This time of year brings so many fond memories to mind: jumping in piles of leaves (after someone else rakes them preferably), breaking out the wind-breaker jackets, going to football games, and carving pumpkins. All fun things!! Another memory that comes to mind, however, is dealing with the multitude of patients and their parents who are concerned about vomiting and diarrhea! That is really what makes Halloween scary!
1. Worldwide, diarrheal illnesses are the leading cause of death in children <5yrs
- Worldwide ~12% of all deaths in children <5years are due to diarrhea
- In the USA, ~1 in 500 children hospitalized with gastrointestinal illness with die of their illness
2. These deaths are almost entirely preventable, as death usually results from severe dehydration
- IV infusions certainly help rehydrate, but worldwide they are expensive and impractical
- Oral Rehydration Solution, which was developed in the ~1970’s, have proven to be useful in preventing and treating dehydration from diarrhea of any eitiology in patients of all ages.
- Remember that Glucose enhances the absorption of sodium and water in the bowel.
- This works even with diarrhea present.
- Currently, Oral Rehydration Therapy is recommended as the first line therapy for mild to moderate dehydration regardless of where you live.\
- While worldwide ORT is known to be the 1st line, in the US, IV therapy is still often the default method for rehydration – why?
3. IV fluids – Pros/Cons
- Pro: it is effective at reversing hypovolemia
- Pro: once the IV is in, fluids can be given “rapidly” (naturally, depending on the situation and the size of the catheter)
- Pro: Doesn’t require much education initially, so it is “easier” on staff and MD’s.
- Pro: It often coincides with parental expectations (what we’ve taught them to be the standard)
- CON: Most patients are not excited about IVs. Most parents are not excited about their child being held down.
- CON: Despite how effortlessly we order the IV, the placement of an IV is never effortless and often made significantly more difficult by the child’s dehydrated state.
- CON: Introduces potential complications like extravasation and thrombophlebitis
- CON: Generally, when we write for accompanying fluids for the IV, we write “NS 20ml/kg”… this will do nothing for the child’s hypoglycemia that is present due to their starvation.
- CON: Can’t be continued at home. So, after IV fluids, you still have to figure out how to keep them hydrated at home.
4. ORT – Pros/Cons
- Pro: No need to place an IV (most would see that as an advantage)
- Pro: Less expensive (cost containment should be ever-present in our minds now-a-days)
- Pro: Found to be associated with lower hospitalizations and shorter length of stays
- Pro: Can be taught and DONE AT HOME!
- Pro: Uses glucose containing fluids, so it gives an energy source in addition to treating hypovolemia.
- CON: Requires parental/caregiver education and buy-in (often undermined by other times when their child was “dehydrated” and got an IV)
- CON: Requires more parental/caregiver involvement (we American’s are generally lazy)
- CON: Can’t be used in the setting of an ileus
- CON: CANNOT rapidly rehydrate someone – not useful in Sever Dehydration (AKA compensated SHOCK).
5. A few additional Morsels to consider when assessing the child with vomiting/diarrea:
- How dehydrated are they?
- Dehydration is not defined by any lab value (yes, labs may be affected, but an elevated BUN or specific gravity does not define dehydration or correlate with severity).
- Your physical exam defines the level of dehydration
- Carefully assess skin turgor, capillary refill, and respiratory pattern as these can be most useful in detecting severe dehydration early and are often underappreciated.
- For Mild/Moderate dehydration, educate about advantages of ORT and start them on the path (very useful if everyone is on the same page – so a protocol is fantastic (see attached)).
- For severe dehydration
- Check a glucose stat. Replete as needed. Start an IV and give 20ml/kg rapidly (over 5 minutes)… and then reassess.
- If you think the kid “looks punky” or “puny” or “kinda green” but they don’t fit the severe dehydration classification… think GLUCOSE, and check a fingerstick.
- Children will use up their glycogen stores rapidly and if they are not repleting them, they can easily become hypoglycemic. (I like to say, “They are like little alcoholics!”)
- Don’t wait for the BMP to return to show you that their sugar is 30 and for you to realize that the last 60 minutes of IVF hasn’t done them any good.
- There is no such thing as “PO Challenge” when it comes to AGE in children [Bold statement I know]
- You should not try to demonstrate that child is safe to go home by the fact that he/she doesn’t vomit while in the ED, because, the child will either throw-up on your discharge papers or in the parking lot or once they get home… and then the family will be back to see you and will be positive that the condition now warrants an IV.
- Instead, teach that the vomiting and diarrhea will continue and that via ORT (which you have been teaching them) performed at home will be sufficient to maintain the child’s hydration throughout the illness.
- Give them appropriate anticipatory guidance regarding the need to monitor for urine output (at least one urination in ~8hrs) and signs of true lethargy – for which they should return to the ED.
- Fluids can be given via NasoGastric Tube also!
– Hartling L, Bellemare S, Wiebe N, Russell KF, Klassen TP, Craig WR. Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children (review). The Cochrane Collaboration. 2010 (Issue 1).
– Munos MK, Walker CLF, Black RE. The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality. Int. J. Epidemiolo (2010) 39 (suppl 1): i75-i87.
– Guarino A, 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 of Pediatr Gastroent and Nutrit. 2008; 46: S81-S122.
– Porter SC, et al. The value of parental report for diagnosis and management of dehydration in the emergency department. Annals of Emerg Med. 2003; 41(2): 196-205. – Steiner MJ, et al. Is This Child Dehydrated? JAMA, 2004; 291(22): 2746 – 2754
– Gorelick MH, et al. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics 1997; 99(5): 1-6.