ORAL REHYDRATION THERAPY

1. ORAL REHYDRATION THERAPY November 17, 2009 Cruz, Kristen Cruz, Riza Mae Cudal, Ivan Dancel Jonathan Dans, Kunny Daquilanea, Michee

3. WHAT IS DEHYDRATION? • Dehydration means that a child's body lacks enough fluid. • Dehydration can result from not drinking, vomiting, diarrhea, or any combination of these conditions. • Rarely, sweating too much or urinating too much can cause dehydration. • Infants and small children are much more likely to become dehydrated than older children or adults, because they can lose relatively more fluid quickly. emedicinehealth.com

4. CAUSES OF DEHYDRATION IN PEDIATRIC PATIENTS • Dehydration is most often caused by a viral infection that causes fever, diarrhea, vomiting, and a decreased ability to drink or eat. • Common viral infections causing include rotavirus, Norwalk virus, and adenovirus. • Sometimes sores in a child's mouth (caused by a virus) make it painful to eat or drink,. • More serious bacterial infections may make a child less likely to eat and may cause vomiting and diarrhea. • Common bacterial infections include Salmonella, Escherichia coli, Campylobacter, and Clostridium difficile.

5. CAUSES OF DEHYDRATION IN PEDIATRIC PATIENTS • Parasitic infections such as Giardia lambliia cause the condition known as giardiasis, which can lead to diarrhea and fluid loss. • Increased sweating from a very hot environment can cause dehydration. • Excessive urination caused by unrecognized or poorly treated diabetes mellitus (not taking insulin) or diabetes insipidus are other causes. • Conditions such as cystic fibrosis or celiac sprue do not allow food to be absorbed and can cause dehydration. Emedicinehealth.com

6. Pediatrician will look at to determine if your child is dehydrated include: • amount of weight loss • which usually correlates to how dehydrated a child • how often and how much they are urinating • the presence of tears, a moist mouth and tongue, and whether or not their eyes are sunken • capillary refill • briefly press on your child's nail bed so that it blanches or turns white, and see how long it takes to return to normal • skin fold recall or skin turgor test • gently pinch your child's skin on their abdomen, hold it for a few seconds and then let it go to see how long it takes to return to the normal position

10. Oral Rehydration Salts (ORS) • Non-proprietary name for a balanced glucose-electrolyte mixture • These solutions rely on the coupled transport of sodium and glucose in the intestine. • First used in 1969 and approved, recommended, and distributed by UNICEF and WHO as a drug for the treatment of clinical dehydration throughout the world. • In 1984, another mixture containing trisodium citrate instead of sodium hydrogen carbonate was developed with the aim of improving the stability of ORS in hot and humid climates. • For more than 20 years, WHO and UNICEF have recommended this single formulation of ORS to prevent or treat dehydration from diarrhoea irrespective of the cause or age group affected. • This product,which provides a solution containing 90 mEq/l of sodium with a total osmolarity of 311 mOsm/l, has proven effective and without apparent adverse effects in worldwide use.

11. Oral Rehydration Salts (ORS) • Vomiting may occur during the first 2 hr of administration of ORS, but it usually does not prevent successful oral rehydration if the ORS is given in small amounts at short intervals (1 tsp every 1–2 min). • Emesis usually lessens over time. • The volume of ORS can be increased slowly, with an increasing interval between feedings. • If sustained and severe vomiting occurs, intravenous therapy should be instituted. • The patient's progress should be assessed frequently and changes in body weight monitored, if possible, to determine the degree of rehydration.

12. WHO • There is a significant difference in the sodium concentration between the WHO solution and the commercially available solutions that are generally used in the USA. • Low-sodium solutions were advocated because hypernatremia was seen frequently in the USA when oral electrolyte solutions with sodium concentrations of 50 mEq/L or more were used to treat infantile diarrhea. • The WHO ORS has also been effective in treating acute diarrheal illnesses in well-nourished children in developed countries. • There is a risk of hypernatremia with the WHO ORS if it is used as a maintenance solution without supplemental water or formula. • Several commercially available electrolyte solutions for oral use have been reformulated with a sodium concentration of approximately 50 mEq/L. These solutions are effective in the treatment of mild to moderate dehydration. • Reduced-osmolality solutions (primarily reduced sodium and glucose) are associated with reduced stool output.

13. The pharmacokinetics and therapeutic values of the substances are as follows: • glucose facilitates the absorption of sodium (and hence water) on a 1:1 molar basis in the small intestine; • sodium and potassium are needed to replace the body losses of these essential ions during diarrhoea (and vomiting); • citrate corrects the acidosis that occurs as a result of diarrhoea and dehydration.

14. Studies to evaluate this approach were reviewed at a consultative technical meeting held in New York (USA) in July 2001 (4), and technical recommendations were made to WHO and UNICEF on the efficacy and safety of reduced osmolarity ORS in children with acute non-cholera diarrhoea, and in adults and children with cholera. • These studies showed that the efficacy of ORS solution for treatment of children with acute non-cholera diarrhoea is improved by reducing its sodium concentration to 75 mEq/l, its glucose concentration to 75 mmol/l, and its total osmolarity to 245 mOsm/l. The need for unscheduled supplemental IV therapy in children given this solution was reduced by 33%. • In a combined analysis of this study and studies with other reduced osmolarity ORS solutions (osmolarity 210-268 mOsm/l, sodium 50-75 mEq/l) stool output was also reduced by about 20% and the incidence of vomiting by about 30%. • The 245 mOsm/l solution also appeared to be as safe and at least as effective as standard ORS for use in children with cholera.

