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Editors: Schwartz, M. William; Bell, Louis M.; Bingham, Peter M.; Chung, Esther K.; Friedman, David F.; Mulberg, Andrew E.; Tanel, Ronn E. Title: 5-Minute Pediatric Consult, 4th Edition 2005 Lippincott Williams & Wilkins Copyright

> Tabl e of Content s > Sect ion II - Specific Diseases > Dehydr ation

Dehydration
Marc H. Gorelick

Database DEFINITION

Dehydration is a negative balance of body fluid, usually expressed as a percentage of body weight. Mild, moderate, and severe dehydration correspond to deficits of <5%, 5% to 10%, and >10%, respectively.

Dehydration is classified into three types based on the serum sodium concentration: isotonic (Na 130 to 150 mmol/L), hypotonic (Na <130 mmol/L), and hypertonic (Na >150 mmol/L).

PATHOPHYSIOLOGY
Dehydration is caused by either excessive fluid losses or inadequate intake. Some conditions leading to dehydration include:

Gastrointestinal lossesvomiting, diarrhea (most common cause of dehydration in pediatric patients) Renal lossesdiabetes mellitus, diabetes insipidus, diuretic agents Insensible lossessweating, fever, tachypnea, increased ambient temperature, large burns Poor oral intakestomatitis, pharyngitis, anorexia, oral trauma, altered mental status Note that infants and debilitated patients are at particular risk as a result of lack of ability to satisfy their thirst freely.

EPIDEMIOLOGY
Approximately 10% of children in the United States with acute gastroenteritis develop at least mild dehydration. Although it accounts for 10% of all nonsurgical hospital admissions for children under 5 years of age, up to 90% of cases can be managed on an outpatient basis.

COMPLICATIONS

Severe dehydration may lead to hypovolemic shock and acute renal failure. Hyponatremia is associated with hypotonia, hypothermia, and seizures. Overly rapid correction of hypernatremia can produce cerebral edema.

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PROGNOSIS
Excellent with appropriate rehydration therapy.

Data Gathering HISTORY

Question: Frequency and duration of emesis and/or diarrhea? Significance: This will give a rough estimate of risk of dehydration. Question: Amount and type of liquids taken? Significance: If there were large quantities of water, be alert for hypotonic dehydration. If excessive electrolyte solution used for hydration, may have hypertonic dehydration. Question: Frequency and quantity of urination (may be difficult to estimate in infants with diarrhea)? Significance: Decreased urination indicates possibility of dehydration. Question: Fever? Significance: Fever increases insensible water loss. Question: Exertion or heat exposure? Significance: Increases insensible water loss.

Physical Examination
Acute change in weight is the best indicator of the fluid deficit. If the child's recent preillness weight is not available for comparison, a reasonable estimate of the degree of dehydration may be made from physical findings. Finding: General appearance Significance: Lethargy, irritability, thirst Finding: Vital signs Significance: Tachycardia; orthostatic increase in heart rate or hypotension; hyperpnea Finding: Skin Significance: Prolonged capillary refill at fingertip (<2 seconds is normal in warm environment); mottling; poor turgor Finding: Eyes Significance: Decreased or absent tears; sunken eyes Finding: Mucous membranes Significance: Dry or parched Finding: Anterior fontanelle Significance: Sunken

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DIAGNOSTIC PITFALLS

Physical signs generally appear when the deficit is at least 2% to 3%. No single finding is pathognomonic of dehydration. A reasonable guideline is that the presence of three or more findings indicates at least mild dehydration. The number and severity of physical signs increase with the degree of dehydration. Urine output decreases early in the course of dehydration, and a history of decreased urination is a nonspecific finding. Capillary refill time is a specific indicator, but may be falsely prolonged by cool ambient temperature (<20C [<68F]). It is not affected by fever. Children with a deficit greater than 15% will show signs of cardiovascular instability such as severe tachycardia and hypotension. Physical findings may be more significant for a given degree of dehydration in children with hyponatremia, leading to overestimation of the deficit. Conversely, the clinical picture is reported to be somewhat moderated in hypernatremia.

Laboratory Aids
Diagnosis of dehydration is best made on clinical grounds. The following laboratory tests are sometimes helpful adjuncts. Test: Serum sodium Significance: Classifies type of dehydration. Hyponatremia and hypernatremia are uncommon (<5% of cases). Measure sodium levels in cases of clinically severe disease, or if risk factors are present (e.g., young infant, history of excessive free water intake, children with significant neurologic impairment limiting their ability to regulate their own intake). Test: Rapid glucose test or serum glucose Significance: To detect hypoglycemia as a result of prolonged fasting Test: Urine specific gravity Significance: This is elevated early in dehydration, but may not become elevated at all in young infants or children with sickle cell disease. Test: Serum bicarbonate Significance: This is frequently low with diarrheal illness, even in the absence of dehydration. Useful to detect significant acidosis when dehydration is clinically severe. Test: Blood urea nitrogen (BUN) Significance: Rises only late in dehydration in children. P.317

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Therapy ORAL REHYDRATION THERAPY (ORT)

Most children can be successfully managed with ORT.

Use rehydration solution containing 2% to 2.5% glucose and 75 to 90 mmol/L Na (e.g., WHO solution), or 45 to 50 mmol/L Na (e.g., Pedialyte [Ross Laboratories, Columbus, OH], Infalyte, [Mead Johnson, Evansville, IN]).

