What is the recommended treatment for dehydration in children using Oral Rehydration Solution (ORS)?

Oral Rehydration Solution (ORS) for Dehydration in Children

Low-osmolarity oral rehydration solution (ORS) is the recommended first-line therapy for mild to moderate dehydration in children with acute diarrhea, administered at 100 ml/kg during the first 4 hours followed by 50-100 ml after each liquid stool. 1

ORS Composition and Types

• The World Health Organization (WHO) recommends low-osmolarity ORS containing:

  • 65-70 mEq/L sodium
  • 75-90 mmol/L glucose
  • Standard preparation: 3.5g NaCl, 2.5g NaHCO₃, 1.5g KCl, and 20g glucose per liter of clean water 1

• Commercially available formulations include:

  • Pedialyte
  • CeraLyte
  • Enfalac Lytren 1

Rehydration Protocol

Mild to Moderate Dehydration

1. Initial Rehydration Phase:

   • Administer 100 ml/kg of ORS during the first 4 hours 1
   • For ongoing losses: provide 50-100 ml after each liquid stool 1

2. Administration Methods:

   • Oral administration is preferred
   • Nasogastric administration may be considered for children who:
     • Cannot tolerate oral intake
     • Have normal mental status but are too weak or refuse to drink adequately 2

3. Monitoring During Rehydration:

   • Urine output (target ≥0.5 ml/kg/h)
   • Vital signs, especially blood pressure and heart rate
   • Electrolytes, particularly sodium levels 1

Severe Dehydration

1. Initial Management:

   • Isotonic intravenous fluids (lactated Ringer's or normal saline) should be administered 2, 1
   • Indications for IV fluids:
     • Severe dehydration
     • Shock
     • Altered mental status
     • Failure of ORS therapy
     • Ileus 2

2. Transition to Oral Rehydration:

   • Continue IV rehydration until pulse, perfusion, and mental status normalize 2
   • Once stabilized, transition to ORS to replace remaining deficit 2

Nutrition During Rehydration

• Breastfeeding: Continue throughout the diarrheal episode 2, 1
• Regular Diet: Resume age-appropriate usual diet during or immediately after rehydration 2, 1
• Early Feeding Benefits: Reduces stool output and duration of diarrhea by approximately 50% compared to gradual reintroduction of food 1
• Recommended Foods: Bland diet including bananas, rice, applesauce, and toast (BRAT diet) 1
• Foods to Avoid: High simple sugars and high-fat foods 1

Common Pitfalls and Contraindications

Contraindications for ORS

• Altered mental status
• Inability to tolerate oral or nasogastric intake
• Ileus (intestinal obstruction)
• Anatomical abnormalities
• Gut malabsorption 3

Medication Cautions

• Antimotility drugs (e.g., loperamide): Should not be given to children <18 years with acute diarrhea 2
• Antibiotics: Generally not indicated for most cases of acute gastroenteritis in children 1
• Antiemetics: Ondansetron may be used if needed to prevent vomiting and improve ORS tolerance 1

Warning Signs Requiring Immediate Medical Attention

• Persistent vomiting preventing ORS intake
• High stool output (>10 mL/kg/hour)
• Bloody diarrhea
• Worsening dehydration despite treatment
• Lethargy or altered mental status 1

ORS Tolerance Test

A practical approach to determine if a child can be managed at home with ORS is the ORS tolerance test:

• Children who can tolerate approximately 25 ml/kg of ORS during a 2-4 hour observation period are more likely to be successfully managed at home 4
• Those who tolerate less (around 11 ml/kg) may require closer monitoring or admission 4

The evidence clearly shows that proper use of ORS is as effective as intravenous fluid therapy for mild to moderate dehydration, with the advantages of being less invasive, more cost-effective, and allowing for home management in many cases 5.