Your activity: 2 p.v.

Oral rehydration therapy

Oral rehydration therapy
Author:
Stephen Freedman, MDCM, MSc
Section Editors:
Tej K Mattoo, MD, DCH, FRCP
Anne M Stack, MD
Deputy Editor:
Laurie Wilkie, MD, MS
Literature review current through: Dec 2022. | This topic last updated: Feb 18, 2022.

INTRODUCTION — Globally, diarrheal disease remains one of the leading causes of childhood mortality and morbidity. Loss of intestinal fluid caused by gastroenteritis may lead to severe hypovolemia, shock, and death, particularly in children younger than five years of age in areas of the world with limited resources. In developed countries, such as the United States, diarrhea caused by gastroenteritis remains a major cause of hospitalizations. (See "Approach to the child with acute diarrhea in resource-limited countries".)

Although the total number of deaths globally from diarrheal diseases from gastroenteritis remains high, the overall mortality rate has steadily declined over the last few decades. This decline, especially in developing countries, is largely due to the use of early and appropriate oral rehydration therapy (ORT), improved nutrition and water sanitation measures, and effective vaccination for rotavirus. (See "Approach to the child with acute diarrhea in resource-limited countries", section on 'Prevention'.)

The composition of oral rehydration solutions and the clinical application of ORT in patients with diarrhea due to gastroenteritis are discussed in this topic review. The assessment and treatment of hypovolemia, and prevention and treatment of viral gastroenteritis in children are discussed separately. (See "Clinical assessment and diagnosis of hypovolemia (dehydration) in children" and "Treatment of hypovolemia (dehydration) in children" and "Acute viral gastroenteritis in children in resource-rich countries: Management and prevention".)

DEFINITIONS OF HYPOVOLEMIA AND DEHYDRATION — The terms volume depletion (hypovolemia) and dehydration often are used interchangeably. However, these terms differentiate physiologic conditions resulting from different types of fluid loss. Much of the clinical literature does not differentiate between the two terms and uses them interchangeably. Thus, we will follow this convention and use the terms hypovolemia, volume depletion, and dehydration interchangeably as referring to all types of fluid deficits. (See "General principles of disorders of water balance (hyponatremia and hypernatremia) and sodium balance (hypovolemia and edema)".)

PHYSIOLOGIC BASIS

Normal mechanisms for water absorption — The following three principal mechanisms are responsible for passive intestinal water absorption (see "Pathogenesis of acute diarrhea in children", section on 'Molecular mechanisms'):

Sodium/hydrogen (Na/H) exchangers

Electrochemical gradient

Sodium-coupled transport with carrier organic solutes (eg, glucose)

Disruption of any of the above processes can result in diarrhea. However, in children with diarrhea due to gastroenteritis, the sodium-coupled co-transport with glucose and other carrier organic solutes remains intact [1,2].

ORS properties for water absorption — Successful oral rehydration solutions (ORSs) take advantage of the preserved co-transport of glucose and sodium in patients with acute infectious diarrhea for water absorption. Studies from the 1960s reported that isotonic ORS formulations with equimolar concentrations of glucose and sodium are as effective as IV hydration in treating hypovolemia in patients with cholera [1,2]. Subsequent formulations have been designed based on this initial formulation (table 1).

The following properties for ORS are recommended by the World Health Organization (WHO) [3]:

Total osmolality between 200 and 310 mOsm/L

Equimolar concentrations of glucose and sodium

Glucose concentration <20 g/L (111 mmol/L)

Sodium concentration between 60 and 90 mEq/L

Potassium concentration between 15 and 25 mEq/L

Citrate concentration between 8 and 12 mmol/L

Chloride concentration between 50 and 80 mEq/L

Fluids with a molar ratio of glucose in excess of sodium (eg, fruit juices, soda, or sports beverages) have the theoretical potential of increasing diarrheal losses because the higher unabsorbed glucose load will increase the osmolality in the lumen, resulting in decreased water absorption.

Fluids with excess sodium concentration compared with glucose (eg, chicken broth) may also increase diarrheal losses, as there is no organic solute to facilitate the transport of sodium. Fluids with high sodium concentration also may result in hypernatremia.

