eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Dehydration: Differential Diagnoses & Workup

Author: Alison Wiley Lozner, MD, Resident Physician, Harvard Affiliated Emergency Medicine Residency, Brigham and Women's Hospital; Clinical Fellow in Emergency Medicine, Harvard Medical School
Coauthor(s): James Kimo Takayesu, MD, Instructor in Surgery, Director of Undergraduate Medical Education, Consulting Staff, Massachusetts General Hospital; Associate Residency Director, Harvard Affiliated Emergency Medicine Residency Partners
Contributor Information and Disclosures

Updated: Feb 5, 2009

Differential Diagnoses

Diabetic Ketoacidosis
Pediatrics, Gastroenteritis
Fever in the Neonate and Young Child
Pediatrics, Gastrointestinal Bleeding
Heat Exhaustion and Heatstroke
Pediatrics, Intussusception
Hypernatremia
Pediatrics, Pyloric Stenosis
Hyperosmolar Hyperglycemic Nonketotic Coma
Shock, Hemorrhagic
Hypokalemia
Shock, Hypovolemic
Hyponatremia
Shock, Septic
Metabolic Acidosis
Toxicity, Salicylate
Pediatrics, Dehydration
Pediatrics, Diabetic Ketoacidosis
Pediatrics, Fever

Workup

Laboratory Studies

Laboratory studies are of limited utility in cases of mild dehydration. However, they should be considered under certain conditions.

  • Consider a fingerstick to check serum glucose level if either hyperglycemia or hypoglycemia is suspected.
  • Consider checking serum electrolytes in the moderately dehydrated child if the history or physical examination findings is inconsistent with straightforward gastroenteritis.
  • Check serum electrolyte levels in all children with severe dehydration and in those receiving intravenous fluids.
  • Pursue appropriate testing when a diagnosis other than straightforward gastroenteritis is suspected.
For children who are in profound hypovolemic shock, the following studies are recommended:
  • Basic metabolic panel: Serum electrolyte levels are important to determine sodium concentration, which can guide replenishment therapy. Bicarbonate and potassium levels also are important to assess the degree of metabolic acidosis and to screen for coexisting hypokalemia. Blood urea nitrogen and creatinine levels measure renal function and intravascular volume. Glucose level may reveal hyperglycemia or hypoglycemia.
  • Venous blood gas: Venous blood gas measurements are indicated in patients with severe volume depletion. Serum pH provides a more direct measure of acidosis than the calculated bicarbonate level.
  • Lactic acid: Serum lactate level is indicative of tissue perfusion and oxygenation. It may be helpful in cases of severe dehydration or sepsis.
  • Complete blood cell count: CBC may be helpful in cases in which dehydration is due to sepsis or hemorrhage.
  • Urinalysis: Urine specific gravity indicates the degree of volume depletion and may reveal an underlying infectious etiology.

Procedures

Prior to vascular access attempts, consider oral rehydration in mild and moderate dehydration.

  • Intravenous access: Typical sites include superficial veins in the dorsum of the hand, antecubital fossa (median cephalic or basilic veins), dorsum of the foot, and scalp veins.
  • Intraosseous access
    • Use intraosseous access if attempts to start percutaneous intravenous lines are unsuccessful.
    • Typical sites are the proximal tibia and the distal femur.
  • Central venous access
    • Typical sites are femoral, external jugular (may be difficult because of short neck in infants and young children), subclavian, and antecubital veins.
    • Umbilical vein catheterization may be difficult and usually is not recommended for neonates who have been discharged from the hospital and are returning to the ED.
  • Venous cutdown
    • Use venous cutdown for emergent access and resuscitation only. Safe performance depends on the skill of the provider.
    • The typical site is the distal saphenous vein, which is anterior and superior to the medial ankle malleolus.

