Porter SC, People feel thirsty, and as dehydration worsens, they may sweat less and excrete less urine. Address correspondence to Amy Canavan, MD, FAAP, Inova Fairfax Hospital for Children, 3300 Gallows Rd., Falls Church, VA 22042 (e-mail: King CK, Porter SC, 1997;13(3):179–182. Copelovitch L. Sarker SA, Vega RM, Skorecki K, Ausiello D. In: Cecil's Medicine. The most useful individual signs for identifying dehydration in children are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern. However, fluid lost always contains a lower concentration of sodium than the plasma. Unlike in adults, calculation of the blood urea nitrogen (BUN)/creatinine ratio is not useful in children. 1. Choose a single article, issue, or full-access subscription. Ann Emerg Med. Hypernatremia (serum sodium level of greater than 145 mEq per L [145 mmol per L]) indicates water loss in excess of sodium loss. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Other sources are renal (eg, diabetic ketoacidosis), cutaneous (eg, excessive sweating, burns), and 3rd-space losses (eg, into the intestinal lumen in bowel obstruction or ileus). Pediatrics. The most useful individual signs for identifying dehydration are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern.5 However, clinical dehydration scales based on a combination of physical examination findings are much better predictors than individual signs.5, In one study, four factors predicted dehydration: capillary refill time of more than two seconds, absence of tears, dry mucous membranes, and ill general appearance; the presence of two or more of these signs indicated a fluid deficit of at least 5 percent.6 In a similar validated scale, general appearance, degree of sunken eyes, dryness of mucous membranes, and tear production were associated with length of hospital stay and need for intravenous fluids in children with acute gastroenteritis.7. Wathen JE, 2004;291(22):2746–2754. Offringa M. However, children with hypernatremia have better hemodynamics (eg, less tachycardia and better urine output) than do children with hyponatremia, in whom fluid has shifted out of the vascular space. Under normal physiologic conditions, water constitutes 70% of lean body mass. Thompson Children's Hospital and a professor in the Department of Pediatrics at the University of Tennessee College of Medicine Chattanooga. Alternatively, the deficit could be replaced during the initial 8 hours followed by the entire day’s maintenance fluid in the next 16 hours (ie, 60 mL/hour); 24 hours of maintenance fluid given in 16 hours reduces mathematically to a rate of 1.5 times the usual maintenance rate and obviates the need for simultaneous infusions (which may require 2 rate-controlling pumps). Additional signs of severe dehydration include circulatory collapse (e.g. Offringa M. Instead, they simply use isotonic fluid for resuscitation and then a single fluid, either 0.9% or 0.45% saline in 5% dextrose, for deficits, ongoing losses, and maintenance. Goals of oral rehydration therapy are restoration of circulating blood volume, restoration of interstitial fluid volume, and maintenance of rehydration. Gorelick MH, Laboratory predictors of fluid deficit in acutely dehydrated children. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. In general, dehydration is defined as follows: Mild: No hemodynamic changes (about 5% body weight in infants and 3% in adolescents), Moderate: Tachycardia (about 10% body weight in infants and 5 to 6% in adolescents), Severe: Hypotension with impaired perfusion (about 15% body weight in infants and 7 to 9% in adolescents). Intestinal transport mechanisms are also the basis for the management of diarrhoea, through oral fluid therapy and feeding. A randomized trial of oral vs intravenous rehydration in a pediatric emergency department. Validation of the clinical dehydration scale for children with acute gastroenteritis. Srivastava R, Dehydration is a frequent reason for emergency room visits and affects at least 2 million children annually.1 Frequently caused by gastroenteritis, dehydration may result in serious morbidity and mortality. Atherly-John YC, Stool electrolyte content and purging rates in diarrhea caused by rotavirus, enterotoxigenic. Stabilization often requires up to 60 mL per kg of fluid within an hour.25 Electrolyte measurement should be performed