Osmolality — Several clinical trials and meta-analyses demonstrated that decreasing osmolality reduces stool volume and the duration of diarrhea [4,5]. Based upon these results, the WHO changed the formulation of ORS in 2002 from an osmolality of 311 mOsm/L to 245 mOsm/L, and concentrations of glucose from 20 g/L (111 mmol/L) to 13.5 g/L (75 mmol/L) and sodium from 90 to 75 mEq/L. The new formulation preserved the molar 1:1 ratio of sodium and glucose, and is the only ORS used globally by the WHO.

There were initial concerns that the reduced-osmolality ORS may result in hyponatremia for patients with cholera who often have diarrheal losses of sodium concentration of 90 to 120 mEq/L. However, a large observational study in Bangladesh reported that the incidence of symptomatic hyponatremia was rare in both children and adults in a study population where 20 percent of the patients were presumed to have cholera [6]. These findings demonstrated that reduced-osmolality ORS is safe and can be used to treat most patients with acute diarrhea.

Carrier organic solute — WHO ORS formulation uses glucose as the carrier organic solute for sodium-coupled transport (table 1). Although other alternative solutes have been studied (eg zinc, prebiotics, glucose polymers, L-isoleucine) with some promising results, there are not conclusive data that they are more effective than glucose. Consequently, we continue to recommend the use of the WHO formulation containing 75 mEq/L of sodium and 75 mmol/L of glucose with an osmolarity of 245 mOsm/L water.

Polymer-based formulations – Polymer-based ORS use rice, wheat, and sorghum as a source of starch rather than glucose. Starch is broken down slowly into glucose molecules by amylase in the small intestine. A systematic review showed that the polymer-based ORS is more effective than high osmolarity glucose-based ORS (≥310 mOsm/L) in reducing stool volume and duration of diarrhea for patients with acute watery diarrhea due to cholera or other causes [7]. However, data were insufficient to show that polymer-based ORS is superior to glucose-based ORS with lower osmolarity (≤270 mOsm/L water).

Until further data demonstrate that polymer-based ORS is significantly more beneficial than the standard ORS (osmolality 245 mOsm/L), we concur with the recommendation of the Centers of Disease Control and Prevention (CDC) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) not to recommend initial use of polymer-based ORS either in developing or developed countries [8]. These formulations have not been shown to be more effective than the standard WHO or commercial ORS, which are more readily available and less costly.

Other carrier solutes – Formulations that use maltodextrins or rice, or add amino acids (glycine, alanine, and glutamine) to glucose are not more effective than standard ORS, and are more costly [9-11]. These formulations should not be routinely used.

EFFICACY — Oral rehydration therapy (ORT) reduces childhood mortality from diarrheal disease [12-14]. This was best illustrated in a 2010 meta-analysis that included three low-quality studies showing diarrhea-specific mortality was lower in communities in which oral rehydration solution (ORS) was promoted compared with control communities without ORS promotion [14].

In addition, clinical trials and meta-analyses have shown that ORT is as effective as intravenous (IV) rehydration therapy in treating hypovolemia from diarrheal illness due to gastroenteritis [15-23]. ORT was also associated with a shorter length of hospitalization, lower costs, and fewer complications (eg, phlebitis).

CLINICAL MANAGEMENT — Oral rehydration therapy (ORT) is the preferred first-line treatment of fluid and electrolyte losses caused by diarrhea due to gastroenteritis in children with mild to moderate dehydration [15-23]. It is used to treat hypovolemia caused by gastroenteritis independent of age, causative agent, or initial sodium values [24]. Advantages of ORT compared with intravenous (IV) hydration include lower cost, easier to administer, less invasive intervention, treatment that can be done or continued at home, and a lower rate of revisits to the emergency department [25]. (See 'Efficacy' above.)

Setting — ORT can be given either at home or in a medically supervised setting.

Home – If care providers are properly instructed to recognize the appropriate clinical signs of dehydration, ORT can be given at home, leading to fewer outpatient and emergency department (ED) visits for hypovolemia [26]. A standard commercially prepared and premixed oral rehydration solution (ORS) is recommended for use in nonmedical settings because major errors can occur when homemade solutions using sugar and sodium are administered (table 1) [27]. Care providers need to recognize signs of illness or treatment failure requiring medical attention [28]. Assessment of the patient at home with gastroenteritis is discussed elsewhere.

Medically supervised setting – Prior to initiation of ORT, the child who presents to a medical clinician's office, the ED, or an urgent care facility with diarrhea should be evaluated to determine the underlying etiology of diarrhea and whether further diagnostic testing and/or intervention is necessary. (See "Diagnostic approach to diarrhea in children in resource-rich countries".)

