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Fluid Replacement Therapy in Children

Children are particularly vulnerable to developing dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration because they have higher insensible water loss and more elevated metabolic rates than adults. In addition, children's inability to communicate their needs compounds with large losses of fluids (e.g., diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia), putting them at even higher risk. Dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration is defined as a decrease in total body water Total body water Body Fluid Compartments, and can be characterized as mild, moderate, or severe. Fluid replacement treatment is based on severity. Clinicians must be prepared to administer optimal rehydration Rehydration Dengue Virus therapy in addition to the other required measures for the causal illness. When treated promptly, dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration starts to resolve clinically within the first few hours.

Last updated: 8 Jan, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration ( hypovolemia Hypovolemia Sepsis in Children) is a decrease in total body water Total body water Body Fluid Compartments, both intracellular and extracellular.

Epidemiology

Dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration in children worldwide is primarily caused by diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea:

  • Diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea accounts for 1 of 9 deaths in children worldwide.
  • 300 children/year die from diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea in the United States.
  • Most diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea is infectious Infectious Febrile Infant:
    • Viral (75%–90%): rotavirus Rotavirus A genus of Reoviridae, causing acute gastroenteritis in birds and mammals, including humans. Transmission is horizontal and by environmental contamination. Seven species (rotaviruses A through G) are recognized. Rotavirus, norovirus Norovirus Norovirus is a nonenveloped, single-stranded, positive-sense RNA virus belonging to the Caliciviridae family. Norovirus infections are transmitted via the fecal-oral route or by aerosols from vomiting. The virus is one of the most common causes of nonbacterial gastroenteritis epidemic worldwide. Symptoms include watery and nonbloody diarrhea, nausea, vomiting, and low-grade fever. Norovirus, and enteroviruses 
    • Bacterial (< 20%): Salmonella Salmonella Salmonellae are gram-negative bacilli of the family Enterobacteriaceae. Salmonellae are flagellated, non-lactose-fermenting, and hydrogen sulfide-producing microbes. Salmonella enterica, the most common disease-causing species in humans, is further classified based on serotype as typhoidal (S. typhi and paratyphi) and nontyphoidal (S. enteritidis and typhimurium). Salmonella, Shigella Shigella Shigella is a genus of gram-negative, non-lactose-fermenting facultative intracellular bacilli. Infection spreads most commonly via person-to-person contact or through contaminated food and water. Humans are the only known reservoir. Shigella, and Escherichia coli Escherichia coli The gram-negative bacterium Escherichia coli is a key component of the human gut microbiota. Most strains of E. coli are avirulent, but occasionally they escape the GI tract, infecting the urinary tract and other sites. Less common strains of E. coli are able to cause disease within the GI tract, most commonly presenting as abdominal pain and diarrhea. Escherichia coli (10% of bacterial)
    • Parasitic (< 5%): Giardia Giardia A genus of flagellate intestinal eukaryotes parasitic in various vertebrates, including humans. Characteristics include the presence of four pairs of flagella arising from a complicated system of axonemes and cysts that are ellipsoidal to ovoidal in shape. Nitroimidazoles and cryptosporidium Cryptosporidium A genus of coccidian parasites of the family cryptosporidiidae, found in the intestinal epithelium of many vertebrates including humans. Hyper-IgM Syndrome

Etiology

  • Excessive water loss
    • Gastrointestinal: 
      • Diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
      • Vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia
    • Urinary: excessive urination from hyperosmolar states (e.g., diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus)
    • Increased insensitive loss from evaporation:
      • Febrile illnesses
      • Burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns
      • Increased respiratory loss with respiratory illness (e.g., bronchiolitis Bronchiolitis Inflammation of the bronchioles. Pediatric Chest Abnormalities)
  • Decreased intake
    • Anorexia Anorexia The lack or loss of appetite accompanied by an aversion to food and the inability to eat. It is the defining characteristic of the disorder anorexia nervosa. Anorexia Nervosa from illness
    • Lack of access to clean water 
    • Neglect Neglect Child Abuse

Diagnosis

In most cases, a good history and physical exam are sufficient to diagnose dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration and its etiology. Laboratory testing is reserved for severe cases and to monitor rehydration Rehydration Dengue Virus.

History

  • Fluid balance:
    • Number of wet diapers/urination per day
    • Increased drinking or asking for water 
  • Recent illness:
    • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
    • Diarrheal episodes (quantity and quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of stool loss can be estimated)
  • Behavioral changes:
    • Lethargy Lethargy A general state of sluggishness, listless, or uninterested, with being tired, and having difficulty concentrating and doing simple tasks. It may be related to depression or drug addiction. Hyponatremia 
    • Irritability

