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Dehydration Treatment & Management

  • Author: Lennox H Huang, MD, FAAP; Chief Editor: Timothy E Corden, MD  more...
Updated: Dec 31, 2015

Medical Care

Hydration and nutrition are the interventions with the greatest impact on the course of acute diarrhea.[12]

Medications such as loperamide, opiates, anticholinergics, bismuth subsalicylate, and adsorbents are not recommended in dehydration because of questionable efficacy and potential adverse effects.

Severe dehydration warrants hospital admission for rehydration with isotonic saline, as do hypernatremic or hyponatremic states.[12]

Inability to tolerate oral rehydration therapy (ORT) may necessitate hospital admission for nasogastric or intravenous fluid therapy.

Oral rehydration solutions

During gastroenteritis, the intestinal mucosa retains absorptive capacity. Sodium and glucose in the correct proportions can be passively cotransported with fluid from the gut lumen into the circulation. Rapid oral rehydration with the appropriate solution has been shown to be as effective as intravenous fluid therapy in restoring intravascular volume and correcting acidosis.

Table 3. Composition of Appropriate Oral Rehydration Solutions (Open Table in a new window)

Solution Carbohydrate (g/dL) Sodium (mEq/L) Potassium (mEq/L) Base (mEq/L) Osmolality
Pedialyte 2.5 45 20 30 250
Infalyte 3 50 25 30 200
Rehydralyte 2.5 75 20 30 310
WHO/UNICEF* 2 90 20 30 310
* World Health Organization/United Nations Children's Fund

All of the commercially available rehydration fluids are acceptable for oral rehydration therapy (ORT). They contain 2-3 g/dL of glucose, 45-90 mEq/L of sodium, 30 mEq/L of base, and 20-25 mEq/L of potassium. Osmolality is 200-310 mOsm/L.

In children with severe acute malnutrition and diarrhea, low osmolarity oral rehydration solution (ORS) (osmolarity: 245, sodium: 75 mEq/L) with added potassium (20 mmol/L) appears to be equally effective for successful rehydration as modified World Health Organization–recommended rehydration solution (ReSoMal) (osmolarity: 300, sodium: 45 mEq/L) but achieves rehydration more quickly.[13]  Both solutions also correct for hypokalemia, but hyponatremia may affect fewer children with the low-osmolarity ORS formultion. These findings indicate that the low osmolarity ORS may be an option in regions where ReSoMal is not available (eg, India).[13]

Table 4. Composition of Inappropriate Oral Rehydration Solutions (Open Table in a new window)

Solution Carbohydrate (g/dL) Sodium (mEq/L) Potassium (mEq/L) Base (mEq/L) Osmolality
Apple juice 12 0.4 26 0 700
Ginger ale 9 3.5 0.1 3.6 565
Milk 4.9 22 36 30 260
Chicken broth 0 2 3 3 330

Traditional clear fluids are not appropriate for ORT. Many contain excessive concentrations of CHO and low concentrations of sodium. The inappropriate glucose-to-sodium ratio impairs water absorption, and the large osmotic load creates an osmotic diarrhea, further worsening the degree of dehydration.

ORT for mild or moderate dehydration

Mild or moderate dehydration can usually be treated very effectively with ORT.[14]

Vomiting is generally not a contraindication to ORT. If evidence of bowel obstruction, ileus, or acute abdomen is noted, then intravenous rehydration is indicated.

Calculate the fluid deficit. Physical findings consistent with mild dehydration suggest a fluid deficit of 5% of body weight in infants and 3% in children. Moderate dehydration occurs with a fluid deficit of 5-10% in infants and 3-6% in children (see Table 1 and Table 2). The fluid deficit should be replaced over 4 hours.

The oral rehydration solution should be administered in small volumes very frequently to minimize gastric distention and reflex vomiting. Generally, 5 mL of oral rehydration solution every minute is well tolerated. Hourly intake and output should be recorded by the caregiver. As the child becomes rehydrated, vomiting often decreases and larger fluid volumes may be used.

