Pediatric Dehydration

Katharine Smart, MD, DTM&H, FRCPC

Pediatric Emergency MedicineAlberta Children’s Hospital

(special thanks to Marc Francis)

Objectives

Review the epidemiology and impact of gastroenteritis in children

Approach to the dehydrated patientReview the evidence for clinical and laboratory

determination of dehydrationReview Oral Rehydration Therapy and its

indicationsDiscuss the concept of “fluid challenge” and

the need for a paradigm shift

Case 1

A 20-month-old girl is brought to the emergency department (ED) after 2 days of vomiting and diarrhea.

Father reports no solid intake since the illness began and now child will not drink

Today- 8 stools and no diapers with urine in themThe child appears mildly ill but makes tears while cryingHer respiratory rate and quality are normal, VSSHer mouth is somewhat dryCRT is 1.5 secondsSkin turgor is normalBUN is 4.3 mmol/L; Bicarb 19 mmol/L

Who Cares?

Dehydration is one of the leading causes of morbidity and mortality in children throughout the worldCauses 30% of worldwide deaths among infants and

toddlersPre-ORT gastro was the number one killer of children in

developing countries- it now falls behind LRTI’s

8000 children younger than 5 years die each day due to gastroenteritis and dehydrationAlmost 3 million/year!!

Who cares?

In the US and Canada, children < 5 average 2 episodes of gastroenteritis/year

Gastro leads to 2 to 3 million office visits and 10% of all pediatric hospital admissions (US data)

The direct costs of outpatient and hospital visits are more than $2 billion per year (US data)

Dehydration is not a disease

1) Decreased intake2) Increased output

Insensible lossesRenal lossesGI losses

3) TranslocationBurnsAscites

Why is this a peds problem?

Sick kids = decreased intake

Higher percentage TBW

Neonate 75%Child 65%Adult 60%

Fever increases fluid needs

Higher metabolic rate in kids

less tolerance to fluid and electrolyte changes

Poor renal concentration mechanisms at young age

Causes of Dehydration

DiarrheaVomitingGastroenteritisStomatitis or

pharyngitisFebrile illnessDKADIBurns

Causes

Diarrhea

DDxGastroenteritisMalabsorptionIBDIBSDrug side effectsThyrotoxicosisInfectionsEndocrine disorders

Diarrhea

Indications for stool studiesToxic appearanceImmunocompromisedBloody or invasiveDuration > 7 daysSuspected parasites

TravelCampingPoor Water

Vomiting

“Vomiting without diarrhea should prompt a thorough search for another cause other than gastro”

Vomiting

GI Obstruction Pancreatitis Appy Pyloric stenosis Volvulus Intussusseption

GU UTI Pyelo RTA

Toxic Drug ingestion Drug side effects

ID Pneumonia Sepsis

Endocrine Addisons CAH

Neuro Meningitis/Encephalitis ↑ ICP

Case #15 mo MaleHPI

Non-bloody profuse watery stool 7 days10-15 stools per day – foul smellingChild eager to take water until this AMNow less interested in drinking and more lethargic

ExamQuiet and tachypneicSunken eyes and a dry mouthTachycardic at 165 bpmCap refill is 3 secondsSkin turgor prolonged

Case #1

How do you want to manage this patient?What are some of the potential pitfalls in

managing this patient?Do you have an approach to this patient?

Approach to Peds Dehydration

1) Initial Resuscitation2) Determine % dehydration3) Define the type of dehydration4) Determine the type and rate of

rehydration fluids5) Final considerations

Approach to Peds Dehydration

1) Initial Resuscitation2) Determine % dehydration3) Define the type of dehydration4) Determine the type and rate of

rehydration fluids5) Final considerations

Initial Resuscitation

ABCsInitial fluid bolus

20cc/kg of NS or RingersAppropriate in all types of dehydrationReassess q5mins and repeat x 3

Initial hypoglycemia5cc/kg of D10W in infants2cc/kg of D25W in children

Think about Shock DDx if unresponsive to 3 attempts at NS bolus

Approach to Peds Dehydration

1) Initial Resuscitation2) Determine % dehydration3) Define the type of dehydration4) Determine the type and rate of

rehydration fluids5) Final considerations

Case #220 mo FHPI

2 days of vomiting and diarrheaNot eating and will not drink8 stools today but dad does not think there were any

diapers with urine in themAfebrile

ExamAppears mildly illTears +Vitals are normal including RRMouth is DryCap Refill time is 2.0 seconds

Survey

How dehydrated is this child?3-5%6-9%>10%

Who wants to do bloodwork?

