Diarrhoea and vomiting caused by gastroenteritis in children under 5 years: summary of NICE guidanceBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1350 (Published 22 April 2009) Cite this as: BMJ 2009;338:b1350
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The recently published NICE guideline for the management of gastroenteritis identifies three distinct clinical groups of children:
i. those that are not clinically dehydrated,
ii. those that are dehydrated and
iii. those that are clinically shocked (1),(2).
Reviewing the fluid strategies for each of these three groups (summarised below), it is clear that calculating the fluid volumes required to rehydrate the dehydrated child is the most complex and as a result, these calculations may prove less accessible in routine clinical practice. This process can however be greatly simplified by the application of a simple, clinical observation described below for the management of the dehydrated child…
i. For those children that are not clinically dehydrated, NICE actively encourage oral drinks.
ii. For clinically dehydrated children, additional fluids are required to not just maintain their normal body water but also to replace their fluid losses. NICE recommend giving 50 ml/kg of oral rehydration salt solutions (ORS) over 4 hours to replace their fluid losses plus an additional volume of ORS to provide the maintenance fluids required by that child during that 4-hour period of time. In making these calculations, the clinician requires not only a knowledge of the child’s weight but also an appreciation of the formulas used in paediatric practice to calculate a child’s daily maintenance fluid requirements. Performing these calculations is a complex process although this can be greatly simplified by the application of some lateral thinking. If average UK child weights (derived from paediatric growth chart data (3)) were to be used in calculating NICE’s fluid recommendations instead of the child’s true weight, these mathematical calculations can be translated into some simple, practical clinical rules for use by clinicians and carers in their daily practice.
Over the first 4-hour period, estimations reveal that:
· a 1-year old child requires approximately 30mls every 10 minutes,
· a 3-year old child requires approximately 40mls every 10 minutes,
· a 5-year old child requires approximately 50mls every 10 minutes.
These figures (combining both replacement fluid and maintenance fluid calculations in a single figure) could be used to give parents specific, practical rehydration advice, with the aim of encouraging successful oral rehydration and decreasing paediatric inpatient admissions. (Appendix 1 details worked calculations).
[These clinical rules cannot be applied across all geographic regions without ensuring that your population has bodily proportions comparable to UK children and excluding other factors, such as malnutrition].
iii. Clinically shocked children require rapid intravenous fluid resuscitation (20ml/kg of 0.9% Sodium Chloride) and urgent hospital transfer.
In summary, NICE’s guidelines for the dehydrated child can easily be followed by offering these specified volumes of fluid every 10 minutes during the first 4-hour period, without the need to resort to complex calculations. Managing children that are either not dehydrated or clinically shocked is (mathematically!) less complex.
Author: Dr Julian M Sandell, MB BS, MRCPI, FRCPCH, FCEM.
Affiliations: Consultant in Paediatric Emergency Medicine, Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, Dorset, BH15 2JB.
1) Practice. Guidelines: Diarrhoea and vomiting caused by gastroenteritis in children under 5 years: summary of NICE guidance. Murphy MS. BMJ 2009; 338: b1350.
2) Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years. NICE Clinical Guideline 84. April 2009. http://www.nice.org.uk/CG84
3) Can age-based estimates of weight be safely used when resuscitating children?" JM Sandell, SC Charman. EMJ. 2009; 26: 43 – 47.
Competing interests: No competing interests
The recently published NICE guideline for the management of gastroenteritis in children aged under 5-years (1) identifies three distinct clinical groups of children:
i) those that are not clinically dehydrated, ii) those that are dehydrated, and iii) those that are clinically shocked, describing their treatments accordingly.
NICE give clear recommendations for the group of children that are not clinically dehydrated, actively encouraging them to drink orally.
They also give clear advice for the group of children that are clinically shocked, recommending rapid intravenous fluid resuscitation (20ml/kg of 0.9% Sodium Chloride) and urgent hospital transfer.
