A “NICE solution” to orally rehydrate the dehydrated child aged under 5-years.
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