Oral rehydration therapy

Editor, – I refer to the article 'Oral rehydration therapy for acute gastroenteritis in children' by Dr E. O'Loughlin (Aust Prescr 1993;16:61-3).

Articles from paediatricians which appear in journals and similar articles written by paediatricians for popular magazines concerning the management of vomiting illnesses give advice based on the condition of children as usually first seen by the specialists or the hospital staff.

The fact that a specialist and/or a hospital are involved indicates the illness has progressed along the road to dehydration and needs significant intervention.

Because advice in magazines warns mothers of the lethal potential of dehydration, they take the hydration advice very seriously indeed. So every time the child vomits, they feed 30 mL or so of ORS which the irritated stomach - not realising the good intention - promptly returns, usually with interest. And rather than reduce fluid loss, the mother usually succeeds in increasing it.

This is the common general practice experience. After a lengthy uphill battle, I eventually convinced 'my mothers' to initially starve the vomiting baby or child. 'Nothing by mouth for 3 hours and then try a little water - if rejected wait another 3 hours and try again, but ring me at any stage if you are getting anxious.' Invariably, those who phoned in earlier would admit that the vomiting returned after 'giving in' because the child asked for something or was licking their lips.

It is difficult to know how successful one is in a general practice, but admissions were uncommon and only moderately sick.

I believe the initial advice in this illness should be to fast as the gastric irritability settles during the first day in most cases.

N.J. Rogers
General Practitioner
Ballina, N.S.W.

Dr E. O'Loughlin, the author of the article, comments:
Dr Rogers raises a number of issues regarding the treatment of acute gastroenteritis which require comment. The suggestion that children with acute vomiting and diarrhoea should be fasted for some hours and then given a little water, because of gastric irritation, is without clinical or scientific foundation. The focus of treatment is the correction or prevention of dehydration as this is the major contributing factor to morbidity and mortality. Restricting fluid intake in a child with vomiting and diarrhoea is potentially dangerous and may add to the dehydration. Water absorption is very inefficient unless accompanied by an appropriate mixture of glucose and electrolytes as provided in oral rehydration solutions. Dr Rogers' contention that 'the irritated stomach - not realizing the good intention - promptly returns, usually with interest' is incorrect in the majority of cases of children treated with oral rehydration solution. Despite ongoing symptoms, enough fluid usually reaches the small intestine to correct dehydration.

Dr Rogers also comments that when hospital specialists become involved, the illness has progressed to the more severe end of the spectrum. In my view, the use of appropriately constituted oral rehydration solutions early in the course of illness may prevent acute gastroenteritis progressing to the stage requiring admission to hospital or the need for specialists to be involved at all. Several thousand children are admitted to hospitals around Australia every year with acute gastroenteritis. Family doctors could be making a major impact on this problem by intervening early with oral rehydration solutions to prevent dehydration.