in all children with severe dehydration and considered in those with moderate dehydration because it may be difficult to predict which children have significant electrolyte abnormalities.27 After resuscitation is completed and normal electrolyte levels are achieved, the patient should receive 100 mL per kg of ORT solution over four hours, then maintenance fluid and replacement of ongoing losses. weak rapid pulse, cool or blue extremities, hypotension), rapid breathing, sunken anterior fontanelle. Effect of fever on capillary refill time. Armon K, This causes an imbalance of electrolytes, which are nutrients the body needs to properly function. J Pediatr. Shaw KN, If dehydration is … Although this process aids understanding of the pathophysiology of fluid balance, in practice, many pediatric centers no longer calculate precise electrolyte requirements. Children with persistent fever may require 1 mL per kg per degree centigrade every hour, in addition to the calculated maintenance therapy. Infants are particularly susceptible to the ill effects of dehydration because of their greater baseline fluid requirements (due to a higher metabolic rate), higher evaporative losses (due to a higher ratio of surface area to volume), and inability to communicate thirst or seek fluid. Thus, in the absence of any fluid replacement, serum sodium rises (hypernatremia). Pediatrics. Alessandrini EA, Due to water retention and drinking following stimulation of ADH secretion and thirst, osmoregulation is overruled by volume conservatory mechanisms, which lead to hyponatremia. Dehydration in neonates, particularly with significant hypernatremia (eg, serum sodium > 160 mEq/L [> 160 mmol/L]) or hyponatremia (eg, serum sodium < 120 mEq/L [< 120 mmol/L]), requires special consideration to avoid complications. This residual amount is given over the next 24 hours. Symptoms and signs include thirst, lethargy, dry mucosa, decreased urine output, and, as the degree of dehydration progresses, tachycardia, hypotension, and shock. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. 1981;98(5):835–838. The Merck Manual was first published in 1899 as a service to the community. 2007;92(6):546–550. Pediatrics. Definition of Diarrhea Diarrhea is the passage of loose or watery stools at least 3 times in a 24- hour period. Oct 04, 2020 water and electrolytes in pediatrics physiology pathophysiology and management Posted By Ann M. MartinPublic Library TEXT ID 7783ca55 Online PDF Ebook Epub Library the prescription of fluid and electrolyte therapy is a common task for the pediatric clinician the clinical situations requiring such therapy are myriad and range from the urgent in cases of children with Rectal temperature is 37° C. Serum measurements are sodium, 136 mEq/L (136 mmol/L); potassium, 4 mEq/L (4 mmol/L); chloride, 104 mEq/L (104 mmol/L); and bicarbonate, 20 mEq/L (20 mmol/L). et al. Total deficit volume is estimated clinically as described previously. Spandorfer PR, However, if the parents report normal tear production, the chance of dehydration is low.2,3, Comparing change in body weight from before and after rehydration is the standard method for diagnosing dehydration.4 To identify dehydration in infants and children before treatment, a number of symptoms and clinical signs have been evaluated and compared with this standard method. DeWalt DA, 20. Clinical dehydration scales based on a combination of physical examination findings are the most specific and sensitive tools for accurately diagnosing dehydration in children and categorizing its severity. Oral rehydration solution without bicarbonate. Water routinely leaves the human body through sweat, breath and urine. 2006;354(16):1698–1705. Copelovitch L. 1984;59(11):1072–1075. Because sodium is restricted to the extracellular fluid space, the typical signs of dehydration are less pronounced in the setting of hypernatremia, and significant circulatory disturbance is not likely to be noted until dehydration reaches 10 percent. This may occur in hypovolemic children with low ECF volume, normovolemic patients with inappropriately increased ADH secretion, and also in hypervolemic individuals with decreased effective circulating volume and … Reid SR, Pediatric Advanced Life Support Provider Manual Dallas, Tex: American Heart Association; 2006: 232. The resuscitation phase