Page 91 - 15Diarrhoeaandvomiting

Diarrhoea and vomiting caused by gastroenteritis in children under 5 years

which might also be associated with distress and complications such as phlebitis or cellulitis. The
GDG considered that nasogastric fluid administration was a reasonable and perhaps preferable
alternative to IVT for some children. However, each case needed to be assessed on its own
merits. Moreover, studies comparing nasogastric tube therapy with IVT should be undertaken.

Recommendation on oral rehydration therapy

In children with clinical dehydration, including hypernatraemic dehydration:
• use low-osmolarity ORS solution (240–250 mOsm/l)* for oral rehydration therapy
• give 50 ml/kg for fluid deficit replacement over 4 hours as well as maintenance fluid
• give the ORS solution frequently and in small amounts
• consider supplementation with their usual fluids (including milk feeds or water, but not
fruit juices or carbonated drinks) if they refuse to take sufficient quantities of ORS solution
and do not have red flag symptoms or signs (see Table 4.6)
• consider giving the ORS solution via a nasogastric tube if they are unable to drink it or if
they vomit persistently
• monitor the response to oral rehydration therapy by regular clinical assessment.

Research recommendation
In children who do not tolerate oral rehydration therapy, is ORS solution administration via
nasogastric tube cost-effective, safe and acceptable in treating dehydration compared with
intravenous fluid therapy?

Why this is important
Oral rehydration therapy is normally preferable to intravenous fluid therapy for rehydration
in children with gastroenteritis. However, some children may not tolerate oral rehydration
therapy, either because they are unable to drink ORS solution in adequate quantities or because
they persistently vomit. In such cases, ORS solution could be administered via a nasogastric
tube, rather than changing to intravenous fluid therapy. This overcomes the problem of ORS
solution refusal. Continuous infusion of ORS solution via a nasogastric tube might reduce the
risk of 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.

5.4 Intravenous fluid therapy (IVT)

Introduction
Although most children with dehydration can be successfully managed using ORT, occasionally
IVT may be indicated. In children with hypovolaemic shock, immediate IVT might be required.
For various reasons, ORT might be unsuccessful and so IVT might be necessary. The GDG
considered the indications for starting IVT, the rate at which IV rehydration should be performed,
the choice of IV fluid, and the option of changing from IVT to ORT to complete the rehydration
process.
A systematic literature search identified 381 publications and 26 articles were retrieved for
reviewing. Secondary screening of these studies led to four studies being finally included as
evidence; however, these studies were of poor quality or gave indirect evidence to inform the
questions. The majority of questions included in this section yielded no evidence considered
to be of sufficient quality on which to base recommendations. Thus the recommendations
developed in this section are based mostly on a combination of non-RCT studies, observational
data, anecdotal reports and expert consensus opinion.

* The BNF for Children (BNFC) 2008 edition lists the following products with this composition: Dioralyte®, Dioralyte® Relief,
Electrolade® and Rapolyte®.

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