Fluid Therapy

The majority of the diarrhea-associated deaths result from dehydration. Parents should be encouraged to increase fluid intake as soon as diarrhea begins and to give oral rehydration solution if available. Children presenting with diarrhea should be assessed for dehydration. Thirst is an early sign of dehydration in a child. Other signs are mucosal dryness (e.g., dry mouth), sunken eyes, and loss of skin turgor. The coexistence of fever or vomiting exacerbates dehydration. The World Health Organization (WHO) guidelines classify dehydration into two categories—some dehydration and severe dehydration. Weight loss is the main clinical index of degree of dehydration. A vast majority of children with diarrhea present with some dehydration or no clinical signs of dehydration. The cornerstone of treatment for these children is oral rehydration solution (ORS) containing glucose or sucrose and electrolytes. ORS is effective but it must start as soon as diarrhea starts. In children with some dehydration, approximately 100 ml/kg of body weight of ORS should be given within 4h. Ongoing stool losses should be replaced with ORS. Rehydration and maintenance of hydration in a vomiting child is feasible using ORS by giving small amounts frequently. Severe dehydration is a medical emergency that requires immediate intravenous fluid replacement, and children should preferably be hospitalized. Patients presenting with severe dehydration should receive 40 ml/kg body weight of Ringers lactate or similar intravenous solutions over a 4-h period. ORS should be given as soon as the child is able to drink.

Regardless of etiology, watery diarrhea requires fluid and electrolyte replacement. For more than three decades, an ORS containing 90 mmol/l of sodium and 111 mmol/l of glucose was used throughout the world. This solution has been credited with saving millions of lives. WHO and UNICEF have recommended the use of a new reduced osmolarity ORS formulation consisting of 75 mmol/l of sodium and 75 mmol/l of glucose and total osmolarity of 245 mOSm/l. This recommendation was made on the basis of studies that have demonstrated that the reduced osmolarity ORS was at least as efficacious as the standard ORS containing 90 mmol/l of sodium and an osmolarity of 311/l. In addition, in a meta-analysis, the reduced osmo-larity ORS was shown to decrease the need for unscheduled intravenous therapy by 33%, the stool output was reduced by 20%, and the incidence of vomiting was reduced by 30%. However, there is concern that this low osmolar ORS may lead to asymptomatic and symptomatic hyponatremia in adults with severe diarrhea. This issue needs to be evaluated in large-scale effectiveness trials. Despite the proven efficacy of ORS, only approximately 20% of children receive appropriate ORS therapy during diarrheal episodes. The barriers to use of ORS include lack of knowledge of the importance of rehydration therapy, lack of access to ORS, and the perception that ORS is not a medicine since it does not stop the diarrhea.

The management of a child with persistent diarrhea is often difficult due to other related heath issues. These children are more likely to be severely undernourished due to micronutrient and protein-energy malnutrition as well as more prone to systematic infections. Due to the systematic infections, appropriate antibiotic therapy is needed.

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