Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Oral rehydration therapy

INTRODUCTION

Diarrheal disease is one of the leading causes of worldwide childhood morbidity and mortality, resulting in 1.4 to 2.5 million deaths annually [1-3]. Loss of intestinal fluid caused by gastroenteritis may lead to severe hypovolemia, shock, and death, particularly in children younger than five years of age.

Although the total number of deaths globally from diarrheal diseases remains high, the overall mortality rate has steadily declined over the last few decades [1]. This decline, especially in developing countries, is largely due to the use of early and appropriate oral rehydration therapy (ORT), as well as improved nutrition and water sanitation measures [4].

In the United States, diarrhea caused by gastroenteritis remains the major cause of hospitalizations (>200,000/year) and outpatient visits (>1.5 million/year); this results in 300 deaths every year [5]. The annual direct medical costs are estimated to be more than 1 billion US dollars per year.

The early use of ORT at home in children with diarrhea decreases the number of outpatient visits and hospitalizations, and overall medical costs [6]. Despite the success of ORT in developing countries, and established guidelines supporting its use in children with gastroenteritis by the American Academy of Pediatrics (AAP) and the Centers for Disease Control (CDC), the full benefit of ORT in the United States and other developed countries has not been realized on account of underutilization [5-9].

The scientific basis and clinical application of ORT in patients with diarrhea, the composition of oral rehydration solutions (ORS), and the limitations and barriers to this therapy are discussed in this topic review. The assessment and treatment of hypovolemia in children is discussed separately. (See "Clinical assessment and diagnosis of hypovolemia (dehydration) in children" and "Treatment of hypovolemia (dehydration) in children".)

                       