The management of the clinically dehydrated child does on initial appearance, look significantly more complex but, after further consideration, can be very much simplified. This group of children require additional fluids to not just maintain their normal body water but also to replace their fluid losses. NICE recommend giving 50 ml/kg of oral rehydration salt solutions (ORS) over 4 hours to replace their fluid losses plus an additional volume of ORS to provide the maintenance fluids required by that child for that 4-hour period of time. These calculations require not only a knowledge of the child’s weight but also an appreciation of the formulas used in paediatric practice to calculate a child’s daily maintenance fluid requirements and so, as a result of their complexity, are not readily accessible to parents or clinicians. If NICE’s recommendations were applied to average UK child weights (derived from paediatric growth chart data (2), these mathematical recommendations can be translated into some practical clinical rules for the dehydrated child.
Simple observation reveals that over a 4-hour period:
• a 1-year old child requires approximately 30mls every 10 minutes,
• a 3-year old child requires approximately 40mls every 10 minutes,
• a 5-year old child requires approximately 50mls every 10 minutes.
These figures (combining both maintenance fluid and replacement fluid calculations in a single figure) could be used to give parents specific, practical rehydration advice, they could well encourage successful oral rehydration and as a result avoid some paediatric inpatient admissions. (see Appendix 1). It should be noted that attempts to apply these clinical rules in other geographic locations are best avoided since the bodily proportions of UK children cannot be applied globally.
Dr Julian M Sandell, MB BS, MRCPI, FRCPCH, FCEM.
Consultant in Paediatric Emergency Medicine, Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, Dorset, BH15 2JB.
(1) Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years. NICE Clinical Guideline 84. April 2009. http://www.nice.org.uk/CG84
(2) Can age-based estimates of weight be safely used when resuscitating children?" JM Sandell, SC Charman. EMJ. 2009; 26: 43 – 47.
Appendix 1: A Guide to Estimate Fluid Requirements in Diarrhoea and Vomiting caused by Gastroenteritis
(Derived from: NICE Clinical Guideline 84. Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years). www.nice.org.uk/CG84
Age UK Average Fluid requirements i.e.Child needs Weight(kg)* in first 4hrs (mls) ....... (mls) every 10 min for next 4hrs Newborn 3.5 233 10mls 3 months 6.0 400 17mls 6 months 7.8 520 22mls 9 months 8.9 593 25mls 12 months 9.8 653 27mls 18 months 11.1 731 30mls 2 years 12.2 795 33mls 3 years 14.4 923 38mls 4 years 16.4 1040 43mls 5 years 18.5 1163 48mls
NICE recommend giving 50 ml/kg of ORS over 4 hours to replace the fluid deficit plus an additional volume of ORS to provide the maintenance fluids required for that 4-hour period of time. The right-hand column performs this calculation, detailing the volume of fluid required every 10 minutes for the first 4-hours of ORS replacement for UK Children of average weight (according to growth chart estimated weight). For smaller or larger children, it is advised to match the fluid volume to that closest to the child’s true weight (Left-hand column).
* Average weight values are estimates and should only be used as a guide. It is the attending physicians’ responsibility to ensure that these approximations are applicable to each patient they treat on their own individual merits.
Competing interests: Age UK Average Fluid requirements i.e.Child needs Weight(kg)* in first 4hrs (mls) ....... (mls) every 10 min for next 4hrsNewborn 3.5 233 10mls3 months 6.0 400 17mls6 months 7.8 520 22mls9 months 8.9 593 25mls12 months 9.8 653 27mls18 months 11.1 731 30mls2 years 12.2 795 33mls3 years 14.4 923 38mls4 years 16.4 1040 43mls5 years 18.5 1163 48mls
Treatment of diarrhoea should rest on understanding of the underlying
pathophysiology: evidence-based medicine is essential to confirm the
validity of such an approach, not to replace it, especially when the
available evidence is fallible. O’Shaugnessy[1,2], who pioneered the use of
rationally based oral and parenteral fluid therapy for acute diarrhoea in
1832 appreciated the importance of treating what we now call acidosis; the
new Clinical Guideline on the treatment of diarrhoea commissioned by NICE
[RCOG Press, April 2009] seems not to and that is not its only defect.
The fundamental nature of diarrhoea
The Guideline includes several clinical definitions of diarrhoea. An
additional pathophysiological definition would illuminate the rationale
for oral rehydration therapy [ORT]: diarrhoea is fundamentally a failure
of enteric salt and water uptake sufficient to overwhelm the compensatory
capacity of the colon . A well formulated oral rehydration solution
[ORS], has an appropriate sodium:glucose ratio for intestinal cotransport,
promoting intestinal sodium and water uptake, so attacking the underlying
problem; it is not simply symptomatic treatment.
