Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis

Question 1

What is the scientific basis of ORT?

Answer 1

the cotransport of glucose and sodium across the intestinal membrane. The sodium-potassium-ATP pump on the basolateral membrane of the enterocyte provides the gradient that drives the process. The cotransport system is relatively intact in infective diarrhea due to viruses or enteropathogenic bacteria, whether invasive or enterotoxigenic. Glucose enhances sodium and, secondarily, water absorption. The optimal glucose to sodium ratio to ensure maximal sodium absorption is 1:1

Question 2

What is the clinical assessment of mild (<5%) dehydration?

Answer 2

Slightly decreased urine output

Slightly increased thirst

Slightly dry mucous membrane

Slightly elevated heart rate

Question 3

What is the clinical assessment of moderate (5-10%) dehydration?

Answer 3

Decreased urine output

Moderately increased thirst

Dry mucous membrane

Elevated heart rate

Decreased skin turgor

Sunken eyes

Sunken anterior fontanelle

Question 4

What is the clinical assessment of severe (>10%) dehydration?

Answer 4

Markedly decreased or absent urine output

Greatly increased thirst

Very dry mucous membrane

Greatly elevated heart rate

Decreased skin turgor

Very sunken eyes

Very sunken anterior fontanelles

Lethargy

Cold extremities

Hypotension

Coma

Question 5

What is the recommended management for a child with acute gastroenteritis and no dehydration?

Answer 5

1. Age appropriate diet

2. Replace ongoing losses with oral rehydration solution (ORS)

Question 6

What is the recommended management for a child with acute gastroenteritis and mild dehydration?

Answer 6

1. Rehydrate with ORS (50mL/kg) over 4h
2. Replace ongoing losses with ORS
3. Age appropriated diet after rehydration

Question 7

What is the recommended management for a child with acute gastroenteritis and moderate dehydration?

Answer 7

1. Rehydrate with ORS (100mL/kg) over 4h
2. Replace ongoing losses with ORS
3. Age appropriated diet after rehydration

Question 8

What is the recommended management for a child with acute gastroenteritis and severe dehydration?

Answer 8

1. IV resuscitation with NS or RL (20-40mL/kg) for 1h
2. Reassess and repeat if necessary
3. Begin ORT when patient is stable
4. Replace ongoing losses with ORS
5. Age-appropriate diet after rehydration

Question 9

What are contraindications to ORT?

Answer 9

1. Protracted emesis despite small, frequent feeding
2. Severe dehydration with a shock-like state
3. Impaired consciousness
4. Paralytic ileus
5. Monosaccharide malabsoprtion

Question 10

What are the recommendations regarding early refeeding?

Answer 10

Early refeeding has been shown to induce digestive enzymes, improve absorption of nutrients, enhance enterocyte regeneration, promote recovery of disaccharidases, reduce the duration of diarrhea, maintain growth and improve nutritional outcomes

Question 11

What are the CPS recommendations?

Answer 11

1. Rehydration and maintenance of adequate fluid and electrolyte balance is the key to the management of a child with acute gastroenteritis. ORT should be the treatment of choice in children with mild or moderate dehydration.
2. ORS should be given at frequent intervals, gradually increased in volume until the child can drink as desired.
3. Children without dehydration should continue to be fed an age-appropriate diet. Children with dehydration should be fed an age-appropriate diet as soon as they have been rehydrated.
4. When evaluating dehydration, loss in body weight should always be corroborated by clinical signs, because errors in weight measurement are common.
5. Fluid therapy should include the following elements: rehydration, replacement of ongoing losses, and maintenance.
6. Premixed ORS, rather than powdered or homemade ones, should be used. ORS powders are more convenient to store, less expensive, and have a longer shelf life than ORS fluids, but they must be mixed precisely to avoid changes in glucose and electrolyte concentrations.
7. Carbonated drinks and sweetened fruit juices are discouraged because of their high carbohydrate content, very low electrolyte content and high osmolarity.Contraindications to ORT include protracted vomiting despite small, frequent feeding, severe dehydration with shock-like state, impaired consciousness, paralytic ileus and monosaccharide malabsorption.
8. Parents should be specifically instructed not to offer plain water to children with acute gastroenteritis to avoid hyponatremia and hypoglycemia.
9. Contraindications to ORT include protracted vomiting despite small, frequent feeding, severe dehydration with shock-like state, impaired consciousness, paralytic ileus and monosaccharide malabsorption.

Question 12

What is the composition o the WHO revised formulation for ORS?

Answer 12

13.5g/L carbohydrate
75 mmol/L Na
20mmol/L K
65mmol/L Cl
10mmol/L base
245mOsm/L Osmolality