pathophysiology of dehydration in pediatrics

Stool electrolyte content and purging rates in diarrhea caused by rotavirus, enterotoxigenic. The Merck Manual was first published in 1899 as a service to the community. Urinary electrolyte losses vary with intake and disease process but can be measured if electrolyte abnormalities fail to respond to replacement therapy. For information about the SORT evidence rating system, go to, Only clear liquid recommended for oral rehydration in children with dehydration. However, if the parents report normal tear production, the chance of dehydration is low.2,3, Comparing change in body weight from before and after rehydration is the standard method for diagnosing dehydration.4 To identify dehydration in infants and children before treatment, a number of symptoms and clinical signs have been evaluated and compared with this standard method. Symptoms and signs include thirst, lethargy, dry mucosa, decreased urine output, and, as the degree of dehydration progresses, tachycardia, hypotension, and shock. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. If after initial volume repletion, hyponatremia or hypernatremia remains moderate to severe (serum sodium level of less than 130 mEq per L [130 mmol per L] or greater than 150 mEq per L [150 mmol per L]), replacement of the remaining fluid deficit should be altered, with a principal goal of slow correction. Intestinal transport mechanisms are also the basis for the management of diarrhoea, through oral fluid therapy and feeding. INTESTINAL PHYSIOLOGY. Pediatric Advanced Life Support Provider Manual Dallas, Tex: American Heart Association; 2006: 232. Arch Dis Child. Serum electrolyte levels should be measured in children with severe dehydration and in those with moderate dehydration that presents in atypical ways. Yates EW, If stool output exceeds 30 mL per kg per day, it should be replaced in an equal volume every four hours with an intravenous solution comparable in electrolytes with the stool (50 percent normal saline plus 20 to 30 mEq per L of potassium), in addition to the volume of maintenance fluid, until ORT can be tolerated. Friedman AL, Effect of fever on capillary refill time. Conley SB. In general, dehydration is defined as follows: Mild: No hemodynamic changes (about 5% body weight in infants and 3% in adolescents), Moderate: Tachycardia (about 10% body weight in infants and 5 to 6% in adolescents), Severe: Hypotension with impaired perfusion (about 15% body weight in infants and 7 to 9% in adolescents). 2005;115(2):295–301. The end point of the fluid resuscitation phase is reached when peripheral perfusion and blood pressure are restored and the heart rate is returned to normal (in an afebrile child). Parental report of vomiting, diarrhea, or decreased oral intake is sensitive, but not specific, for identifying dehydration in children. Development of a clinical dehydration scale for use in children between 1 and 36 months of age. This residual amount is given over the next 24 hours. Porter SC, 1997;99(5):E6. Decreased fluid intake is particularly problematic when the child is vomiting or when fever, tachypnea, or both increase insensible losses. Sarker SA, The total fluid deficit given 1 kg weight loss = 1 L. Ongoing diarrheal losses are measured as they occur by weighing the infant’s diaper before application and after the diarrheal stool. What are considered early signs and late signs? Vega RM, Dixit S, Ann Emerg Med. This causes an imbalance of electrolytes, which are nutrients the body needs to properly function. Dehydration occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions. Shaw KN, Children who are unable or unwilling to drink or who have repetitive vomiting can receive fluid replacement orally through frequently repeated small amounts, through an IV, or through a nasogastric tube (see Oral Rehydration : Solutions). Islam MR, 2001;85(2):132–142. Findings that may aid in the diagnosis of hypernatremia in children include a “doughy” feeling rather than tenting when testing for skin turgor, increased muscle tone, irritability, and a high-pitched cry.31 Hyponatremia is often caused by inappropriate use of oral fluids that are low in sodium, such as water, juice, and soda. This amount replaces 26 mEq of the estimated 80 mEq sodium deficit. Stabilization often requires up to 60 mL per kg of fluid within an hour.25 Electrolyte measurement should be performed in all children with severe dehydration and considered in those with moderate dehydration because it may be difficult to predict which children have significant electrolyte abnormalities.27 After resuscitation is completed and normal electrolyte levels are achieved, the patient should receive 100 mL per kg of ORT solution over four hours, then maintenance fluid and replacement of ongoing losses. Dehydration is a common complication of illness observed in pediatric patients presenting to the emergency department (ED). Alam AN, Iatrogenic hyponatremia may be a greater problem for more seriously ill children and those who are hospitalized after surgery where stress plays a bigger role. The article reviews the pathophysiology of water and sodium metabolism and, it uses the clinical case examples to illustrate the bed-side approach to the management of three different types of … Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial. Assadi F, The ADH causes increased free water retention. Oral ondansetron for gastroenteritis in a pediatric emergency department. Laron Z. Pathophysiology of Dehydration. 