Who wants to start an IV to rehydrate?

AAP Guideline

The AAP guideline states that “the treatment of a child with diarrhea is directed primarily by the degree of dehydration present”Mild (3%-5%)Moderate (6%-9%)Severe (>9%)

Mild to Moderate- ORTSevere- IV fluidsCDC uses a similar assessment and scale

WHO Classification

None (3-5%)Some (5-10%)Severe (>10%)

Treatment recommendations are the sameNone- maintain hydrationNone-Some- ORTSevere- IV fluids

So what’s up??

Despite recommendations for oral rehydration in mild or moderate dehydration, ORT is used in < 30% of the cases of gastro for which it is indicated

Clinicians tend to overestimate the degree of dehydration

May result in more invasive intravenous rehydration

What do you think?

Determine % Dehydration

Gold standard is pre and post weightWhat are the markers that we use to assess

this?ClinicalLaboratory

How reliable and precise are these markers?

Is this Child Dehydrated?Michael J. Steiner; Darren A. DeWalt; Julie S. Byerley, JAMA. 2004;291(22):2746-2754

Quantifying dehydration is important and common

Utility of the clinical history, physical examination, and laboratory tests had not previously been systematically reviewed

Teaching the assessment of dehydration often based on clinical experience and medical tradition

Steiner et al, conducted a systematic review of the literature on the precision and accuracy of history, physical examination, and laboratory tests in identifying dehydration in children between 1 month and 5 years old

Clinical Signs

Capillary Refill Time- what is normal?

Although many practitioners use other sites to measure capillary refill time, most studies of this sign use the palmar surface of the distal fingertip

Using this approach, values for non-dehydrated children are less than 1.5 to 2 seconds

Gorelick et al, found that fever did not affect the test characteristics in children with vomiting, diarrhea, or poor oral intake

Laboratory Signs

BUN >8= >2.9 mmol/L

>18= >6.4 mmol/L

>27= >9.6 mmol/L

>45= >16 mmol/L

Validity and Reliability of Clinical Signs in the Diagnosis of Dehydration in Children, Marc H. Gorelick, Kathy N. Shaw and Kathleen O. Murphy, Pediatrics 1997;99;e6

Scale gave equal weight to 10 commonly elicited signs: Decreased skin elasticity CRT > 2 seconds General appearance Absence of tears Abnormal respirations Dry mucous membranes Sunken eyes Abnormal radial pulse Tachycardia (heart

rate150/min) Decreased urine output

3 of the 10 signs 87% sensitive and 82% specific in detecting 5% dehydration LR positive, 4.9

7 of 10 signs 82% sensitive and 90% specific in detecting 10% dehydration LR positive of 8.4

Gorelick, cont’d

Logistic regression analysis showed 4 signs contained most of the predictive power: Capillary refill time Dry mucous membranes Absence of tears Abnormal overall

appearance

2 of 4 signs was 79% sensitive and 87% specific for diagnosing 5% dehydration LR positive of 6.1

3 of 4 signs was 82% sensitive and 83% specific for diagnosing 10% dehydration LR positive of 5.1

* Not statistically different than 10 sign model

History- “they haven’t peed all day!”

Steiner pooled 3 studies to evaluate the accuracy of history taking in assessing dehydration

All 3 of these studies evaluated history of low urine output as a test for dehydration

Low urine output did not increase the likelihood of 5% dehydration (LR, 1.3; 95% CI, 0.9-1.9)

Also NOT predictive of dehydration:A history of vomiting, diarrhea, decreased oral intake,

reported low urine output, a previous trial of clear liquids, and having seen another clinician during the illness prior to presenting to the ED

Development of a Clinical Dehydration Scale for use in Children between 1 and 36 months of age. J. Friedman, et al. J Peds, Aug 2004 pp.201-207

Developed a clinical score to assess severity and response to treatment in children aged 1-36 months

Score not intended to be diagnosticFound 4 of 9 items to be the most valid and

reliableGeneral appearanceMucous membranesSunken eyesAbsent tears

Of 137 patients only 1 had severe dehydration (>10% weight loss) but 94 (69%) received IV fluids; 9 patients had moderate dehydration (6-9% weight loss)

Steiner conclusions

Data suggest that signs of dehydration can be imprecise and inaccurate

Difficult for clinicians to predict the exact degree of dehydration

Combination of clinical symptoms better than individual signs or lab findings

Steiner et al agrees with WHO and other groups that recommend using the physical examination to classify dehydration as none, some, or severe

This general assessment can then be used to guide clinical management

What does it mean for us?

