Rehydration Therapy

Rehydration is the cornerstone of treatment for cholera. Oral rehydration salts and, when necessary, intravenous fluids and electrolytes, if administered in a timely manner and in adequate volumes, will reduce fatalities to well under 1%.

Low-osmolarity oral rehydration solution and cereal-based oral rehydration solution are the preferred replacement fluids for most patients. However, a modified rehydration solution called ReSoMal [PDF - 50 pages] (see Appendix 3) was formulated for rehydration of severely malnourished children. Breastfed children should also continue to breastfeed. Other types of fluids, such as juice, soft drinks, and sports drinks should be avoided. Safe (treated) water should be used to prepare oral rehydration solutions. 

WHO Fluid Replacement or Treatment Recommendations

No dehydration	Oral rehydration salts	Administer after each stool:
		Age		Volume of ORS
		<2 years		50–100 ml, up to 500 mL/day
		2–9 years		100–200 ml, up to 1000 mL/day
		≥10 years		As much as wanted, up to 2000 mL/day
Some dehydration	Oral rehydration salts	Administer in first 4 hours:
		Age	Weight	Volume of ORS
		<4 months	<5 kg	200–400 mL
		4–11 months	5–7.9 kg	400–600 mL
		1–2 years	8–10.9 kg	600–800 mL
		2–4 years	11–15.9 kg	800–1200 mL
		5–14 years	16–29.9 kg	1200–2200 mL
		≥15 years	30 kg or more	2200–4000 mL
Severe dehydration	Intravenous Ringer’s Lactate or, if not available, normal saline and oral rehydration salts as outlined above	Administer up to 200 ml/kg IV fluids in first 24 hours
		Age< 12 months
		Timeframe		Total volume
		0–30 min		30 ml/kg*
		30 min–6 h		70 ml/kg
		6 h–24 h		100 ml/kg
		Age≥ 1 year
		Timeframe		Total volume
		0–30 min		30 ml/kg*
		30 min–3 h		70 ml/kg
		3 h–24 h		100 ml/kg

*Repeat once if radial pulse is still very weak or not detectable

• Reassess the patient every 1-2 hours and continue hydrating. The volumes and time intervals shown are guidelines provided on the basis of usual needs.
  • If necessary, the rate of fluid administration can be increased, or the fluid can be given at the same rate for a longer period, to achieve adequate rehydration. If hydration is not improving, give fluids more rapidly. 200ml/kg or more of intravenous fluids may be needed during the first 24 hours of treatment.
  • Similarly, the amount of fluid can be decreased if hydration is achieved earlier than expected.
• Switch from intravenous hydration to oral rehydration solution once hydration is improved and the patient can drink. This will conserve IV fluids and reduce the risk of phlebitis and other complications.
• Nasogastric tubes can be used to administer oral rehydration solution if patient is alert but unable to drink sufficient quantities independently.
• Patients should continue to eat a normal diet and breastfeeding children should continue to breastfeed during rehydration.

Additional Resources

• First do no harm: Making oral rehydration solution safer in a cholera epidemic
• Reaching Every District (RED) approach: a way to improve immunization performance

References

• Alam NH, Hamadani JD, Dewan N, Fuchs GJ. Efficacy and safety of a modified oral rehydration solution (ReSoMaL) in the treatment of severely malnourished children with watery diarrhea. J Pediatr. 2003 Nov;143(5):614-9.
• Daniels NA, Simons SL, Rodrigues A, Gunnlaugsson G, Forster TS, Wells JG, Hutwagner L, Tauxe RV, Mintz ED. First do no harm: making oral rehydration solution safer in a cholera epidemic. Am J Trop Med Hyg. 1999 Jun;60(6):1051-5.
• Gregorio GV, Gonzales ML, Dans LF, Martinez EG. Polymer-based oral rehydration solution for treating acute watery diarrhoea [PDF – 65 pages]. Cochrane Database Syst Rev. 2009 Apr;(2):CD006519.
• Hahn S, Kim Y, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhea in children. Cochrane Database Syst Rev. 2002 Jan;(1):CD002847.
• First steps for managing an outbreakof acute diarrhea [PDF – 2 pages]. WHO Global Task Force on Cholera Control. World Health Organization. 2004.
• WHO position paper on Oral Rehydration Salts to reduce mortality from cholera [PDF – 1 page]. WHO Global Task Force on Cholera Control. World Health Organization. 2008 Dec.
• Bulletin of the World Health Organization. Reaching Every District (RED) Approach: A Way to Improve Immunization Performance. 2008;86(3):161-240