Physical exam

Table: Physical exam to recognize the degree of dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration in children
Mild Moderate Severe
Weight loss Weight loss Decrease in existing body weight. Bariatric Surgery < 5% in infants, < 3% in older children 5%–10% in infants, 3%–9% in older children < 10% in infants, < 9% in older children
Dry mucosas (first sign) +/-, looks dry +, looks parched
Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions turgor (last sign) + +/- -, tenting
Anterior fontanelle Anterior Fontanelle Physical Examination of the Newborn depression + +/++
Mental status Normal Fatigued/irritable Apathy Apathy Lack of emotion or emotional expression; a disorder of motivation that persists over time. Wernicke Encephalopathy and Korsakoff Syndrome/ lethargy Lethargy A general state of sluggishness, listless, or uninterested, with being tired, and having difficulty concentrating and doing simple tasks. It may be related to depression or drug addiction. Hyponatremia
Enophthalmos Enophthalmos Recession of the eyeball into the orbit. Marfan Syndrome + +
Breathing Normal Deep, may be tachypneic Deep and tachypneic
Heart rate Heart rate The number of times the heart ventricles contract per unit of time, usually per minute. Cardiac Physiology Normal Increased Very high
Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension + +
Distal perfusion Normal Feels cold, 3–4 seconds Acrocyanotic, > 4 seconds
Urinary output Decreased Oliguria Oliguria Decreased urine output that is below the normal range. Oliguria can be defined as urine output of less than or equal to 0. 5 or 1 ml/kg/hr depending on the age. Renal Potassium Regulation Oliguria Oliguria Decreased urine output that is below the normal range. Oliguria can be defined as urine output of less than or equal to 0. 5 or 1 ml/kg/hr depending on the age. Renal Potassium Regulation/ anuria Anuria Absence of urine formation. It is usually associated with complete bilateral ureteral (ureter) obstruction, complete lower urinary tract obstruction, or unilateral ureteral obstruction when a solitary kidney is present. Acute Kidney Injury

Laboratory testing

  • Basic metabolic panel Basic Metabolic Panel Primary vs Secondary Headaches (CHEM-7) in cases of severe dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration can show: 
    • glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance 
    • ↑ blood urea Urea A compound formed in the liver from ammonia produced by the deamination of amino acids. It is the principal end product of protein catabolism and constitutes about one half of the total urinary solids. Urea Cycle nitrogen Nitrogen An element with the atomic symbol n, atomic number 7, and atomic weight [14. 00643; 14. 00728]. Nitrogen exists as a diatomic gas and makes up about 78% of the earth’s atmosphere by volume. It is a constituent of proteins and nucleic acids and found in all living cells. Urea Cycle (BUN)
    • sodium Sodium A member of the alkali group of metals. It has the atomic symbol na, atomic number 11, and atomic weight 23. Hyponatremia and chloride Chloride Inorganic compounds derived from hydrochloric acid that contain the Cl- ion. Electrolytes
    • bicarbonate Bicarbonate Inorganic salts that contain the -HCO3 radical. They are an important factor in determining the ph of the blood and the concentration of bicarbonate ions is regulated by the kidney. Levels in the blood are an index of the alkali reserve or buffering capacity. Electrolytes
    • ↑ creatinine
  • Creatinine kinase (CK): 
    • When concerned about rhabdomyolysis Rhabdomyolysis Rhabdomyolysis is characterized by muscle necrosis and the release of toxic intracellular contents, especially myoglobin, into the circulation. Rhabdomyolysis
    • Elevated in severe dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration
  • Stool studies: to identify etiology in cases of prolonged diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea

Management

Mild-to-moderate dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration

  • 1st-line therapy: oral rehydration Rehydration Dengue Virus therapy (ORT)
  • Oral rehydration Rehydration Dengue Virus solutions with similar electrolyte contents to fluid lost should be used:
    • Pedialyte or enfalyte
    • Breastfed infants should continue to nurse.
    • Fluids with high sugar content should be avoided as they may worsen diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea.
  • Goal is to provide 50–100 cc/kg of fluids over 2–4 hours. Route of administration depends on patient age and frailty:
    • Syringe or spoon-feeding 
    • Nasogastric (NG) tube
  • +/- ondansetron Ondansetron A competitive serotonin type 3 receptor antagonist. It is effective in the treatment of nausea and vomiting caused by cytotoxic chemotherapy drugs, including cisplatin, and has reported anxiolytic and neuroleptic properties. Antiemetics to prevent vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia
  • Clinical hydration status should be monitored frequently.
  • Failure to improve with ORT should prompt intravenous hydration.

Severe dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration

Severe dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration can cause hypoperfusion of the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification and vital organs and is considered a medical emergency to be addressed rapidly.