We can classify children as:Not dehydrated- need advice on how to

maintain hydrationSome dehydration- need ORT and if successful

advice on how to maintain hydrationSevere dehydration- need fluid resuscitation

followed by rehydration

Approach to Peds Dehydration

1) Initial Resuscitation2) Determine % dehydration3) Define the type of dehydration4) Determine the type and rate of

rehydration fluids5) Final considerations

Case #4

6 day old FemaleFirst child born at termGBS negative motherNormal preg and delivery D/C’d within 24 hrsExclusively breastfed

HPIMom says child is a “poor feeder” Not sure if her breastmilk has come in fullyChild much more listless today Having to wake to feedNo urine output or stools noted in the last 48hrs

Case #4 con’t

ExamVitals = HR 160, RR 38, T36.9°C, Sats 94%, BG4.1Generally – difficult to rouse but irritable upon

awakeningCVS – normal pulse and cap refill Resp – clearHydration – MM dry, no tears noted, skin is noted to

be very soft and doughy

Case #4 con’t

LabsCBC

WBC 4.8Hgb 179Plt 433

LytesNa 167 K 6.8Cl 132Bicarb 16

BUN = 7mmol/LCreatinine = 90umol/L

What type of dehydration is this?

What is the most likely cause?

Define the type of dehydration Three major classes of dehydration

based on relative losses of Na and Water1) Isonatremic dehydration (80%)2) Hypernatremic dehydration (15%)3) Hyponatremic dehydration (5%)

Thanks to Marc Francis for upcoming slides

Body FluidsICF (mEq/L) ECF (mEq/L)

Sodium 20 135-145Potassium 150 3-5 Chloride --- 98-110Bicarbonate 10 20-25Phosphate 110-115 5Protein 75 10

Isonatremic dehydration

By far the most commonEqual losses of Na and WaterNa = 130-150No significant change between fluid

compartments No need to correct slowly

Hypernatremic Dehydration

Water loss > sodium lossNa >150mmol/LWater shifts from ICF to ECFChild appears relatively less ill

More intravascular volumeLess physical signsAlternating between lethargy and hyperirritability

Hypernatremic Dehydration

Physical findingsDry doughy skinIncreased muscle tone

CorrectionCorrect Na slowlyIf lowered to quickly causes

massive cerebral edemaintractable seizures

Hyponatremic Dehydration

Sodium loss > Water lossNa <130mmol/LWater shifts from ECF to ICFChild appears relatively more ill

Less intravascular volumeMore clinical signsCerebral edemaSeizure and Coma with Na <120

Hyponatremic Dehydration

CorrectionMust again be performed slowly unless actively

seizingRapid correction of chronic hyponatremia

thought to contribute to….Central Pontine Myelinolysis

Fluctuating LOCPseudobulbar palsy Quadraparesis

Approach to Peds Dehydration

1) Initial Resuscitation2) Determine % dehydration3) Define the type of dehydration4) Determine the type and rate of

rehydration fluids5) Final considerations

Case #4

18 mo M previously heatlhy

HPIDiarrhea and vomiting for 3 days Mom says stools are liquid and foul smelling with no

mucous or blood6 episodes of diarrhea and 4 episodes of vomiting

per day not feeding well and activity level ↓He seems weak and tiredDecreased number of wet diapers

Case cont

ExamVS = T 37.0, P 110, RR 25, BP 100/75, 11.3 kgGenerally: alert, crying, looks tiredHEENT: minimal tears, lips dry, mucous membranes

tackyCVS: mild tachycardia, no murmursRESP: clear, no distressABDO: flat, soft, and non-tender with hyperactive

bowel soundsHydration: capillary refill time is 2-3 seconds and his

skin turgor is slightly diminished

Comparison of ORT

Gatorade 59 20 3 N/A 3 350

Oral Rehydration Therapy

Discovered in the 60’sCombination of salt and sugar enhances fluid absorptionSodium and glucose transport in the small intestine are

coupled; glucose promotes absorption of both sodium ions and water

Diarrhea is caused by derangement of fluid absorption and secretion from the gut

Coupling sodium and glucose allows absorption, even during active fluid secretion due to infection

Rehydration can take place even with large fluid losses ie. cholera

The optimal glucose to sodium ratio to ensure maximal sodium absorption is 1:1

ORT

Initial WHO ORS contained 90mmol/L of Na and 110 mmol/L carbohydrate- total osmolarity 311

New low osmolarity solution introduced in 2002- 75 mmol/L of Na and 75 mmol/L of carbohydrate- total osmolarity 245

Cochrane review shows less diarrhea and vomiting with low osmol solution, fewer episodes of unscheduled IV fluid use with no increase in hyponatremia *studies done in hospitalized children

ORT for no dehydration

Maintenance of hydration:<10 kg 60-120 mls of ORS following each

episode of vomiting or diarrhea>10 kg 120-240 mls of ORS following each

episode of vomiting or diarrhea

Continue breastfeeding and DAT

ORT for some dehydration

ORS of 50-100 ml/kg given over 2-4 hoursMaintenance phase same as above

Severe dehydration

Resuscitation with 20ml/kg of Ringers or NS IV

Rehydration with100 ml/kg of ORS over 4 hours ORD5W1/2NS at 2x maintenance for 4 hours

A randomized trial of oral vs intravenous rehydration in a pediatric emergency department.Atherly-John YC, Cunningham SJ, Crain EF. Arch Pediatr Adolesc Med 2002;156:1240–3.

A randomized trial of ORS versus IV rehydration for dehydrated children

Demonstrated shorter stays in EDs and improved parental satisfaction with oral rehydration

Vomiting

Many patients with acute diarrhea also have vomiting

The majority can be orally rehydrated successfully

Give limited volumes of ORS (5 mL) every 5 minutes, with a gradual increase in the amount consumed

Administration with a spoon or syringe under close supervision

Ensure a gradual progression in the amount taken

Vomiting

Correction of acidosis and dehydration lessens the frequency of vomiting

Alternative is continuous slow NG infusion of ORS through a feeding tube

Even if some emesis occurs after NG administration of fluid, treatment not necessarily adversely affected

NG rehydration may help the initial rehydration, speed up tolerance to refeeding and lead to improved patient disposition and quicker discharge

Enteral vs intravenous rehydration therapy for children with gastroenteritis: A metaanalysis of randomized controlled trials. Fonseca, et al Arch Pediatr Adolesc Med 2004;158:483-90

A meta-analysis of 16 randomized controlled trials conducted in 11 countries involving 1545 children

The investigators concluded that ORT is as effective, if not better than, intravenous rehydration

ORT is associated with significantly fewer major adverse events and a shorter hospital stay compared with intravenous therapy

ORT is successful in almost all children; < 5% fail ORT

ObjectiveTo test the hypothesis that the failure rate of ORT

would not be more than 5% greater than that of IVTRCT

Non-inferiority study designN=73 pts

ED based studyChildren 8 weeks to 3 years oldModerate dehydration on validated scaleWith viral gastroenteritis

MethodsPatients were randomized to receive either ORT or

IVT during the 4-hour studyTreating physicians were blindedPatients were assessed before randomization and at

2 and 4 hours of therapySuccessful rehydration at 4 hours was defined as

resolution of moderate dehydrationproduction of urineweight gainabsence of severe emesis (>5 mL/kg).

Results:Half of both the ORT and IVF groups were rehydrated

successfully at 4 hours with no statistical differences

Results: The time required to initiate therapy was less in the ORT group Less than one third of the ORT group required hospitalization,

whereas almost half of the IVF group was hospitalized No difference in parental preference of therapy

Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children

Hartling, L. et al. Cochrane Database of Systematic Reviews. 4, 2006

RCTs comparing IVT with ORT in children up to 18 yo with gastroenteritis

17 trials of poor to moderate quality were included

N = 1811 ptsSix deaths occurred in the IVT group and two in the

ORT groups (4 trials)

Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children

Hartling, L. et al. Cochrane Database of Systematic Reviews. 4, 2006

Results:No clinically important differences between

ORT and IVT groupsORT group did have a higher risk of paralytic ileusThe IVT group was exposed to risks of intravenous

therapy For every 25 children (95% CI 14 to 100) treated

with ORT one would fail and require IVT

Case #4

9 month old MalePreviously healthy Weight 10kg

5 day hx of severe diarrhea with intermittent vomiting

Mother says stool like liquidHas been aggressively rehydrating him with water at homeToday is much more lethargic and difficult to rouseBy ambulance to the ED

Case #4

ExamVitals = HR 172, RR 41, BP 65/40, Temp 37.2, Child is minimally responsive to painHe is Tachycardic and TachypneicCap refill time is >3 secondsAs you are examining him he begins to have a

seizureWhat do you want to do now?Investigations?