With mild dehydration, restoration of extracellular fluid [ECF] volume,
through improved renal perfusion, may correct acidosis without provision
of bicarbonate precursor. In severe diarrhoea, bicarbonate precursor is
important in both oral and parenteral therapy- as already noted by
O’Shaugnessy by 1832. Indeed, the lethal potential of acidosis was
expounded 90 years ago by the American humorist H. L. Mencken ‘Life is a
struggle, not against sin, not against money power, but against hydrogen
ions…The dying man doesn’t struggle much and he isn’t much afraid. As his
alkalies give out he succumbs to a blest stupidity. His mind fogs. His
will power vanishes. He submits decently. He scarcely gives a damn.’ 
Neglecting acidosis in discussing the treatment of severe diarrhoea,
however, is unblest stupidity; the Guideline scarcely gives a damn; it
advocates saline for ECF volume replacement. Saline is appropriate
treatment for metabolic alkalosis; it can not also be correct for
acidosis. What evidence establishes that rapid i/v rehdyration with
saline, 40 ml/kg is appropriate even with shock [p72] ? With both severe
diarrhoea and shock, metabolic alkalosis is improbable: acidosis, with its
associated hyperkalaemia, is potentially dangerous. The suggested dose,
equivalent to 200ml of bicarbonate-free fluid per litre of ECF, would
dilute plasma bicarbonate eg from 12 mmol/l to 10 mmol/l, increasing base
deficit by 17%. Suggesting even 50-100 mmol/l could increase base deficit
by 50%. Although Table 5.4 [p68] includes 4 studies utilising lactated
Ringers, their efficacy in correcting acidosis is not discussed.
Sodium in ORSs
The sodium concentration of an ORS reflects the optimum for enteric
uptake, not faecal sodium loss or ‘normal’ intake. Clinical anxiety about
hypernatraemia rests substantially on the misapprehension that it is
caused by excess sodium intake: actually it reflects predominant water
loss or inadequate water intake. Every litre of ECF deficit inescapably
requires 140 mmol of sodium to correct it: the less per litre of ORS, the
more ORS will be needed unless, improbably, reduced sodium is outweighed
by enhanced absorbtion. The Guideline, commendably, acknowledges the
excessive preoccupation with hypernatraemia [p71]. Indeed, although the
differences are not statistically significant, the failure rate [need for
supplementation with i/v fluids] for low Na ORS [45mmol/l] was double that
with high Na [90 mmol/l] ORS [p62]. Nevertheless the verdict favours low
Na ORSs, essentially influenced by a Cochrane Review by Hahn et al [cited
as 2007, but analysed in detail by Michell in 2005;the essential data
remain unchanged, May 2009]. Of 13 studies providing this key evidence,
which has directed paediatric ORT towards hypotonic solutions, 9 aroused
A glutamine-containing ORS has been used to treat neonatal diarrhoea in
calves for over 10 years, because it supports recovery of villus
architecture, whereas a conventional glutamine-free WHO-type ORS was
associated with deterioration of villus architecture[5-7].If children
responded similarly, glutamine would seem particularly important,
especially if they are already malnourished, before their diarrhoea.
Carneiro-Filhoe et al refer to its ‘great potential in oral rehydration
for diarrhoea’ and a BMJ article in 2005 advocated research on this
solution for paediatric use. The Guideline has several recommendations
for research, but no mention of glutamine.
Issues for research
From what has already been said, these should include
• Would diarrhoeic children, especially those who are malnourished,
benefit from a glutamine-containing ORS ?
• Is saline, as opposed to lactated Ringers solution, appropriate i/v
therapy in the face of metabolic acidosis; if so, how severe can the
dehydration and the acidosis be for replacement of ECF volume with
solutions lacking a bicarbonate precursor to be effective in correcting
the acidosis ?
• Stool output is a notoriously fallible guide to the efficacy of
rehdration1 yet it is widely used as a criterion in judging ORSs; should
such papers be excluded from systematic reviews ?