should reduce moderate or severe dehydration to a deficit of about 8% body weight. The extracellular fluid space has two components: plasma and lymph as a delivery system, and interstitial fluid for solute exchange.13 The goal of rehydration therapy is first to restore the circulating blood volume, if necessary; then to restore the interstitial fluid volume; and finally to maintain hydration and replace continuing losses, such as diarrhea and increased insensible losses caused by fever. This amount replaces the sodium deficit (when using 0.45% saline, 0.8 L × 77 mEq sodium/L [77 mmol/L] = 62 mEq sodium); the additional 62 mEq of sodium given by using 0.9% saline is not clinically significant as long as renal function is intact. Pediatr Nephrol. Shaw KN. Parents are also more satisfied with the visit when ORT had been used.16 With ORT, the same fluid can be used for rehydration, maintenance, and replacement of stool losses; and ORT can be initiated more quickly than intravenous fluid therapy.17, The principles of ORT to treat dehydration from gastroenteritis apply to the treatment of dehydration from other causes. 8. Bollen CW, Ahmed SM. Antidiuretic hormone (ADH) release can also occur in response to vascular volume and not osmolarity (nonosmotic ADH release). Capillary refill time is performed in warm ambient temperature, and is measured on the sternum of infants and on a finger or arm held at the level of the heart in older children. Atherly-John YC, © 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA), Cystic Fibrosis: Defective Chloride Transport, © 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, Maintenance Fluid Calculation for Children, Holliday-Segar Formula for Maintenance Fluid Requirements by Weight, Musculoskeletal and Connective Tissue Disorders, Nausea and Vomiting in Infants and Children. David A. Goff, MD 2. Rahman O, Development of a clinical dehydration scale for use in children between 1 and 36 months of age. Gorelick MH, Friedman AL, Of the extracellular fluid, 75% is interstitial and 25% is intravascular. If dehydration isn't treated it can get worse and become a serious problem. The estimated residual sodium deficit is 54 mEq (80 − 26 mEq). 13. Decreased fluid intake is common during mild illnesses such as pharyngitis or during serious illnesses of any kind. 19. 2008;122(3):545–549. Shaw KN, Pharmacologic agents are not recommended to decrease diarrhea because of limited evidence and concern for toxicity. 18. Murphy KO. Likewise, when parents are asked about physical signs of dehydration, a number of positive answers suggest dehydration. 11. 7(October 1, 2009) Dehydration is a common complication of illness observed in pediatric patients presenting to the emergency department (ED). Bennish ML, Friedman JN, Islam MR, For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.xml. Bos AP, In infants, the proportion is approximately 75%. For children between these age ranges, clinicians must estimate values between those for infants and those for adolescents based on clinical judgment. Although the normal BUN level is the same for children and adults, the normal serum creatinine level changes with age (0.2 mg per dL [17.68 μmol per L] in infants to 0.8 mg per dL [70.72 μmol per L] in adolescents). Crain EF. 1957;19(5):816–822. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Parkin PC. The severity of dehydration ranges from mild to severe and can be fatal when fluid loss exceeds more than 15% of total body water content. King CK, Copyright © 2020 American Academy of Family Physicians. Traditional rehydration calculations aim to precisely estimate electrolyte losses and select replacement fluids that provide that specific amount. 1,000 mL, plus 50 mL per kg for each kg between 11 and 20 kg, 40 mL, plus 2 mL per kg for each kg between 11 and 20 kg, 1,500 mL, plus 20 mL per kg for each kg over 20 kg, 60 mL, plus 1 mL per kg for each kg over 20 kg. Because 0.45% saline has 77 mEq sodium per liter (77 mmol/L), it is usually an appropriate fluid choice, particularly in children with diarrhea because the electrolyte content of diarrhea is typically 50 to 100 mEq/L (50 to 100 mmol/L—see Table: Estimated Electrolyte Deficits by Cause); 0.9% saline may be used as well. Sarker SA, Conley SB. 28. This site complies with the HONcode standard for trustworthy health information: Dehydration is a symptom or sign of another disorder, most commonly diarrhea. Friedman AL, 1. 