Paediatric Pearls

Most children who are dehydrated presenting to UK emergency departments can be rehydrated orally. 

• Give 50ml/kg ORS solution over 4hrs, plus ORS solution for maintenance, often and in small amounts (even by syringe or spoon)
• Continue breast feeding
• Consider supplementing with usual fluids (but not fruit juices or carbonated drinks) if a child without red flag symptoms or signs (see http://www.nice.org.uk/CG84) refuses to take sufficient ORS solution.  Don’t give solids.
• Consider giving ORS solution via ng tube if child is unable to take it or continues to vomit (esp. with red flag symptoms/signs)
• Monitor carefully

This is a worked example for a 3 year old child weighing 14kgs who has been assessed as about 5% dehydrated.

Maintenance = 100mls/kg for first 10kgs and 50mls/kg for next 10 kgs = 1000mls + 200mls = 1200mls over 24 hours

Replacement = 5 x 14 x 10 = 700mls over the first 4 hours (extra to maintenance needs)

Therefore the child needs 225mls per hour for the first 4 hours (1200/24 + 700/4), followed by 50mls (1200/24) per hour.

The 225 mls is best given as 18 mls every 5 minutes or 56mls every 15 minutes if vomiting seems to have stopped or if using nasogastric tube.

They should have 5mls/kg = 70mls extra diarolyte (ORS) with each diarrhoeal stool or vomit.

Give parents written information to go home with so they understand that diarrhoea may continue for a few days but this does not matter as long as they are able to get enough fluid in the top end.  The NICE guideline parent information is at http://guidance.nice.org.uk/CG84/PublicInfo/pdf/English.

This is the first time in ages I’ve managed to get the finalised version on line in time for the end of the month!  NICE on autism this month, a bit on the use of corticosteroids in croup with help from the Cochrane Library, update on secondary prevention of meningococcal disease and a pointer to our local educational psychologist service which is hoping to make stronger links with the borough’s GPs (see also below).  Our feeding series continues with an article on colic from one of the junior paediatricians with lots of useful links and updates.

A move away from NICE guidelines this month to cover the 2011 BTS/SIGN asthma guidelines and a link to a succinct summary of the current UK immunisation schedule written by one of our registrars.  Also a bit from the literature on management of gastro-oesophageal reflux disease and a few pointers about Forced Marriage which is an important safeguarding issue in our region.  Do leave comments.

June already!  A move away from NICE guidelines this month to cover the 2011 BTS/SIGN asthma guidelines.  Also a bit from the literature on management of gastro-oesophageal reflux disease and a few pointers about Forced Marriage which is an important safeguarding issue in our region.  Do leave comments.

Any words of wisdom on this topic very welcome here!  A slightly lax lower oesophageal sphincter is pretty normal in the under 1s but a lot of energy is expended in trying to do something about the symptoms.  The paper cited in this month’s Paediatric Pearls from the Drugs and Therapeutics bulletin is really rather depressing in its comments on both pharmacological and non-pharmacological management of reflux.  Even surgery doesn’t always work.  It is particularly common among preterm babies and much has been written about that group of patients too – with similar levels of evidence generated as with term infants.  You might want to read: Gastrooesophageal reflux disease in preterm infants: current management and diagnostic dilemmas. J L Birch, S J Newell, Arch Dis Child Fetal Neonatal Ed 2009 or Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the NASPGHAN and the ESPGHAN. J Pediatr Gastroenterol Nutr; 2009 on this topic.