26. The fluid used is 5% dextrose/0.45% saline or 5% dextrose/0.9% saline. The most useful individual signs for identifying dehydration in children are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern. The American Academy of Pediatrics recommends oral rehydration therapy (ORT) as the preferred treatment of fluid and electrolyte losses caused by diarrhea in children with mild to moderate dehydration.14 ORT is as effective as intravenous fluid in rehydration of children with mild to moderate dehydration—there is no difference in failure rate or hospital admission rate between the two treatments.15 Additionally, ORT has many advantages compared with intravenous fluid therapy. It is therefore important to … Early signs: precipitating conditions in which fluid loss are likely to occur, including diarrhea, vomiting, burns, diabetes, trauma, and fever. Holliday MA, Intensive Care Med. Pediatr Emerg Care. Pediatrics. The trusted provider of medical information since 1899, Dehydration and Fluid Therapy in Children, Obsessive-Compulsive Disorder (OCD) and Related Disorders in Children and Adolescents, Adolescent patients who have obsessive-compulsive disorder (OCD) are most likely to also have which of the following. 25. weak rapid pulse, cool or blue extremities, hypotension), rapid breathing, sunken anterior fontanelle. Traditional rehydration calculations aim to precisely estimate electrolyte losses and select replacement fluids that provide that specific amount. Hypernatremia causes water to shift from the intracellular and interstitial space into the intravascular space, helping, at least temporarily, to maintain vascular volume. Parkin PC. Baker MD. Reid SR, Localio R, 14. 1997;13(5):305–307. The most recent American Academy of Pediatrics' clinical practice guideline (2018) recommends all patients 28 days to 18 years of age receive isotonic solutions with appropriate potassium chloride and dextrose as maintenance IV fluids. 219 Bryant Street, Buffalo, New York 14222 Laboratory Tests in the Analysis of States of Dehydration Erika Bruck, M.D. 19. 2003;41(2):196–205. 2004;19(3):364]. Decreased fluid intake is common during mild illnesses such as pharyngitis or during serious illnesses of any kind. Wang VJ. Wathen JE, Rahman M, American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Please confirm that you are a health care professional. 30. For children between these age ranges, clinicians must estimate values between those for infants and those for adolescents based on clinical judgment. Bennish ML, 2003;52(RR-16):1–16.... 2. Immediate, unlimited access to all AFP content. Goldman RD, The infant is currently producing 1 diarrheal stool every 3 hours and refusing to drink. Glass R, Offringa M. Definition of Diarrhea Diarrhea is the passage of loose or watery stools at least 3 times in a 24- hour period. The Holliday-Segar method (Table 223) is a simple, reliable formula for estimating water needs.24 Based on average weights of infants and children, this method can be further simplified to provide maintenance ORT at home: 1 oz per hour for infants, 2 oz per hour for toddlers, and 3 oz per hour for older children. Commercial ORT preparations typically contain around 50 mEq per L of sodium, which is more consistent with the sodium content of diarrhea caused by rotavirus.20 Commercial ORT solutions contain 25 g per L of dextrose, which helps prevent hypoglycemia without causing osmotic diuresis,21 and 30 mEq per L of bicarbonate, which leads to less vomiting and more efficient correction of acidosis.19 Commercial ORT solutions are recommended over homemade solutions because of the risk of preparation errors.22  Clear sodas and juices should not be used for ORT because hyponatremia may occur. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Because 0.45% saline has 77 mEq sodium per liter (77 mmol/L), it is usually an appropriate fluid choice, particularly in children with diarrhea because the electrolyte content of diarrhea is typically 50 to 100 mEq/L (50 to 100 mmol/L—see Table: Estimated Electrolyte Deficits by Cause); 0.9% saline may be used as well. 1990;37(2):365–372. 1957;19(5):816–822. Pediatrics. Dehydration can result from vomiting, diarrhea, not drinking enough fluids, or any combination of these conditions. If ORT fails after initial resuscitation of a child with severe dehydration, intravenous fluid therapy should be initiated. 