Oral Rehydration Therapy for Acute Gastroenteritis in Children: Updated Recommendations From the CDC

Acute gastroenteritisremains amajor cause ofmorbidity andhospitalizationamong infants and childrenin this country. Every yearin the United States, acutediarrheal illness accountsfor more than 1.5 millionpediatric outpatient visits,200,000 hospitalizations--and approximately 300deaths.Oral rehydration therapy(ORT) has been widelycredited with reducing thenumber of deaths from diarrhealdiseases--and withimproving health outcomesamong children in the developingworld. Nevertheless,the CDC reports thatORT is underused in thisand in other developedcountries.The CDC recently updatedits recommendationsfor assessing and treatingchildren with acute diarrhea--including those whoare dehydrated. Highlightsof the CDC's therapeuticrecommendations are thefocus here.INITIATING THERAPY
Most children with uncomplicatedcases of diarrheacan be treated at homewith an oral rehydrating solution(ORS). Early interventionis key to loweringthe risk of such complicationsas dehydration andmalnutrition--and to reducingthe number of visits tothe pediatrician's office or the hospital. Encourageparents to keep a supply ofa standard commerciallyavailable ORS at home.Fluid replacement andadequate nutrient intakewith an age-appropriate dietare crucial for children withdiarrheal illness. For olderchildren, this means morefluid; for infants, it meansmore frequent feedings.RECOGNIZING THEDANGER SIGNS
Teach parents andcaregivers to recognize thesigns and symptoms oftreatment failure and thepoint at which to seekmedical intervention forthe child (Box). In general,the smaller the child, thelower the threshold shouldbe for parents to seek aclinician's assessment.

• In infants, the first signsof distress signal the needfor medical attention.
• The presence of fever in achild with acute diarrhealillness signals the need fora clinician to rule out otherserious illnesses.
• Symptoms of dehydration(Table 1) indicate theneed for immediate medicalintervention.
• Changes in a child's mentalstatus indicate the needfor immediate evaluation.

THERAPY BASEDON THE DEGREE OFDEHYDRATION

The broadened definitionof ORT includes 2phases:

1.

The rehydration phase,during which the fluiddeficit is replaced over a periodof 3 to 4 hours.

2.

The maintenance phase,in which maintenancecalories and fluids areadministered.The goal is to have thepatient return quickly to anage-appropriate unrestricteddiet including solidfoods. Gut rest is not indicated,and breast-feedingshould continue, even duringinitial rehydration.

Table 2

lists specificguidelines for fluid replacementaccording to the degreeof dehydration.

LIMITATIONSOF ORT

ORT is recommendedin all age groups for diarrheaof any cause, but it iscontraindicated in patientswith:

• Hemodynamic shock.
• Abdominal ileus wherebowel sounds are absent.
• Suspected bowelobstruction.

Oral rehydration isless successful in childrenwith a stool output that exceeds 10 mL/kg of bodyweight/h. Nevertheless the CDC recommends thatpatients not be denied ORTsimply because of a highpurging rate. Most childrendo respond well when theyreceive adequate replacementfluid.Most patients withconcomitant vomiting canbe successfully rehydratedby initiating a limited volumeof ORS (5 mL every5 minutes) that is graduallyincreased. Nasogastric infusionof ORS may be helpful,and correction ofacidosis and dehydrationwill often lessen thefrequency of vomiting inthese patients.

DIET

Breast-fed infantsshould continue to nurseon demand; formula-fed infantsneed to continue theirusual formula feedingsimmediately after rehydration.Children who eatsemisolid or solid foodsshould not alter their usualdiet during episodes of diarrhea;however, foods thatare high in simple sugars(eg, carbonated softdrinks, juice, gelatin desserts)are to be avoided.The CDC emphasizes thatthe practice of withholdingfood for 24 hours or moreis inappropriate.

PHARMACOLOGICTHERAPY

Antimicrobial agents.In this country, acute diarrheais most often causedby a viral infection; consequently,treatment with anantimicrobial agent is notrecommended. In an outpatientsetting, antimicrobialtreatment is not warrantedfor children, evenwhen a bacterial cause issuspected. Acute diarrheais generally self-limitedand antimicrobial agentsdo not shorten the durationof illness. Consider antimicrobialtherapy on an individualbasis for childrenwho have special needs(eg, premature infants orthose with immunocompromiseor other underlyingcondition).

Non-antimicrobialdrugs.

Antimotility agents,nonspecific antidiarrhealagents, and toxin bindersare commonly used inolder children and adults,although data on their efficacyare limited. Antiemeticsare generally unnecessary,and phenothiazinesmight cause drowsinessand interfere with oralrehydration.In general, drug therapymay unnecessarily increase the costs associatedwith acute diarrhea, resultin adverse events, and takethe focus of therapy awayfrom ORT.

Supplemental zinc.

A number of reports linkdiarrhea with abnormalzinc status. Zinc supplementationmay improve outcomein children withacute or chronic diarrhea,and it may play a role inprophylaxis.

WRAP-UP

Although ORT is underusedin this country,this approach to therapycan be instrumental in improvinghealth outcomes.The CDC offers these possibleexplanations as towhy this approach to themanagement of acute diarrhealillness is underused:

• The use of intravenoustherapy is deeply ingrained.
• A technologically simplesolution may be perceivedas less appealing thantraditional methods ofmanagement.
• The practice of continuedfeeding during diarrhealepisodes has beendifficult to establish as anaccepted standard ofcare--even though it issupported by substantialdata that show improvedGI function and clinicaloutcomes.

The CDC emphasizesthe importance of adheringto these principles:

• Early intervention withORT can reduce complications(eg, dehydration, malnutrition)and, thus, thecost of care.
• Gut rest is not indicated.
• The combination of oralrehydration and early nutritionalsupport has beenshown to be effective.
• Antibiotics, antimotilityagents, and antiemetics aregenerally unnecessary.
• Zinc supplementationmay reduce disease incidenceand severity.

References:

REFERENCE:

1.

King CK, Glass R, Bresee JS, DugganC, and the Centers for DiseaseControl and Prevention. Managingacute gastroenteritis among children:oral rehydration, maintenance, andnutritional therapy.

MMWR RecommenRep.

2003;52(RR-16):1-16.