Oral rehydration therapy

Author:
Stephen Freedman, MDCM, MSc
Section Editors:
Tej K Mattoo, MD, DCH, FRCP
Anne M Stack, MD
Deputy Editor:
Melanie S Kim, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jan 2017. | This topic last updated: Jan 25, 2017.

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)".)
BACKGROUND Although oral rehydration therapy (ORT) was first introduced in 1945, its
use declined because of reports of multiple cases of hypernatremia due to the use of oral
rehydration solution (ORS) with inappropriately high carbohydrate levels [1]. However, the
success of intravenous (IV) hydration in decreasing mortality and morbidity in children with
diarrhea in developing countries led to renewed efforts in the 1960s to develop an effective ORT
that would be less expensive and easier to administer [2,3]. Subsequently, improvements in
ORS formulations have led to ORT's successful use in treating hypovolemia caused by
gastroenteritis [4-6]. (See 'Efficacy' below.)

Physiologic basis

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

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 [7,8].

ORS properties ORT is based on the preserved co-transport of glucose and sodium in
patients with diarrhea due to gastroenteritis. Studies from the 1960s showed an ORS
formulation that is isotonic with equimolar concentrations of glucose and sodium is as effective
as IV hydration in treating hypovolemia in patients with cholera [7,8]. Subsequent formulations
are based on this initial formulation (table 1).

The following properties for ORS are recommended by the World Health Organization (WHO)
[9]:

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) will increase 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) will
increase diarrheal losses, as there is no organic solute for facilitated transport of sodium. Fluids
with high sodium concentration also may result in hypernatremia.

Osmolality Several clinical trials and meta-analyses showed that decreasing osmolality
reduced stool volume and the duration of diarrhea [10,11]. 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.

Although 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, 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 [12]. These findings demonstrated that
reduced-osmolality ORS is as safe as the previous formulation 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. As a result, 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 [13]. However, data were insufficient to show that polymer-
based ORS is superior to glucose-based ORS with lower osmolarity (270 mOsm/L water).
As a result, 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 [14]. 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 [15-17]. These formulations should not be routinely used.

EFFICACY Oral rehydration therapy (ORT) reduces childhood mortality from diarrheal
disease [2,3,18]. 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 (0.2 versus 0.8 percent) [18].

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
[5,6,19-25]. ORT was also associated with a shorter length of hospitalization, lower costs, and
fewer serious 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 [5,6,19-25]. ORT is used to treat hypovolemia caused by
gastroenteritis independent of age, causative agent, or initial sodium values [26]. Advantages of
ORT compared with intravenous (IV) hydration include lower cost, easier to administer, less
invasive intervention, and treatment that can be done or continued at home.
(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 [4]. 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 "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) [14,28]. 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 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 isotonic saline. 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 [10-12,15-
17,23,33-45].

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 ORS,
which have equimolar concentration of glucose and sodium with osmolality between 200 and
310 mOsm/L, should be used for ORT. Commercially available ORS vary in osmolality and
sodium concentration (table 1). All commercial ORS contain 2 to 3 percent carbohydrate, as
glucose, rice, or other cereal; this amount is sufficient to maintain nutritional status in the short
term (24 to 48 hours) 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 [23,36]. 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]. Based on the available data,
the differences in composition between commercially available products and the 2002 WHO
ORS do not appear to be significant when administered to children with diarrhea in developed
countries. (See 'ORS properties' 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 to 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 antiemetics has
facilitated the administration of ORT by reducing vomiting. (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 developing
countries, ORT remains underutilized in the United States and other developed countries.
Barriers for utilization include:

Lack of compliance and knowledge by 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) [50]. 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 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].

INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials,
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Here are the patient education articles that are relevant to this topic. We encourage you to print
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Basics topics (see "Patient education: Giving your child over-the-counter medicines (The
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Beyond the Basics topics (see "Patient education: Acute diarrhea in children (Beyond the
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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' 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.