Page 95 - 15Diarrhoeaandvomiting

Diarrhoea and vomiting caused by gastroenteritis in children under 5 years

in duration with at least five episodes in the 24 hours preceding presentation, presence of normal
serum sodium levels (130–149 mEq/l) and metabolic acidosis (serum bicarbonate < 18 mEq/l) at
the time of presentation. Each patient received an infusion of 20–30 ml/kg isotonic crystalloid
solution over 1–2 hours, followed by a trial of oral rehydration. Children who subsequently
vomited were admitted for continued IV rehydration therapy, while those tolerating oral fluids
were discharged with home-care instructions. To identify variables that might identify children
who would not tolerate oral fluids after outpatient rapid IV rehydration, regression analysis was
conducted with data from the two groups of children – those successfully tolerating oral fluids
and those requiring admission for continued IVT. [EL = 2−]

This study enrolled a convenience sample of 58 children with age ranging from 6 months to
13 years (median age 22 months). One-third of the children were clinically assessed to have
moderate dehydration (deficit of 6–10 % body weight) while the rest had mild dehydration.
After rapid outpatient IV rehydration, 16 patients (28%) did not tolerate oral fluids while the rest
42 (72%) tolerated orally and were discharged home. The baseline characteristics of these two
groups were not described. Of the discharged patients, 14% (6/42) were re-admitted owing to
recurrent vomiting and dehydration. A significantly higher proportion of children who did not
tolerate orally after rapid IV rehydration had metabolic acidosis (69% versus 2%; P < 0.001) and
were moderately dehydrated (56% versus 24%; P < 0.01) compared with the patients discharged
home. There were no differences between the two groups regarding the age and severity of
diarrhoea or vomiting.
In another non-comparative study, from Canada, children aged between 1 and 6 years with mild
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or moderate dehydration secondary to gastroenteritis were recruited. Children were included if
they had diarrhoea and/or vomiting for less than 5 days with mild to moderate dehydration, had
normal nutritional status and were unable to retain small amounts of clear fluid or refused to take
them. Children who had taken medication, those having an underlying disease and those with
electrolyte abnormalities were excluded. A trial of rehydration was initially attempted with small
amounts of clear fluids (the authors did not specify how they defined ‘clear fluid’), and if the fluid
was refused or vomited, the child was considered for the study. IVT was administered by giving
3.3% dextrose and 0.3% saline at a rate of 10 ml/kg per hour for 3 hours (total 30 ml/kg). During
IVT, patients did not receive any oral fluid. Discharge was allowed if there were no clinical signs
of dehydration, no persistent vomiting, normal central nervous system examination and if the
parents felt the child had improved. [EL = 3]

Seventeen children (mean age 2.6 ± 1.7 years) met the study inclusion criteria. All had had
vomiting for an average 2.1 ± 1.2 days prior to presentation at the emergency department,
and 10 of them had had diarrhoea for the preceding 1.9 ± 1.9 days. Seven children had at
least 6% dehydration and 7/12 (58.3%) had mild metabolic acidosis with a base deficit of 5
or more. All patients improved after IVT and only 6/17 had vomited after therapy. One patient
continued vomiting till 48 hours after IVT and required another course of IVT, following which
there was no vomiting. None of the patients required hospital admission after discharge from
the emergency department.

Evidence summary

There was a lack of good-quality evidence available for the clinical effectiveness of rapid IV
rehydration in children with gastroenteritis and moderate or severe dehydration. The first study
with a historical control group [EL = 2−] suggested that rapid rehydration by ORT or IVT in
moderately dehydrated children led to a significant reduction in the hospital admission rate and
an increase in discharge from the emergency department within 8 hours of presentation. No
statistically significant difference was seen for these outcomes in the group of mildly dehydrated
children. Results from the other two studies (a poorly conducted cohort study and a non-
comparative study) showed rapid IVT to be successful in achieving rehydration in most of the
dehydrated children. However, the study population in these two studies was not homogeneous
and included children with mild dehydration. In the cohort study, more than 70% of the children
given rapid rehydration were able to tolerate orally and the majority of children not tolerating
orally had metabolic acidosis and/or moderate dehydration.

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