ORT indications and contraindications (**Indicated:** mild–moderate dehydration with tolerated oral intake · **Contraindicated/absent oral route:** shock, severe dehydration, altered consciousness, ileus, intractable vomiting (consider NG ORS before IV if no shock) — **NOT** sports drinks, juice, or water alone as sole therapy (ESPGHAN, WHO, NICE, CPS))
Max 3000 mg/dose · Duration: 4 h · 50 mL/kg over 4 h (calculator: total mL = 50 × weight kg) — small frequent aliquots; reassess at 4 h; ~5% dehydration estimate (WHO 2022, ESPGHAN, NICE NG84)
• **Mild dehydration (~5%):** give **50 mL/kg** ORS over **4 hours** (calculator: total mL = 50 × weight kg) — offer small frequent volumes (5–10 mL q2–5 min by spoon/syringe); reassess hydration q1–2 h (WHO Pocket Book 2022, ESPGHAN/NASPGHAN, NICE NG84).
• **Moderate dehydration (5–10%):** give **50–100 mL/kg** ORS over **3–4 hours** — ESPGHAN/WHO typically **75–100 mL/kg** for moderate deficit; calculator uses 75 mL/kg default (range 50–100); if vomiting, pause 10 min then resume slower; NG tube ORS if oral not tolerated and no shock (ESPGHAN 2014, WHO 2022, CPS).
• **Ongoing loss replacement:** after each **diarrheal stool** or **vomit**, give additional **10 mL/kg** ORS (calculator: mL = 10 × weight kg per event) — continue until diarrhea resolves; this is in addition to deficit replacement (WHO IMCI, ESPGHAN Rec. 5, NICE NG84).
• **Zinc (gastroenteritis):** **10 mg/day** (age <6 months) or **20 mg/day** (≥6 months) for **10–14 days** in developing-endemic settings and per WHO/ESPGHAN in acute diarrhea — reduces duration and recurrence (WHO 2022, ESPGHAN 2014, AAP).
• **What NOT to use:** avoid hypertonic fluids (undiluted juice, sports drinks, cola), plain water alone (hyponatremia risk), and anti-motility agents in bloody diarrhea or suspected invasive bacterial enteritis (ESPGHAN, NICE, CDC); antiemetics not routine in gastroenteritis (ESPGHAN/NASPGHAN).
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Zinc sulfate • p.o. • 10–10 mg/kg/dose • 1×/day
Max 20 mg/dose · Duration: 10–14 days · Elemental zinc: 10 mg/day if <6 months; 20 mg/day if ≥6 months — for 10–14 days in acute diarrhea per WHO/ESPGHAN; calculator shows mg/dose (WHO 2022, ESPGHAN 2014, AAP)
• IV fluids: failed ORT after appropriate supervised rehydration trial (e.g. 4 h moderate ORS without improvement), increasing dehydration, shock, altered consciousness, or ileus — use moderate–severe IV variant (ESPGHAN, WHO, NICE NG84).
• NG ORS before IV: persistent vomiting without shock — NG ORS 50–100 mL/kg over 3–4 h may avoid hospitalization; if NG fails or clinical deterioration, proceed to IV (ESPGHAN, WHO Pocket Book, CPS).
• Zinc: recommended in acute gastroenteritis per WHO and ESPGHAN — 10 mg/day (<6 months) or 20 mg/day (≥6 months) × 10–14 days; evidence strongest in developing settings but supported broadly for pediatric diarrhea (WHO 2022, ESPGHAN 2014, AAP).
• Breastfeeding/feeding: do NOT withhold feeds during ORT — continue breastfeeding on demand; resume normal age-appropriate diet as soon as tolerated; no need for restrictive BRAT diet (ESPGHAN/NASPGHAN 2018, NICE NG84, AAP).
• Outpatient vs admission: most mild–moderate dehydration managed at home/observation unit with ORS and caregiver education — admit if social concerns, caregiver unable to administer ORS, young infant (<3 months) with significant losses, or comorbidities (WHO, ESPGHAN, CPS).
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Clinical notes
• Dehydration severity assessment: estimate % fluid deficit clinically — **mild ~5%** (thirst, slightly dry mucosa), **moderate 5–10%** (sunken eyes, decreased turgor, tachycardia, oliguria), **severe >10%** (shock, altered mental status, very poor perfusion) — weight change if known (pre-illness weight) improves accuracy; capillary glucose and electrolytes if altered consciousness or prolonged illness (WHO 2022, ESPGHAN/NASPGHAN, NICE NG84, AAP).
• Oral vs IV indications: **ORT first-line** for mild–moderate dehydration tolerating oral/NG; **IV** for shock, severe dehydration, failed ORT, altered consciousness, ileus, or inability to replace losses orally despite NG trial — do NOT give routine IV bolus for uncomplicated dehydration without shock (ESPGHAN 2014, WHO 2022, NICE, CPS).
• Ongoing loss replacement: after each diarrheal stool or vomit give **10 mL/kg** ORS in addition to deficit plan; in IV therapy add ongoing losses to maintenance (typically 10 mL/kg per stool, adjust per clinical losses) — underestimate losses prolongs dehydration (WHO IMCI, ESPGHAN Rec. 5, NICE NG84).
• Monitoring: reassess hydration **q1–2 h** during active rehydration — mental status, eyes, mucous membranes, skin turgor, HR, BP, CRT, urine output (≥1 void in 4–6 h good sign); weigh if possible; if IV — monitor electrolytes (Na+, K+, Cl−, bicarbonate, glucose) at baseline and q12–24 h or sooner if clinical change; fluid balance chart (WHO, ESPGHAN, NICE).
• Discharge criteria and admission: **discharge** when hydrated, tolerating oral fluids/feeds, caregiver educated on ORS and danger signs; **admit** for shock/severe dehydration, failed outpatient ORT, persistent vomiting without NG access, altered consciousness, suspected surgical abdomen, infants <3 months with significant dehydration, electrolyte disturbances, or social inability to manage at home (WHO Pocket Book 2022, ESPGHAN, NICE NG84, CPS, AAP).
• ESPGHAN / NASPGHAN — Evidence-based guidelines for management of acute gastroenteritis (ORT and fluids) (2014)
• ESPGHAN / NASPGHAN — Universal recommendations for management of acute diarrhea (2018)
• WHO — Pocket Book of Hospital Care for Children (dehydration and ORT) (2022)
+ 4 more
• WHO — The treatment of diarrhoea: a manual for physicians and senior health workers (low-osmolarity ORS) (2022)
• NICE NG84 — Diarrhoea and vomiting caused by gastroenteritis in under 5s (2017)
• AAP Red Book — Fluid and electrolyte management in acute gastroenteritis (2024)
• CPS — Acute gastroenteritis and dehydration in children (2024)
