Dehydration in children overview

Infants and children are more likely to become dehydrated than adults because they weigh less and their bodies turn over water and electrolytes more quickly.

Dehydration in sick children is often a combination of refusing to eat or drink anything and losing fluid from vomiting, diarrhea, or fever.

Most dehydration is caused by viral infections that naturally run their course. The most dangerous problem with viruses is dehydration, which can kill infants and children.

In most cases, providing adequate fluid, either by mouth or via a drip, is all that is necessary to assure your child's complete recovery.

Dehydration  pure (tissue) water loss and hypovolemia to sodium loss and thus loss of blood volume.

Loss of water from the extracellular fluid volume, vascular  and interstitial fluids.

It is literally the removal of water or deficiency of fluid within an organism.

Extracellular Fluid Volume Deficit (ECFVD)

 Intracellular fluid Volume      Deficit (ICFVD)

Losses can be : 1. Mild – loss of 1 to 2 L of water (2% of body 

weight is lost).2. Moderate – loss of 3 to 5 L of water (5% of 

body weight is lost).3. Severe – loss of 5 to 10 L of water (8% of 

body weight is lost).

Fluids are normally found in three spaces:  Inside the cells (Intracellular) Around the cells (Interstitial) In the bloodstream (Intravascular)

Pathophysiology

                             Dehydration  is seen when the normal compensation  for  fluid  in  the  bloodstream cannot be  corrected by  stored fluid elsewhere. When  fluids  are  lost  from  the  intravascular spaces because of  lack of  intake or excess  loss, interstitial  fluids  move  in  to  restore  vascular volume.  Because  the  actual  volume  of  fluid  in the  interstitial  space  limited,  other compensation  systems  are  initiated  to  restore fluid volume.

           If the dehydration is not corrected, fluid is shifted from the cells into the vascular system.

Cellular Dehydration         The loss of cellular fluid is dangerous because the 

cells need fluid for cellular function.   Intracellular fluid Volume Deficit (ICFVD) Less fluid is available for temperature regulation via 

sweating, and lowered blood volume decreases the body’s ability to transport core heat to the periphery for conducive loss.

There is cerebrospinal fluid and less fluid in fat pads around the eyes. If cerebral cells become dehydrated, thought processes may be impaired.

Causes of dehydration in children

Common viral infections causing vomiting and diarrhea include rotavirus or winter vomiting disease (norovirus).

Common bacterial infections include Salmonella, E coli, Campylobacter and  C.difficile. 

Parasitic infections such as Giardia lamblia cause the condition known as giardiasis.

Dehydration can be caused by losing too much fluid, not drinking enough water or fluids, or both.Your body may lose too much fluids from:Excessive sweating Excessive urine outputFeverVomiting or diarrheaExercise during high heat and humidity

Clinical Manifestations of Dehydration

Clinical Manifestations

Mild Dehydration

Moderate Dehydration Severe Dehydration

Level of consciousness Alert Lethargic Obtunded

Capillary refill time 2 seconds 2-4 seconds Greater than 4 seconds, cool limbs

Mucous membranes Normal Dry Parched, cracked

Heart rate Slight increase Increased Very increased

Respiratory rate Normal Increased Increased and hyperpnea

Blood pressure Normal Normal, but orthostatic Decreased

Pulse Normal Thready Faint or impalpable

Skin turgor Normal Slow Tenting

Eyes Normal Sunken Very sunken

Urine output Decreased Oliguria Oliguria/anuria

√ Three types of dehydration based on serum sodium levels:

1.hypotonic or hyponatremic (referring to this as primarily a loss of electrolytes, sodium in particular)

2.hypertonic or hypernatremic (referring to this as primarily a loss of water)

3.isotonic or isonatremic (referring to this as equal loss of water and electrolytes).

Differential Diagnosis:

 External or stress-related causes§Infectious diseasesMalnutrition

Signs :

dry or sticky mouthfew or no tears when cryingeyes that look sunken into the headsoft spot (fontanels) on top of head that looks sunkenlack of urine or wet diapers for 6 to 8 hours in an infant (or only a very small amount of dark yellow urine)lack of urine for 12 hours in an older child (or only a very small amount of dark yellow urine)dry, cool skin (poor skin turgor)

Symptoms:

excessive loss of fluid from vomiting or diarrhea  if the child refuses to eat or drink.lethargy or irritabilityfatigue or dizziness in an older childthirst and discomfortloss of appetite

  Skin turgor assessment – this assessment can be done on the forearm. Skin that does not flatten immediately after release is called “tenting”, an example of fluid volume deficit.

  Dry and cracked lips 

Sunken eyes

  Thirst and discomfort

Examinations and tests

Delayed capillary refillLow blood pressurePoor skin turgor -- the skin may not be as elastic as normal and sag back into position slowly when the health care provider pinches it up into a fold (normally, skin springs right back into place)Rapid heart rateShock (hypovolemic)Complete blood count (CBC)Blood chemistries (to check electrolytes, especially sodium, potassium, and bicarbonate levels)Blood urea nitrogen (BUN)CreatinineUrine specific gravityOther tests may be done to determine the cause of the dehydration (for example, blood sugar level to check for diabetes).

