PEDIATRIC UPDATE

ORAL REHYDRATION OF THE PEDIATRIC PATIENT WITH MILD TO MODERATE DEHYDRATION

Author: Stephen Jablonski, BS, RN, CEN, CPEN, Somerville, NJ Section Editors: Joyce Foresman-Capuzzi, BSN, RN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P, Michelle Tracy, MA, RN, CEN, CPN, and Sue M. Cadwell, RN, MSN

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cute gastroenteritis is a very common illness in infants and children that accounts for more than 1.5 million outpatient visits, 200,000 hospitalizations, and approximately 300 deaths a year.1 A significant number of these children will be needlessly subjected to blood work and intravenous rehydration during the course of their treatment. This article will explain why oral rehydration for pediatric patients with mild to moderate dehydration is the preferred method of treatment and why the common use of intravenous (IV) therapy should be avoided.

exclude all other causes.2 Careful assessments of pediatric patients experiencing dehydration are of the utmost importance because misdiagnoses can have potentially lethal consequences.3
Oral Rehydration Therapy Versus IV Therapy

Mild to Moderate Dehydration

What is mild to moderate dehydration? A child with mild to moderate dehydration can lose an estimated 3% to 9% of body weight. The child can either appear normal mentally or appear tired or restless; he or she will be thirsty and want to drink and will have a normal to increased heart rate with normal to decreased pulses. Respirations may be normal to tachypneic. Tears will be present but decreased, and the tongue will appear dry. Capillary refill will be prolonged, the extremities will be cool, and urine output will be decreased1 (Table). The risk of dehydration varies with age. There are several risk factors for the development of dehydration, including age, frequency of stools and vomiting, and initial nutritional status.2 It is important to make the determination that the cause of the dehydration is actually caused by gastroenteritis and

Stephen Jablonski, Member, ENA Chapter 026, is Staff Nurse, Somerset Medical Center, Somerville, NJ. For correspondence, write: Stephen Jablonski BS, RN, CEN, CPEN, 7 Fieldstone Place, Flemington, NJ 08822; E-mail: stevejablonski@comcast.net. J Emerg Nurs 2012;38:185-7. Available online 13 January 2012. 0099-1767/$36.00 Copyright 2012 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2011.12.001

Many rehydration studies have been conducted over the years, and although many of these studies were conducted in third-world countries, the results show that oral rehydration therapy is as effective as IV therapy. Currently, oral rehydration therapy is the preferred treatment as recommended by the American Academy of Pediatrics and the World Health Organization.4 Oral rehydration therapy has many benefits. Some of these benefits include sparing a child from the painful process of obtaining IV access, but most importantly, parents can be taught how to provide this therapy at home. As Vollmerhaus and Wilson5 explain, When approaching rehydration in children, consider the number of IV attempts needed, the pain involved and the psychological impact of IV initiation versus oral rehydration. In one study it was found that treatment was started sooner, fewer patients were hospitalized, and in comparison with IV treatment, differences in outcomes were statistically insignificant. Despite the success of oral hydration therapy, many health care providers still rely on the IV method as their first recourse for rehydration. Many practitioners believe that the process of oral rehydration is too time consuming. They also believe that they have an obligation to meet the expectations of parents and referring physicians.4 Other practitioners argue that because the child needs to have blood work done anyway, IV fluid resuscitation should be initiated at the same time. However, because oral rehydration therapy is the preferred method for treatment, routine laboratory work is unnecessary.6 It is the nurses responsibility to educate both practitioners and parents about the effectiveness and safety of oral rehydration therapy. It also is important to point out that the use of oral rehydration has the potential to reduce ED visits and decrease health care costs.