Replace entire deficit in 4 to 6 hours for mild dehydration, 50 mL/kg; for moderate to severe dehydration, 80 to 100 mL/kg. Include ongoing losses, approximately 5 mL/kg for each diarrheal stool. Begin with slow administration, with strict limits when vomiting is present 5 mL every 1 to 2 minutes. For infants, use a syringe or spoon rather than a bottle. After 1 hour, if the oral liquids have been tolerated, increase the volume and rate. Have the child's caregiver participate in giving the fluids, and provide education regarding fluid replacement and signs of dehydration. Monitor weight, intake and output, and clinical signs. Failure of ORT includes intractable vomiting, clinical deterioration, or lack of improvement after 4 hours.

INTRAVENOUS FLUID THERAPY

Intravenous fluids are required when ORT fails or is contraindicated, such as in severe dehydration or shock, poor gag or suck, depressed mental status, preterm infant, severe hypernatremia (Na >160 mmol/L), suspected surgical abdomen.

Administer intravenous bolus of normal saline or Ringer lactate, 20 mL/kg, over 10 to 30 minutes. Repeat as needed to restore cardiovascular stability. Avoid dextrose-containing solutions for boluses except to correct documented hypoglycemia.

Calculate maintenance fluid requirements: 100 mL/kg for the first 10 kg, plus 50 mL/kg for the next 10 kg, plus 20 mL/kg over 20 kg. Calculate fluid deficit based on clinical estimate or known weight loss. For isotonic or hypotonic dehydration, give one -third to one-half normal saline with 5% dextrose, at a rate to provide maintenance and replace deficit over 24 hours. For hypertonic dehydration, replace deficit over 48 hours, using one-fifth to one-fourth normal saline with 5% dextrose. Monitor weight, intake and output, and clinical signs. With hypernatremia, measure serum sodium every 4 to 6 hours; do not exceed rate of fall of 1 mmol/L per hour. For mild to moderate isonatremic dehydration, rapid replacement of deficit over 2 to 6 hours may be possible. Give normal saline, or one -half normal saline with 2.5% dextrose, at a rate to replace the estimated deficit at a rate of 25 to 40 cc/kg per hour.

Follow-Up

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After rehydration, children with ongoing losses, as in gastroenteritis, should receive a maintenance solution in addition to regular feedings to maintain a positive fluid balance. Recommend 5 to 10 mL/kg for each diarrheal stool. Avoid clear liquids with excessive glucose, such as fruit juices, punches, and soft drinks, as these can promote osmotic fluid losses in the stool. In infants less than 6 months old, do not give large amounts of plain water, which can lead to hyponatremia.

PREVENTION
Many cases of frank dehydration may be prevented by early institution of adequate oral maintenance fluid therapy in children with gastroenteritis, with particular attention to replacement of ongoing stool losses and slow administration of fluids to children with vomiting. Use of appropriate solutions is essential to prevent electrolyte disturbance and worsening of diarrhea.

Common Questions and Answers

Q: How can an oral rehydration solution be prepared at home? A: An acceptable rehydration solution (2.2% glucose, 70 mmol Na/L) can be prepared with the following: half teaspoon of table salt, half teaspoon of baking soda, and 1 cup of orange juice, added to 3 cups of water. For maintenance solution, decrease the table salt to a quarter teaspoon. Q: Can commercially available maintenance solutions be used for rehydration as well as maintenance? A: Data suggest that reduced-osmolarity maintenance solutions, with a sodium concentration of 45 to 50 mmol/L, are equally effective for rehydration as solutions with a higher sodium content. Q: How can oral rehydration solution be made more palatable? A: Rehydration solutions may be more palatable if iced, or flavored with apple or orange juice (1 part juice to 4 parts rehydration solution) or unsweetened Kool-Aid powder (2.5 mL powder per 240 mL of solution). ICD-9-CM 276.5

Bibliography
American Academy of Pediatrics Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Practice parameter: the management of acute gastroenteritis in young children. Pediatrics 1996;97:424436. Armon K, Stephenson T, MacFaul R, et al. An evidence and consensus based guideline for acute diarrhea management. Arch Dis Child 2001;85 (2):132142. Armon K, Stephenson T, MacFaul R, Eccleston P, Werneke U. An evidence and consensus based guideline for acute diarrhoea management: practice guideline. Review. [Review, Academic] Arch Dis Child 2001;85(2):132142.

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CHOICE Study Group. Multicenter, randomized, double -blind clinical trial to evaluate the efficacy and safety of a reduced osmolarity oral rehydration salts solution in children with acute watery diarrhea. Pediatrics 2001;107 (4):613618. Farthing MJ. Oral rehydration: an evolving solution. J Pediatr Gastroenterol Nutr 2002;34 Suppl 1:S64S67. Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics 1997;99(5):e6. Gorelick MH. Rapid IV rehydration in the emergency department: a systematic review. PEM-Database. Org. Available at http://www.researchinpem.homestead.com/files/rapid_iv_hydration_23.07.doc Accessed February 17, 2004. Kallen RJ. The management of diarrheal dehydration in infants using parenteral fluids. Pediatr Clin North Am 1990;37:265286. Roberts KB. Fluid and electrolytes: parenteral fluid therapy. Pediatr Rev 2001;22(11):380387.

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