Oral rehydration therapy
- Stephen Freedman, MDCM, MSc
Stephen Freedman, MDCM, MSc
- Associate Professor of Paediatrics
- Alberta Children’s Hospital, University of Calgary
- Alberta Children’s Hospital Research Institute
- Lead, Alberta Provincial Pediatric Enteric Infection Team
- Section Editors
- Tej K Mattoo, MD, DCH, FRCP
Tej K Mattoo, MD, DCH, FRCP
- Section Editor — Pediatric Nephrology
- Professor of Pediatrics
- Wayne State University School of Medicine
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
Globally, diarrheal disease remains one of the leading causes of childhood mortality and morbidity. Loss of intestinal fluid caused by gastroenteritis may lead to severe hypovolemia, shock, and death, particularly in children younger than five years of age in areas of the world with limited resources. In developed countries, such as the United States, diarrhea caused by gastroenteritis remains a major cause of hospitalizations. (See "Viral gastroenteritis in children: Epidemiology, clinical presentation, and diagnosis", section on 'Epidemiology' and "Approach to the child with acute diarrhea in resource-limited countries".)
Although the total number of deaths globally from diarrheal diseases from gastroenteritis remains high, the overall mortality rate has steadily declined over the last few decades. This decline, especially in developing countries, is largely due to the use of early and appropriate oral rehydration therapy (ORT), improved nutrition and water sanitation measures, and effective vaccination for rotavirus. (See "Approach to the child with acute diarrhea in resource-limited countries", section on 'Prevention' and "Viral gastroenteritis in children: Epidemiology, clinical presentation, and diagnosis", section on 'Epidemiology' and "Viral gastroenteritis in children: Prevention and treatment", section on 'Prevention'.)
The composition of oral rehydration solutions and the clinical application of ORT in patients with diarrhea due to gastroenteritis are discussed in this topic review. The assessment and treatment of hypovolemia, and prevention and treatment of viral gastroenteritis in children are discussed separately. (See "Clinical assessment and diagnosis of hypovolemia (dehydration) in children" and "Treatment of hypovolemia (dehydration) in children" and "Viral gastroenteritis in children: Prevention and treatment".)
DEFINITIONS OF HYPOVOLEMIA AND DEHYDRATION
The terms volume depletion (hypovolemia) and dehydration often are used interchangeably. However, these terms differentiate physiologic conditions resulting from different types of fluid loss. Much of the clinical literature does not differentiate between the two terms and uses them interchangeably. Thus, we will follow this convention and use the terms hypovolemia, volume depletion, and dehydration interchangeably as referring to all types of fluid deficits. (See "General principles of disorders of water balance (hyponatremia and hypernatremia) and sodium balance (hypovolemia and edema)".)
Although oral rehydration therapy (ORT) was first introduced in 1945, its use declined because of reports of multiple cases of hypernatremia due to the use of oral rehydration solution (ORS) with inappropriately high carbohydrate levels . However, the success of intravenous hydration in decreasing mortality and morbidity in children with diarrhea in developing countries led to renewed efforts in the 1960s to develop an effective ORT that would be less expensive and easier to administer [2,3]. Subsequently, improvements in ORS formulations have led to ORT’s successful use in treating hypovolemia caused by gastroenteritis [4-6]. (See 'Efficacy' below.)
- Santosham M, Keenan EM, Tulloch J, et al. Oral rehydration therapy for diarrhea: an example of reverse transfer of technology. Pediatrics 1997; 100:E10.
- Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ 2000; 78:1246.
- Mahalanabis D, Choudhuri AB, Bagchi NG, et al. Oral fluid therapy of cholera among Bangladesh refugees. Johns Hopkins Med J 1973; 132:197.
- Duggan C, Lasche J, McCarty M, et al. Oral rehydration solution for acute diarrhea prevents subsequent unscheduled follow-up visits. Pediatrics 1999; 104:e29.
- 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.
- Listernick R, Zieserl E, Davis AT. Outpatient oral rehydration in the United States. Am J Dis Child 1986; 140:211.
- 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.
- 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.
- 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).
- 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.
- 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.
- 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.
- 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.
- Gregorio GV, Gonzales ML, Dans LF, Martinez EG. Polymer-based oral rehydration solution for treating acute watery diarrhoea. Cochrane Database Syst Rev 2009; :CD006519.
- Duggan C, Fontaine O, Pierce NF, et al. Scientific rationale for a change in the composition of oral rehydration solution. JAMA 2004; 291:2628.
- 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.
- 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.
- 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.
- 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.
- Vesikari T, Isolauri E, Baer M. A comparative trial of rapid oral and intravenous rehydration in acute diarrhoea. Acta Paediatr Scand 1987; 76:300.
- 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.
- 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.
- Spandorfer PR, Alessandrini EA, Joffe MD, et al. Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial. Pediatrics 2005; 115:295.
- Freedman SB, Ali S, Oleszczuk M, et al. Treatment of acute gastroenteritis in children: an overview of systematic reviews of interventions commonly used in developed countries. Evid Based Child Health 2013; 8:1123.
