DEHYDRATION IN

CHILDREN
Ebele Uzo-Peters
OUTLINE

• Introduction/Definitions
• Physiology
• Epidemiology
• Classification (Symptomatology)
• Treatment
• Conclusion
 Introduction

 Dehydration refers to a negative balance of body

fluid usually expressed as a percentage of body
weight.
 Mild, moderate and severe dehydration correspond to
deficits of <5%, 5-10% and >10% respectively.
 Based on serum sodium it is classified into isotonic,
hypotonic and hypertonic.
 Untreated promptly and adequately, it may lead to
shock, which is a life-threatening emergency.
 Total Body Water
(TBW)= 50-75% of Total
Body Mass
 TBW = Intracellular
Fluid (ICF) +
Extracellular Fluid (ECF)
 ICF = 2/3 of TBW
 ECF = 1/3 of TBW --
25% of body weight
 ECF = Plasma
(intravascular) +
Interstitial fluid
 ECF/ICF ratio varies with age
 Neonates and infants have
proportionately larger ECF vol
 Infants: high daily fluid requirement
with little fluid reserve; this makes
the infant vulnerable to dehydration
 Excretion is via the urine, feces, lungs
and skin
 have greater daily fluid loss than
older child more dependent upon
adequate intake
 Greater skin surface area (BSA),
therefore greater insensible loss.
 Respiratory and metabolic rates are
higher therefore, dehydrate more
rapidly
Epidemiology

One of the most common medical problems

In the U.S. - 10% of all pediatric admissions
Worldwide, over 3 million children under 5 years die from dehydration
 History and Physical Exam

Risk Factors
3 main goals 1. Age < 12 months.
Estimate the level of dehydration 2. Discontinuation of breast
Identify likely causes on the basis feeding
of history and clinical findings 3. Frequent stools > 8/day.
Determine if additional studies 4. Vomiting > 2/day
and/or medications are necessary
5. Severe malnutritution.
 History
 Age: Infants & Toddlers
 Onset, frequency, quantity, and character of diarrhea
 Associated symptoms: nausea, vomiting, fever, abdominal
pain, tenesmus, malaise
 Recent oral intake
 Micturation: Oliguria or anuria
 PMH: Diarrhea, Measles, Malnutrition or any other illnesses.
 Prenatal, natal and early neonatal hx: Duration of illness,
IUGR, Maternal illness, SGA and LBW.
 Growth and Development: Weight gain; milestones
attainment, sitting, crawling, standing & walking.
 Nutritional Hx: Breast feeding, complementary
feeds, weaning practices and family based diet.
 Immunization Hx: OPV, BCG, Vit A, DPT,
Measles. Rota virus vaccine available.
 Family& Social Hx: Any family member with
diarrhea recently, child fed by someone else.
Washing hand practices.
-Socioeconomic status of the family (income, occupation,
literacy levels of parents)
-Number of children
-Source of water supply
-Fecal disposal
Physical Exam

o Weight, Height
o Vitals, vitals, vitals!
o ENT: inflamed tonsils, otitis media
o Chest: Infection, pulmonary oedema
o CVS: HR, JVP, BP
o Abdominal exam
o Signs of dehydration
 Degree of Dehydration
Factors Mild < 5% Moderate (5-10%) Severe >10%
General Condition Well, alert Restless, thirsty, irritable Drowsy, cold extremities, lethargic

Eyes Normal Sunken Very sunken, dry

Anterior fontanelle Normal depressed Very depressed

Tears Present Absent Absent

Mouth + tongue Moist Sticky, dry Parched

Skin turgor Slightly decreased Decreased Very decreased

Pulse (N=110-120 Slightly increased Rapid, weak Rapid, sometime impalpable

beat/min)
BP (N=90/60 mm Hg) Normal Deceased Deceased, may be unrecordable

Respiratory rate Slightly increased Increased Deep, rapid

Urine output Normal Reduced Markedly reduced

WHO Classification
Clinical Signs Degree of Dehydration

No Dehydration Some Dehydration Severe Dehydration

1. Look at General Condition Well, alert *Restless, irritable *Lethargic, drowsy or

unconscious

Eyes Normal Sunken Very sunken and dry

Tears Present Absent Absent

Mouth & Tongue Moist Dry Very Dry

Thirst Drinks normally not thirsty *Thirsty drinks eagerly *Drinks poorly not able to
drink.
2. Feel: Skin Pinch Goes back quickly *Goes back slowly Goes back very slowly
Decide No detectable signs of 2 or more signs plus at least one 2 or more signs plus at least
dehydration *sign=Some dehydration one
*sign=Severe dehydration
Treat A B C
3. Estimate the Fluid Deficit

Assessment Fluid deficit as % of Fluid deficit in ml/kg

body weight body weight

No signs of dehydration < 5% < 50ml/kg

Some dehydration 5 – 10% 50 – 100ml/kg

Severe dehydration > 10% > 100ml/kg

 Types of Dehydration
Isotonic Dehydration : The net losses of
water and sodium are in the same
proportion with ECF
o Balanced deficit of water and sodium
o Serum Na conc. is normal (130 – 150
mmol/l)
o Serum osmolality is normal (275 -
295mOsmol/l)
o Hypovolemia occurs as a result of
substantial loss of ECF
Physical signs appear when fluid deficit
approaches 5% of the body weight and
worsens as the deficit increases.
Hypertonic (Hypernatremic)
Dehydration: There is a net loss of water
in excess of sodium when compared with
ECF
o There is deficit of water and sodium but
the deficit of water is greater
o Serum Na conc. is  (> 150 mmol/L)
o Serum osmalality is  (> 295 m
Osmol/L)
o Thirst is severe and out of proportion to
the apparent degree of dehydration, the
child is very irritable.
o Seizures may occur especially when the
serum Na Conc exceeds 165 mmol/L
Hypotonic (Hyponatremic)
dehydration: There is net loss
of Na in excess of water.
o Deficit of water and sodium
but the deficit of sodium is
greater
o Serum Na conc. is low (< 130
mmol/L)
o Serum osmolality is low (<
275 m Osmol/L)
o The child is lethargic,
infrequently there are
seizures
Fluid Replacement

