PEDIATRIC UPDATE

ORAL REHYDRATION OF THE PEDIATRIC PATIENT

WITH MILD TO MODERATE DEHYDRATION
Author: Stephen Jablonski, BS, RN, CEN, CPEN, Somerville, NJ
Section Editors: Joyce Foresman-Capuzzi, BSN, RN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P,
Michelle Tracy, MA, RN, CEN, CPN, and Sue M. Cadwell, RN, MSN

Earn Up to 9 CE Hours. See page 201.

cute gastroenteritis is a very common illness in exclude all other causes.2 Careful assessments of pediatric

A infants and children that accounts for more than

1.5 million outpatient visits, 200,000 hospitaliza-
tions, and approximately 300 deaths a year.1 A significant
number of these children will be needlessly subjected to
blood work and intravenous rehydration during the
course of their treatment. This article will explain why
oral rehydration for pediatric patients with mild to mod-
erate dehydration is the preferred method of treatment
and why the common use of intravenous (IV) therapy
should be avoided.
Mild to Moderate Dehydration
What is mild to moderate dehydration? A child with mild
to moderate dehydration can lose an estimated 3% to 9%
of body weight. The child can either appear normal men-
tally or appear tired or restless; he or she will be thirsty
and want to drink and will have a normal to increased
heart rate with normal to decreased pulses. Respirations
may be normal to tachypneic. Tears will be present but
decreased, and the tongue will appear dry. Capillary refill
will be prolonged, the extremities will be cool, and urine
output will be decreased1 (Table). The risk of dehydration
varies with age. There are several risk factors for the devel-
opment of dehydration, including age, frequency of stools
and vomiting, and initial nutritional status.2 It is impor-
tant to make the determination that the cause of the
dehydration is actually caused by gastroenteritis and
Stephen Jablonski, Member, ENA Chapter 026, is Staff Nurse, Somerset Med-
ical Center, Somerville, NJ.
For correspondence, write: Stephen Jablonski BS, RN, CEN, CPEN, 7 Field-
stone Place, Flemington, NJ 08822; E-mail: stevejablonski@comcast.net.
J Emerg Nurs 2012;38:185-7.
Available online 13 January 2012.
0099-1767/$36.00
Copyright 2012 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
doi: 10.1016/j.jen.2011.12.001
patients experiencing dehydration are of the utmost
importance because misdiagnoses can have potentially
lethal consequences.3
Oral Rehydration Therapy Versus IV Therapy
Many rehydration studies have been conducted over the
years, and although many of these studies were conducted
in third-world countries, the results show that oral rehydra-
tion therapy is as effective as IV therapy. Currently, oral
rehydration therapy is the preferred treatment as recom-
mended by the American Academy of Pediatrics and the
World Health Organization.4
Oral rehydration therapy has many benefits. Some of
these benefits include sparing a child from the painful pro-
cess of obtaining IV access, but most importantly, parents
can be taught how to provide this therapy at home. As Voll-
merhaus and Wilson5 explain, When approaching rehy-
dration in children, consider the number of IV attempts
needed, the pain involved and the psychological impact of
IV initiation versus oral rehydration. In one study it was
found that treatment was started sooner, fewer patients were
hospitalized, and in comparison with IV treatment, differ-
ences in outcomes were statistically insignificant.
Despite the success of oral hydration therapy, many
health care providers still rely on the IV method as their
first recourse for rehydration. Many practitioners believe
that the process of oral rehydration is too time consuming.
They also believe that they have an obligation to meet the
expectations of parents and referring physicians.4 Other
practitioners argue that because the child needs to have
blood work done anyway, IV fluid resuscitation should
be initiated at the same time. However, because oral rehy-
dration therapy is the preferred method for treatment, rou-
tine laboratory work is unnecessary.6
It is the nurses responsibility to educate both practi-
tioners and parents about the effectiveness and safety of
oral rehydration therapy. It also is important to point out
that the use of oral rehydration has the potential to reduce
ED visits and decrease health care costs.

