Am Fam Physician. 2003 Jun 15;67(12):2604-2606.
Acute gastroenteritis in children younger than five years is responsible for a significant number of acute-care visits each year in the United States. This illness results in 220,000 pediatric admissions and about 925,000 hospital days per year. Current treatment guidelines from the Centers for Disease Control and Prevention and the American Academy of Pediatrics support the use of oral rehydration in the treatment of mild to moderate dehydration in patients with acute gastroenteritis. Several studies have shown that oral rehydration is as effective as intravenous rehydration. Nonetheless, many emergency departments and primary care physicians use intravenous rehydration therapy instead. Cited reasons include parental preference and time required for oral rehydration. Atherly-John and associates compared oral rehydration and intravenous rehydration in the treatment of moderate dehydration in children. They also sought to determine whether reported barriers to the use of oral rehydration therapy would be substantiated.
All children three months to 17 years of age who presented to an urban pediatric emergency department with symptoms of acute gastroenteritis for less than one week were screened for participation in the study. The children had to meet at least four published criteria for moderate dehydration. They were excluded from the study if they had a chronic illness, protracted vomiting, severe dehydration or shock, or absent bowel sounds, or if they required intravenous access for reasons other than rehydration.
The participants were randomly assigned to receive oral or intravenous rehydration therapy. Children in the oral rehydration group were given a commercially prepared electrolyte solution at the rate of 5 mL every five minutes if they were younger than four years of age, and 10 mL every five minutes if they were four years or older. If the patient tolerated the first hour of rehydration without vomiting, the volume of solution was doubled and given every five minutes. If the child vomited, administration of the solution was stopped for 30 minutes and then restarted at the initial rate. Oral rehydration was considered to have failed if the patient vomited three or more times; in this event, intravenous therapy was administered.
Children in the intravenous rehydration group received an initial bolus of 20 mL per kg of an isotonic sodium chloride solution over 30 minutes. A second bolus was administered at the discretion of the treating physician. Children two years of age and older then received an intravenous solution of 5 percent dextrose in 0.45 percent saline, and children younger than two years received a solution of 5 percent dextrose in 0.33 percent saline. The dextrose-saline solution was administered at a rate of 1.5 times daily maintenance.
Length of stay in the pediatric emergency department was the primary outcome measure. Other outcome measures included hospitalization admission rates, relapse after discharge from the emergency department, staff time required for patient care, and parental satisfaction. Two to four days after the child was discharged from the emergency department, the parents were surveyed by telephone to determine whether the child had a relapse and to evaluate parental satisfaction with the emergency department visit.
Of the 34 patients enrolled in the study, 18 received oral rehydration, and 16 received intravenous rehydration. Three patients failed oral rehydration therapy and required intravenous treatment. The mean length of stay in the pediatric emergency department was significantly lower in the oral rehydration group compared with the intravenous rehydration group. The mean staff time required for patient care was significantly less for the oral rehydration group. There was no significant difference between the groups with regard to hospitalization rate, and there were no relapses in either group. Compared with the parents of the children who received intravenous hydration, the parents of children who received oral rehydration therapy were significantly more likely to report high satisfaction with all aspects of the emergency department visit.
The authors conclude that perceived barriers to oral rehydration therapy were not supported by this study. They add that if further studies support their data, physicians should consider using oral rehydration therapy instead of intravenous therapy in children with moderate dehydration resulting from acute gastroenteritis.
Atherly-John YC, et al. A randomized trial of oral vs intravenous rehydration in a pediatric emergency department. Arch Pediatr Adolesc Med. December 2002;156:1240–3.
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