If there is evidence that rehydration is appropriate, ORT using a standard commercial formulation should be initiated if the patient has mild to moderate hypovolemia and there are no contraindications to enteral therapy.

ORT based on degree of dehydration

Assessment of dehydration — Once the decision is made to begin hydration therapy, clinical assessment of the patient's hydration status is necessary, as it guides clinical decisions in the use of ORT. The goal of hydration assessment for patients with diarrhea is to determine the fluid management approach for individuals as follows:

Identify patients who are not dehydrated and can be safely sent home with ORT maintenance

Identify patients who are mildly to moderately dehydrated, in whom ORT is the preferred therapy for rehydration

Identify patients who are severely dehydrated and require IV rehydration

Traditionally, attempts have been made to differentiate between mild and moderate hypovolemia (table 2). However, it is often clinically difficult to distinguish between the two degrees of dehydration [29]. As a result, experts in the field, including the author, group these patients and use the same management approach, as the observed signs or symptoms overlap and encompass a relatively wide range of fluid deficits (ie, from 3 to 9 percent volume depletion). (See "Clinical assessment and diagnosis of hypovolemia (dehydration) in children", section on 'Degree of hypovolemia'.)

The following sections outline recommendations for ORT based on guidelines from the Centers of Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP), European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), and European Society for Paediatric Infectious Diseases (ESPID) [8,28]. These guidelines are based on data acquired from efficacy trials conducted in both developing and developed countries.

Treatment is divided into two phases:

Rehydration phase – The fluid deficit is replaced quickly over three to four hours, returning the patient to a euvolemic state. ORS is administered in frequent, small amounts of fluid by spoon or syringe. A nasogastric tube can be used in the child who refuses to drink [28,30-32]. Each aliquot given must be small enough to avoid accumulation of a large amount of fluid in the stomach that might trigger vomiting. Five mL (one teaspoon), administered every one to two minutes, allows as much as 150 to 300 mL/hour to be given. If the patient is breastfed, breastfeeding continues during this phase as well as during the maintenance phase.

Maintenance phase – Maintenance calories and fluids are administered. Rapid realimentation begins after completion of the rehydration phase, with the goal to return the patient to an age-appropriate unrestricted diet. (See "Maintenance intravenous fluid therapy in children".)

During both phases, ongoing losses from diarrhea and vomiting are replaced with ORS. If the losses can be measured accurately, 1 mL of ORS should be administered for each gram of diarrheal stool. Alternatively, 10 mL/kg of body weight of ORS should be administered for each watery or loose stool, and 2 mL/kg of body weight for each episode of emesis.

No dehydration — For patients with diarrhea but no evidence of dehydration, ORT is used to maintain hydration by replacement of stool losses, as outlined above. If the stool output is minimal, ORS may not be required. Regardless of stool output, age-appropriate feeding (including breastfeeding) should be continued along with supplemental fluids. (See 'Common household beverages and fluids' below.)

Mild to moderate dehydration — Several experts in the field use the same management approach for patients with mild and moderate dehydration (range of 3 to 9 percent volume loss). While some individuals with lesser degrees of dehydration can be cared for at home once proper oral rehydration techniques have been taught, the care of patients with greater degrees of dehydration is best provided in a medically supervised setting.

Repletion phase – Hydration should be restored by administering ORS at a volume of 50 to 100 mL/kg over four hours. Additional ORS is given to replace ongoing gastrointestinal losses (eg, stool or emesis). Reassessment of the patient's hydration status and replacement of ongoing losses should occur hourly.

Maintenance phase – Once repletion is completed, feeding and fluids should be started as discussed previously. ORT is continued for ongoing gastrointestinal losses. The patient's hydration status and ongoing stool and emesis losses should be calculated, with the total hourly loss added to the amount to be given over the next hour.

Severe dehydration — Severe dehydration is defined as 10 percent or greater volume loss.

Repletion phase – Severe dehydration is a medical emergency, and requires emergent IV therapy with rapid infusion of 20 mL/kg of an isotonic solution (eg, 0.9 percent NaCl, plasmalyte or lactated Ringer). A more complete discussion on treatment of severe dehydration can be found elsewhere in the program. (See "Treatment of hypovolemia (dehydration) in children", section on 'Emergent fluid repletion phase'.)