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TABLE

Degrees of dehydration
Assessment Mild Moderate Severe

Heart rate Respiratory rate Blood pressure Capillary refill Mental status Skin turgor Mucous membranes Tears Eyes Urine output Fontanelle

Normal Normal Normal Normal Alert, restless Normal Slightly moist Present Normal Decreased Normal

Increased Increased Normal/Decreased 2-3 s Irritable Decreased Dry Decreased Darkened Oliguria Sunken

Weak, rapid Increased, labored Hypotensive >3 s Lethargic Tenting Dry None Sunken Anuria Concave

Procedure

Oral rehydration should be conducted using an oral replacement solution with a specific osmolarity. A standard solution with a very high osmolarity was adopted by the World Health Organization and UNICEF in 1975. However, in 2002 it was recommended that the osmolarity be reduced because of recent studies that showed no clinical significance in using a solution with a higher osmolarity.1 Currently these recommendations are 75 mEq/L sodium, 75 mmol/L glucose, and a total osmolarity of 245 mOsm/L. Currently many commercially available oral rehydration solutions are available to the public. Some children will resist drinking the electrolyte solution because of its salty taste. Taste should not be a roadblock or excuse not to provide oral rehydration; manufacturers of these solutions have added flavors and even make ice pops that may help make the treatment more palatable. It is important to educate parents not to use sports drinks because they include inappropriate proportions of electrolytes. In one study, a proper electrolyte balance was made by using a 4:1 electrolyte to juice ratio, which also may make the treatment more palatable.5 Mild dehydration is corrected by giving 50 mL/kg, as well as any continuing losses, during a 4-hour period. Moderate dehydration is corrected by giving 100 mL/kg, as well as replacing any continuing losses during a 4-hour period.7 Correcting moderate dehydration orally can be a challenging task and is certainly one of the main reasons practitioners shy away from this type of treatment. However, even children who have been vomiting can be treated this way. Because of the time involved, it is very important to enlist the help of the caregiver. To deliver 100 to 150 mL an hour, you should start with 5 mL every 1 to

2 minutes for the first 10 minutes. For the next 20 minutes you should administer 10 mL every 5 minutes, and then 20 mL every 10 to 15 minutes during the next 30 minutes. It is important to note that you should wait 15 to 30 minutes after the child vomits before starting the rehydration therapy.5 As soon as rehydration is completed, the child should be fed an ageappropriate diet.
Conclusion

Children commonly experience acute gastroenteritis, and treating them may even seem intimidating to some practitioners. Far too often these children are treated with the so-called tried and true method of IV therapy. Unfortunately, this method is both traumatic for the patient and costly for the institution. Oral rehydration therapy is, in fact, the real tried and true method of treatment for mild to moderate dehydration in children. It is the recommended treatment of the World Health Organization and the American Academy of Pediatrics and should be embraced by nurses as the standard of excellence in our practice.
REFERENCES
1. King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1-16. 2. Fitzpatrick P, Nicholson A. Effects of acute gastroenteritis. World Ir Nurs Midwif. 2010;18(10):45-7. 3. Larson CE. Evidence-based practice. Safety and efficacy of oral rehydration therapy for the treatment of diarrhea and gastroenteritis in pediatrics. Pediatr Nurs. 2000;26(2):177-9.

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4. Spandorfer PR, Alessandrini EA, Joffe MD, Localio R, Shaw KN. Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial. Pediatrics. 2005;115(2):295-301. 5. Vollmerhaus L, Wilson S. Pediatric oral rehydrationeverybodys business. NENA Outlook. 2005;28(1):19-21. 6. Burkhart DM. Management of acute gastroenteritis in children. Am Fam Physician. 1999;60(9):2555-63. 7. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Practice parameter: the management of acute gastroenteritis in young children. Pediatrics. 1996;97(3):424-35.

Submissions to this column are encouraged and may be sent to Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P joyceforesmancapuzzi@rcn.com or Michelle Tracy, RN, MA, CEN, CPN jmtracy2001@yahoo.com or Sue M. Cadwell, RN, MSN sue.cadwell@hcahealthcare.com

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