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Guideline Summary
Guideline Title
Oral rehydration therapy (ORT) in children.
Bibliographic Source(s)
Medical Services Commission. Oral rehydration therapy (ORT) in children. Victoria (BC): British Columbia Medical Services Commission; 2010 Sep 1. 6 p. [14 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Mild to moderate dehydration as the result of suspected gastroenteritis

Guideline Category
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Emergency Medicine
Family Practice
Gastroenterology
Internal Medicine
Pediatrics
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To address the oral rehydration of children age 6 months to 17 years with mild to moderate dehydration as the result of suspected gastroenteritis

Target Population

Children aged 6 months to 17 years old presenting with either vomiting and/or diarrhea fewer than 7 consecutive days, resulting in mild to moderate dehydration

Note: The following populations are excluded from this guideline. Children presenting with:

  • Severe dehydration (unstable vital signs, poor perfusion)
  • Altered level of consciousness (Glasgow Coma Score <15)
  • Persistent lethargy or acute head injury
  • Possible surgical abdomen (bloody or bilious vomiting, bloody diarrhea, abdominal distension & tense, absent bowel sounds, guarding or rigidity and right lower quadrant pain)
  • Chronic health conditions (such as gastric or jejunal feeding tubes dependence, known inflammatory bowel disease, known immunodeficiency syndrome, known metabolic disorders, insulin dependent diabetes, heart or renal disorder and neurosurgical history).
Interventions and Practices Considered
  1. Clinical assessment of child's degree of hydration
    • Body weight
    • Fontanelle
    • Mucous membranes
    • Skin turgor
    • Capillary refill time
    • Urine output
    • Mental status
  2. Management of hydration
    • Mild - home-based treatment
    • Moderate - oral rehydration for 1 hour, then reassess
    • Severe - admit patient, do blood work
Major Outcomes Considered

Hydration status

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Evidence was obtained through a systematic review of peer-reviewed literature (up to March 2010) using the databases MEDLINE, PubMed, EBSCO, Ovid, and the Cochrane Collaboration's Database for Systematic Reviews. Clinical practice guidelines from other jurisdictions for rehydration, gastroenteritis and diarrhea were also reviewed (up to March 2010).

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Not stated
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

This guideline is an evidence-based clinical guideline for general practitioners with consensus statements when evidence is not available. It is based on scientific evidence current as of the Effective Date.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

This guideline was approved by the British Columbia Medical Association and adopted by the Medical Services Commission.

Recommendations

Major Recommendations

Diagnosis/Investigation

Assessing Dehydration in Children

When a child presents with symptoms of gastroenteritis, whether in the clinic/office or emergency department (ED), one of the main roles is to assess the child's hydration status and then decide on the appropriate management. Loss of body weight during the illness is the gold standard for measuring the magnitude of dehydration; however, the pre-illness weight may not be available.

Table. Clinical Assessment of Degree of Dehydration

Degree of Dehydration Mild
(5%-7% body weight)
Moderate
(7%-9% body weight)
Severe
(>10% body weight)
Fontanelle Slightly sunken Very sunken Very sunken
Mucous membranes Slightly sticky Dry Very dry
Skin turgor Normal Slightly decreased Markedly decreased
Capillary refill time Normal (<3 seconds) Normal (<3 seconds) Delayed (≥3 seconds)
Urine output Normal Slightly decreased Decreased or absent
Mental status Normal Slightly fussy Irritable or lethargic

Based on the degree of dehydration, the following approach to management has been suggested:

Table. Management of Dehydration

Degree of Dehydration Management
Mild Home-based treatment - see Parent Education and Resources in the original guideline document
Moderate Oral rehydration for 1 hour, then reassess
  • Post-reassessment if normal discharge home
  • If dehydration still moderate: continue oral rehydration
  • Reassess, if concerned do blood work - give 20 mL/kg bolus intravenous (IV) fluids over 1 hour, check pH, bicarbonate, nitrogen, discharge after bolus if improved but if pH <7.32, bicarbonate (bicarb) <18: Admit patient, administer IV fluids
Severe Admit patient, do blood work - give 20 mL/kg bolus IV fluids over 1 hour, check pH, bicarbonate, nitrogen. Continue IV as required.

Management of Rehydration

Acute gastroenteritis is one of the most common causes of dehydration affecting infants and children. Oral rehydration therapy is replacement of fluids and electrolytes, such as sodium, potassium, and chloride necessary for normal physiological functions and is effective in 95% of cases of mild to moderate dehydration. Oral rehydration therapy is less invasive, less expensive, is associated with less morbidity and can be dispensed outside of the hospital setting, while being as effective as IV treatment.

There is insufficient evidence to recommend the regular use of sports drinks for oral rehydration therapy in pediatric patients. The osmolarity and electrolyte concentrations of sports drinks can vary widely and may result in imbalances such as hypokalemia.

Oral rehydration solutions are available in ready-to-serve preparations.

Table. Oral Rehydration Solutions

Recommended Not Recommended (see Rationale section in the original guideline document)
  • Electrolytes (e.g., Pedialyte®, Enfalyte®)
  • Gastrolyte powder
  • Breastmilk
  • Tea
  • Sugar drinks (e.g., apple juice, carbonated soft drinks)
  • Sports drinks (e.g., Gatorade®)
  • Homemade remedies
Clinical Algorithm(s)

A flow chart of emergency management of dehydration is provided in Appendix A of the original guideline document.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

This guideline is an evidence-based clinical guideline for general practitioners with consensus statements when evidence is not available. The type of supporting evidence is not specifically stated for each recommendation.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Effective diagnosis and management of dehydration in children

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Clinical Algorithm
Mobile Device Resources
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Medical Services Commission. Oral rehydration therapy (ORT) in children. Victoria (BC): British Columbia Medical Services Commission; 2010 Sep 1. 6 p. [14 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Sep 1
Guideline Developer(s)
British Columbia Children's Hospital - Hospital/Medical Center
Child Health BC - Professional Association
Medical Services Commission, British Columbia - State/Local Government Agency [Non-U.S.]
Provincial Health Services Authority - State/Local Government Agency [Non-U.S.]
Source(s) of Funding

Medical Services Commission, British Columbia

Guideline Committee

Guideline and Protocols Advisory Committee

Composition of Group That Authored the Guideline

Not stated

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the British Columbia Ministry of Health Web site External Web Site Policy.

The guideline is also available for mobile devices from the British Columbia Ministry of Health Web site External Web Site Policy.

Availability of Companion Documents

The following is available:

  • Pediatric dehydration: sample physician orders CTAS level 2 or 3. Victoria (BC): British Columbia Medical Services Commission; 2010 Sep. 1 p. Electronic copies: Available in Portable Document Format (PDF) from the British Columbia Ministry of Health Web site External Web Site Policy.
Patient Resources

A patient guide is available in the original guideline document External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on January 31, 2013. The information was verified by the guideline developer on March 20, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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