If vomiting persists, infusion of oral rehydration solution via a nasogastric tube may be temporarily used to achieve rehydration. Intravenous fluid administration (20-30 mL/kg of isotonic sodium chloride 0.9% solution over 1-2 h) may also be used until oral rehydration is tolerated. According to a Cochrane systematic review, for every 25 children treated with ORT for dehydration, one fails and requires intravenous therapy.[15]

Replace ongoing losses from stools and emesis (estimate volume and replace) in addition to replacing the calculated fluid deficit.

An age appropriate diet may be started as soon as the child is able to tolerate oral intake.

Severe dehydration

Laboratory evaluation and intravenous rehydration are required. The underlying cause of the dehydration must be determined and appropriately treated.

Phase 1 focuses on emergency management. Severe dehydration is characterized by a state of hypovolemic shock requiring rapid treatment. Initial management includes placement of an intravenous or intraosseous line and rapid administration of 20 mL/kg of an isotonic crystalloid (eg, lactated Ringer solution, 0.9% sodium chloride). Additional fluid boluses may be required depending on the severity of the dehydration. The child should be frequently reassessed to determine the response to treatment. As intravascular volume is replenished, tachycardia, capillary refill, urine output, and mental status all should improve. If improvement is not observed after 60 mL/kg of fluid administration, other etiologies of shock (eg, cardiac, anaphylactic, septic) should be considered. Hemodynamic monitoring and inotropic support may be indicated.

Phase 2 focuses on deficit replacement, provision of maintenance fluids, and replacement of ongoing losses. Maintenance fluid requirements are equal to measured fluid losses (urine, stool) plus insensible fluid losses. Normal insensible fluid loss is approximately 400-500 mL/m2 body surface area and may be increased by factors such as fever and tachypnea.

Alternatively, daily fluid requirements may be roughly estimated as follows:

  • Less than 10 kg = 100 mL/kg
  • 10-20 kg = 1000 + 50 mL/kg for each kg over 10 kg
  • Greater than 20 kg = 1500 + 20 mL/kg for each kg over 20 kg

Severe dehydration by clinical examination suggests a fluid deficit of 10-15% of body weight in infants and 6-9% of body weight in older children. The daily maintenance fluid is added to the fluid deficit. In general, the recommended administration is one half of this volume administered over 8 hours and administration of the remainder over the following 16 hours. Continued losses (eg, emesis, diarrhea) must be promptly replaced.

If the child is isonatremic (130-150 mEq/L), the sodium deficit incurred can generally be corrected by administering the fluid deficit plus maintenance as 5% dextrose in 0.45-0.9% sodium chloride. Potassium (20 mEq/L potassium chloride) may be added to maintenance fluid once urine output is established and serum potassium levels are within a safe range.

An alternative approach to the deficit therapy approach is rapid replacement therapy. With this approach, a child with severe isonatremic dehydration is administered 20-40 mL/kg of isotonic sodium chloride solution or lactated Ringer solution over 15-60 minutes. As perfusion is restored, the child improves and is able to tolerate an oral rehydration solution for the remainder of his rehydration. This approach is not appropriate for hypernatremic or hyponatremic dehydration.

Hyponatremic dehydration

Phase 1 management of hyponatremic dehydration is identical to that of isonatremic dehydration. Rapid volume expansion with 20 mL/kg of isotonic (0.9%) sodium chloride solution or lactated Ringer solution should be administered and repeated until perfusion is restored.

Severe hyponatremia (< 130 mEq/L) indicates additional sodium loss. In phase 2 management, rehydration is calculated as for isonatremic dehydration. The additional sodium deficit must be calculated and added to the rehydration fluids. The deficit may be calculated to restore the sodium to 130 mEq/L and administered over 24 hours, as follows:

  • Sodium deficit = (sodium desired - sodium actual) X volume of distribution X weight (kg)
  • Example: Sodium = 123, weight = 10 kg, assumed volume of distribution of 0.6; Sodium deficit = (130-123) X 0.6 X 10 kg = 42 mEq sodium

A simplified approach is to use 5% dextrose in 0.9% sodium chloride as the replacement fluid. The sodium is closely monitored, and the amount of sodium in the fluid is adjusted to maintain a slow correction (< 0.5 mEq/L/h).

