Evaluation and Management of Dehydration in Children

https://doi.org/10.1016/j.emc.2017.12.004Get rights and content

Section snippets

Key points

  • The degree of pediatric dehydration may be difficult to clinically quantify.

  • Dehydration may be treated with oral, subcutaneous, or intravenous fluids.

  • Most children with mild to moderate dehydration can be successfully rehydrated with oral rehydration.

  • When intravenous fluids are chosen for rehydration, isotonic solutions should be used to avoid iatrogenic hyponatremia.

Diagnosis

This article discusses evidence-based treatment of dehydration due to acute gastroenteritis in children. Many other common childhood illnesses, such as bronchiolitis, influenza, gingivostomatitis, and urinary tract infections, may cause dehydration as well. Although some of these other illnesses require specific therapy, the approach to associated dehydration is generally the same as presented in this article. Although diarrhea and dehydration are major causes of morbidity and mortality in

Prognosis

Although dehydration is not a major cause of mortality in the United States, it is one of the most common reasons for unscheduled hospital admissions in children of all ages in the United States.4 In North American countries where life-threatening complications and death due to dehydration are rare, quality improvement focuses on decreased admission rates, decreased emergency department (ED) length of stay, and decreased unplanned return visits.

Ideally, the least invasive treatment plan is used

Clinical management

The goal of clinical management is to replace fluid deficits and ongoing losses in the least invasive yet effective manner. Effective circulating volume has an impact on distal tissue perfusion and untreated hypovolemia may result in ischemic end-organ damage. Emergent correction of severe dehydration should occur; treatment of severe dehydration is typically with IV therapy but can be successful by alternative means, such as with ORT, via nasogastric tube (NGT), and by subcutaneous

Hyponatremia/Hypernatremia

Most cases of hypovolemia caused by acute gastroenteritis are isonatremic, but either hyponatremia or hypernatremia may occur. The serum sodium concentration is the best estimate of water balance in relation to solute. A normal value implies balance, but it does not reveal volume status. When the sodium is abnormal, there must be caution in the administration of fluids with attention given to the rate of change in sodium. Overly rapid correction of hyponatremia or hypernatremia may result in

Controversies

One study examined the use of dilute apple juice followed by a patient’s preferred oral fluids rather than flavored, commercially available ORS.58 This study of children with mild gastroenteritis who were either minimally dehydrated or not dehydrated found that the group randomized to dilute apple juice was less likely to require IV rehydration in the next week.58 Children with more significant degrees of dehydration were not included in the study, so it is unclear if results can be

Special circumstances

Nonphysiologic ADH release (also known as syndrome of inappropriate antidiuretic hormone secretion) may occur in ill children and result in decreased free water excretion and potential hyponatremia. Lack of appropriate release of ADH (central diabetes insipidus) results in polyuria and potential hypernatremia. Additionally, infants have immature renal function and are more prone to electrolyte abnormalities. Increased insensible water losses from the skin may occur in premature/young infants as

Summary

Pediatric dehydration occurs frequently and is most commonly secondary to acute gastroenteritis. The degree of fluid deficit may be difficult to clinically quantify and there is no laboratory value that is either sensitive or specific to estimate the degree of dehydration in children. Rehydration may occur via oral, subcutaneous, or IV routes. Oral rehydration is underused in the United States. IV fluids should be isotonic to avoid iatrogenic hyponatremia and its potentially devastating

First page preview

First page preview
Click to open first page preview

References (59)

  • L. Hartling et al.

    Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children

    Cochrane Database Syst Rev

    (2006)
  • S.B. Freedman et al.

    Emergency department revisits in children with gastroenteritis

    J Pediatr Gastroenterol Nutr

    (2013)
  • J.E. Wathen et al.

    Usefulness of the serum electrolyte panel in the management of pediatric dehydration treated with intravenously administered fluids

    Pediatrics

    (2004)
  • S.B. Freedman et al.

    Predictors of outcomes in pediatric enteritis: a prospective cohort study

    Pediatrics

    (2009)
  • A. Guarino et al.

    European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014

    J Pediatr Gastroenterol Nutr

    (2014)
  • Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis

    Pediatrics

    (1996)
  • A. Leung et al.

    Oralrehydration therapy and early refeeding in the management of childhoodgastroenteritis

    Paediatr Child Health

    (2006)
  • World Health Organization Department of Child and Adolescent Health and Development

    Clinical management of acute diarrhoea: WHO/UNICEF joint statement [WHO/FCH/CAH/04.7]

    (2004)
  • Y.C. Atherly-John et al.

    A randomized trial of oral vs intravenous rehydration in a pediatric emergency department

    Arch Pediatr Adolesc Med

    (2002)
  • P.R. Spandorfer et al.

    Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial

    Pediatrics

    (2005)
  • B.J. Bender et al.

    Intravenous rehydration for gastroenteritis: how long does it really take?

    Pediatr Emerg Care

    (2004)
  • B.K. Fonseca et al.

    Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials

    Arch Pediatr Adolesc Med

    (2004)
  • G.V. Gregorio et al.

    Polymer-based oral rehydration solution for treating acute watery diarrhoea

    Cochrane Database Syst Rev

    (2016)
  • K.A. Santucci et al.

    Frozen oral hydration as an alternative to conventional enteral fluids

    Arch Pediatr Adolesc Med

    (1998)
  • Z. Fedorowicz et al.

    Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents

    Cochrane Database Syst Rev

    (2011)
  • S.B. Freedman et al.

    Impact of increasing ondansetron use on clinical outcomes in children with gastroenteritis

    JAMA Pediatr

    (2014)
  • R. Keren

    Ondansetron for acute gastroenteritis: a failure of knowledge translation

    JAMA Pediatr

    (2014)
  • A. Cheng

    Emergency department use of oral ondansetron for acute gastroenteritis-related vomiting in infants and children

    Paediatr Child Health

    (2011)
  • S.L. Ralston et al.

    Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474–e1502

    Pediatrics

    (2015)
  • Cited by (15)

    View all citing articles on Scopus

    The authors received no funding for the preparation of this article and have no relevant financial disclosures.

    View full text