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Three Part Question

In [children with moderate dehydration] are [naso-gastric fluids better than intravenous fluids] at [producing satisfactory rehydration]

Clinical Scenario

A 3yr old boy is brought to the Emergency Department suffering with diarrhoea and vomiting. You estimate him to be suffering from moderate (5-10%) dehydration, and feels he needs rehydrating. Aware that he does not want to take oral fluids, and is likely to vomit these back anyway, you wonder whether naso-gastric rehydration would be a satisfactory alternative.

Search Strategy

Medline database using Ovid Interface: 1966 – March 2007.
{(exp Intubation, Gastrointestinal/ or nasogastric.mp.) AND (exp GASTROENTERITIS/ or gastroenteritis.mp.) OR (exp Vomiting/ or vomit$.mp.) OR (exp DIARRHEA/ or exp DIARRHEA, INFANTILE/ or diarrh?ea.mp.)} LIMIT to (Human and English Language)

Search Outcome

619 papers were found of which 6 helped to answer the question, one being a metanalysis.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Nager et al 2002 USA	90 children aged 3 to 36 months with diarrhoea/ vomiting, assigned to rapid nasogastric rehydration or rapid IV rehydration	PRCT	Complications	Greater failure rate in IV (61.4% v 4.3%; p<0.0001). No difference in vital signs	Non – blinded Patients with persistent emesis excluded Telephone follow up
			Persistent emesis post discharge	No significant difference. No difference in return rates
Armon et al 2001 UK	Children from precvious studies on general management of gastroenteritis	Systematic review and Delphi consensus document.	Guideline development	Recommendation of NG rehydration for moderate group with persistent dehydration post ORS	Level V evidence. Grade D recommendation
Gremse et al 1995 USA	24 patients aged 2 to 19 months with failed oral rehydration, randomized to NG or IV rehydration	PRCT	Duration of hospitalisation	Shorter in NG group	Small numbers of patients
			Complications	No difference
McKenzie et al 1994 Australia	104 children age 3 to 36 months with dehydration and diarrhoea, rabdomised to IV or oral/NG	PRCT	Successful Rehydration	Failure rate 3.8% in oral group, nil in IV	Oral and NG rehydration analysed together. IV group allowed oral fluid
			Number of vomits and stools post rehydration	Vomiting more common in oral group (52% v 22%; p<0.01). No difference in number of stools
Phin et al, 2003, Australia	145 moderately dehydrated children with d&v for <48 hours. Rapidly rehydrated via iv or NG route (intervention group) with 20ml/kg of N/2 saline with 2.5% dextrose and compared with historical controls.	Case control study and guideline development	Discharge from ED in 8 hours	More in intervention group discharged within 8 hours (44.2% vs 3.7%, p<0.001).	Control group was historical. No randomisation as to who had NGT or iv, down to preference Patients analysed together
			Rates of admission	Reduced in intervention group (55.8% vs 96.3%, p<0.001).
			Representation within 48hrs of discharge from ED.	No difference between 2 groups.
Fonseca et al, 2004, Australia	16 trials looking at 1545 children	Meta-analysis	Major adverse event rates (including death or seizures)	Compared with iv group, oral group had significantly fewer adverse events (RR 0.36, CI 0.14-0.89)	Half the trials done in developing countries, 5 included severely dehydrated children. 10 compared oral with iv, 3 NGT with iv
			Weight gain with treatment	No difference between 2 groups.
			Length of hospital stay	Oral group had significant reduction (mean 21 hours).
			Failure rate of therapy	3.3% in those with NG rehydration, 4.7% with oral. By definition none with iv.

Comment(s)

It seems that when treating dehydration oral rehydration offers advantages in terms of reduced admission rates, earlier discharge from the ED, lower complications and costs compared with the intravenous route. Nasogastric rehydration may be regarded as invasive and unpleasant, but maybe less so than the iv route. In all cases oral therapy should be attempted first.

Clinical Bottom Line

In almost all children who have vomiting and diarrhoea oral rehydration therapy should be attempted and is appropriate first line therapy. Intravenous rehydration should be reserved for those who are shocked, severely dehydrated, or who are unable to tolerate oral fluids. Naso gastric rehydration would appear to be both safe and efficacious and should be considered when oral attempts have failed. This can be done safely in the Emergency department and may facilitate an early discharge home.

References

1. Nager AL. Wang VJ Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration Pediatrics 109(4):566-72, 2002 Apr
2. Armon K. Stephenson T. MacFaul R. Eccleston P. Werneke U An evidence and consensus based guideline for acute diarrhoea management Archives of Disease in Childhood 85(2):132-42, 2001 Aug
3. Gremse DA Effectiveness of nasogastric rehydration in hospitalized children with acute diarrhea Journal of Pediatric Gastroenterology & Nutrition 21(2):145-8, 1995 Aug
4. Mackenzie A. Barnes G Randomised controlled trial comparing oral and intravenous rehydration therapy in children with diarrhoea BMJ 303(6799):393-6, 1991 Aug 17
5. Phin SJ, McCaskill M, Browne G, Lam L. Clinical pathway using rapid rehydration for children with gastroenteritis. Journal of Paediatrics and Child Health (2003) 39; 343-348.
6. Fonseca B, Holdgate A, Craig J. Enteral vs Intravenous rehydration therapy for children with gastroenteritis. Archives Pediatric Adolescent Medicine. Vol 158, May 2004; 483-490.