Severe DehydrationManagement of severe dehydration

requires IV fluidsFluid selection and rate should be dictated

by The type of dehydrationThe serum NaClinical findings

Aggressive IV NS bolus remains the mainstay of early intervention in all subtypes

Isonatremic Dehydration

Calculate the fluid deficitDeficit (cc’s) = % dehydration x body wt

D5½NS is fluid of choice(½ deficit – the bolus) over the first 8hrs

Add maintenance and any ongoing losses to aboveFurther ½ the deficit replaced over the next 16hrs

Monitor electrolytes and U/O

Hypernatremic Dehydration

Fluid deficit =(Current Na/Desired Na – 1) x 0.6 x body wt• Replace with D50.2%NS• Replace over 48hrs• Reduce sodium by no more than 10mEq/L/24hrs

(½ deficit – the bolus) over the first 24hrsAdd maintenance and any ongoing losses to aboveFurther ½ the deficit replaced over the next 24hrs

Hyponatremic dehydration

Na deficit =(Nadesired- Nacurrent) x 0.6 x Weight (kg)

Divide above by Na in mEq/L within the replacement fluid to get volume

154 mEq in NS77 mEq in D5½ NS 513 in 3% saline

Rate of infusion:Na+ requirement (mmol) x1000--------------------------------------------Infusate Na+ (mmol/L) x time (hours)

Hyponatremic Dehydration

If seizing Correct with 3% Saline bolusTarget a Na of 120Further correction beyond this with D5½ NS

If not SeizingCorrect with D5½ NS Target a Na of 130

Watch for Central Pontine MyelinolysisMore likely in chronic hypo-Na with less SxCorrect slowly at rate of 0.5mEq/L/hr

Back to our case

ExamVitals = HR 172, RR 41, BP 65/40, Temp 37.2, Child is minimally responsive to painHe is Tachycardic and TachypneicCap refill time is 5 secondsFontanelle and eyes are sunkenAs you are examining him he begins to have a seizure

What do you want to do now? Investigations?Cap gas comes back and the patients sodium is 115!!!

Case cont

Initial bolus 20cc/kg of NS

SeizingCorrect Na to 120 with 3% saline bolus(120 – 115) x 0.6 x 10kg = 30mEq30mEq ÷ 513mEq/L = 58cc bolus

Further correction after aboveCorrect Na to 130 with D5½ NS(130-120) x 0.6 x 10kg = 60mEqRate= (60mEq x 1000)/(77 mEq x 24 H)32 cc/hr

Want to make life easier?

http://www.medcalc.com/pedifen.html

Approach to Peds Dehydration

1) Initial Resuscitation2) Determine % dehydration3) Define the type of dehydration4) Determine the type and rate of

rehydration fluids5) Final considerations

Final considerationsDoes and Acid-Base Deficit exist?

Does a potassium disturbance exist?

What is the patients renal function?

Does and Acid-Base Deficit exist?

AcidosisLactateKetonesLoss of Bicarb in diarrhea

Most will resolve with simple rehydrationConsider HCO3 for pH<7.0

Controversial

Does a potassium disturbance exist?K+ losses

GIRenal

Remember that K shifts with acidosis and certain therapies

Always insure renal function prior to IV replacement

What is the patients renal function?