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PEDIATRIC UPDATE/Jablonski

TABLE
Degrees of dehydration
Assessment Mild Moderate Severe
Heart rate Normal Increased Weak, rapid
Respiratory rate Normal Increased Increased, labored
Blood pressure Normal Normal/Decreased Hypotensive
Capillary refill Normal 2-3 s >3 s
Mental status Alert, restless Irritable Lethargic
Skin turgor Normal Decreased Tenting
Mucous membranes Slightly moist Dry Dry
Tears Present Decreased None
Eyes Normal Darkened Sunken
Urine output Decreased Oliguria Anuria
Fontanelle Normal Sunken Concave

Procedure 2 minutes for the first 10 minutes. For the next 20 minutes you
should administer 10 mL every 5 minutes, and then 20 mL
Oral rehydration should be conducted using an oral repla-
every 10 to 15 minutes during the next 30 minutes. It is impor-
cement solution with a specific osmolarity. A standard
tant to note that you should wait 15 to 30 minutes after the
solution with a very high osmolarity was adopted by the
child vomits before starting the rehydration therapy.5 As soon
World Health Organization and UNICEF in 1975. How-
as rehydration is completed, the child should be fed an age-
ever, in 2002 it was recommended that the osmolarity be
appropriate diet.
reduced because of recent studies that showed no clinical sig-
nificance in using a solution with a higher osmolarity.1 Cur-
rently these recommendations are 75 mEq/L sodium, 75 Conclusion
mmol/L glucose, and a total osmolarity of 245 mOsm/L.
Children commonly experience acute gastroenteritis, and
Currently many commercially available oral rehydration
treating them may even seem intimidating to some prac-
solutions are available to the public. Some children will resist
titioners. Far too often these children are treated with
drinking the electrolyte solution because of its salty taste. Taste
the so-called tried and true method of IV therapy.
should not be a roadblock or excuse not to provide oral rehy-
Unfortunately, this method is both traumatic for the
dration; manufacturers of these solutions have added flavors
patient and costly for the institution. Oral rehydration
and even make ice pops that may help make the treatment
therapy is, in fact, the real tried and true method of
more palatable. It is important to educate parents not to use
treatment for mild to moderate dehydration in children.
sports drinks because they include inappropriate proportions
It is the recommended treatment of the World Health
of electrolytes. In one study, a proper electrolyte balance was
Organization and the American Academy of Pediatrics
made by using a 4:1 electrolyte to juice ratio, which also may
and should be embraced by nurses as the standard of
make the treatment more palatable.5
excellence in our practice.
Mild dehydration is corrected by giving 50 mL/kg, as well
as any continuing losses, during a 4-hour period. Moderate
dehydration is corrected by giving 100 mL/kg, as well as repla- REFERENCES
cing any continuing losses during a 4-hour period.7 Correcting 1. King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis
among children: oral rehydration, maintenance, and nutritional therapy.
moderate dehydration orally can be a challenging task and is
MMWR Recomm Rep. 2003;52(RR-16):1-16.
certainly one of the main reasons practitioners shy away from
2. Fitzpatrick P, Nicholson A. Effects of acute gastroenteritis. World Ir Nurs
this type of treatment. However, even children who have been Midwif. 2010;18(10):45-7.
vomiting can be treated this way. Because of the time involved, 3. Larson CE. Evidence-based practice. Safety and efficacy of oral rehydra-
it is very important to enlist the help of the caregiver. To deliver tion therapy for the treatment of diarrhea and gastroenteritis in pediatrics.
100 to 150 mL an hour, you should start with 5 mL every 1 to Pediatr Nurs. 2000;26(2):177-9.

186 JOURNAL OF EMERGENCY NURSING VOLUME 38 ISSUE 2 March 2012

 Jablonski/PEDIATRIC UPDATE

4. Spandorfer PR, Alessandrini EA, Joffe MD, Localio R, Shaw KN. Oral Submissions to this column are encouraged and may be sent to
versus intravenous rehydration of moderately dehydrated children: a ran-
Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN,
domized, controlled trial. Pediatrics. 2005;115(2):295-301.
SANE-A, EMT-P
5. Vollmerhaus L, Wilson S. Pediatric oral rehydrationeverybodys busi-
joyceforesmancapuzzi@rcn.com
ness. NENA Outlook. 2005;28(1):19-21.
or
6. Burkhart DM. Management of acute gastroenteritis in children. Am Fam
Physician. 1999;60(9):2555-63.
Michelle Tracy, RN, MA, CEN, CPN
jmtracy2001@yahoo.com
7. American Academy of Pediatrics, Provisional Committee on Quality
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meter: the management of acute gastroenteritis in young children. Pedia- Sue M. Cadwell, RN, MSN
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