**4.5 Other rehydration methods**

Nasogastric route is a safe rehydration technique with minimal adverse effects which has been adequately studied. Many clinical trials showed this method to have similar efficacy compared to IV therapy. Rapid NG rehydration using gastrolyte, 50 ml/kg for fluid deficit replacement over 4 hours, appears to be appropriate for children with mild-to-moderate dehydration [22]. If nasogastric rehydration is required beyond 4 hours, check urea and electrolyte concentration (UEC) and blood glucose level (BGL), and reassess the patient for hydration status.

### **4.6 Intravenous (IV) rehydration**

Intravenous rehydration should be reserved for patients with severe dehydration or shock and for those with some (mild-to-moderate) dehydration who fail ORT. Fluid containing not less than 0.9% sodium chloride is preferred for rehydration [23, 24]. Using hypotonic fluids predisposes for dilutional hyponatremia due to excess antidiuretic hormone (ADH) secretion in children with AGE. Serum electrolytes and BGL are required in children with severe dehydration and/or requiring IV fluid therapy for correction of dehydration.

The WHO recommends IV rehydration to be rapidly completed over 3–4 hours [8]. Rapid replacement of ECF improves gastrointestinal and renal perfusion, allowing earlier oral intake and a faster correction of electrolyte and acid-base abnormalities, which results in excellent recovery rate and decreased length of stay in ED [25].

#### *4.6.1 Resuscitation*

Resuscitate shock/near shock with a prompt intravenous infusion of 20 ml/kg of 0.9% sodium chloride solution or Ringer's lactate solution as fast as possible. Reassessing and repeating boluses given, as necessary, are required until the patient is recovered from shock and then followed by maintenance IV fluids [26].

#### *4.6.2 Rapid standard-volume IV rehydration*

The clinical standard is to administer 20 mL/kg/h of isotonic crystalloid fluid, such as 0.9% normal saline or lactated Ringer's solution. Reassess the patient after each bolus, and if the patient is still dehydrated, a total of 2–4 fluid boluses may allow rapid restoration of intravascular volume which can bring rapid recovery. Rapid IV rehydration followed by oral fluids is adequate for initial rehydration for most patients requiring IV fluid therapy. For those refusing oral intake, continuous infusion of maintenance IV fluids are to be given until oral fluids are tolerated [27]. Glucose solution should be added once ECF volume has been restored and addition of potassium considered once the child passes urine and serum electrolytes are known [28].

#### *4.6.3 Rapid large-volume IV rehydration*

Refer to the correction of dehydration using a large volume of fluids over a relatively shorter time (50–60 ml/kg/hour). Ultra-rapid IV rehydration may be associated with electrolyte abnormalities and longer hospital stay or delayed discharge and therefore is not recommended [29, 30].

Children with acute watery diarrhea and severe dehydration, such as cholera, who fail ORT, can benefit from large-volume IV rehydration (100 ml/kg) of Ringer's lactate solution or normal saline over 3–6 hours. Frequent reassessment is required, and if hydration status is not improving, IV fluids should be given more rapidly [31]. Further research investigations are needed to justify the use of rapid large-volume IV rehydration in pediatric gastroenteritis.

#### **5. Electrolyte disturbances**

Dyselectrolytemia is a serious complication of AGE with dehydration. The majority of electrolyte disorders associated with AGE in children can be adequately treated using ORT.

#### **5.1 Hypernatremia (serum sodium > 145 mmol/L)**

Hypernatremia leads to hypertonicity that can be potentially dangerous as there is a greater likelihood of neurological manifestations. Most frequently, it is due to water deficit from increased water losses in diarrhea and due to reduced water intake during the illness.

As in any type of dehydration, the primary aim should be restoration of hemodynamic stability by administration of isotonic fluids. The gradual replacement of water deficit remains the gold standard treatment for hypernatremic dehydration [32]. The recent advance in management of hypernatremia is to give isotonic (0.9% sodium chloride + 5% glucose) than hypotonic solution to correct the calculated fluid deficit slowly. The more the solution contains free water, the higher the risk of developing hyponatremia during rehydration [23, 33].

#### **5.2 Hyponatremia (serum sodium < 135 mmol/L)**

It represents an excess of water in relation to sodium in ECF [34]. Hyponatremia is seldom symptomatic unless the serum Na is <120 or if the hyponatremia occurs quickly [35]. Hyponatremia may be presented with nausea,

**43**

**Figure 3.**

*Flow chart for the management of pediatric gastroenteritis with dehydration.*

*Dehydration*

logic impairment [36].

serum Na by 5 mEq/L.

**children**

See **Figure 3**.

*DOI: http://dx.doi.org/10.5772/intechopen.83408*

vomiting, headache, irritability, lethargy, confusion, muscle cramps, convulsions, disorientation, and reduced consciousness and places the patient at risk of neuro-

The initial goal in treating hyponatremia is the restoration of intravascular volume with isotonic saline and to be followed by a slower correction using 0.9% sodium chloride + 5% glucose. In severe hyponatremia or symptomatic children, the goal is to raise the serum sodium to 120–125 mmol/L or until the seizure stops [35]. As a rule of thumb, IV infusion of 3% NaCl, 3–5 ml/kg over 15–30 min, will raise

**6. Systematic approach to a child with AGE and dehydration: summary of the assessment and management of AGE with dehydration in** 

#### *Dehydration DOI: http://dx.doi.org/10.5772/intechopen.83408*

vomiting, headache, irritability, lethargy, confusion, muscle cramps, convulsions, disorientation, and reduced consciousness and places the patient at risk of neurologic impairment [36].

The initial goal in treating hyponatremia is the restoration of intravascular volume with isotonic saline and to be followed by a slower correction using 0.9% sodium chloride + 5% glucose. In severe hyponatremia or symptomatic children, the goal is to raise the serum sodium to 120–125 mmol/L or until the seizure stops [35]. As a rule of thumb, IV infusion of 3% NaCl, 3–5 ml/kg over 15–30 min, will raise serum Na by 5 mEq/L.