As the patient's clinical condition stabilizes and his/her level of consciousness returns to normal, therapy can be changed to ORT. A nasogastric tube can be used in patients who have a normal mental status but may be too weak to adequately drink the necessary volume of fluid. The IV line should remain in place until it is certain there is successful transition to ORT. ORS is started at a volume of 100 mL/kg over four hours or 25 mL/kg per hour. Additional ORS is given to replace ongoing gastrointestinal losses, as previously outlined. At the end of each hour, the patient's hydration status and continuing stool and emesis losses should be calculated, with the total hourly loss added to the amount to be given over the next hour.

Maintenance phase – Once repletion is completed, feeding and fluids should be started as discussed previously. ORT is continued for ongoing gastrointestinal losses [4-6,9-11,21,33-45].

Discharge from medical setting and return to home management — Patients can be discharged from a medical setting and returned to home ORT management when the following end-points are achieved [28]:

A reasonable amount of ORT for the degree of dehydration has been successfully administered. Sufficient intake is reflected by normalization of vital signs, improved level of consciousness and activity, urine output (if there has been none for a prolonged period of time), and resolution of signs of dehydration. In addition, there is no evidence of intractable vomiting or ORS refusal.

No concern for other possible illnesses that might complicate the clinical course.

No social or logistical concerns that might prevent return evaluation, if necessary.

Caregivers have been sufficiently educated regarding the use of ORT at home, and the criteria for return or need for further medical advice (eg, signs of dehydration).

Contraindications to ORT — There are clinical settings when ORT should not be used. These include in children with the following conditions:

Altered mental status with concern for aspiration

Abdominal ileus

Underlying disorder that limits intestinal absorption of ORT (eg, short gut, carbohydrate malabsorption)

Severe dehydration (see 'Severe dehydration' above)

Once ORT has been initiated, intervention with IV hydration is indicated:

If stool output continues to be excessive, and ORT is unable to adequately rehydrate the child

If there is severe and persistent vomiting, and inadequate intake of ORS

Commercial and standard ORS — Either the standard WHO or commercially available oral rehydration solutions (ORS) should be used for ORT. These solutions have equimolar concentration of glucose and sodium with osmolality between 200 and 310 mOsm/L; the precise composition varies slightly as summarized in the table (table 1). Based on the available data, differences in the composition of commercially available products and the 2002 WHO ORS do not appear to be clinically significant when administered to children with diarrhea in developed countries.  

All commercial ORS contain 2 to 3 percent carbohydrate as glucose, rice, or other cereal; this amount is sufficient to promote intestinal water absorption while avoiding a large osmotic load in the intestinal lumen. Studies in the United States demonstrated successful treatment with commonly used commercial ORS in children with mild to moderate dehydration [21,36]. In children between 5 and 10 years of age, sucralose-sweetened ORS solutions (eg, Pedialyte and Pediatric Electrolyte) appear to be more palatable than comparable rice-based solutions (eg, Enfalyte) [46]. (See 'ORS properties for water absorption' above.)

Other therapeutic measures

Common household beverages and fluids — Commonly used household fluids for children with gastroenteritis include gelatin, tea, fruit juice, sports drinks, and soft drinks. These fluids have much lower sodium concentration, and nearly all have a much higher carbohydrate and osmolality content than commercial and standard ORS (table 1). As a result, they have not been recommended as an alternative to commercial standard ORS for rehydration in children with gastroenteritis because of concerns that they could induce osmotic diarrhea resulting in hyponatremia. However, a Canadian clinical trial in children between 6 to 60 months of age with mild gastroenteritis and no clinical signs of dehydration demonstrated that half-strength apple juice (diluted 1:1 apple juice:water) compared with apple-flavored commercial standard ORS resulted in fewer episodes of treatment failure (17 versus 25 percent) [47]. In this single-center study, treatment failure was defined as any of the following events occurring within seven days of enrollment: IV rehydration, hospitalization, subsequent unscheduled physician encounter, protracted symptoms, crossover to the other fluid, and 3 percent or more weight loss or signs of significant dehydration based on an in-person follow-up visit. Following emergency department discharge, the group assigned to half-strength apple juice were allowed to consume whatever fluids the children desired to replace ongoing losses, and the ORS group continued with electrolyte maintenance solution. These results show that diluted apple juice followed by a permissive approach to fluids consumption can be used to maintain hydration in young children with mild gastroenteritis and minimal dehydration in high-income countries.

On the other hand, chicken soup with a high sodium concentration may result in hypernatremia, and should be avoided as a rehydration fluid source [28].