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jul 2014. | This topic last updated: Jul 12, 2012.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Kosek M, Bern C, Guerrant RL. The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. Bull World Health Organ 2003; 81:197.
  2. Parashar UD, Bresee JS, Glass RI. The global burden of diarrhoeal disease in children. Bull World Health Organ 2003; 81:236.
  3. Bryce J, Boschi-Pinto C, Shibuya K, et al. WHO estimates of the causes of death in children. Lancet 2005; 365:1147.
  4. Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ 2000; 78:1246.
  5. Santosham M, Keenan EM, Tulloch J, et al. Oral rehydration therapy for diarrhea: an example of reverse transfer of technology. Pediatrics 1997; 100:E10.
  6. Duggan C, Lasche J, McCarty M, et al. Oral rehydration solution for acute diarrhea prevents subsequent unscheduled follow-up visits. Pediatrics 1999; 104:e29.
  7. Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics 1996; 97:424.
  8. Avery ME, Snyder JD. Oral therapy for acute diarrhea. The underused simple solution. N Engl J Med 1990; 323:891.
  9. King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 2003; 52:1.
  10. HARRISON HE. The treatment of diarrhea in infancy. Pediatr Clin North Am 1954; :335.
  11. DARROW DC. The retention of electrolyte during recovery from severe dehydration due to diarrhea. J Pediatr 1946; 28:515.
  12. Paneth N. Hypernatremic dehydration of infancy: an epidemiologic review. Am J Dis Child 1980; 134:785.
  13. Schultz SG, Fuisz RE, Curran PF. Amino acid and sugar transport in rabbit ileum. J Gen Physiol 1966; 49:849.
  14. Hirschhorn N, Kinzie JL, Sachar DB, et al. Decrease in net stool output in cholera during intestinal perfusion with glucose-containing solutions. N Engl J Med 1968; 279:176.
  15. Pierce NF, Sack RB, Mitra RC, et al. Replacement of water and electrolyte losses in cholera by an oral glucose-electrolyte solution. Ann Intern Med 1969; 70:1173.
  16. World Health Organization. Reduced osmolarity oral rehydration salts (ORS) formulation. UNICEF House, New York, NY 2001. Available at: www.who.int/child-adolescent-health/New_Publications/NEWS/Expert_consultation.htm (Accessed on January 18, 2006).
  17. Mahalanabis D, Choudhuri AB, Bagchi NG, et al. Oral fluid therapy of cholera among Bangladesh refugees. Johns Hopkins Med J 1973; 132:197.
  18. Santosham M, Daum RS, Dillman L, et al. Oral rehydration therapy of infantile diarrhea: a controlled study of well-nourished children hospitalized in the United States and Panama. N Engl J Med 1982; 306:1070.
  19. Tamer AM, Friedman LB, Maxwell SR, et al. Oral rehydration of infants in a large urban U.S. medical center. J Pediatr 1985; 107:14.
  20. Listernick R, Zieserl E, Davis AT. Outpatient oral rehydration in the United States. Am J Dis Child 1986; 140:211.
  21. Vesikari T, Isolauri E, Baer M. A comparative trial of rapid oral and intravenous rehydration in acute diarrhoea. Acta Paediatr Scand 1987; 76:300.
  22. Atherly-John YC, Cunningham SJ, Crain EF. A randomized trial of oral vs intravenous rehydration in a pediatric emergency department. Arch Pediatr Adolesc Med 2002; 156:1240.
  23. Fonseca BK, Holdgate A, Craig JC. Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch Pediatr Adolesc Med 2004; 158:483.
  24. Hartling L, Bellemare S, Wiebe N, et al. Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. Cochrane Database Syst Rev 2006; :CD004390.
  25. Munos MK, Walker CL, Black RE. The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality. Int J Epidemiol 2010; 39 Suppl 1:i75.
  26. Guarino A, Albano F, Ashkenazi S, et al. European Society for Paediatric Gastroenterology, Hepatology, and Nutrition/European Society for Paediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe. J Pediatr Gastroenterol Nutr 2008; 46 Suppl 2:S81.
  27. Stanton BF, Rowland MG, Clemens JD. Oral rehydration solution--too little or too much? Lancet 1987; 1:33.
  28. Meyers A, Sampson A, Saladino R, et al. Safety and effectiveness of homemade and reconstituted packet cereal-based oral rehydration solutions: a randomized clinical trial. Pediatrics 1997; 100:E3.
  29. World Health Organization. The treatment of diarrhea: a manual for physicians and other senior health workers. World Health Organization, Geneva, Switzerland 1995. Available at: www.who.int/child-adolescent-health/New_Publications/CHILD_HEALTH/ISBN_92_4_159318_0.pdf (Accessed on September 14, 2007).
  30. Mackenzie A, Barnes G. Randomised controlled trial comparing oral and intravenous rehydration therapy in children with diarrhoea. BMJ 1991; 303:393.
  31. Gremse DA. Effectiveness of nasogastric rehydration in hospitalized children with acute diarrhea. J Pediatr Gastroenterol Nutr 1995; 21:145.