2006;32(7):995–1003. The trusted provider of medical information since 1899, Dehydration and Fluid Therapy in Children, Obsessive-Compulsive Disorder (OCD) and Related Disorders in Children and Adolescents, Adolescent patients who have obsessive-compulsive disorder (OCD) are most likely to also have which of the following. Brody School of Medicine East Carolina University Greenville, NC Common Electrolyte Problems in Pediatrics—Hypernatremia. Five percent dextrose/0.45% saline (or 5% dextrose/0.9% saline) also is used to replace ongoing losses; volume and rate are determined by the amount of diarrhea. Failure rate of nasogastric tube placement is significantly less than that of intravenous lines, and significant complications of nasogastric tube placement are rare. Friedman JN, JAMA. 2. Pediatrics. Table 1 compares the electrolyte composition of commercial electrolyte solutions with other clear liquids. A single dose of ondansetron (Zofran) may facilitate ORT in children with dehydration. If dehydration is moderate, 20 mL/kg (2% body weight) is given IV over 20 to 30 minutes, reducing a 10% deficit to 8%. In: Pediatric Hospital Medicine. 1990;37(2):365–372. This does not worsen the symptoms of mild diarrhea, and may decrease its duration.14. The fluid used is 5% dextrose/0.45% saline or 5% dextrose/0.9% saline. CausesCauses Diarrhea Vomiting Excessive Sweating Diabetes Burns Excessive blood loss caused by trauma or accident 3. Dehydration remains a major cause of morbidity and mortality in infants and young children worldwide. Meyers A, Previous: Same-Day Initiation of Hormonal Contraceptives, Home Alessandrini EA, Diagnosis and Management of Dehydration in Children. What is Pediatric Dehydration? 27. Holliday MA, Armon K, However, clinical dehydration scales based on a combination of physical examination findings are better predictors than individual signs. MMWR Recomm Rep. Rahman M, 4. Pediatrics. Eccleston P, Laron Z. Rahman O, Ongoing electrolyte losses can be estimated by source or cause (see Table: Estimated Electrolyte Deficits by Cause). The main cause of pediatric hyponatremia is an abundance of free water. Dehydration is treated with fluids containing electrolytes, such as sodium and chloride. Mondolfi A. When urine output is established, potassium is added at a concentration of 20 mEq/L (20 mmol/L; for safety reasons, no attempt is made to replace complete potassium deficit acutely). This content is owned by the AAFP. Output is more than input. Duggan C, Overdiagnosis of dehydration may lead to unnecessary tests and treatment, whereas underdiagnosis may lead to increased morbidity (e.g., protracted vomiting, electrolyte disturbances, acute renal insufficiency). Oral rehydration therapy is the preferred treatment of mild to moderate dehydration caused by diarrhea in children. Reprints are not available from the authors. Murphy KO, Spandorfer PR, Clear sodas and juices are not recommended because hyponatremia may occur, This method can be further simplified to provide maintenance ORT at home: 1 oz per hour for infants, 2 oz per hour for toddlers, and 3 oz per hour for older children. 12. Vomiting, diarrhea, excessive sweating, burns, kidney failure, and use of diuretics may cause dehydration. 2003;18(11):1152–1156. Volume of ongoing losses should be measured directly (eg, nasogastric tube, catheter, stool measurements) or estimated (eg, 10 mL/kg per diarrheal stool). Severe dehydration should be treated with intravenous fluids until the patient is stabilized (i.e., circulating blood volume is restored). 1988;113(4):654–660. Segar WE. At home, caregivers should provide maintenance therapy and replace ongoing losses every two hours as described for mild dehydration. Parkin PC. This may be because you haven't drunk enough fluid to replace the fluids you have lost, such as when sweating or in your wee (urine). Other electrolytes (eg, magnesium, calcium) are not routinely added. Dehydration remains a major cause of morbidity and mortality in infants and young children worldwide. Cost to the family may be a deterrent to home ORT; therefore, ORT solution provided by the physician's office or emergency department increases the likelihood that parents will use ORT and reduces unscheduled follow-up visits.16, Nasogastric rehydration therapy with ORT solution is an alternative to intravenous fluid therapy in patients with poor oral intake. Electrolyte losses resulting from diarrhea in a eunatremic patient (see Table: Estimated Electrolyte Deficits by Cause) are an estimated 80 mEq of sodium and 80 mEq of potassium. N Engl J Med. Sampson A, These nutrients include calcium, chloride, magnesium, phosphate, potassium and sodium. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Bos AP, The patients were referred to the investigators by Joffe MD, American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Usefulness of the serum electrolyte panel in the management of pediatric dehydration treated with intravenously administered fluids. Islam MR, Patients with signs of hypoperfusion should receive fluid resuscitation with boluses of isotonic fluid (eg, 0.9% saline or Ringer's lactate). Administration. Lasche J, 1996;97(3):424–435. Pediatrics. Nager AL, Bresee JS, Mandl KD. verify here. The rotavirus vaccine has … 2009 Oct 1;80(7):692-696. Bonadio WA. This amount replaces 26 mEq of the estimated 80 mEq sodium deficit. Wang VJ. From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world. If parents report that the child does not have diarrhea, has normal oral intake, and has normal urine output, the chance of dehydration is low. Adams W, Typically, half (400 mL) is given over the first 8 hours (400 ÷ 8 = 50 mL/hour) and the other half is given over the next 16 hours (25 mL/hour). Crain EF. Dehydration means that a child's body lacks enough fluid. Sodium deficits are usually about 60 mEq/L (60 mmol/L) of fluid deficit, and potassium deficits are usually about 30 mEq/L (30 mmol/L) of fluid deficit. If severe dehydration is present, a child with hypernatremia or hyponatremia should receive isotonic crystalloid until stabilized. Goldman RD, A prospective study of the usefulness of clinical and laboratory parameters for predicting percentage of dehydration in children. Shaw KN, Sack DA, Intensive Care Med. Bollen CW, font size decrease font size increase font size; Print; Email; Dehydration reveals itself through numerous body signals, such as thirst, dizziness, and low energy. Assadi F, 21. Oral rehydration solution without bicarbonate. The value of parental report for diagnosis and management of dehydration in the emergency department. Pediatr Clin North Am. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. If dehydration is severe, 3 boluses of 20 mL/kg (6% body weight) may be required. The most common acid-base derangement that occurs with volume depletion, especially in infants, is metabolic acidosis. The traditional approach to calculating the composition of maintenance fluids was also based on the Holliday-Segar formula. If ORT fails after initial resuscitation of a child with severe dehydration, intravenous fluid therapy should be initiated. Sign up for the free AFP email table of contents. 1999;13(4):292–297. 2008;23(5):677–680. Effect of fever on capillary refill time. † These findings are for patients with a serum sodium level in the normal range; clinical manifestations may differ with hypernatremia and hyponatremia. 1997;13(5):305–307. Early signs: precipitating conditions in which fluid loss are likely to occur, including diarrhea, vomiting, burns, diabetes, trauma, and fever. Severe hypernatremic dehydration induces brain shrinkage, which can tear cerebral blood vessels, leading to cerebral hemorrhage, seizures, paralysis, and encephalopathy. Salam MA. Fluid therapy for children: facts, fashions and questions. 1996;28(3):318–323. 1997;99(5):E6. Murphy KO, Findings that may aid in the diagnosis of hypernatremia in children include a “doughy” feeling rather than tenting when testing for skin turgor, increased muscle tone, irritability, and a high-pitched cry.31 Hyponatremia is often caused by inappropriate use of oral fluids that are low in sodium, such as water, juice, and soda. It can be administered at home, reducing the need for outpatient and emergency department visits; requires less emergency department staff time; and leads to shorter emergency department stays. Murphy KO. In one study, blood glucose levels of less then 60 mg per dL (3.33 mmol per L) were detected in 9 percent of children younger than nine years (mean age 18 months) admitted to the hospital with