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The degree of pediatric dehydration may be difficult to clinically quantify.
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Dehydration may be treated with oral, subcutaneous, or intravenous fluids.
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Most children with mild to moderate dehydration can be successfully rehydrated with oral rehydration.
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When intravenous fluids are chosen for rehydration, isotonic solutions should be used to avoid iatrogenic hyponatremia.
Evaluation and Management of Dehydration in Children
Section snippets
Key points
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
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