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Diarrhoea and vomiting caused by gastroenteritis in children under 5 years: summary of NICE guidance

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1350 (Published 22 April 2009) Cite this as: BMJ 2009;338:b1350

Rapid Response:

A “NICE solution” to orally rehydrate dehydrated children under 5-years.

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.

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.

References:

(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:
None declared

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

05 May 2010
Julian M Sandell
Consultant in Paediatric Emergency Medicine
Department of Child Health, Poole Hospital NHS Foundation Trust, Poole, Dorset, BH15 2JB