Frequently reassessing the serum sodium level during correction is imperative. Rapid correction of chronic hyponatremia (>2 mEq/L/h) has been associated with central pontine myelinolysis. Rapid partial correction of symptomatic hyponatremia has not been associated with adverse effects. Therefore, if the child is symptomatic (seizures), a more rapid partial correction is indicated. Hypertonic (3%) sodium chloride solution (0.5 mEq/mL) may be used for rapid partial correction of symptomatic hyponatremia. A bolus dose of 4 mL/kg raises the serum sodium by 3-4 mEq/L.

Hypernatremic dehydration

Phase 1 management of hypernatremic dehydration is identical to that of isonatremic dehydration. Rapid volume expansion with 20 mL/kg of isotonic sodium chloride solution or lactated Ringer solution should be administered and repeated until perfusion is restored.

Varied regimens may be successfully followed to achieve correction of severe hypernatremia (>150 mEq/L). In phase 2 management, the most important goal is to reestablish intravascular volume and return serum sodium levels toward the reference range by not more than 10 mEq/L/24h. Rapid correction of hypernatremic dehydration can have disastrous neurologic consequences, including cerebral edema and death.

The most cautious approach is to plan a slow correction of the fluid deficit over 48 hours. Following adequate intravascular volume expansion, rehydration fluids should be initiated with 5% dextrose in 0.9% sodium chloride. Serum sodium levels should be assessed every 4 hours. If the sodium has decreased by less than 0.5 mEq/L/h, then the sodium content of the rehydration fluid is decreased. This allows for a slow controlled correction of the hypernatremic state.

Hyperglycemia and hypocalcemia are sometimes associated with hypernatremic dehydration. Serum glucose and calcium levels should be closely monitored.

Pharmacologic management

Note the following:

  • Antidiarrheal agents are not recommended because of a high incidence of side effects including lethargy, respiratory depression, and coma.
  • Routine empiric antibiotics should be avoided and may worsen some specific diarrheal disease states (eg, hemolytic-uremic syndrome, Clostridium difficile).
  • Over-the-counter antiemetics are not recommended due to side effects including drowsiness and impaired oral rehydration.
  • In a study of 170 children aged 3 months to 5 years with acute diarrhea with vomiting and some dehydration, those who received treatment with a single dose of oral ondansetron (n = 85) and standard dehydration protocols showed faster rehydration, fewer vomiting episodes, and better caregiver satisfaction than those who were administered placebo and standard management of dehydration (n = 85). [16]
  • In an emergency department study, ondansetron has been shown to decrease likelihood of vomiting, increase oral intake, and decrease emergency department length of stay but has not shown significant effects on hospitalization rates or long-term outcomes. [17]  
  • Dimenhydrinate, although used in Europe and Canada, has not been found to improve oral rehydration. [18]


ORT may be continued at home if clear instructions are provided for the family and if the family members can be relied upon to carry out the hydration regimen. Close follow-up by the primary physician is recommended.

Children with dehydration from gastroenteritis have decreased duration of diarrhea when feedings are started as soon as the patient is able to tolerate oral intake.

Diluting milk or formula is not indicated. Breast-feeding should be resumed as soon as possible.

Foods that contain complex carbohydrates (eg, rice, wheat, potatoes, bread, cereals), lean meats, fruits, and vegetables are encouraged. Fatty foods and simple carbohydrates should be avoided.



