Dehydration

Last Updated: March 30, 2006

Synonyms and related keywords: dehydration, negative fluid balance, diarrheal illness, diarrhea, isonatremic dehydration,
hypernatremic dehydration, hyponatremic dehydration
AUTHOR INFORMATION
Author: Dan L Ellsbury, MD, FAAP, Consulting Staff, Pediatrix Medical Group of Iowa; Consulting Staff, Department of
Pediatrics, Neonatology Intensive Care Unit, Mercy Medical Center of Des Moines
Coauthor(s): Caroline S George, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Critical Care,
Children's Hospital of Iowa, University of Iowa Hospital and Clinics
INTRODUCTION
Background: Dehydration describes a state of negative fluid balance that may be caused by a number of disease entities.
Diarrheal illnesses are the most common etiologies. Worldwide, dehydration secondary to diarrheal illness is the leading cause of
infant and child mortality.
Pathophysiology: The negative fluid balance causing dehydration results from decreased intake, increased output (renal,
gastrointestinal, or insensible losses), or fluid shift (ascites, effusions, and capillary leak states such as burns and sepsis). The
decrease in total body water causes reductions in both the intracellular and extracellular fluid volumes. Clinical manifestations of
dehydration are most closely related to intravascular volume depletion. As dehydration progresses, hypovolemic shock ultimately
ensues, resulting in end organ failure and death.
Dehydration is often categorized according to serum sodium concentration as isonatremic (130-150 mEq/L), hyponatremic (<130
mEq/L), or hypernatremic (>150 mEq/L). Isonatremic dehydration is the most common (80%). Hypernatremic and hyponatremic
dehydration each comprise 5-10% of cases. Variations in serum sodium reflect the composition of the fluids lost and have
different pathophysiologic effects.
Isonatremic (isotonic) dehydration occurs when the lost fluid is similar in sodium concentration to the blood. Sodium and water
losses are of the same relative magnitude in both the intravascular and extravascular fluid compartments.
Hyponatremic (hypotonic) dehydration occurs when the lost fluid contains more sodium than the blood (loss of hypertonic fluid).
Relatively more sodium than water is lost. Because the serum sodium is low, intravascular water shifts to the extravascular space,
exaggerating intravascular volume depletion for a given amount of total body water loss.
Hypernatremic (hypertonic) dehydration occurs when the lost fluid contains less sodium than the blood (loss of hypotonic fluid).
Relatively less sodium than water is lost. Because the serum sodium is high, extravascular water shifts to the intravascular space,
minimizing intravascular volume depletion for a given amount of total body water loss.
Neurologic complications can occur in hyponatremic and hypernatremic states. Rapid correction of chronic hyponatremia (>2
mEq/L/h) has been associated with central pontine myelinolysis. During hypernatremic dehydration, water is osmotically pulled
from cells into the extracellular space. To compensate, cells can generate osmotically active particles (idiogenic osmoles) that
pull water back into the cell and maintain cellular fluid volume. During rapid rehydration of hypernatremia, the increased
osmotic activity of these cells can result in a large influx of water, causing cellular swelling and rupture, with cerebral edema
being the most devastating consequence. Slow rehydration over 48 hours generally minimizes this risk.
Frequency:

In the US: Diarrheal illnesses in children causes 3 million physician visits, 220,000 hospitalizations (10% of all
children who require hospitalization), and 400 deaths per year.

Internationally: Diarrheal illnesses with subsequent dehydration account for nearly 4 million deaths per year in
infants and children.

Mortality/Morbidity: Mortality and morbidity are generally dependent upon the severity of dehydration and the promptness of
oral or intravenous rehydration. If treatment is rapidly and appropriately obtained, morbidity and mortality are low.
Age: Children younger than 5 years are at the highest risk.
CLINICAL
History:

Intake of fluids, including the volume, type (hypertonic or hypotonic), and frequency

Urine output, including the frequency of voiding, presence of concentrated or dilute urine, hematuria

Stool output, frequency of stools, stool consistency, presence of blood or mucus in stools

Emesis, including frequency and volume and whether bilious or nonbilious, hematemesis

Contact with ill people, especially others with gastroenteritis

Underlying illnesses, especially cystic fibrosis, diabetes mellitus, hyperthyroidism, renal disease

Fever

Appetite patterns

Weight loss

Travel

Recent antibiotic use

Possible ingestions

Physical: A complete physical examination is essential to determine the underlying cause of the patient's dehydration and to
define the severity of dehydration. The clinical assessment of severity of dehydration determines the approach to management.
Table 1. Clinical Findings of Dehydration

Symptom/Sign

Mild
Dehydration

Moderate
Dehydration

Severe Dehydration

Level of
consciousness*

Alert

Lethargic

Obtunded

Capillary refill*

2 Seconds

2-4 Seconds

Greater than 4 seconds, cool

limbs

Mucous membranes*

Normal

Dry

Parched, cracked

Tears*

Normal

Decreased

Absent

Heart rate

Slight increase

Increased

Very increased

Respiratory rate

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

Table 2. Estimated Fluid Deficit
Severity
Mild dehydration

Infants (weight <10 kg)

5% or 50 mL/kg

Children (weight >10 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

Causes: Determination of the cause of dehydration is essential. Poor fluid intake, excessive fluid output and increased insensible
fluid losses all may cause intravascular volume depletion. Successful treatment requires identification of the underlying disease
state.

Common causes

Gastroenteritis: This is the most common cause of dehydration. If both vomiting and diarrhea are present,
dehydration may progress rapidly.

Stomatitis: Pain may severely limit oral intake.

Diabetic ketoacidosis (DKA): Dehydration is caused by osmotic diuresis. Weight loss is caused by both
excessive fluid losses and tissue catabolism. Rapid rehydration, especially rapid initial volume
resuscitation, may be associated with a poor neurologic outcome. DKA requires very specific and
controlled treatment (see Diabetic Ketoacidosis).

o
o

Febrile illness: Fever causes increased insensible fluid losses and may affect appetite.
Pharyngitis: This may decrease oral intake.

Life-threatening causes

Gastroenteritis

Diabetic ketoacidosis

Burns: Fluid losses may be extreme. Very aggressive fluid management is required (see Burns, Thermal).

Congenital adrenal hyperplasia: This may have associated hypoglycemia, hypotension, hyperkalemia, and
hyponatremia.

Gastrointestinal obstruction: This is often associated with poor intake and emesis. Bowel ischemia can
result in extensive capillary leak and shock.

Heat stroke: Hyperpyrexia, dry skin, and mental status changes may occur.

Cystic fibrosis: This results in excessive sodium and chloride losses in sweat, placing patients at risk for
severe hyponatremic hypochloremic dehydration.

Diabetes insipidus: Excessive output of very dilute urine can result in large free water losses and severe
hypernatremic dehydration.

Thyrotoxicosis: Weight loss is observed, despite increased appetite. Diarrhea occurs.

DIFFERENTIALS
Acidosis, Metabolic
Adrenal Insufficiency
Alkalosis, Metabolic
Bowel Obstruction in the Newborn
Burns, Thermal
Dehydration
Diabetes Insipidus
Diabetic Ketoacidosis
Diarrhea
Eating Disorder: Anorexia
Enteroviral Infections
Fluid, Electrolyte, and Nutrition Management of the Newborn

Gastroenteritis
Hyperkalemia
Hypernatremia
Hypochloremic Alkalosis
Hypoglycemia
Hypokalemia
Hyponatremia
Intestinal Malrotation
Intestinal Volvulus
Intussusception
Neonatal Sepsis
Oliguria
Pyloric Stenosis, Hypertrophic
Small-Bowel Obstruction
WORKUP
Lab Studies:

Laboratory data are generally not required if the etiology is apparent and mild-to-moderate dehydration is present.

With severe dehydration, the following laboratory studies are suggested:

Serum sodium should be determined because hyponatremia (Na <130 mEq/L) and hypernatremia (Na
>150 mEq/L) require specific treatment regimens.

Potassium may be elevated (eg, congenital adrenal hyperplasia, renal failure) or low (eg, pyloric stenosis,
alkalosis).

Chloride may be low in pyloric stenosis (eg, hypochloremic, hypokalemic, or metabolic alkalosis).

Poor tissue perfusion in dehydration results in production of lactic acid. Bicarbonate is consumed as lactic
acid levels increase. In DKA, ketoacids also consume bicarbonate. Bicarbonate levels can also be reduced
because of loss of bicarbonate in diarrheal stools.

Glucose may be dangerously low because of poor intake or extremely elevated in DKA.

Blood urea nitrogen and creatinine may be elevated because of renal hypoperfusion.

Urine specific gravity may be elevated; diabetes insipidus causes the urine to be dilute.

Urinalysis may show findings of DKA (eg, ketones, glucose).

Electrolyte analysis of any fluid that is lost (eg, urine, stool, gastric fluid) can be performed to further
refine the composition of replacement fluids.

Procedures:

Intravenous line

If severe dehydration is present, peripheral intravenous line insertion may be difficult. The preferred sites
for initial insertion attempts include the basilic and cephalic veins in the antecubital fossa and the
saphenous veins near the ankle. Transillumination of the insertion site with a fiberoptic light source may
be used to facilitate locating the desired vein.

If peripheral intravenous access cannot be rapidly achieved (<90 s) in a child with severe dehydration and
shock, intraosseous cannulation should be attempted. If the child is not in extremis, more time may be
taken to establish central venous access percutaneously (eg, femoral, subclavian, internal, external
jugular).

Intraosseous line: Intraosseous cannulation can easily and rapidly be achieved in children younger than 6 years.
Specially designed intraosseous infusion needles or Jamshidi-type bone marrow aspiration needles may be used. Short

large-bore spinal needles may also be used but often bend during placement. The ideal site of insertion is the
anteromedial surface of the tibia, 1-3 cm below the anterior tibial tuberosity.
TREATMENT
Medical Care: Medications such as loperamide, opiates, anticholinergics, bismuth subsalicylate, and adsorbents are not
recommended because of questionable efficacy and potential adverse effects.
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
Solution

CHO*, g/dL

Na, mEq/L

K, mEq/L

Base, mEq/L

Osmolality

2.5

45

20

30

250

50

25

30

200

2.5

75

20

30

310

90

20

30

310

Pedialyte
Infalyte
Rehydralyte
WHO/UNICEF

*Carbohydrate

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.
Table 4. Composition of Inappropriate Oral Rehydration Solutions
Solution

CHO, g/dL

Na, mEq/L

K, mEq/L

Base, mEq/L

Osmolality

Apple juice

12

0.4

26

700

Ginger ale

3.5

0.1

3.6

565

4.9

22

36

30

260

330

Milk
Chicken broth

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.

Oral rehydration therapy for mild or moderate dehydration

o
o
o
o

o
o
o

Mild or moderate dehydration can usually be treated very effectively with ORT.
Vomiting is generally not a contraindication to ORT. If evidence of bowel obstruction, ileus, or acute
abdomen exists, then intravenous rehydration is indicated.
Calculate 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 solution
over 1-2 h) may also be used until oral rehydration is tolerated.
Replace ongoing losses from stools and emesis (estimate volume and replace) in addition to replacing the
calculated fluid deficit.
Once the child is rehydrated, start an age-appropriate diet (see below).

Severe dehydration

o
o

Laboratory evaluation and intravenous rehydration are required. The underlying cause of the dehydration
must be determined and treated appropriately.
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 lactated Ringer solution or isotonic sodium chloride solution.
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. Daily maintenance fluid requirements may calculated as follows:
Less than 10 kg = 100 mL/kg

o
o

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 replaced promptly.
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% NaCl. Potassium (20 mEq/L
KCl) may be added once urine output is established.
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
o Phase 1 management of hyponatremic 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.
o 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.
Sodium deficit = (sodium desired - sodium actual) X volume of distribution X weight (kg)

o
o

Example: Na = 123, weight = 10 kg, assumed volume of distribution of 0.6; Na deficit = (130123) X 0.6 X 10 kg = 42 mEq Na
A simplified approach is to use 5% dextrose in 0.9% NaCl or 0.45% NaCl as the replacement fluid. The
sodium is monitored closely, 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%) isotonic
sodium chloride solution (0.5 mEq/mL) may be used for rapid partial correction of symptomatic
hyponatremia. A dose of 4 mL/kg raises the serum sodium by 3-4 mEq/L.

Hypernatremic dehydration
o 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.
o 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/24 h. Rapid correction of
hypernatremic dehydration can have disastrous neurologic consequences, including cerebral edema and
death.
o 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%
NaCl. 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.
o Hyperglycemia and hypocalcemia are sometimes associated with hypernatremic dehydration. Serum
glucose and calcium levels should be monitored closely.

Diet:

Once the child is rehydrated, an age-appropriate diet should be started. Children with dehydration from gastroenteritis
have decreased duration of diarrhea when feedings are rapidly restarted.

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

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

FOLLOW-UP
Further Inpatient Care:

Severe dehydration warrants hospital admission for rehydration, as do hypernatremic or hyponatremic states.

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

Further Outpatient Care:

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.

Complications:

Complications may include irreversible shock, sagittal or other venous sinus thrombosis, intractable seizures, and
renal failure.

Prognosis:

Prognosis is excellent if the child is promptly and effectively treated. However, the child with severe dehydration and
hypovolemic shock can have significant morbidity and mortality if treatment is delayed.

Patient Education:

An excellent Web site containing patient education materials regarding dehydration, gastroenteritis, and oral
rehydration therapy can be found at AAFP Family Health Facts. Additional patient education resources can be found
by visiting eMedicine's Children's Health Center. Also, see eMedicine's patient education article Dehydration in
Children.

MISCELLANEOUS
Medical/Legal Pitfalls:

Failure to recognize and appropriately treat DKA

Failure to recognize hypoglycemia

Failure to recognize severe hyponatremia or hypernatremia

Failure to recognize an acute abdomen

Inadequate volume administration (too slow, not enough) for the child with severe dehydration

Failure to recognize cardiogenic shock (gallop rhythm, hepatomegaly): Rapid fluid resuscitation may further impair
cardiac output.