Zinc — Zinc supplementation should be administered in children with diarrhea in developing countries, in which there is a high prevalence of zinc deficiency [48,49]. Zinc supplementation in these settings is discussed in greater detail elsewhere in the program. (See "Approach to the child with acute diarrhea in resource-limited countries", section on 'Zinc'.)

Antiemetic therapy — In patients with clinically significant vomiting, the use of the antiemetic ondansetron has facilitated the administration of ORT by reducing vomiting [50]. (See "Acute viral gastroenteritis in children in resource-rich countries: Management and prevention", section on 'Antiemetic agents'.)

Barriers for use in developed countries — Despite its universal success in low and middle-income countries, ORT remains underutilized in the United States and other high-income countries. Barriers for utilization include:

Lack of compliance and knowledge by health care providers – Surveys conducted over the past two decades showed healthcare providers had insufficient knowledge regarding ORT and did not follow guidelines developed by the AAP or CDC on the appropriate use of ORT in patients with hypovolemia due to gastroenteritis [41-43]. In a 2011 survey, 44 of the 94 pediatric emergency clinicians from the United States (47 percent) reported using ORT as initial therapy in children with moderate dehydration compared with 103 of 136 Canadian clinicians (76 percent) [51]. This may reflect findings from an early report of American emergency clinicians who preferred IV hydration to ORT in treating moderate dehydration in children with gastroenteritis, even among those who indicated familiarity with the guidelines promoting ORT [40].

These results demonstrate the need for continued efforts to educate health care providers on the benefits of ORT over IV hydration.

Expense – The cost of commercially available ORS may limit its home use in low socioeconomic families [44]. As noted above, diluted apple juice and other fluids routinely consumed by children are reasonable options for children with mild gastroenteritis and no clinical symptoms of dehydration. (See 'Common household beverages and fluids' above.)

Public access to inaccurate information – There was one case report of a child whose care was compromised by following advice to use nonphysiologic fluids at a decreased rate from a hospital's Internet site [28,45].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Fluid and electrolyte disorders in children".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Giving your child over-the-counter medicines (The Basics)" and "Patient education: Dehydration in children (The Basics)")

Beyond the Basics topics (see "Patient education: Acute diarrhea in children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

We recommend oral rehydration therapy (ORT) as the initial treatment for most patients with mild to moderate hypovolemia due to gastroenteritis (table 2) (Grade 1A). ORT is as effective as intravenous (IV) hydration to treat hypovolemia in patients with gastroenteritis, but is less invasive and costly, and easier to administer. (See 'Efficacy' above and 'ORT based on degree of dehydration' above.)

We suggest that a standard commercially prepared oral rehydration solution (ORS) or one available from the World Health Organization (WHO), which has equimolar concentrations of glucose and sodium and an osmolality between 200 and 310 mOsm/L, be used for ORT in children with clinical signs of dehydration (table 1) (Grade 2B). However, for children with mild gastroenteritis and no clinical signs of dehydration, half-strength apple juice is a reasonable option for ORT. Homemade solutions that use sugar and sodium should not be used because of the risk of major errors. (See 'ORS properties for water absorption' above and 'Setting' above and 'Common household beverages and fluids' above.)

ORT is contraindicated in patients with impaired mental status at risk for aspiration, abdominal ileus or other conditions that preclude adequate fluid absorption from the intestinal tract, severe hypovolemia, or persistent vomiting. IV hydration should be administrated to patients with these conditions as well as to those who fail ORT. Specifically, in patients with severe dehydration, emergent IV therapy is required with rapid infusion of 20 mL/kg of isotonic saline. Once the patient is stable, ORT can be started. (See "Treatment of hypovolemia (dehydration) in children".)

We recommend the following approach for patients with gastroenteritis and mild, moderate, or no hypovolemia, which divides ORT into rehydration and maintenance phases (Grade 1B). In both phases, ongoing losses from diarrhea and vomiting are replaced with ORS. (See 'ORT based on degree of dehydration' above.)

Rehydration – In patients with mild or moderate hypovolemia, ORS is administrated in frequent small amounts, no more than 5 mL administered every one to two minutes by spoon or syringe, for a total volume of 50 to 100 mL/kg replaced quickly over three to four hours. If the patient is breastfed, breastfeeding is maintained during the rehydration phase and is continued into the maintenance phase.