- 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.
- Stanton BF, Rowland MG, Clemens JD. Oral rehydration solution--too little or too much? Lancet 1987; 1:33.
- 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.
- 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.
- Guarino A, Ashkenazi S, Gendrel D, et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014. J Pediatr Gastroenterol Nutr 2014; 59:132.
- Mackenzie A, Barnes G. Randomised controlled trial comparing oral and intravenous rehydration therapy in children with diarrhoea. BMJ 1991; 303:393.
- Gremse DA. Effectiveness of nasogastric rehydration in hospitalized children with acute diarrhea. J Pediatr Gastroenterol Nutr 1995; 21:145.
- Nager AL, Wang VJ. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Pediatrics 2002; 109:566.
- Fayad IM, Hirschhorn N, Abu-Zikry M, Kamel M. Hypernatraemia surveillance during a national diarrhoeal diseases control project in Egypt. Lancet 1992; 339:389.
- Nalin DR, Hirschhorn N, Greenough W 3rd, et al. Clinical concerns about reduced-osmolarity oral rehydration solution. JAMA 2004; 291:2632.
- 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.
- Freedman SB, Adler M, Seshadri R, Powell EC. Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med 2006; 354:1698.
- 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.
- 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.
- Ozuah PO, Avner JR, Stein RE. Oral rehydration, emergency physicians, and practice parameters: a national survey. Pediatrics 2002; 109:259.
- 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.
- Snyder JD. Use and misuse of oral therapy for diarrhea: comparison of US practices with American Academy of Pediatrics recommendations. Pediatrics 1991; 87:28.
- Reis EC, Goepp JG, Katz S, Santosham M. Barriers to use of oral rehydration therapy. Pediatrics 1994; 93:708.
- Meyers A, Siegel B, Vinci R. Economic barriers to the use of oral rehydration therapy. A case report. JAMA 1991; 265:1724.
- 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.
- 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.
- Suh JS, Hahn WH, Cho BS. Recent Advances of Oral Rehydration Therapy (ORT). Electrolyte Blood Press 2010; 8:82.
- Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework. BMJ Open 2012; 2.
- Freedman SB, Hall M, Shah SS, et al. Impact of increasing ondansetron use on clinical outcomes in children with gastroenteritis. JAMA Pediatr 2014; 168:321.
- 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.
- Levine DA. Antiemetics for acute gastroenteritis in children. Curr Opin Pediatr 2009; 21:294.
- Ramsook C, Sahagun-Carreon I, Kozinetz CA, Moro-Sutherland D. A randomized clinical trial comparing oral ondansetron with placebo in children with vomiting from acute gastroenteritis. Ann Emerg Med 2002; 39:397.
- Yilmaz HL, Yildizdas RD, Sertdemir Y. Clinical trial: oral ondansetron for reducing vomiting secondary to acute gastroenteritis in children--a double-blind randomized study. Aliment Pharmacol Ther 2010; 31:82.
- Freedman SB, Uleryk E, Rumantir M, Finkelstein Y. Ondansetron and the risk of cardiac arrhythmias: a systematic review and postmarketing analysis. Ann Emerg Med 2014; 64:19.
- Gener B, Burns JM, Griffin S, Boyer EW. Administration of ondansetron is associated with lethal outcome. Pediatrics 2010; 125:e1514.
- http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm272041.htm (Accessed on September 20, 2011).
- Kita F, Hinotsu S, Yorifuji T, et al. Domperidone With ORT in the Treatment of Pediatric Acute Gastroenteritis in Japan: A Multicenter, Randomized Controlled Trial. Asia Pac J Public Health 2015; 27:NP174.
- 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.
- Freedman SB, Fuchs S. Antiemetic therapy in pediatric emergency departments. Pediatr Emerg Care 2004; 20:625.
- Starke PR, Weaver J, Chowdhury BA. Boxed warning added to promethazine labeling for pediatric use. N Engl J Med 2005; 352:2653.
- Uhlig U, Pfeil N, Gelbrich G, et al. Dimenhydrinate in children with infectious gastroenteritis: a prospective, RCT. Pediatrics 2009; 124:e622.
- Gouin S, Vo TT, Roy M, et al. Oral dimenhydrinate versus placebo in children with gastroenteritis: a randomized controlled trial. Pediatrics 2012; 129:1050.
- Freedman SB, Sivabalasundaram V, Bohn V, et al. The treatment of pediatric gastroenteritis: a comparative analysis of pediatric emergency physicians' practice patterns. Acad Emerg Med 2011; 18:38.
- DEFINITIONS OF HYPOVOLEMIA AND DEHYDRATION
- Physiologic basis
- - Water absorption
- ORS properties
- - Osmolality
- - Carrier organic solute
- CLINICAL MANAGEMENT
- ORT based on degree of dehydration
- - No dehydration
- - Mild to moderate dehydration
- - Severe dehydration
- - Discharge from medical setting and return to home management
- Commercial and standard ORS
- - Zinc
- - Ondansetron
- Adverse effects
- - Other antiemetic agents
- Barriers for use in developed countries
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS