Dehydration in pediatreics

DEHYDRATION1 Ped(6-C) TUCOM
Water is an essential element of the body. Up to 75% of the body's weight is made up of water. Most of the
water is found in:
 (intracellular space)
 (extravascular space)
 (interstitial space).
 Dehydration occurs when the amount of water leaving the body is greater than the amount being
taken in.
 In normal situations the body is in water balance it means that input is equal to out put
Normal Intestinal physiology:
 The intestine has an important role in balancing water and electrolytes and any abnormality will lead
to disturbance.
 In term baby the total body water is approximately70%-75% of body Water. Post Nataly the TBW will
be adjusted to approx.65% of the total body wt. This fraction remains constant until puberty, when
the TBW decreases to 55-60% of the body wt.
 Approximately 2/3 of the TBW is intracellular & 1/3 is extra cellular
 These two fluids are separated by the cell membranes of the which is water permeable.
 Normally the volume of both ECF & ICF do not change because the conc. of dissolved particles is
identical on each side of the membrane.
Dehydration:
 is defined as an excessive loss of body fluid & electrolytes.
 Output is more than input.
Normal routes of water gain and loss:

Pathophysiology of dehydration:
1. The normal response to dehydration, i.e. decreased effective arterial blood volume or effective
circulating volume is described.
2. Due to water retention and drinking following stimulation of ADH secretion and thirst,
osmoregulation is overruled by volume conservatory mechanisms, which lead to hyponatremia.
3. Only patients with impaired mental function or those who are unable to drink will develop a
progressive water deficit--with or without salt depletion--recognizable by hypernatremia.
4. Decreased effective arterial blood volume and hypernatremia affect cerebral function in a way that
perception of external stimuli as well as perception of pain will be impaired.
5. Alert dehydrated patients are disturbed mainly by thirst and dryness of the mouth.
6. Both symptoms are perceived more intensely by young than by elderly persons.
7. Dryness of the mouth increase thirst on its own. Distress by thirst and oral dryness increases as a
function of the level and the rapidity of developing hypernatremia.
8. The simple act of filling the oral cavity with fluid and swallowing alleviates thirst in the absence of
any change in plasma sodium concentration.
9. Thirst quenching efficacy is increased by administering chilled hypotonic fluid with lemon or other
fruit acid added (for stimulation of salivation).
Types of dehydration based on type of fluid loss:
1. Hyponatremic: primarily a loss of electrolytes, particularly
sodium less than 135 ml
2. Hypernatremic: primarily a loss of water, Na more than
158 ml
3. Isonatremic: equal loss of water and electrolytes sodium
135_154 ml
Types of dehydration based on severity:
 Mild:
when the total fluid loss reaches 5% or less.
 Moderate:
when the total fluid loss reaches 5_10%.
 Severe:
when the total fluid loss reaches more than 10%, considered
an emergency case.
Causes of dehydration in general:
1. Diarrhea
2. Vomiting
3. Excessive Sweating
4. Diabetes
5. Burns
6. Excessive blood loss caused by trauma or accident

Etiology)_ (from Medscape)
The mechanisms of dehydration may be broadly divided into 3 categories: (1) decreased intake e.g. due
to diseases such as stomatitis, (2) increased fluid output e.g. from diarrhea or osmotic diuresis from
uncontrolled diabetes mellitus, and (3) increased insensible losses e.g. such as with fever.
Pediatric dehydration is frequently the result of increased output from gastroenteritis, characterized by
vomiting and diarrhea. However, vomiting and diarrhea may be caused by other processes as
summarized below:
CNS causes of vomiting include the following:
1. Infections
2. Increased intracranial pressure
3. Psychogenic vomiting is not seen in infants and is rare in children
GI causes of vomiting include the following:
1. Gastroenteritis
2. Obstruction
3. Hepatitis
4. Liver failure
5. Appendicitis
6. Peritonitis
7. Intussusception
8. Volvulus
9. Pyloric stenosis
10. Drug toxicity (ingestion, overdose, drug effects)
Endocrine causes of vomiting include the following:
1. Diabetic ketoacidosis (DKA)
2. Congenital adrenal hypoplasia
3. Addisonian crisis
Renal causes of vomiting include the following:
1. Infection
2. Pyelonephritis
3. Renal failure
4. Renal tubular acidosis
GI causes of diarrhea include the following:
1. Gastroenteritis
2. Malabsorption (e.g., milk intolerance, excessive fruit juice)
3. Intussusception
4. Irritable bowel syndrome
5. Inflammatory bowel disease
6. Short gut syndrome
Endocrine causes of diarrhea include the following:
1. Thyrotoxicosis
2. Congenital adrenal hypoplasia
3. Addisonian crisis
4. Diabetic enteropathy

PRESENTAION:
History: ask
1- Feeding pattern and fluids given
2- Fluid loss (e.g., vomiting, diarrhea)
3- Number of wet diapers compared with normal, suggesting oliguria or anuria
4- Activity level
5- Possible ingestions that may cause vomiting
6- Heat and sunlight exposures for insensible losses
7- Current illness pattern, fever, ill contacts
8- Recent weight prior to current illness (infants typically have regular well child appointments with
weight recorded)
Physical Examination: look for any of the following:
1- Abnormal capillary refill time
2- Abnormal skin turgor
3- Abnormal respiratory pattern
Differential Diagnoses:
1- Diabetic Ketoacidosis
2- Hypernatremia in Emergency Medicine
3- Hyperosmolar Hyperglycemic Nonketotic Coma
4- Hypokalemia in Emergency Medicine
5- Hyponatremia in Emergency Medicine
6- Hypovolemic Shock
7- Metabolic Acidosis in Emergency Medicine
8- Pediatric Gastroenteritis in Emergency Medicine
9- Pediatric Pyloric Stenosis
Tests and diagnosis:
 Blood tests:
1- to check level of electrolytes.
2- BUN
3- Creatinine
 Urine analysis test.
SIGNS AND SYMPTOMS OF DEHYDRATION:
Mild dehydration (S&S):
1- No dehydration
2- Thirsty
3- Conscious
4- Less than 5% of body Weight is lost.

Moderate dehydration (S&S):
1- Dry skin and mucous membranes
2- Thirst
3- Decreased urine output
4- Crying baby with tears
5- Muscle weakness
6- Drowsiness
7- light head ache
8- sunken fontanels
9- Decreased BP
10- Increased Pulse rate (tachycardia)
11- 5 to10 % of body Weight is lost
12- Capillary refill
13- Shallow rapid RR
Severe dehydration S&S
1- Extreme thirst
2- Very dry mouth, skin and mucous membranes
3- Sunken eyes
4- Sunken fontanels
5- No tears
6- Anuria
7- Dry skin that lacks elasticity and slowly “bounces back” when pinched into a fold
8- Rapid heartbeat
9- Rapid and shallow breath
10- Unconsciousness
11- More than 10 % of body Weight is loss
12- Delay Capillary refill for more than 2 seconds
Possible Complications:
1- Permanent brain damage
2- Seizures
3- hypernatremia
4- Hyponatremia
5- hypovolemic shock
6- renal failure
7- Coma and death
TREATMENT IN GERNRAL
1- dehydration treatment depends on age, weight, the severity of dehydration and its cause.
2- Oral rehydration solution (ORS) for mild and moderate dehydration
3- IV fluid replacement (for severe dehydration)
4- Treating the cause of dehydration
5- A single dose of ondansetron (Zofran) orally(tablet) used to prevent nausea and vomiting

MANAGEMENT OF DEHYDRATION:
 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. Reassessment of perfusion, cardiac
function, mentation should take place after each intervention.
 At times, cardiac failure can mimic volume depletion leading to further deterioration of clinical
findings after fluid administration.
 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 recommended without
medical supervision.
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.
 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.
If commercially prepared ORS is not available, the following recipe may be used:
1- 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)
2- If baking soda is not available, use another quarter teaspoon of salt instead
3- If available, add one-half cup of orange juice, coconut water, or a mashed ripe banana to the drink
4- Use a safe water source, boil water if source is questioned
Contraindications for ORS:
1. Severe dehydration.
2. Unconsciousness.
3. Frequent vomiting attacks.

Moderate Volume Depletion:
1- Oral rehydration solution (ORS):
 should receive approximately 50-100 mL/kg body weight over 2-4 hours, again starting with 5
mL every 5 minutes.
 Children in whom ORS fails should be given a bolus (20 mL/kg) of isotonic fluid intravenously.
2- Continues breastfeeding.
3- A single dose of ondansetron (Zofran) orally(tablet)
Severe Volume Depletion:
BOLUS intravenous isotonic fluid boluses (20-60 mL/kg) (NOTE: Fluid boluses should be repeated until vital
signs, perfusion, and capillary refill have normalized)
Once vital sign abnormalities are corrected, initiate maintenance fluid therapy plus additional fluid to
make up for any continued losses. 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
(SO IT IS: BOLUS FLUID=20ML/KG, maintenance fluid therapy AND DIFICET FLUID=%DEHYDRATION BY
WEIGHT IN GRAM)
Fluid requirements (burn victim):
 TBSA burned (%) x Wt.(kg) x 4 ml
example: a child weighs 15kg, he has his leg burned
TBSA=18
18x15x4=1080ml.
 Give half of total requirements in first 8 hours, second half over
next 16 hours.
 Give IV fluid to the burned victim (child)
If the TBSA is 10% or more.
Example: patient with severe dehydration his weight is 10 kg. mx?
1-bollus fluid =20ml/kg =200 ml should repeated every 30 min until vital signs, perfusion, and
capillary refill have normalized.
2- Maintenance fluid: his weight is 10, so 100 ml/kg = 1000 ml
3-dificet fluid = 10/100 x 10000=1000 ml
You should give him in all of the above (bollus+maintenece+dificet) =2000 ml in 24 hr.
In first 8 hr. give half of the recommended so give 1000 in this case
In the 15 hr. that remain should give the deficit fluid (but should give away the amount of bolus you
given) so it is 1000? ---- the amount of bolus? so it is now =800 ml should give in 15hr.

Calculating Drop rate per minutes:
(Solution) ml x 15 /hr. x min
 Example:
540 ml x15/8 hr. x 60 =16 drops per minute.
540mlx15/16x60=8 drops per minute.
Prevention and home care:
• Notify physician immediately in case of continues vomiting and diarrhea.
• teach the mother how to prepare ORS at home
in case of mild and moderate dehydration if Oral rehydration solution (ORS) was not available:
• (6 tea spoon) of sugar.
• (1/2 tea spoon) of salt.
• (4.25 Cups) of water.
Ahmed E AlBayaty 2017-07-31
Sources: TUCOM, MEDSCAPE

Dehydration in pediatreics

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