Maintenance – During the maintenance phase, maintenance calories and fluids are administered to replace ongoing losses. Rapid realimentation begins after completion of the rehydration phase, with the goal to return the patient to an age-appropriate unrestricted diet.

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Bonita Stanton, MD, Joshua B Evans, MD, and Bobby Batra, MD, who contributed to an earlier version of this topic review.

  1. Hirschhorn N, Kinzie JL, Sachar DB, et al. Decrease in net stool output in cholera during intestinal perfusion with glucose-containing solutions. N Engl J Med 1968; 279:176.
  2. Pierce NF, Sack RB, Mitra RC, et al. Replacement of water and electrolyte losses in cholera by an oral glucose-electrolyte solution. Ann Intern Med 1969; 70:1173.
  3. World Health Organization. Reduced osmolarity oral rehydration salts (ORS) formulation. UNICEF House, New York, NY 2001. Available at: www.who.int/child-adolescent-health/New_Publications/NEWS/Expert_consultation.htm (Accessed on January 18, 2006).
  4. Hahn S, Kim Y, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration due to diarrhoea in children: systematic review. BMJ 2001; 323:81.
  5. Hahn S, Kim S, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. Cochrane Database Syst Rev 2002; :CD002847.
  6. Alam NH, Yunus M, Faruque AS, et al. Symptomatic hyponatremia during treatment of dehydrating diarrheal disease with reduced osmolarity oral rehydration solution. JAMA 2006; 296:567.
  7. Gregorio GV, Gonzales ML, Dans LF, Martinez EG. Polymer-based oral rehydration solution for treating acute watery diarrhoea. Cochrane Database Syst Rev 2016; 12:CD006519.
  8. Guarino A, Ashkenazi S, Gendrel D, et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014. J Pediatr Gastroenterol Nutr 2014; 59:132.
  9. Duggan C, Fontaine O, Pierce NF, et al. Scientific rationale for a change in the composition of oral rehydration solution. JAMA 2004; 291:2628.
  10. Bhan MK, Mahalanabis D, Fontaine O, Pierce NF. Clinical trials of improved oral rehydration salt formulations: a review. Bull World Health Organ 1994; 72:945.
  11. Nalin DR, Cash RA, Rahman M, Yunus M. Effect of glycine and glucose on sodium and water adsorption in patients with cholera. Gut 1970; 11:768.
  12. Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ 2000; 78:1246.
  13. Mahalanabis D, Choudhuri AB, Bagchi NG, et al. Oral fluid therapy of cholera among Bangladesh refugees. Johns Hopkins Med J 1973; 132:197.
  14. Munos MK, Walker CL, Black RE. The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality. Int J Epidemiol 2010; 39 Suppl 1:i75.
  15. Tamer AM, Friedman LB, Maxwell SR, et al. Oral rehydration of infants in a large urban U.S. medical center. J Pediatr 1985; 107:14.
  16. Listernick R, Zieserl E, Davis AT. Outpatient oral rehydration in the United States. Am J Dis Child 1986; 140:211.
  17. Santosham M, Daum RS, Dillman L, et al. Oral rehydration therapy of infantile diarrhea: a controlled study of well-nourished children hospitalized in the United States and Panama. N Engl J Med 1982; 306:1070.
  18. Vesikari T, Isolauri E, Baer M. A comparative trial of rapid oral and intravenous rehydration in acute diarrhoea. Acta Paediatr Scand 1987; 76:300.
  19. Atherly-John YC, Cunningham SJ, Crain EF. A randomized trial of oral vs intravenous rehydration in a pediatric emergency department. Arch Pediatr Adolesc Med 2002; 156:1240.
  20. Fonseca BK, Holdgate A, Craig JC. Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch Pediatr Adolesc Med 2004; 158:483.
  21. Spandorfer PR, Alessandrini EA, Joffe MD, et al. Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial. Pediatrics 2005; 115:295.
  22. Freedman SB, Ali S, Oleszczuk M, et al. Treatment of acute gastroenteritis in children: an overview of systematic reviews of interventions commonly used in developed countries. Evid Based Child Health 2013; 8:1123.
  23. Hartling L, Bellemare S, Wiebe N, et al. Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. Cochrane Database Syst Rev 2006; :CD004390.
  24. Stanton BF, Rowland MG, Clemens JD. Oral rehydration solution--too little or too much? Lancet 1987; 1:33.