  32. Nager AL, Wang VJ. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Pediatrics 2002; 109:566.
  33. Fayad IM, Hirschhorn N, Abu-Zikry M, Kamel M. Hypernatraemia surveillance during a national diarrhoeal diseases control project in Egypt. Lancet 1992; 339:389.
  34. Duggan C, Fontaine O, Pierce NF, et al. Scientific rationale for a change in the composition of oral rehydration solution. JAMA 2004; 291:2628.
  35. Gore SM, Fontaine O, Pierce NF. Impact of rice based oral rehydration solution on stool output and duration of diarrhoea: meta-analysis of 13 clinical trials. BMJ 1992; 304:287.
  36. Bhan MK, Mahalanabis D, Fontaine O, Pierce NF. Clinical trials of improved oral rehydration salt formulations: a review. Bull World Health Organ 1994; 72:945.
  37. Nalin DR, Cash RA, Rahman M, Yunus M. Effect of glycine and glucose on sodium and water adsorption in patients with cholera. Gut 1970; 11:768.
  38. Hahn S, Kim Y, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration due to diarrhoea in children: systematic review. BMJ 2001; 323:81.
  39. Hahn S, Kim S, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. Cochrane Database Syst Rev 2002; :CD002847.
  40. Nalin DR, Hirschhorn N, Greenough W 3rd, et al. Clinical concerns about reduced-osmolarity oral rehydration solution. JAMA 2004; 291:2632.
  41. Alam NH, Yunus M, Faruque AS, et al. Symptomatic hyponatremia during treatment of dehydrating diarrheal disease with reduced osmolarity oral rehydration solution. JAMA 2006; 296:567.
  42. Spandorfer PR, Alessandrini EA, Joffe MD, et al. Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial. Pediatrics 2005; 115:295.
  43. Cohen MB, Mezoff AG, Laney DW Jr, et al. Use of a single solution for oral rehydration and maintenance therapy of infants with diarrhea and mild to moderate dehydration. Pediatrics 1995; 95:639.
  44. Freedman SB, Adler M, Seshadri R, Powell EC. Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med 2006; 354:1698.
  45. Roslund G, Hepps TS, McQuillen KK. The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial. Ann Emerg Med 2008; 52:22.
  46. DeCamp LR, Byerley JS, Doshi N, Steiner MJ. Use of antiemetic agents in acute gastroenteritis: a systematic review and meta-analysis. Arch Pediatr Adolesc Med 2008; 162:858.
  47. Ozuah PO, Avner JR, Stein RE. Oral rehydration, emergency physicians, and practice parameters: a national survey. Pediatrics 2002; 109:259.
  48. Conners GP, Barker WH, Mushlin AI, Goepp JG. Oral versus intravenous: rehydration preferences of pediatric emergency medicine fellowship directors. Pediatr Emerg Care 2000; 16:335.
  49. Snyder JD. Use and misuse of oral therapy for diarrhea: comparison of US practices with American Academy of Pediatrics recommendations. Pediatrics 1991; 87:28.
  50. Reis EC, Goepp JG, Katz S, Santosham M. Barriers to use of oral rehydration therapy. Pediatrics 1994; 93:708.
  51. Meyers A, Siegel B, Vinci R. Economic barriers to the use of oral rehydration therapy. A case report. JAMA 1991; 265:1724.
  52. Crocco AG, Villasis-Keever M, Jadad AR. Two wrongs don't make a right: harm aggravated by inaccurate information on the Internet. Pediatrics 2002; 109:522.
  53. Gregorio GV, Gonzales ML, Dans LF, Martinez EG. Polymer-based oral rehydration solution for treating acute watery diarrhoea. Cochrane Database Syst Rev 2009; :CD006519.
  54. Suh JS, Hahn WH, Cho BS. Recent Advances of Oral Rehydration Therapy (ORT). Electrolyte Blood Press 2010; 8:82.
  55. Freedman SB, Cho D, Boutis K, et al. Assessing the palatability of oral rehydration solutions in school-aged children: a randomized crossover trial. Arch Pediatr Adolesc Med 2010; 164:696.
  56. Sturm JJ, Hirsh DA, Schweickert A, et al. Ondansetron use in the pediatric emergency department and effects on hospitalization and return rates: are we masking alternative diagnoses? Ann Emerg Med 2010; 55:415.
  57. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm272041.htm (Accessed on September 20, 2011).
  58. Levine DA. Antiemetics for acute gastroenteritis in children. Curr Opin Pediatr 2009; 21:294.
  59. Gener B, Burns JM, Griffin S, Boyer EW. Administration of ondansetron is associated with lethal outcome. Pediatrics 2010; 125:e1514.
  60. Gouin S, Vo TT, Roy M, et al. Oral dimenhydrinate versus placebo in children with gastroenteritis: a randomized controlled trial. Pediatrics 2012; 129:1050.
  61. Uhlig U, Pfeil N, Gelbrich G, et al. Dimenhydrinate in children with infectious gastroenteritis: a prospective, RCT. Pediatrics 2009; 124:e622.
  62. Marchetti F, Maestro A, Rovere F, et al. Oral ondansetron versus domperidone for symptomatic treatment of vomiting during acute gastroenteritis in children: multicentre randomized controlled trial. BMC Pediatr 2011; 11:15.