o Oral rehydration therapy

o Appropriate for mild to moderate dehydration
Contraindications to ORT
o Safer o Severe dehydration (≥10%)

o Less costly o Ileus or intestinal obstruction

o Administered in various clinical settings via teaspoon, syringe, or medicine o Unable to tolerate (Persistent
dropper vomiting)
o Fluid replacement should be over o Signs of shock
o Decreased LOC (Level of
o 3-4hrs consciousness) or unconscious
o 50ml/kg for mild dehydration o Unclear diagnosis
o 100ml/kg for moderate dehydration
o Psychosocial situations
o 10ml/kg for each episode of vomiting or watery diarrhea
Fluid Replacement

Treatment plan A (Home treatment of dehydration):

 Used for treatment of diarrhea with no dehydration  Extra fluid to include: Longer
breastfeeding, giving ORS or clean
 Transition from plans C and B for the caregiver who water in addition to breast milk,
wishes to be discharged after a successful treatment plan C. giving
 ORS solution, food based fluids
Counsel the mother on the 3 rules of home treatment (soup, rice water, yogurt drinks) or
1. Give extra fluid clean water to children not
exclusively breastfed; Give 2 extra
2. Continue breastfeeding sachets of ORS; Teach caregiver
3. When to return (sicker, drinks poorly, feverish, bloody how to mix ORS or prepare home
stools, cough, fast breathing ) SSS and how to give it
Some dehydration (Plan B)
Amount ORS to give during first 4 hours in the
Weight Age Amount of ORS in the
child with some dehydration is shown 1st 4 hours

o Teach the caregiver how to give ORS - Small <5kg <4 months 200-400 ml
frequent sips by cup and spoon or sips from the
cup. 5-<8kg 4-12 months 400-600 ml

o Give more if child so desires. Give slowly, wait 8-<11kg 12 months to 600-800 ml
for 10mins if child vomits <2 years
11-<16kg 2-<5 years 800-1,200 ml
o Continue breastfeeding whenever the child wants
16-50kg 5-15 years 1200-2200 ml
o Reassess after 4 hrs for dehydration

o Explain the 3 rules of home treatment for

mothers wanting to leave
Severe dehydration (Plan C)

o Require urgent IV fluid therapy with Age 1st give Then give
Ringer’s lactate (Hartmann’s solution or 30ml/kg 70ml/kg
normal saline. (**Do not use 5% dextrose!). in in

o If child can take orally & abdomen is not Infants 1 hour 5 hours
under 12
distended start ORS solution while drip is months of
being set up. age
o Give total of 100ml/kg as on the table
Children 30 21/2 hours
o Reassess 1-2 hrly. Repeat fluid Rx once if 12 months minutes
radial pulse is still feeble or undetectable. and above

o Switch to ORS as soon as patient shows

improvement and can tolerate orally. (plan
 Flowchart for Management of dehydration
ASSESS FOR DEHYDRATION

MILD DEHYDRATION
· ORS – 30-50ml/kg over 4hours NO DEHYDRATION
MODERATE DEHYDRATION · Advice on nutrition, prevention, immunization
· ORS 60-90ml/kg over 4hours · Fluids as tolerated
· REASSESS · ORS 10ml/kg/loose stool

SEVERE DEHYDRATION
· Admit
· IV Ringer,s or 0.9% saline, give bolus 20-30ml/kg over 30min–1hr
· Reassess after boluses (max 3boluses)
· E/U, blood gas, Stool m/c/s, Virology

NO MORE DEHYDRATION
· Fluid as tolerated
· Advice on nutrition IF PERIPHERAL CIRCULATION ESTABLISHED
· ORS 10ml/kg/loose stool · If unable to drink or persistent vomiting or abd distension
 Continue with IVF using 0.45% saline with 5% dextrose (or 0.18%saline with
4.3% dextrose in neonates)
 Over 8hours – ½ deficit + 1/3 maintenance (=approx. 80ml/kg)
 Next 16 hours – ½ deficit + 2/3 maintenance
· Add KCl (10-20mmol/500ml IV bag) after urine is passed.
· If patient can drink, continue rehydration with ORS & gradually
discontinue IVF
· REASSESS FREQUENTLY
 Treatment of shock

 Shock is an emergency & it’s due to hypovolaemia

 It requires rapid intravenous or intraosseous infusion of isotonic crystalloid
solution.
 Acceptable solutions are normal saline or Ringer’s lactate.
 Fluid dose is 20 ml /kg given over 30 minutes.
 Reassess. Rx may need to be repeated at same fluid dose.
 Complications of uncompensated or terminal shock will need appropriate
treatment
Management of Dehydration (Contd)

o Investigate and treat concurrent Illnesses.

o Do stool analysis and m/c/s should not delay use of antibiotics for dysentery.
o Identify and treat complications which may include
=Hypoglycemia
=Electrolyte derangement (Na+, K+, HCO3-etc )
=Convulsions
o Counsel on feeding, immunization and diarrhoeal diseases.
 Management OF DEHYDRATION

1. Advise unrestricted oral fluids

2. C. T. Breast feeding
3. In high risk cases advise unrestricted normal drinks and 10ml/kg of ORS
after each loose stool.
4. Teach mother how to prepare SSS at home
5. Ask mother to return with child for follow up.
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