diarrhea.27 History and physical examination findings did not indicate that these children were at risk; therefore, blood glucose screening may be indicated for toddlers with diarrhea. Werneke U. The most common estimate is the Holliday-Segar formula, which uses patient weight to calculate metabolic expenditure in kcal/24 hours, which approximates fluid needs in mL/24 hours (see Holliday-Segar Formula for Maintenance Fluid Requirements by Weight). Dehydration is a general state in which there is a total-body fluid deficit. Diagnosis is based on history and physical examination. Simplified treatment strategies to fluid therapy in diarrhea [published correction appears in. Yates EW, This method also may be used when a child with moderate dehydration fails ORT. Laboratory testing is usually reserved for moderately or severely ill children, in whom electrolyte disturbances (eg, hypernatremia, hypokalemia, metabolic acidosis or metabolic alkalosis) are more common, and for children who need IV fluid therapy. The value of parental report for diagnosis and management of dehydration in the emergency department. Assadi F, Stool electrolyte content and purging rates in diarrhea caused by rotavirus, enterotoxigenic E. coli, and V. cholerae in children. Am Fam Physician. However, this method depends on knowing a precise, recent preillness weight. Pathophysiology of dehydration 4. 219 Bryant Street, Buffalo, New York 14222 Laboratory Tests in the Analysis of States of Dehydration Erika Bruck, M.D. Hypernatremia causes water to shift from the intracellular and interstitial space into the intravascular space, helping, at least temporarily, to maintain vascular volume. Steiner MJ, 6. Validation of the clinical dehydration scale for children with acute gastroenteritis. Gorelick MH, Usefulness of the serum electrolyte panel in the management of pediatric dehydration treated with intravenously administered fluids. Powell EC. Dehydrated children with hyponatremia may appear only mildly dehydrated but are actually closer to hypotension and cardiovascular collapse than are equally dehydrated children with elevated or normal sodium levels. Molla A. Dehydration is a symptom or sign of another disorder, most commonly diarrhea. Glass R, Ray PE, Parkin PC. Clinical findings of dry mucous membranes, poor skin turgor, markedly decreased urine output, and tachycardia with normal blood pressure and capillary refill suggest 10% fluid deficit. BUN alone and urine specific gravity also have poor sensitivity and specificity for predicting dehydration in children.10, In combination with a clinical dehydration scale, a serum bicarbonate level of less than 17 mEq per L (17 mmol per L) may improve sensitivity of identifying children with moderate to severe hypovolemia.11 Additionally, a serum bicarbonate level of less than 13 mEq per L (13 mmol per L) is associated with increased risk of failure of outpatient rehydration efforts.12. Shaw KN, The infant is currently producing 1 diarrheal stool every 3 hours and refusing to drink. Learn more about our commitment to Global Medical Knowledge. Extracellular fluid restoration in dehydration: a critique of rapid versus slow. Plan of Study Patients admitted to the Children's Hospital of Buffalo with dehydration and a concentration of sodium in the serum above 150 mEq/liter were admitted to the study. Nitrogen ( BUN ) /creatinine ratio is not after initial resuscitation of a clinical scales. Medicine Chattanooga, Salam MA in those with moderate dehydration in children with severe dehydration and resolve in. Predictors than individual signs for identifying dehydration in children with persistent fever may require 1 mL per per! Guideline for acute diarrhoea management are rare the loss of commercial electrolyte solutions with other liquids... Intravascular space into the interstitium at the expense of vascular volume and not osmolarity ( nonosmotic release. Decreased oral intake is particularly problematic when the child is vomiting or when,... Children with dehydration by mouth an imbalance of electrolytes, which are nutrients body! An abundance of free water dehydrated children. ) for trustworthy health information: verify here producing diarrheal.: what it is the preferred treatment of mild diarrhea, or decreased oral intake sensitive! 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