In a study of hospitalizations for pediatric dehydration, Shanley et al found evidence that a large number of these hospitalizations were preventable. The study involved 85 children (mean age 1.6 y) who were diagnosed with dehydration, with a cross-sectional survey conducted of the children’s primary care physicians (PCP), inpatient attending physicians, and parents to determine factors contributing to their hospitalization. In 12% of cases, there was unanimous agreement between the PCP, attending physician, and parent that the hospitalization could have been prevented, while in 45% of cases at least one of these believed that the hospitalization was preventable.

Based on the survey, reasons that the preventable hospitalizations occurred included the following[19] :

  • Insufficient education of parents by physicians
  • Inadequate rehydration of the child at home
  • Delays in seeking health care
  • Cost and insurance factors
  • Inappropriate hospital admissions
  • Inadequate health-care quality
  • Dissatisfaction of parents with their PCPs
Contributor Information and Disclosures

Lennox H Huang, MD, FAAP Associate Professor and Chair, Department of Pediatrics, McMaster University School of Medicine; Chief of Pediatrics, McMaster Children's Hospital

Lennox H Huang, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Physician Leadership, Canadian Medical Association, Ontario Medical Association, Society of Critical Care Medicine

Disclosure: Nothing to disclose.


Dan L Ellsbury, MD Consulting Staff, Pediatrix Medical Group of Iowa; Consulting Staff, Department of Pediatrics, Neonatology Intensive Care Unit, Mercy Medical Center of Des Moines

Dan L Ellsbury, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Caroline S George, MD Associate Professor, Consulting Staff, Department of Pediatrics, Division of Critical Care Medicine, University of Minnesota Medical School

Caroline S George, MD is a member of the following medical societies: American Academy of Pediatrics, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Krishnapriya R Anchala, MD, MS, FAAP Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, McMaster University

Krishnapriya R Anchala, MD, MS, FAAP is a member of the following medical societies: American Academy of Pediatrics, Canadian Medical Association, Ontario Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Society of Critical Care 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.

Additional Contributors

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami Leonard M Miller School of Medicine/ Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Director, Palliative Care Team, Holtz Children's Hospital; Medical Manager, FEMA, South Florida Urban Search and Rescue, Task Force 2

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

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Table 1. Clinical Findings of Dehydration
Symptom/Sign Mild Dehydration Moderate Dehydration Severe Dehydration
level of consciousness Alert Lethargic Obtunded
Capillary refill* 2 s 2-4 s >4 s, cool limbs
Mucous membranes Normal Dry Parched, cracked
Tears Normal Decreased Absent
Heart rate Slightly increased Increased Very increased
Respiratory rate/pattern* Normal Increased Increased and hyperpnea
Blood pressure Normal Normal, but orthostasis Decreased
Pulse Normal Thready Faint or impalpable
Skin turgor* Normal Slow Tenting
Fontanel Normal Depressed Sunken
Eyes Normal Sunken Very sunken
Urine output Decreased Oliguria Oliguria/anuria
* Best indicators of hydration status[10]
Table 2. Estimated Fluid Deficit
Severity Infants (weight < 10 kg) Children (weight >10 kg)
Mild dehydration 5% or 50 mL/kg 3% or 30 mL/kg
Moderate dehydration 10% or 100 mL/kg 6% or 60 mL/kg
Severe dehydration 15% or 150 mL/kg 9% or 90 mL/kg
Table 3. Composition of Appropriate Oral Rehydration Solutions
Solution Carbohydrate (g/dL) Sodium (mEq/L) Potassium (mEq/L) Base (mEq/L) Osmolality
Pedialyte 2.5 45 20 30 250
Infalyte 3 50 25 30 200
Rehydralyte 2.5 75 20 30 310
WHO/UNICEF* 2 90 20 30 310
* World Health Organization/United Nations Children's Fund
Table 4. Composition of Inappropriate Oral Rehydration Solutions
Solution Carbohydrate (g/dL) Sodium (mEq/L) Potassium (mEq/L) Base (mEq/L) Osmolality
Apple juice 12 0.4 26 0 700
Ginger ale 9 3.5 0.1 3.6 565
Milk 4.9 22 36 30 260
Chicken broth 0 2 3 3 330
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