ORS monitoring charts to improve treatment of mild/moderate dehydration.
Caregiver oral rehydration solution fluid monitoring charts versus standard care for the management of some dehydration among Kenyan children: a randomized controlled trial
Kailemia M, Kariuki N, Laving A, Agweyu A, Wamalwa D. Int Health. 2018;10(6):442-450. doi:10.1093/inthealth/ihy040
To evaluate the effectiveness of a care-giver administered fluid balanced chart
Dehydration is an incredibly common pathology causing significant pathology in low resource settings. In these settings there is often a large volume of patients and minimal staff to ensure that the prescribed Oral Rehydration solution (ORS) is being given. The author's only identified studies in high-resource settings evaluation nurse led interventions and none regarding care-giver led observations.
Open label single centre randomised control trial
Paediatric department of district hospital in Nairobi, Kenya.
Inclusion criteria; Patient aged 2-59 months with "some" dehydration based on clinical signs as per WHO guidelines.
Exclusion criteria; Severe dehydration, shock, severe acute malnutrition, bloody stools or illiterate caregivers .
268 patients enrolled.
All patients received ORS 75mls/kg over 4 hours by cup or cup and spoon. Evaluated at 4 hours and management continued as per guidelines.
Intervention group; carers received instruction on how to complete the chart which included how much fluid to give over one hour and advice to give more if not sufficient quantity over that hour
Standard group; no intervention
Dehydration status at 4 hours
Acceptability of fluid monitoring chart
7/122 (5.7%) were still dehydrated following 4 h of ORS administration vs 20/130 (15.4%) in the control group (risk ratio 0.37 [95% confidence interval 0.16–0.85])
The use of fluid monitoring charts reduced the frequency of dehydration and was well accepted by caregivers, representing a promising innovation for the management of diarrhoea and dehydration in resource-limited settings.
Useful clinical question
Simple intervention, easily applied in most low resource settings.
Sensible patient-orientated outcome, resolution of dehydration is presumably something the care-giver cares about, in addition is resource saving if saves admission and more aggressive fluid regimes (nasogastric or intravenous)
Uses standard interventions and definitions for dehydration
Easily implementable in any clinic or hospital
Cheap! No cost effectiveness calculations but one would presume it would be
Plausible difference in levels of dehydration
High literacy rates decreases generalisability
Daytime hours; possible selection bias- however in my experience overnight mild paediatric presentations are less common so not inappropriate.
No blinding of clinicians who were assessing dehydration; this would seem a relatively simple intervention to decrease bias.
The chart seems quite complicated to me; although the care-givers seemed to understand without difficulty
My humble opinion
This small single centre RCT demonstrates a plausible impact on children with mild or moderate dehydration. Certainly in my practice I see lots of children with ORS prescribed but an uncertain amount of fluid actually inside the patient. The chart could be easily adapted to local needs (e.g. made simpler) but I would have concerns about forcing on some care-givers who had limited literacy (it was nice in the study they did not implement with care-givers who seem fearful of it; good acknowledgement of cultural context), however for select populations and care-givers it would be a really simple tool to save nursing time and to enable staff to monitor fluid intake more easily. It would be nice to see a similar RCT in a different context. However, it would be little harm in implementing this strategy if working in context with a significant proportion of children with mild/moderate dehydration who do not improve.