Asses for underlying renal dysfuctionPre-renal vs renal failure

Renal dysfuctionFluid overloadHyperkalemiaNeed for Dialysis?Nephro consultation

Quick Cases

Case

2yo F (14kg)3 days of diarrhea and vomiting

Decreased u/o as per mother

Exam Generally appears wellMM dry and no significant tearsSkin turgor normalTachycardic but not tachypneicCap refill 2 seconds

Approach to Peds Dehydration

1) Initial Resuscitation2) Determine % dehydration3) Define the type of dehydration4) Determine the type and rate of

rehydration fluids5) Final considerations

Answers

Initial resuscitationdeferred

% dehydration5-9%moderate

Dehydration TypeLikely Isonatremic

Rehydration fluidsORTPedialyte

Rate and volumesModerate dehydration

100cc/kg = 1400ccReplace over 3-4hrsFurther 10cc/kg with

ongoing losses

Final considerationsNone

Case

8mo M (8kg)4 day hx of severe

diarrhea and vomitingNo further ongoing

losses

Exam Limp and coldMottled with weak rapid

pulseSunken eyes and

fontanelleCap refill 5sTenting of skin

LabsNa = 170K = 3.1HCO3 = 18

Approach to Peds Dehydration

1) Initial Resuscitation2) Determine % dehydration3) Define the type of dehydration4) Determine the type and rate of

rehydration fluids5) Final considerations

Answers

Initial resuscitation160cc NS bolus

% dehydration>10%Severe

Dehydration TypeHypernatremic

Rehydration fluidsIV fluidsD50.2NS

Rate and volumesVolume deficit

remaining = 640ccCorrect slowly over

48hrs39cc/hr over first 24hrs45cc/hr over next 24hrs

Final considerationsAdd 20 mEq K to IV

fluids

Case

16mo F3 day Hx of vomiting and diarrhea

Tolerating fluids not solidsGood u/o

Exam Appears well with normal vitalsTears + MM moistCap refill <2sSkin turgor normal

Approach to Peds Dehydration

1) Initial Resuscitation2) Determine % dehydration3) Define the type of dehydration4) Determine the type and rate of

rehydration fluids5) Final considerations

Answers

Send this kid home!!!

Case

2 yo M (16kg)4 day Hx of vomiting

and diarrheaExam

Appears drowsy but not lethargic

Good toneTachycardiac and

tachypneicBP normalVery Dry MMCap refill 3s

LabsNa = 134K = 3.1HCO3 = 16

Approach to Peds Dehydration

1) Initial Resuscitation2) Determine % dehydration3) Define the type of dehydration4) Determine the type and rate of

rehydration fluids5) Final considerations

Answers

Initial resuscitation320cc of NS

% dehydration>10%Severe

Dehydration TypeIsonatremic

Rehydration fluidsD5½ NS

Rate and volumesVolume deficit =

10% x 16kg= 1600mls

110cc/hr over first 8hrs100cc/hr over next

16hrsFinal considerations

Add 20 mEq K to IV fluids

Watch for metabolic acidosis to resolve

Case

1yo F (10kg)4 day Hx of severe

diarrhea and vomitingExam

Lethargic and limpWeak rapid pulseFontanelle sunkenCap refill 5sCool and mottledTenting of skin

LabsNa = 114 K = 3.4HCO3 = 18

During your exam the patient starts Seizing

Approach to Peds Dehydration

1) Initial Resuscitation2) Determine % dehydration3) Define the type of dehydration4) Determine the type and rate of

rehydration fluids5) Final considerations

Answers

Initial resuscitation200cc NS

% dehydration>10%Severe

Dehydration TypeHyponatremic

Rehydration fluidsIV Initially 3% salineD5½ NS after above

Rate and volumesInitially correct to Na of

120 with 3%= 70cc bolus“Complex vs. simple

method”Then correct to Na of

130 with D5½ NS at rate of 0.5mEq/L/hr

= 32cc/hrFinal considerations

Add 20 mEq K to IV fluids

So is there anything else….

What else could/should we be doing for these vomiting kiddos?

What about Ondansetron?

Systematic review and RCTOndansetron (v placebo) reduced

vomiting during oral replacement therapy, need for intravenous fluids, and hospital admission

Increased risk of diarrhea and representation after discharge

Not recommended for routine use

Oral ondansetron for gastroenteritis in a pediatric emergency department. Freedman SB, Adler M, Seshadri R et al. N Engl J Med 2006;354:1698-705.

A double blind randomized control trial of a single dose of oral dissolvable ondansetron in 215 children aged 6 months to 10 years with vomiting, diarrhea and dehydration

Those who received ondansetron were less likely to vomit (14% vs. 35%, RR 0.40, 95% CI 0.26-0.61)

Tended to vomit less often (0.18 episodes/child vs. 0.65, P<0.001)

Had greater oral intake (239 ml vs. 196 ml, P=0.001)Both the treatment and placebo groups had similar rates of

hospitalization (4% vs. 5%, P=1.0)No significant adverse events during the 7 days following

ondansetron were identifiedTreatment group had more episodes of diarrhea during oral

rehydration (1.4 vs. 0.5, P<0.001)

No child met their definition of severe dehydration (score >16)

IV fluids at physician’s discretion- no set criteria

Does this study really tell us that we think kids who vomit while taking ORT need an IV?