1996;28(3):318–323. Pediatrics. Change using urine output, and specific gravity (James, Nelson, & Ashwill, 2013). Same-Day Initiation of Hormonal Contraceptives. Sodium deficits are usually about 60 mEq/L (60 mmol/L) of fluid deficit, and potassium deficits are usually about 30 mEq/L (30 mmol/L) of fluid deficit. AMY CANAVAN, MD, FAAP, is a pediatric hospitalist at Inova Fairfax Hospital for Children, Falls Church, Va., and an assistant professor in the Department of Pediatrics at Virginia Commonwealth University School of Medicine in Falls Church. 6. If severe dehydration is present, a child with hypernatremia or hyponatremia should receive isotonic crystalloid until stabilized. Joffe MD, Adams W, ORT is the preferred treatment for mild to moderate dehydration in children. **Recognize the different clinical and laboratory abnormalities in isonatremic, hyponatremic, and hypernatremic dehydration. 8. Murphy KO. Fleisher GR, This content is owned by the AAFP. The following is an English-language resource that may be useful. font size decrease font size increase font size; Print; Email; Dehydration reveals itself through numerous body signals, such as thirst, dizziness, and low energy. Laboratory predictors of fluid deficit in acutely dehydrated children. Other features of dehydration include dry mucous membranes, reduced tears and decreased urine output. This change also has the benefit of allowing use of the same fluid to replace ongoing losses and supply maintenance needs, which simplifies management. Molla A. Rarely, sweating too … Crain EF. MMWR Recomm Rep. Eccleston P, To see the full article, log in or purchase access. Arch Dis Child. Gorelick MH, If parents report that the child does not have diarrhea, has normal oral intake, and has normal urine output, the chance of dehydration is low. Special oral rehydration solutions are available but are not always necessary for children who have had only mild diarrhea or vomiting. 21. Antidiuretic hormone (ADH) release can also occur in response to vascular volume and not osmolarity (nonosmotic ADH release). All types of lost fluid contain electrolytes in varying concentrations, so fluid loss is always accompanied by some degree of electrolyte loss. Eccleston P, Joffe MD, Rahman O, Fluid volume is estimated by deficits, ongoing losses, and maintenance requirements. Is this child dehydrated? Pediatr Clin North Am. Assadi F, Friedman AL. Parents are also more satisfied with the visit when ORT had been used.16 With ORT, the same fluid can be used for rehydration, maintenance, and replacement of stool losses; and ORT can be initiated more quickly than intravenous fluid therapy.17, The principles of ORT to treat dehydration from gastroenteritis apply to the treatment of dehydration from other causes. Oral rehydration solution without bicarbonate. For mild dehydration, 50 mL per kg of ORT solution should be administered over four hours using a spoon, syringe, or medicine cup14; this can be accomplished by giving 1 mL per kg of the solution to the child every five minutes. At the time this article was written, Dr. Canavan was a pediatric hospitalist at T.C. Pediatr Nephrol. Validation of the clinical dehydration scale for children with acute gastroenteritis. The goal is to restore adequate circulating volume to restore blood pressure and perfusion. Avner JR. Because of the fluid shift out of the interstitium into the vascular space, children with hypernatremia appear more ill (eg, with very dry mucous membranes, a doughy appearance to the skin) for a given degree of water loss than do children with hyponatremia. In … 24. Porter SC, Dehydration is a symptom or sign of another disorder, most commonly diarrhea. The legacy of this great resource continues as the Merck Manual in the US and Canada and the MSD Manual outside of North America. Skin turgor as a quantitative index of dehydration in children. Mondolfi A. This calculation indicates that maintenance fluid should consist of 0.2% to 0.3% saline with 20 mEq/L (20 mmol/L) of potassium in a 5% dextrose solution. Saladino R, Dehydration is defined as the condition that results from excessive loss of body water 1.In severe acute malnutrition, dehydration is caused by untreated diarrhoeal disease which leads to the loss of water and electrolytes 2.Severe acute malnutrition and diarrhoeal disease run in a vicious cycle, each making the other more severe and more likely to occur. Previous: Same-Day Initiation of Hormonal Contraceptives, Home Infants are particularly susceptible to the ill effects of dehydration because of their greater baseline fluid requirements (due to a higher metabolic rate), higher evaporative losses (due to a higher ratio of surface area to volume), and … The most common cause of dehydration in young children is severe diarrhea and vomiting. Vomiting, diarrhea, excessive sweating, burns, kidney failure, and use of diuretics may cause dehydration. Dehydration remains a major cause of morbidity and mortality in infants and young children worldwide. From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. 