Meta-analysis of fallible criteria
Meta-analysis of unreliable data can not create reliable conclusions. The
feasible measurements in paediatric cases of severe diarrhoea, especially
in epidemics in isolated communities, are very restricted. The fallibility
of clinical criteria in assessing severity of dehydration and success of
rehydration are well known and reaffirmed in the Guidance [17, 42-48].
Even loss of bodyweight has pitfalls as an index of severity of
dehydration. Death can occur with relatively little loss of weight if
there is a huge accumulation of fluid within the gut, causing lethal
hypovolaemia before the output of fluid faeces can increase.
In contrast, ORT in calves rests on a line of research which defined
the therapeutic targets which demarcate likely death from likely
survival10, and then evaluated the beneficial effects of ORSs of different
composition on plasma and ECF volume, plasma Na, K and pH, GFR, PCV (not
just an index of hypovolaemia; in shock a raised PCV reminds us that blood
viscosity rises exponentially with PCV, further impeding tissue perfusion)
and villus architecture. It also corroborated the fallibility of stool
output as a guide to effective rehydration. This is not surprising; if
most of the ORS restores ECF volume, loss of the remainder as increased
faecal output is inefficient but clinically unimportant. Moreover faecal
output becomes normal before the small intestine, because of the
compensatory capacity of the colon. Calves are not children, but unlike
adult cattle, they are non-herbivorous, non-ruminant, functionally simple
stomached; prima facie they offer a valid model for the evaluation of ORT
in acute diarrhoea. Effectiveness of ORSs in improving plasma
electrolytes, pH, plasma volume and GFR in diarrhoeic calves reflected
adequate content of Na and bicarbonate precursor; improvement of pH and
GFR were also potentiated by glutamine.
This debate is not simply academic: for millions of children
throughout the world it is a matter of life and death. Ten thousand die of
this eminently treatable disease daily, mostly in poor countries: the
media are missing the real medical headlines. The burden of proof is not
whether calves are like children; since more reliable data are obtainable
from calves the burden of proof is to establish, with due precautions,
whether similar principles could save children’s’ lives.
A.R. Michell, Dept Biochemical Pharmacology, Harvey Institute, Barts
& the London School of Medicine & Dentistry, London EC1M 6BQ.
1 O’Shaugnessy. WB Lancet 1831; 1: 490.
2 O’Shaugnessy. WB Report on the chemical pathology of malignant cholera.
London: S.Wiley, 1832
3 Michell AR. The clinical biology of sodium Oxford, Elsevier. Chapter 3.
4 Michell AR. Why has oral rehydration for calves and children diverged:
direct vs indirect criteria of efficacy. Research in Veterinary Science
5 Brooks HW, Hall, GA, Wagstaff AJ, MichellAR. Detrimental effects on
villus form and function during conventional oral rehydration for
diarrhoea in calves: . alleviation by a nutrient
oral rehydration solution containing glutamine. Veterinary Journal 1998; 155: 263-274.
6 Michell AR. Oral rehydration for diarrhoea: symptomatic treatment or
fundamental therapy Journal of Comparative Pathology 1998; 118: 175-193.
7 Michell AR. How may advances in oral rehydration therapy for animals
benefit children ? Pharmaceutical Journal 2004; 272: 580-581.
8 Carneiro-Filho BA, Bushen OY, Brito GA, Lima AA, Guerrant RL. Glutamine
analogues as adjunctive therapy for infectious diarrhoea. Current
Infectious Disease Reports 2003; 5: 114-119
9 Michell AR. Why shouldn’t children benefit from oral rehydration
solutions for calves ? British Medical Journal 2005; 331: 1267
10 Groutides CP, Michell AR. Changes in plasma composition in calves
surviving or dying from diarrhoea. British Veterinary Journal 1990; 146:
Consultant on oral rehydration to veterinary pharmaceutical companies
Competing interests: No competing interests
In response to the EDITOR, Khanna R et al regarding the use of
antiemetics in AG, I would like to say that I agree with the author as we
need more studies to find out about the effects and importance of using
antiemetics in AG.As weather is getting warmer and we will expect more
cases of AG,the use of antiemetic is going to be more needed. Working in
paediatrics and general Practice, I gained the experience that antiemetics
like Ondansetron is quite useful and may significantly reduce the
admission and prevention of dehydration.
