† These findings are for patients with a serum sodium level in the normal range; clinical manifestations may differ with hypernatremia and hyponatremia. Friedman AL. Patients may be treated at home.14 If the child vomits, treatment should be resumed after 30 minutes.15  After the four-hour treatment period, maintenance fluids should be given and ongoing losses assessed and replaced every two hours. Turgor (i.e., time required for the skin to recoil) is normally instantaneous and increases linearly with degree of dehydration.9 Respiratory pattern and heart rate should be compared with age-specific normal values. 11. 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 … afpserv@aafp.org for copyright questions and/or permission requests. Clear sodas and juices are not recommended because hyponatremia may occur. Validation of the clinical dehydration scale for children with acute gastroenteritis. It may also be a sign of neglect. Pharmacologic agents are not recommended to decrease diarrhea because of limited evidence and concern for toxicity. 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. The traditional approach to calculating the composition of maintenance fluids was also based on the Holliday-Segar formula. Address correspondence to Amy Canavan, MD, FAAP, Inova Fairfax Hospital for Children, 3300 Gallows Rd., Falls Church, VA 22042 (e-mail: amy.canavan@inova.org). Shaw KN, First, 100 mL per kg of isotonic crystalloid should be administered over four hours, followed by a maintenance solution. Boluyt N, Oral rehydration therapy is the preferred treatment of mild to moderate dehydration caused by diarrhea in children. Brody School of Medicine East Carolina University Greenville, NC Common Electrolyte Problems in Pediatrics—Hypernatremia. 1997;13(3):179–182. Bennish ML, Diarrheal disease and dehydration account for 14% to 30% of worldwide deaths among infants and toddlers. Diarrhea and Dehydration Clifton E. Yu, MD, FAAP Douglas A. Lougee, MD, MPH Dr. Jorge R. Murno. Offringa M. If stool output exceeds 30 mL per kg per day, it should be replaced in an equal volume every four hours with an intravenous solution comparable in electrolytes with the stool (50 percent normal saline plus 20 to 30 mEq per L of potassium), in addition to the volume of maintenance fluid, until ORT can be tolerated. What are considered early signs and late signs? 13. Stool electrolyte content and purging rates in diarrhea caused by rotavirus, enterotoxigenic. Diagnosis and Management of Dehydration in Children. The most common cause of dehydration in young children is severe diarrhea and vomiting. Residual fluid deficit is 800 mL (1000 initial − 200 mL resuscitation). Learn more about our commitment to Global Medical Knowledge. Wassner SJ. 1996;97(3):424–435. This development is likely due to volume-related ADH release as well as to significant amounts of stimuli-related ADH release (eg, from stress, vomiting, dehydration, hypoglycemia). 2008;23(5):677–680. Rahman O, Dehydration is treated with fluids containing electrolytes, such as sodium and chloride. In … Skorecki K, Ausiello D. In: Cecil's Medicine. Rahman M, Bresee JS, The American Academy of Pediatrics recommends oral rehydration therapy (ORT) as … Sarker SA, 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. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.xml. Pediatrics. Dehydration is one of the leading causes of pediatric morbidity and mortality throughout the world. Saladino R, Ray PE, This calculation indicates that maintenance fluid should consist of 0.2% to 0.3% saline with 20 mEq/L (20 mmol/L) of potassium in a 5% dextrose solution. Powell EC. Holliday MA, Glass R, 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 … 2002;156(12):1240–1243. Fluid therapy for children: facts, fashions and questions. However, this method depends on knowing a precise, recent preillness weight. Wang VJ. Adams W, Laboratory predictors of fluid deficit in acutely dehydrated children. The end point of the fluid resuscitation phase is reached when peripheral perfusion and blood pressure are restored and the heart rate is returned to normal (in an afebrile child). Steiner MJ, Adler M, N Engl J Med. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Effect of fever on capillary refill time. Goldman RD, 19. Volume rarely must be exactly determined but generally should aim to provide an amount of water that does not require the kidney to significantly concentrate or dilute the urine. 2004;19(3):364]. 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). Lasche J, Safety and effectiveness of homemade and reconstituted packet cereal-based oral rehydration solutions: a randomized clinical trial. The fluid used is 5% dextrose/0.45% saline or 5% dextrose/0.9% saline. Postoperatively and in children with central nervous system infection or injury, 20 to 50 percent less fluid and fluid with higher sodium content may be needed because of abnormal antidiuretic hormone secretion.28 These adjustments in fluid rates are guided by regular measurement of urine output and vital signs. Kohane IS, Recent literature suggests that hospitalized dehydrated children receiving 0.2% saline for maintenance fluid sometimes develop hyponatremia. Laron Z. Extracellular fluid restoration in dehydration: a critique of rapid versus slow. Molla AM, Sack DA, This method also may be used when a child with moderate dehydration fails ORT. A single dose of ondansetron (Zofran) may facilitate ORT in children with dehydration. Maintenance fluid therapy: what it is and what it is not. Iatrogenic hyponatremia may be a greater problem for more seriously ill children and those who are hospitalized after surgery where stress plays a bigger role. Rahman M, dehydration and its treatments. The maintenance need for water in parenteral fluid therapy. Werneke U. Bollen CW, Avner JR. 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. 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. Due to this possibility of iatrogenic hyponatremia, many centers are now using a more isotonic fluid such as 0.45% or 0.9% saline for maintenance in dehydrated children. The most common source of increased fluid loss is the gastrointestinal tract—from vomiting, diarrhea, or both (eg, gastroenteritis). The main cause of pediatric hyponatremia is an abundance of free water. 219 Bryant Street, Buffalo, New York 14222 Laboratory Tests in the Analysis of States of Dehydration Erika Bruck, M.D. Pediatr Emerg Care. Offringa M. Laron Z. Physical examination findings during dehydration represent desiccation of tissue, the body's compensatory reaction to maintain perfusion, or both. Dixit S, Other laboratory abnormalities in dehydration include relative polycythemia resulting from hemoconcentration, elevated blood urea nitrogen (BUN), and increased urine specific gravity. Bothner JP. Copelovitch L. DeWalt DA, / Vol. Segar WE. It is therefore important to … Other electrolytes (eg, magnesium, calcium) are not routinely added. note: 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. Murphy KO. Crain EF. Pediatr Nephrol. Feld LG. Ahmed SM. This amount replaces 26 mEq of the estimated 80 mEq sodium deficit. 1999;104(3):e29. Please confirm that you are a health care professional. Traditional rehydration calculations aim to precisely estimate electrolyte losses and select replacement fluids that provide that specific amount. It becomes a medical concern when there is an extreme loss of water known as dehydration. The value of parental report for diagnosis and management of dehydration in the emergency department. 1981;98(5):835–838. Severe dehydration should be treated with intravenous fluids until the patient is stabilized (i.e., circulating blood volume is restored). Effect of fever on capillary refill time. 80/No. Appropriate oral rehydration therapy is as effective as intravenous fluid in managing fluid and electrolyte losses and has many advantages. Change using urine output, and specific gravity (James, Nelson, & Ashwill, 2013). 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). 1957;19(5):823–832. MacFaul R, If dehydration isn't treated it can get worse and become a serious problem. Clin Pediatr (Phila). ORT is the preferred treatment for mild to moderate dehydration in children. 1996;28(3):318–323. 16. Steiner MJ, Bos AP, Avner JR. 2003;18(11):1152–1156. 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. 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