Page 93 - 15Diarrhoeaandvomiting

Diarrhoea and vomiting caused by gastroenteritis in children under 5 years

Table 5.4 Fluid regimens used for rehydration in children in different studies

Study Initial IVT Oral fluid administration
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CHOICE study group 40 ml/kg per hour for 2 hours Began once child was able to
take fluids
Alam et al. 98 Within 1–2 hours according to WHO guidelines Began after initial IV rehydration
Bhargava et al. 99 Ringer’s lactate 20–30 ml/kg per hour until Following initial IVT, rehydration
blood pressure and pulse returned to normal completed with oral solutions
Patra et al. 100 Ringer’s lactate for 1–2 hours for those Began after approximately
presenting with signs of hypovolaemic shock 2 hours
Sack et al. 93 70% of estimated fluid deficit replaced in the Began after 2 hours
first 2 hours
Santosham et al. 94 40 ml/kg per hour of Ringer’s lactate until blood Rehydration completed within
pressure and pulse returned to normal 94 4 hours by ORT
Maulen-Radovan et 40 ml/kg per hour of Ringer’s lactate solution Hydration continued using
al. 101 until blood pressure and pulse improved and assigned ORS solution
patients able to tolerate fluids

for dehydration if, while being treated in the emergency department, children were vomiting
or had an inadequate intake of oral fluids. None of the children were severely dehydrated.
After enrolment, participants were randomly allocated to receive either 0.9% saline plus 2.5%
dextrose (NS) or 0.45% saline plus 2.5% dextrose (N/2). The rate of infusion was decided by
the treating physician. The options used were a ‘rapid replacement protocol’ (RRP) consisting of
10 ml/kg per hour for 4 hours or a slow replacement protocol in which children received their
fluid deficit based on estimated percentage dehydration over a 24 hour period (in addition to
their maintenance fluids). The primary outcome examined was the incidence of hyponatraemia
defined as plasma sodium < 135 mmol/l. The authors presented the results separately for those
with hyponatraemia and those with normal plasma sodium levels measured prior to starting IVT.
Altogether, 102 children were enrolled in the study. Of these, 36% (37/102) were hyponatraemic
before starting IVT. The median duration of illness prior to presentation was longer in the
hyponatraemic group than in those with normal plasma sodium, but apart from this there were
no statistically significant differences in their baseline clinical characteristics or biochemical
test results. In total, 51 children were randomly assigned to each treatment group. In those
with initial hyponatraemia given 0.45% saline (n = 16), there was no change in mean plasma
sodium after 4 hours, but in those with an initially normal plasma sodium (n = 35) there was a
significant decrease in the mean sodium concentration after 4 hours (135 ± 1.8 mmol/l versus 137
± 1.7 mmol/l; P < 0.001). Hyponatraemic children given 0.9% saline (n = 21) had a significant
increase in mean sodium concentration (134 ± 2.1 mmol/l versus 132 ± 2.4 mmol/l; P < 0.001),
but in those with an initially normal plasma sodium (n = 30) there was no statistically significant
change. [EL = 1+]

Evidence summary
No study was identified which gave direct evidence on the immediate IVT regimen in children
with severe dehydration and/or hypovolaemic shock. However, processes followed in various
trials suggest that these children were initially rehydrated with Ringer’s lactate solution given at a
rate of 20–40 ml/kg per hour over a period of 1–2 hours or until there was improvement in blood
pressure and pulse volume.
Evidence from another RCT [EL = 1+] suggested that rehydration with 0.9% saline IVT led to a
significant increase in the mean plasma sodium levels in children with hyponatraemic dehydration
while the use of 0.45% saline did not correct this abnormality. Moreover, the use of 0.45% saline
was associated with a significant decrease in the plasma sodium concentration in those with
normal plasma sodium concentrations prior to IVT while the use of 0.9% saline was not.

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