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Pediatric Dehydration Treatment & Management

  • Author: Alex Koyfman, MD; Chief Editor: Timothy E Corden, MD  more...
 
Updated: Oct 04, 2015
 

Approach Considerations

Address emergent airway, breathing, and circulatory problems first. Obtain intravenous access, and give a 20 mL/kg isotonic fluid bolus (Ringer lactate or normal saline) to children with severe volume depletion. This should not delay transport to the appropriate facility. Overly aggressive replacement of volume deficits can lead to serious CNS sequelae listed above.

Failure to diagnose appendicitis, intussusception, or small bowel obstruction places patients at risk of serious complications (including death).

Antidiarrheal medications have adverse effects and are generally not necessary.

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Mild Volume Depletion

Patients with minimal to mild volume depletion should be encouraged to continue an age-appropriate diet and adequate intake of oral fluids. Oral rehydration solution (ORS) should be used. Children should be given sips of ORS (5 mL or 1 teaspoon) every 2 minutes.[10] As an estimate for the amount of fluid to replace, the goal should be to drink 10 mL/kg body weight for each watery stool and estimate volume of emesis for each episode of vomiting.[4, 10]

If commercially prepared ORS is not available, the following recipe may be used:

  • In 1 L of water, add 2 level tablespoons of sugar or honey, a quarter teaspoon of table salt (NaCl), and a quarter teaspoon of baking soda (bicarbonate of soda)
  • If baking soda is not available, use another quarter teaspoon of salt instead
  • If available, add one-half cup of orange juice, coconut water, or a mashed ripe banana to the drink
  • The water is safer if boiled, but do not lose time doing this if the child is very ill
  • Before giving the drink, taste it to be sure it is no saltier than tears

Inpatient therapy generally is not indicated for mild volume depletion. However, it is prudent to arrange outpatient follow-up evaluation within 48 hours, with instructions to return sooner if symptoms worsen.

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Moderate Volume Depletion

The literature supports use of oral rehydration for the moderately dehydrated child. Similar outcomes have been achieved in randomized studies comparing ORS with intravenous fluid therapy with fewer complications and higher parent satisfaction in the ORS groups. Moreover, ORS can typically be initiated sooner than IV fluid therapy. However, children must be cooperative and have caregivers available to instruct and administer the oral fluids.[10]

With ORS, patients should receive approximately 50-100 mL/kg body weight over 2-4 hours, again starting with 5 mL every 5 minutes.[4] If the child can tolerate this amount and asks for more fluids, the amount given can gradually be increased. Once the fluid deficit has been corrected, parents should be instructed on how to replace volume losses at home if the child continues to have vomiting or diarrhea.

Children in whom ORS fails should be given a bolus (20 mL/kg) of isotonic fluid intravenously. This may be followed by 1.5-2 times maintenance therapy. Over the next few hours, the patient may be transitioned to oral rehydration as tolerated, at which point the intravenous therapy may be discontinued.

Children with moderate volume depletion may require inpatient treatment if they are unable to tolerate oral fluids despite rehydration. Hospitalization may also be required for treatment of the underlying cause of the fluid deficit.

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Severe Volume Depletion

Patients with severe volume depletion should receive intravenous isotonic fluid boluses (20-60 mL/kg).[4] In children with difficult peripheral access, perform intraosseous or central access promptly. Fluid boluses should be repeated until vital signs, perfusion, and capillary refill have normalized.

If a patient reaches 60-80 mL/kg in isotonic crystalloid boluses and is not significantly improved, consider other causes of shock (eg, sepsis, hemorrhage, cardiac disease). In addition, consider administering vasopressors and instituting advanced monitoring, such as a bladder catheter, central venous pressure, and measuring mixed venous oxygen saturation.

Although physicians typically give normal saline for these initial boluses, it is important to remember to check a bedside glucose level for patients who appear lethargic or altered. Treat hypoglycemia promptly. The appropriate dose is 0.25 g/kg IV (2.5 mL/kg of 10% dextrose or 1 mL/kg of 25% dextrose).

Once vital sign abnormalities are corrected, initiate maintenance fluid therapy plus additional fluid to make up for any continued losses. For the early phase of rehydration, 1.5-2 times maintenance therapy should be adequate. Daily requirements for maintenance fluids can be approximated as follows:

  • If the patient weighs less than 10 kg, give 100 mL/kg/d
  • If the patient weighs less than 20 kg, give 1000 mL/d plus 50 mL/kg/d for each kilogram between 10 and 20 kg
  • If the patient weighs more than 20 kg, give 1500 mL/d, plus 20 mL/kg/d for each kilogram over 20 kg
  • Divide the total by 24 to obtain the hourly rate

Daily fluid requirements may be met using dextrose 5% in half-normal saline solution. For patients with significant hyponatremia or hypernatremia, it is preferable to use dextrose 5% in normal saline. Dextrose is important to include because these patients generally have a notable ketosis.

The emergency physician also should consider daily sodium and potassium requirements as follows:

  • Sodium 2-3 mEq/kg/d
  • Potassium 2-3 mEq/kg/d

Isonatremic and hyponatremic volume depletion states may be treated with normal saline or other isotonic solutions. The goal for correction rates for either hyponatremic or hypernatremic patients should be no more than 1 mEq/L/h to prevent the devastating CNS complications of overrapid correction (central pontine myelinolysis and cerebral edema, respectively). Full correction of severe sodium abnormalities usually should be staged over 24 hours or longer.