  • Acute resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome phase
    • Goal: correct or prevent hypovolemic shock Hypovolemic Shock Types of Shock
    • Rapid volume expansion through fluid boluses:
      • 20 cc/kg given over 20 minutes
      • Can be repeated up to 3x
      • Monitor vital signs between each bolus.
    • Choice of replacement fluid:
      • Isotonic Isotonic Solutions having the same osmotic pressure as blood serum, or another solution with which they are compared. Renal Sodium and Water Regulation fluids only
      • Lactated Ringer’s or normal saline Normal saline A crystalloid solution that contains 9. 0g of sodium chloride per liter of water. It has a variety of uses, including: as a contact lens solution, in ophthalmic solutions and nasal lavage, in wound irrigation, and for fluid therapy. Intravenous Fluids are appropriate.
    • Glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance monitoring:
      • Point of care (POC) monitoring for hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia
      • IV glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance should be administered.
      • 5–10 ml/kg of D10 NS OR 2-4ml/kg of D25 NS
  • Resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome phase
  • After 24 hours if clinically stable → continue maintenance fluids

Volume-replacement calculations

  • Standard bolus:
    • 20 cc/kg/20 min
    • Up to 3x
    • Monitor vital signs.
  • Maintenance calculations:
    • 4-2-1 rule:
      • 1st 10 kg = 4 cc/kg/hr
      • 2nd 10 kg = 2 cc/kg/hr
      • Further kg = 1 cc/kg/hr
    • Example: a child who weighs 37 kg
      • (10 kg x 4 cc/kg/hr) + (10 kg x 2 cc/kg/hr) + (17 kg x 1 cc/kg/hr) = (40 cc/hr) + (20 cc/hr) + (17 cc/hr) = 77 cc/hr
  • Rehydration Rehydration Dengue Virus is calculated by weight and severity of dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration:
    • Amount calculated is added to the maintenance amount, spread throughout the day. 
    • < 10 kg:
      • Mild: 50 cc/kg/day
      • Moderate: 100 cc/kg/day
      • Severe: 150 cc/kg/day
    • > 10 kg:
      • Mild: 30 cc/kg/day
      • Moderate: 60 cc/kg/day
      • Severe: 90 cc/kg/day

Complete management example

A child who weighs 25 kg with severe dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration:

  • Acute resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome phase:
    • 3 x 20 cc/kg boluses = 1,500 cc
  • Resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome phase:
    • Total fluid = maintenance fluids + ( rehydration Rehydration Dengue Virus – bolus already given)
    • Maintenance: (10 kg x 4 cc/kg/hr) + (10 kg x 2 cc/kg/hr) + (5 kg x 1 cc/kg/hr) = 65 cc/hr → 1,560 cc/day 
    • Rehydration Rehydration Dengue Virus: 25 kg x 90 cc/kg/day = 2,250 cc/day 
    • Rehydration Rehydration Dengue Virus – bolus already given: 2,250 cc/day – 1,500 cc = 750 cc/day
    • Total fluid replacement: 1,560 cc/day + 750 cc/day = 2,310 cc/day
    • Rehydration Rehydration Dengue Virus divided into 2 phases of treatment: 2,310 cc / 2 = 1,155 cc
    • Volume for first 8 hours: 1,155 cc/8 hr 
    • Volume for next 16 hours: 1,155 cc/16 hr 
    • After 24 hours → continue maintenance fluids

Monitor response

  • Urine Urine Liquid by-product of excretion produced in the kidneys, temporarily stored in the bladder until discharge through the urethra. Bowen Disease and Erythroplasia of Queyrat output: optimal > 1 cc/kg/hr
  • Clinical improvement of signs of dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration
    • Increased skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions turgor
    • Improved pulse
    • Improved capillary refill
    • Improved mental status
    • Resolution of enophthalmos Enophthalmos Recession of the eyeball into the orbit. Marfan Syndrome
Flowchart about fluid replacement treatment in children

Approach to evaluation and treatment with oral replacement fluid (ORF) or intravenous (IV) fluids of children with dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration based on severity of symptoms

Image by Lecturio.

Special Populations (Infants)

Daily requirements = maintenance fluids + growth fluids:

  • Term infants:
    • Day 1 = 80 cc/kg/day (maintenance fluids) 
    • Daily increase by increment of 20 cc/kg/day (growth fluids) until goal reached
  • Preterm infants:
    • Day 1 = 70 cc/kg/day
    • Daily increase by increment of 10 cc/kg/day (growth fluids) 
    • Premature Premature Childbirth before 37 weeks of pregnancy (259 days from the first day of the mother’s last menstrual period, or 245 days after fertilization). Necrotizing Enterocolitis babies take longer to reach goal.
  • The quantity fed is progressively increased every day until a daily input above 150 cc/kg/day is met MET Preoperative Care.
    • Term infants: by days 5–7
    • Preterm infants: by days 14–21
  • Growth fluids should ensure a daily weight increase of 30–40 g.
  • Daily output should be more than input.

References

  1. CDC. (2015). Diarrhea: Common Illness, Global Killer. https://www.cdc.gov/healthywater/global/diarrhea-burden.html 
  2. Managing Acute Gastroenteritis Among Children Oral Rehydration, Maintenance, and Nutritional Therapy. Prepared by Caleb K. King, M.D., Roger Glass, M.D., Ph.D., Joseph S. Bresee, M.D., Christopher Duggan, M.D., University of North Carolina, Chapel Hill, North Carolina Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC, Children’s Hospital Bostom, Boston, Massachusetts https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm

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