Results:NNT= 5 to prevent

one episode of vomiting

(95% CI 3.2-10.6)

NNT=6 to prevent one episode of IV rehydration

(95% CI 3.6-17.0)

Mean length of stay in the ED was reduced in the Ondansetron group

12% reduction (P=0.02)

No statistical difference in hospitalization rates

The 11 articles that met the inclusion criteria evaluated various antiemetic agents: ondansetron (n=6), domperidone (n=2), trimethobenzamide (n=2), pyrilamine- pentobarbital (n=2), metoclopramide (n=2), dexamethasone (n=1), and promethazine (n=1).

Meta analysis of 6 randomized, double-masked placebo controlled trials of ondansetron: Decreased risk of further

vomiting (5 studies; relative risk [RR], 0.45; 95% confidence interval [CI], 0.33-0.62 ;NNT= 5

Reduced need for intravenous fluid (4 studies; RR, 0.41; 95% CI, 0.28-0.62; NNT=5

Decreased risk of immediate hospital admission (5 studies; RR, 0.52; 95% CI, 0.27-0.95; NNT=14)

Diarrheal episodes increased in ondansetron-treated patients in 3 studies

Ondansetron use did not significantly affect return to care (5 studies; RR, 1.34; 95% CI, 0.77-2.35)

Conclusion:Ondansetron should

be considered in select children with gastro

Other things you may have heard about…..

What about probiotics?

1 systematic reviewProbiotics reduce diarrhea at 3 days

(relative risk 0.66, 0.55 to 0.77)Reduces mean duration of diarrhoea (by

30.48 hours, 18.51 to 42.46)Type, regimen, and dosage of probiotics

not yet established

What about Immodium?

5 RCT’sLoperamide (v placebo) reduced duration

of diarrhea in mild-moderate dehydration and increased weight gain in 2 trials

No effect on hospital stay or stool output in 2 other trials

Insufficient evidence to assess risk of adverse effects

Not recommended for routine use

What about diluting formula?

Medical practice has often favored beginning feedings with diluted (e.g., half- or quarter-strength) formula

Controlled clinical trials have demonstrated that this practice is unnecessary and is associated with prolonged symptoms and delayed nutritional recovery

What about lactose-free diet?

Systematic reviews and RCTsConflicting results on duration of diarrhoea

with lactose-free (v lactose containing) milk

Systematic review limited by heterogeneity, poor quality of trials

Not recommended for routine use, may have a role in select patients

What do we recommend now?

15-30 mls of Pedialyte q15 minutes x 4 hrs10 kg child= 15mlx4=60mlx4=240 ml

24 ml/kg in 4 hours10 kg child= 30mlx4=120mlx4=480 ml

48 ml/kg in 4 hoursRecommended 50-100 ml/kg:

10 kg child= 75 mlx10kg= 750 ml50 ml/15 minutes

What is a “fluid challenge”?

Most children who present to our ED with gastro are started on a “fluid challenge”

Terminology may send wrong message to parents

More important to determine degree of dehydration and appropriate pathway for child

Vomiting does not equal failureGastroenteritis clinical pathway group working to

improve care of these childrenWill require a paradigm shift

Quiz- True or False

Children with moderate dehydration (5-10%) can be successfully rehydrated with ORT.

Moderate to severe dehydration is common in children with gastro.

Children with vomiting cannot be rehydrated using ORT.

Clinicians are good at estimating a child’s degree of dehydration.

Quiz- True or False

A child with “no wet diapers” should be considered moderately dehydrated.

Bloodwork is generally helpful in determining the degree of dehydration.

IV fluids are a faster and more effective way to rehydrate children with gastro.

Ondansetron is the holy grail for vomiting children.

Take home messages

Almost all of the children we care for are mild-moderately dehydrated and can be rehydrated orally- even if they vomit!

ORT is better for children, empowers families and shortens the stay in the ED

Our ORT guidelines should be weight based to reflect best practice

We can improve of care of children with gastroenteritis

Thank-you!