids might also
have a role in the management of children with gastroenteritis. Fluids other than ORS solution
are often given to children with diarrhoea and the GDG considered this practice. This section
also examines the evidence regarding ORS solution composition. There has been much debate
regarding the optimal constituents and their concentrations in ORS solutions. Finally, the GDG
considered strategies for the administration of oral fluids to children with dehydration.

Primary screening of 403 articles and abstracts identified from the systematic literature search
resulted in the retrieval of 139 articles. After reviewing hard copies of these studies, three studies
were finally included under this section. Two reviews had compared high-osmolarity/high-
sodium ORS solution with low-osmolarity/low-sodium ORS solution, while the third review
compared glucose-based ORS solution with rice-based ORS solution. No study was identified to
provide evidence on the effectiveness of different types of oral fluids (other than ORS solution),
different regimens of ORS solution for treating dehydration, or the frequency and volume of oral
fluids to be administered.

Clinical question
Which oral fluids are most effective in treating dehydration?
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In a survey of American paediatricians in public and private practice and of staff from a children’s
hospital in Boston, up to 90% reported that they would recommend the use of clear fluids other
than ORS solution for children with diarrhoea. Anecdotally, such practice is common in the UK.
Although ORS solution has been extensively studied and has been shown to be a highly effective
fluid for the treatment of dehydration, other fluids such as tap water or fruit juices might also be
effective.

Evidence overview
No published study was identified that examined the effectiveness of fluids other than ORS
solution in the treatment of dehydration. However, one study characterised the composition of
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a wide range of readily available fluids and commercially produced drinks. The analysis included
tap water and about 90 commercial ‘clear’ fluids including soups, juices, fruit-flavoured drinks
and carbonated drinks. Sodium concentrations ranged from 0.1 to 251 mmol/l, potassium
concentration from 0.0 to 65 mmol/l, and osmolalities ranged from 246 to 2000 mOsm/l.
Among the fruit juices tested (apple, grape, lemon, orange), none had a sodium concentration
greater than 10 mmol/l or a potassium concentration less than 24 mmol/l. The osmolality of the
soups tested ranged from 293 to 543 mOsm/l. Soups prepared from crystals had slightly higher
osmolalities than those prepared from liquid concentrates.

Evidence summary
No study was found to evaluate the effectiveness of juices, tap water or other commercial clear
fluids in the treatment of dehydration. Evidence from one cross-sectional study showed great
variation in the concentration of sodium and potassium, and in the osmolarity of readily available
commercial clear fluids such as juices, soups and carbonated drinks.

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