  25. Freedman SB, Thull-Freedman JD, Rumantir M, et al. Emergency department revisits in children with gastroenteritis. J Pediatr Gastroenterol Nutr 2013; 57:612.
  26. Duggan C, Lasche J, McCarty M, et al. Oral rehydration solution for acute diarrhea prevents subsequent unscheduled follow-up visits. Pediatrics 1999; 104:e29.
  27. Meyers A, Sampson A, Saladino R, et al. Safety and effectiveness of homemade and reconstituted packet cereal-based oral rehydration solutions: a randomized clinical trial. Pediatrics 1997; 100:E3.
  28. King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 2003; 52:1.
  29. Freedman SB, Vandermeer B, Milne A, et al. Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis. J Pediatr 2015; 166:908.
  30. Mackenzie A, Barnes G. Randomised controlled trial comparing oral and intravenous rehydration therapy in children with diarrhoea. BMJ 1991; 303:393.
  31. Gremse DA. Effectiveness of nasogastric rehydration in hospitalized children with acute diarrhea. J Pediatr Gastroenterol Nutr 1995; 21:145.
  32. Nager AL, Wang VJ. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Pediatrics 2002; 109:566.
  33. Fayad IM, Hirschhorn N, Abu-Zikry M, Kamel M. Hypernatraemia surveillance during a national diarrhoeal diseases control project in Egypt. Lancet 1992; 339:389.
  34. Gore SM, Fontaine O, Pierce NF. Impact of rice based oral rehydration solution on stool output and duration of diarrhoea: meta-analysis of 13 clinical trials. BMJ 1992; 304:287.
  35. Nalin DR, Hirschhorn N, Greenough W 3rd, et al. Clinical concerns about reduced-osmolarity oral rehydration solution. JAMA 2004; 291:2632.
  36. Cohen MB, Mezoff AG, Laney DW Jr, et al. Use of a single solution for oral rehydration and maintenance therapy of infants with diarrhea and mild to moderate dehydration. Pediatrics 1995; 95:639.
  37. Freedman SB, Adler M, Seshadri R, Powell EC. Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med 2006; 354:1698.
  38. Roslund G, Hepps TS, McQuillen KK. The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial. Ann Emerg Med 2008; 52:22.
  39. 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; 162:858.
  40. Ozuah PO, Avner JR, Stein RE. Oral rehydration, emergency physicians, and practice parameters: a national survey. Pediatrics 2002; 109:259.
  41. Conners GP, Barker WH, Mushlin AI, Goepp JG. Oral versus intravenous: rehydration preferences of pediatric emergency medicine fellowship directors. Pediatr Emerg Care 2000; 16:335.
  42. Snyder JD. Use and misuse of oral therapy for diarrhea: comparison of US practices with American Academy of Pediatrics recommendations. Pediatrics 1991; 87:28.
  43. Reis EC, Goepp JG, Katz S, Santosham M. Barriers to use of oral rehydration therapy. Pediatrics 1994; 93:708.
  44. Meyers A, Siegel B, Vinci R. Economic barriers to the use of oral rehydration therapy. A case report. JAMA 1991; 265:1724.
  45. Crocco AG, Villasis-Keever M, Jadad AR. Two wrongs don't make a right: harm aggravated by inaccurate information on the Internet. Pediatrics 2002; 109:522.
  46. Freedman SB, Cho D, Boutis K, et al. Assessing the palatability of oral rehydration solutions in school-aged children: a randomized crossover trial. Arch Pediatr Adolesc Med 2010; 164:696.
  47. Freedman SB, Willan AR, Boutis K, Schuh S. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. JAMA 2016; 315:1966.
  48. Suh JS, Hahn WH, Cho BS. Recent Advances of Oral Rehydration Therapy (ORT). Electrolyte Blood Press 2010; 8:82.
  49. Tran CD, Hawkes J, Graham RD, et al. Zinc-fortified oral rehydration solution improved intestinal permeability and small intestinal mucosal recovery. Clin Pediatr (Phila) 2015; 54:676.
  50. Niño-Serna LF, Acosta-Reyes J, Veroniki AA, Florez ID. Antiemetics in Children With Acute Gastroenteritis: A Meta-analysis. Pediatrics 2020; 145.
  51. Freedman SB, Sivabalasundaram V, Bohn V, et al. The treatment of pediatric gastroenteritis: a comparative analysis of pediatric emergency physicians' practice patterns. Acad Emerg Med 2011; 18:38.
Topic 6129 Version 40.0

References