More on Pediatrics, Dehydration

Overview: Pediatrics, Dehydration
Differential Diagnoses & Workup: Pediatrics, Dehydration
Treatment & Medication: Pediatrics, Dehydration
Follow-up: Pediatrics, Dehydration
References
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References

  1. King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. Nov 21 2003;52(RR-16):1-16. [Medline].

  2. [Best Evidence] Spandorfer PR, Alessandrini EA, Joffe MD, Localio R, Shaw KN. Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial. Pediatrics. Feb 2005;115(2):295-301. [Medline].

  3. [Best Evidence] Freedman SB, Adler M, Seshadri R, Powell EC. Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med. Apr 20 2006;354(16):1698-705. [Medline].

  4. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Dec 13 2005;112(24 Suppl):IV1-203. [Medline].

  5. [Best Evidence] Alhashimi D, Alhashimi H, Fedorowicz Z. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev. Oct 18 2006;CD005506. [Medline].

  6. American Academy of Pediatrics. Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics. Mar 1996;97(3):424-35. [Medline].

  7. Barkin RM, Ward DG. Infectious diarrheal disease and dehydration. In: Marx JA. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 3. 6th ed. Philadelphia, Pa: Mosby/Elsevier; 2006:2623-34.

  8. Bezerra JA, Stathos TH, Duncan B, Gaines JA, Udall JN Jr. Treatment of infants with acute diarrhea: what's recommended and what's practiced. Pediatrics. Jul 1992;90(1 Pt 1):1-4. [Medline].

  9. Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA. 1991;266(9):1242-5. [Medline].

  10. De Bruin WJ, Greenwald BM, Notterman DA. Fluid resuscitation in pediatrics. Crit Care Clin. Apr 1992;8(2):423-38. [Medline].

  11. Holliday M. The evolution of therapy for dehydration: should deficit therapy still be taught?. Pediatrics. Aug 1996;98(2 Pt 1):171-7. [Medline].

  12. Idris AH, Melker RJ. High-flow sheaths for pediatric fluid resuscitation: a comparison of flow rates with standard pediatric catheters. Pediatr Emerg Care. Jun 1992;8(3):119-22. [Medline].

  13. Kallen RJ, Lonergan JM. Fluid resuscitation of acute hypovolemic hypoperfusion states in pediatrics. Pediatr Clin North Am. Apr 1990;37(2):287-94. [Medline].

  14. Kersten H. Oral ondansetron decreases the need for intravenous fluids in children with gastroenteritis. J Pediatr. Nov 2006;149(5):726. [Medline].

  15. Lozon MM. Pediatric vascular access and blood sampling techniques. In: Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia: WB Saunders; 2004:357-8.

  16. Mange K, Matsuura D, Cizman B, et al. Language guiding therapy: the case of dehydration versus volume depletion. Ann Intern Med. Nov 1 1997;127(9):848-53. [Medline].

  17. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?. JAMA. Jun 9 2004;291(22):2746-54. [Medline].

  18. Wathen JE, MacKenzie T, Bothner JP. Usefulness of the serum electrolyte panel in the management of pediatric dehydration treated with intravenously administered fluids. Pediatrics. Nov 2004;114(5):1227-34. [Medline].

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Further Reading

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Keywords

dehydration, dehydration in kids, dehydration in baby, dehydration symptoms, dehydration treatment, water loss, fluid loss, diarrhea, vomiting, volume depletion, hypovolemia, fluid deficit

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Contributor Information and Disclosures

Author

Alison Wiley Lozner, MD, Resident Physician, Harvard Affiliated Emergency Medicine Residency, Brigham and Women's Hospital; Clinical Fellow in Emergency Medicine, Harvard Medical School
Alison Wiley Lozner, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

James Kimo Takayesu, MD, Instructor in Surgery, Director of Undergraduate Medical Education, Consulting Staff, Massachusetts General Hospital; Associate Residency Director, Harvard Affiliated Emergency Medicine Residency Partners
James Kimo Takayesu, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Sigma Xi, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

James Li, MD, Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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