Competing interests: No competing interests
Thank you very much for your comment. Practice varies a lot from
country to country. I was trained in India and use of antiemetic was very
common and in 1982 I came to UK and not used antiemetic in any patients.
In 1989 I took my son to India on a holiday and he was sick for 2 days with
Gastro-enteritis and was dehydrated. Indian Paediatrician gave him one
dose of anti-emetic and he settled very well. May be just a co-incidence.
However, here since 1982 I have not used anti-emetic in any child and
all children have settled after a couple of days. Does anti-emetic
shorten the vomiting, do parents find it useful, does it help children to
recover quickly, is it cost effective and will we make more children ill
by anti-emetics? These are the questions we have probably got to consider.
However, I am not convinced that anti-emetic has a huge role and all
children with Gastro-enteritis will settle provided we keep a watch on
Competing interests: No competing interests
EDITOR, Khanna R et al. reported the NICE current practice
recommendations to treat paediatric acute gastroenteritis (AG) without
including pharmacological treatment for vomiting (1). However, vomiting
from AG is distressing for patients and their families. In addition,
vomiting is not only a direct cause of fluid loss but can also hamper
successful oral rehydration therapy (ORT) and it is a major factor of ORT
failure. Many physicians believe that vomiting is a contraindication to
ORT. Paediatricians providing care in the emergency department,
consistently favour intravenous fluid therapy (IVT) for mild or moderate
dehydration when vomiting is the major symptom (2). Thus, effective
treatment for vomiting would lead to an important reduction in IVT use.
In clinical practice, antiemetic drugs are frequently used in
children with AG. A recent retrospective survey retrieved data from 4
national and international databases and showed that prescription of
antiemetic medications varied considerably (3). In particular, between 2%
and 23% of children with AG received prescriptions for antiemetic
medications. Antihistamines were most frequently used in Germany and
Canada, whereas promethazine was preferentially prescribed in United
States. In France, Spain and Italy domperidone was the favourite
antiemetic treatment. Ondansetron was chosen in a minor proportion of
As demonstrated in recently published meta-analysis, the literature
evaluating the efficacy of symptomatic drugs in reducing acute vomiting
for AG in paediatric age is methodologically limited and focuses mainly on
ondansetron (4,5). The same evidence showed that an adequate evaluation of
anti-emetic drugs largely used in clinical practice, such as domperidone,
is completely missing. The Cochrane reviewers explicitly indicated that
further research is needed to assess the effectiveness and cost-
effectiveness of antiemetic drugs use (4).
In light of these considerations, further randomised controlled
trials aiming to compare the efficacy of ondansetron and other antiemetic
drugs, such as domperidone, for the symptomatic treatment of vomiting in
AG are needed. The study could answer to the following clinical questions:
a) would anti-emetic agents reduce the percentage of children who keeps
vomiting? b) would anti-emetic treatment favour the ORT and reduce the
need for nasogastric or IVT? c) would the treatment reduce the percentage
of children accessing health services and needing hospital admission?
We believe that the results of such a trial could significantly impact
current clinical practice.
Federico Marchetti, Anna Erenbourg, Luca Ronfani
Department of Pediatrics, Institute of Child Health, IRCCS Burlo
Garofolo, University of Trieste, via dell’Istria 65/1. 34100 Trieste,
Corresponding Author: Federico Marchetti, MD.
1. Khanna R, Lakhanpaul M, Burman-Roy S, Murphy MS; Guideline
Development Group and the technical team. Diarrhoea and vomiting caused by
gastroenteritis in children under 5 years: summary of NICE guidance. BMJ.
2009;338:b1350. doi: 10.1136/bmj.b1350.
2. Ozuah PO, Avner JR, Stein RE. Oral rehydration, emergency
physicians, and practice parameters: a national survey. Pediatrics
3. Pfeil N, Uhlig U, Kostev K, et al. Antiemetic medications in
children with presumed infectious gastroenteritis--pharmacoepidemiology in
Europe and Northern America. J Pediatr 2008;153(5):659-62.
4. Alhashimi D, Alhashimi H, Fedorowicz Z. Antiemetics for reducing
vomiting related to acute gastroenteritis in children and adolescents.
Cochrane Database Syst Rev 2009;(2):CD005506.
5. 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(9):858-865
Competing interests: No competing interests