Although a potassium deficit is present in all cases of volume depletion, it is not usually clinically significant; few patients with moderate dehydration require supplemental potassium. However, failure to correct for hypokalemia during volume repletion may result in clinically significant hypokalemia.

Add potassium to fluids when the patient has documented hypokalemia. For all other patients, avoid adding potassium to fluids until the patient has received several hours of resuscitation and the patient has demonstrated adequate urine output.

Children with severe volume depletion, especially those with hypernatremia or hyponatremia, require inpatient therapy. Children with severe hyperosmolar states, severe electrolyte derangements, or associated renal failure may require admission to a critical care unit.

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Pharmacologic Therapy

The emergency medicine literature now supports the use of a single dose of oral ondansetron in combination with oral rehydration for patients with dehydration, nausea, and vomiting.[11, 12, 13] However, the use of an antiemetic should not shift the focus away from adequate fluid resuscitation.

Acute gastroenteritis is typically a self-limited condition that does not require antibiotics.[14] Chronic infectious cases of diarrhea may require antimicrobial agents after appropriate stool studies have indicated the etiology.[15] Antidiarrheal agents are not recommended. When dehydration is caused by other disease processes, such as diabetic ketoacidosis or sepsis, appropriate pharmacologic therapy should be initiated as soon as possible.

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Consultations

Infants and children who present to the ED with mild to moderate dehydration may respond to fluid boluses and may be discharged home with close follow-up with their primary care provider. Patients who are severely volume depleted or who are unable to tolerate oral fluids must be admitted, with a pediatric consultation if appropriate.

If the child is in shock, is unable to drink fluids, or does not respond to intravenous bolus therapy, significant abnormalities requiring correction may exist. In such patients, obtain pediatric consultation for admission and further therapy. If renal tubular acidosis or other primary renal or endocrine disorder is suspected, specialty consultation may be indicated.

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Contributor Information and Disclosures
Author

Alex Koyfman, MD Assistant Professor, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Parkland Memorial Hospital

Alex Koyfman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Carrie Ng, MD Resident Physician, Department of Pediatrics, Bellevue Hospital Center, New York University School of Medicine

Carrie Ng, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Institute of Ultrasound in Medicine

Disclosure: Nothing to disclose.

Mark P Foran, MD, MPH Assistant Professor of Emergency Medicine, New York University School of Medicine; Attending Emergency Physician, Bellevue Hospital Center and NYU Langone Medical Center

Mark P Foran, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Richard G Bachur, MD Associate 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.

Ann G Egland, MD Consulting Staff, Department of Operational and Emergency Medicine, Walter Reed Army Medical Center

Ann G Egland, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Association of Military Surgeons of the US, Medical Society of Virginia, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Terrance K Egland, MD Director, Business Planning and Development, Bureau of Medicine and Surgery

Terrance K Egland, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

James Li, MD Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine

Disclosure: Nothing to disclose.

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.

James Kimo Takayesu, MD, MSc Assistant Professor 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, MSc 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.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

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.

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

  2. Singhi SC, Shah R, Bansal A, Jayashree M. Management of a child with vomiting. Indian J Pediatr. 2013 Apr. 80(4):318-25. [Medline].

  3. Glaser NS, Ghetti S, Casper TC, Dean JM, Kuppermann N. Pediatric diabetic ketoacidosis, fluid therapy, and cerebral injury: the design of a factorial randomized controlled trial. Pediatr Diabetes. 2013 Mar 13. [Medline]. [Full Text].

  4. King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21. 52:1-16. [Medline].

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

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

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

  8. Jauregui J, Nelson D, Choo E, Stearns B, Levine AC, Liebmann O, et al. The BUDDY (Bedside Ultrasound to Detect Dehydration in Youth) study. Crit Ultrasound J. 2014. 6 (1):15. [Medline].

  9. Jauregui J, Nelson D, Choo E, Stearns B, Levine AC, Liebmann O, et al. The BUDDY (Bedside Ultrasound to Detect Dehydration in Youth) study. Crit Ultrasound J. 2014. 6(1):15. [Medline]. [Full Text].

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

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

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

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

  14. 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. 1996 Mar. 97(3):424-35. [Medline].

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

  16. Hom J, Sinert R. Evidence-based emergency medicine/systematic review abstract. Comparison between oral versus intravenous rehydration to treat dehydration in pediatric gastroenteritis. Ann Emerg Med. 2009 Jul. 54(1):117-9. [Medline].

 
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Table. Physical Examination Findings in Pediatric Dehydration
Symptom Degree of Dehydration
Mild (< 3% body weight lost) Moderate (3-9% body weight lost) Severe (>9% body weight lost)
Mental status Normal, alert Restless or fatigued, irritable Apathetic, lethargic, unconscious
Heart rate Normal Normal to increased Tachycardia or bradycardia
Quality of pulse Normal Normal to decreased Weak, thready, impalpable
Breathing Normal Normal to increased Tachypnea and hyperpnea
Eyes Normal Slightly sunken Deeply sunken
Fontanelles Normal Slightly sunken Deeply sunken
Tears Normal Normal to decreased Absent
Mucous membranes Moist Dry Parched
Skin turgor Instant recoil Recoil < 2 seconds Recoil >2 seconds
Capillary refill < 2 seconds Prolonged Minimal
Extremities Warm Cool Mottled, cyanotic
Adapted from 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.[4]
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