15. The reduced osmolarity ORS containing 75 mEq/l sodium, 75 mmol/l glucose (total osmolarity of 245 mOsm/l) is as effective as standard ORS in adults with cholera. • However, it is sometime associated with an increased incidence of transient, asymptomatic hyponatraemia. • Because of the improved effectiveness of reduced osmolarity ORS solution WHO and UNICEF now recommend that countries use and manufacture, for diarrhoea of all etiologies and in all age groups, the following formulation with a total osmolarity of 245 mOsmol/l, in place of the previously recommended ORS solution with a total osmolarity of 311 mOsm/l.

17. COMMERCIALLY AVAILABLE ORS

18. M.J. • 2 year old, female • 12 kg • 1 day of watery diarrhea, no fever • PE: closed, non-bulging fontanelles, eyeballs not sunken, good skin turgorNot thirsty CASE 1

19. A: NO DEHYDRATION • For a sick child who has no dehydration he is treated with Plan A. • Plan A involves counselling the child’s mother or caretaker about the 3 Rules of HOME TREATMENT. • These are: • 1) give extra fluids (as much as the child will take), • 2) continue feeding • 3) when to return (when the child is not able to drink or breastfeed, becomes sicker, develops a fever, has blood in the stool, and drinks poorly)

20. A: NO DEHYDRATION a)Tell the mother to breastfeed frequently and for longer at each feed. b)If the child is exclusively breastfed, it is important for this child to be breastfed more frequently than usual. • Also give ORS solution or clean water. • Breastfed children under 4 months should first be offered a breastfeed, then given ORS. c)If the child is not exclusively breastfed, give one or more of the following: • ORS solution, food-based fluids, clean water • In most cases a child who is not dehydrated does not really need ORS solution. Give him extra food-based fluids such as soups, rice water or ―am‖ and yoghurt drinks and clean water (preferably given along with food).

23. Case 2 • M.A. • 15 month old, male • 10 kg • 2 day hx: watery stools • Drinks eagerly, moist lips and buccal mucosa, no sunken eyeballs • (+) urine iutput

27. T.S. • 8 months, male • 7.5 kg. • 3 days vomiting and diarrhea, (+) fever-Temp.max:38.9C • PE: irritable, drinks eagerly, dry buccal mucosa, with sunken eyeballs • Can’t tolerate ORS CASE 3

28. Sabinidra follow daw nelsons 18thed way same for case 4 • Case 3 moderate dehydration though using IV therapy

29. R.D. • 6 month old, male • 6.5 kg • 6 days: watery stools (approx: 5-6 episodes per day, ½ cup,non-bloody) 2 days: vomiting of previously ingested food, 2 days: fever max temp:39C, loss of appetite, Rx Paracetamol 100mg/mL 1 mL every 6 hours • PE: lethargic, skin pinch more than 2 seconds, sunken eyeballs, dry buccal mucosa, drink poorly, weak pulses, absent tears CASE 4

31. Severely dehydrated children need to have water and salts quickly replaced. • Intravenous fluids are usually used for this purpose. • Rehydration therapy using IV fluids or using a nasogastrictube (NGT) is recommended ONLY for children who has SEVERE DEHYDRATION. • The treatment of the severely dehydrated child depends on: •the type of equipment available at your clinic, or at a nearby clinic or hospital; •the training you have received; and •whether the child can drink

32. A: SEVERE DEHYDRATION • PLAN • IV hydration therapy with PLRS • Initial phase: 30 ml/kg over 1 hour • 195 ml, to be given at 48-49 ml/min • (repeat once if radial pulse is still weak or imperceptible) • Subsequent phase: 70 ml/kg over 5 hours • 455 ml = 91 ml/h, to be given at 22-23 ml/min • Reassess every 1-2 hours

33. A: SEVERE DEHYDRATION • Give ORS 5 ml/kg/h once able to drink • 32.5 ml/h • Or my start OGT rehydration with ORS 20 ml/kg/h to be given over 6 hours (total of 120 ml/kg/h) • 30 ml/min/h

37. If the setting limits giving IV treatment in the clinic or health centerand there is no nearby clinic or hospital offering IV treatment, the next option is to use an NGT to rehydrate the child by giving ORS solution. Is the health worker trained to use a nasogastrictube (NGT)? • •A nasogastrictube is a tube that is inserted into the nose down to the level of the stomach. This access to the gastrointestinal system is another option to rehydrate severlydehydrated children. Correct positioning of the tube in the stomach is known by listening to the presence of abdominal sounds after a small amount of air is introduced into the tube.

39. Diarrhea • Diarrhea is also called loose or watery stools. • In many regions, diarrheai s defined as 3 or more loose or watery stools in a 24-hour period. • It is common in children, especially those between 6 months to 2 years of age. It is more common in babies under 6 months who are drinking cow’s milk or infant formulas. • Frequent passing of normal stools is not diarrhea. The number of stools normally passed in a day varies with the diet and age of the child. • Babies who are exclusively breastfed often have stools that are soft; this is not diarrhea.

45. Persistent diarrhea • SEVERE PERSISTENT DIARRHEA • child has had diarrheafor 14 days or more and also has some or severe dehydration • They need urgent referral to the hospital. • They may need a change in diet and laboratory tests to identify the cause of diarrhea. • Treat the child’s dehydration first before referral to the hospital unless the child has another severe classification. • Treating dehydration in children with another severe disease can be difficult • PERSISTENT DIARRHEA • the child has had diarrheafor 14 days or more and has no signs of dehydration • they may need special feeding recommendations • may have difficulty digesting milk other than breastmilk. • need to temporarily reduce the amount of other milk in the diet • They will need to return for follow-up after 5 days