Table 4.

Management of rehydration

Dehydration status	Treatment
Milda (<3% weight loss)	Oral rehydration salts, at home Practical advice: – Liquids should be administered in small amounts frequently (each 15–30 minutes) – For children over 14 years old and adults: ensure at least 2 L per day and add one glass (200 mL) per each bowel movement	Children less than 2 years old: 50–100 mL of oral rehydration solution (ORS), after each evacuation, providing a volume similar to the assessed fluid loss (gastrointestinal and urinary) Children between 1 and 14 years old: 100–200 mL of ORS, after each evacuation, providing a volume similar to the assessed fluid loss (gastrointestinal and urinary) Children over 14 years old and adults: drink the amount of ORS needed, ingesting a volume similar to the assessed fluid loss (gastrointestinal and urinary); up to 2 L daily
Moderatea (3%–8% weight loss)  Sunken eyes with ocular hypotony  Absence of tears  Dryness of the oral mucosa, tongue, and mucous membrane  Intense thirst, drinks eagerly  Skin pinch goes back slowly (1–2 seconds)	Oral rehydration salts and close clinical monitoring, especially in children under 18 months of age Practical advice: – It is recommended that the patient be sitting up during treatment – If the taste of the solution causes nausea: oral rehydration via nasogastric tube	Administer within first 4 hours: Children less than 4 months (less than 5 kg): 200–400 mL Children 4–11 months (5–7.9 kg): 400–600 mL Children 13–23 months (8–10.9 kg): 600–800 mL Children 2–4 years (11–15.9 kg): 800–1200 mL Children 5-years (16–29.9 kg): 1200–2200 mL Children over 15 years and adults (30 kg or more): 2200–4000 mL
Severeb	Rehydrate in two phases: 1. Intravenous rehydration  Practical advice:  – Absence of or weak radial pulse indicates a life-threatening emergency. Two or more lines should be installed in order to reach the necessary perfusion speed. Solutions may be pumped into the patient. As soon as radial pulse is palpable, the perfusion can be adjusted to the guideline  –Lactated Ringer’s solution is the first option. In an emergency situation, if it is not available, isotonic saline solution (CINa 0.9%) can be used  – never use glucose solution 2. Oral rehydration  Practical advice:  – Sit the patient, supporting the arms on a table, at the beginning of the oral rehydration. This keeps the patient alert and improves the oral tolerance Closely monitor fluid balance during this phase in order to guarantee sufficient replenishment of volume. If this is not done, the patient is at risk of developing renal failure	1. Intravenous rehydration (2–4 hours)  Intravenous lactated Ringer’s solution is recommended at the following perfusion rates:  1st hour: 50 mL/kg  2nd hour: 25 mL/kg  3rd hour: 25 mL/kg  Clinical assessment should be used to determine whether to continue intravenous rehydration  Closely monitor radial pulse or capillary nail-refillc time to assess the dehydration. If the pulse is weak or the capillary perfusion is greater than 2 seconds, increase the speed of perfusion 2. Oral rehydration  Start oral rehydration as soon as the patient is able to drink.  Follow the guidelines for moderate dehydration, always adapting to the volume of fluid loss

Notes:

^aBased on World Health Organization;¹¹⁸

^bbased on Ognio;¹¹⁹

^cin the capillary nail-refill test, pressure is applied on the nail bed until this becomes white. Once the tissue has paled, pressure is removed. While the patient sustains the hand above the heart, the health professional measures the time that it takes for the blood to return to the tissue, indicated by the return of the pink color to the nail. This time has to be less than 2 seconds. If it is longer, it indicates severe dehydration or shock. © 2009 Biomedia. Reproduced with permission from Caramia G, Ruffini E, Salvatori P. Infectious gastroenteritis. Neonatal Infectious Diseases Study Group of the Italian Society of Neonatology. Manual of Neonatal Infectious Diseases. Milan: Biomedia; 2009.⁵⁵