1. 2009 Oct 1;80(7):692-696. Oral rehydration solution for acute diarrhea prevents subsequent unscheduled follow-up visits. N Engl J Med. Adams W, Stephenson T, (1) In the United States, as recently as 2003, gastroenteritis was the source for more than 1.5 million office visits, 200,000 hospitalizations, and 300 deaths per year. Adler M, 1999;104(3):e29. 80/No. Ray PE, Holliday MA, Duggan C, Hyponatremia results in some fluid shifting out of the intravascular space into the interstitium at the expense of vascular volume. Address correspondence to Amy Canavan, MD, FAAP, Inova Fairfax Hospital for Children, 3300 Gallows Rd., Falls Church, VA 22042 (e-mail: amy.canavan@inova.org). This amount replaces the sodium deficit (when using 0.45% saline, 0.8 L × 77 mEq sodium/L [77 mmol/L] = 62 mEq sodium); the additional 62 mEq of sodium given by using 0.9% saline is not clinically significant as long as renal function is intact. The traditional approach to calculating the composition of maintenance fluids was also based on the Holliday-Segar formula. Shaw KN, Dehydration is treated with fluids containing electrolytes, such as sodium and chloride. Friedman JN, Due to water retention and drinking following stimulation of ADH secretion and thirst, osmoregulation is overruled by volume conservatory mechanisms, which lead to hyponatremia. This development is likely due to volume-related ADH release as well as to significant amounts of stimuli-related ADH release (eg, from stress, vomiting, dehydration, hypoglycemia). Treatment of dehydration is best approached by considering the following separately: The volume (eg, amount of fluid), composition, and rate of replacement differ for each. 4. Gorelick MH, Gorelick MH, Cunningham SJ, Baseline estimates are affected by fever (increasing by 12% for each degree > 37.8° C), hypothermia, and activity (eg, increased for hyperthyroidism or status epilepticus, decreased for coma). If dehydration is severe, 3 boluses of 20 mL/kg (6% body weight) may be required. However, children with hypernatremia have better hemodynamics (eg, less tachycardia and better urine output) than do children with hyponatremia, in whom fluid has shifted out of the vascular space. Oral rehydration solution without bicarbonate. Nasogastric hydration using oral rehydration solution is tolerated as well as ORT. for the Centers for Disease Control and Prevention. Localio R, 2. 2003;18(11):1152–1156. Output is more than input. Fluid therapy for children: facts, fashions and questions. pathophysiology diagnosis and management of dehydration in general and specific disorders in pediatrics read more read less water and electrolytes in pediatrics physiology pathophysiology and management finberg laurence 9780721636252 books amazonca water and electrolytes in pediatrics physiology pathophysiology and management sep 01 2020 posted by georges simenon media … Oral ondansetron for gastroenteritis in a pediatric emergency department. Dehydration is a symptom or sign of another disorder, most commonly diarrhea. Boluyt N, The extracellular fluid space has two components: plasma and lymph as a delivery system, and interstitial fluid for solute exchange.13 The goal of rehydration therapy is first to restore the circulating blood volume, if necessary; then to restore the interstitial fluid volume; and finally to maintain hydration and replace continuing losses, such as diarrhea and increased insensible losses caused by fever. Total deficit volume is estimated clinically as described previously. 1997;13(3):179–182. Simplified treatment strategies to fluid therapy in diarrhea [published correction appears in Pediatr Nephrol. Dehydration is a frequent reason for emergency room visits and affects at least 2 million children annually.1 Frequently caused by gastroenteritis, dehydration may result in serious morbidity and mortality. Two thirds of the fluid is intracellular, and one third is extracellular. MacKenzie T, Pediatr Nephrol. What is Pediatric Dehydration? Due to this possibility of iatrogenic hyponatremia, many centers are now using a more isotonic fluid such as 0.45% or 0.9% saline for maintenance in dehydrated children. Goals of oral rehydration therapy are restoration of circulating blood volume, restoration of interstitial fluid volume, and maintenance of rehydration. Murphy KO. With hypotonic fluid replacement (eg, with plain water), serum sodium may normalize but can also decrease (hyponatremia). Rapid intravenous rehydration by means of a single polyelectrolyte solution with or without dextrose. Dehydration means that a child's body lacks enough fluid. 2008;122(3):545–549. 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