 ManagementMild and Moderate Dehydration:1. Fluid Restoration Oral Rehydration 

› Oral Rehydration Solution “ORS”› Standard home solutions

Intravenous Rehydration Monitoring for complications of fluid 

restoration Monitor Intake and Output for fluid 

replacement Nutritious food and supplements

Severe Dehydration:1. Laboratory evaluation and intravenous rehydration 

are required. The underlying cause of the dehydration must be determined and appropriately treated.

Phase 1 focuses on emergency management. Severe dehydration is characterized by a state of hypovolemic shock requiring rapid treatment. o IV fluido Tachycardia, capillary refill, urine output, and mental status 

all should improve. Phase 2 focuses on deficit replacement, provision of 

maintenance fluids, and replacement of ongoing losses.

Maintenance fluid requirements are equal to measured fluid losses 

Solution Contents Uses Comments

Hypotonic

5% dextrose in water (D5W)

50g dextrose

No electrolytes

Replaces deficits of total body water.

Not used alone to expand ECF volume because dilution of electrolytes can occur.

Supplies 170 kcal/L and free water

Distilled water cannot be given IV because it would cause hemolysis of RBCs.

Dextrose is metabolized on first pass through liver, leaving a solution of water but without hemolytic problems.

Isotonic

0.9% NaCl (normal saline olution, NS, 0.9% NS)

154 mEq/L Na and Cl ECF deficits in clients with low serum levels of Na or Cl and metabolic alkalosis

Before and after infusion of blood products

Not used for routine administration of IV fluids because it contains more sodium than ECF

Expands plasma and interstitial volume and does not enter cells

Lacteted Ringers

Solution (LR)

130 mEq/L Na

4 mEq/L K

3 mEq/L Ca

109 mEq/L Cl

28 mEq/L lactate

ECF deficits, such as fluid loss with burns and bleeding and dehydration from loss of bile or diarrhea

Solution is roughly isotonic to plasma but does not contain magnesium or phosphate

Lactate is equivalent to bicarbonate and solution can be used to treat many forms of acidosis

Cannot be used in people with alkalosis

Intravenous Water and Electrolyte Solutions

Hypertonic

Lactated Ringer’s

Solution with 5% dextrose (D5/LR)

5o g dextrose

130 mEq/L Na

4 mEq/L K

3 mEq/L K

109 mEq/L Cl

28 mEq/L lactate

FCF deficits, such as fluid loss with burns and bleeding and dehydration from loss of bile or diarrhea

Provides modest calories (170 kcal)

Solution hypertonic because it is combination of two solutions (D5W and LR)

5% dextrose and normal saline (D5/o.9 NS)

50g dextrose

154 mEq/L Na and Cl

ECF deficits in clients with low serum levels of Na or Cl and metabolic alkalosis

Before and after infusion of blood products

Provides modest calories (170 kcal)

Solution is hypertonic because it is combination of two solutions (D5W and NS)

5% dextrose and 0.45% normal saline (D5/0.45 NS; D5/1/2 NS)

50g dextrose

77 mEq/L Na and Cl

Can be used as an initial fluid for hydration because it provides more water than sodium

Provides modest calories (170 kcal)

Commonly used as a maintenance fluid

5% dextrose and 0.225% normal saline

(D5/0.2 NS; D5/1/4 NS)

50g dextrose

34 mEq/L Na and Cl

Can be used as an initial fluid for hydration because it provides more water than sodium

Provides modest calories (170 kcal)

Commonly used as a maintenance fluid

Nursing Management Keep  fresh water  or  other  fluids  in  an  easily accessible location. Provide fluids of choice Encourage family members to assist the client  Provide  oral  care  every  2  hours  to  help decrease  discomfort  from  dry  mucous membranes Record intake and Output of the client Educate client how to self-care at homeMonitor for signs of Hypovolemic shock

 Preventive measures

Even when you are healthy, drink plenty of fluids every day. Drink more when the weather is hot or you are exercising.

Carefully monitor someone who is ill. If you believe that the child is getting dehydrated, call your health care provider before the person becomes dehydrated. Begin fluid replacement as soon as vomiting and diarrhea start -- DO NOT wait for signs of dehydration.

Always encourage a child who is sick to drink fluids. Remember that fluid needs are greater with a fever, vomiting, or diarrhea. The easiest signs to monitor are urine output (there should be frequent wet diapers or trips to the bathroom), saliva in the mouth, and tears when crying.

Encourage adequate rest balanced with moderate          activity.  Promote adequate nutritional intake.

TreatmentOral re-hydration solutions (ORS) Fluid replacementIntravenous rehydration therapyAlternative therapiesProper  food intakeAdequate rest and sleep patternMonitor intake and outputSevere cases: IVF/ NGTMedical treatment:

  In  cases  of  severe  dehydration,  admission  to hospital  may  be  required.  Fluid  may  be  given through  a  tube  through  the  nose  or  saline  drip intravenously.

 Complications

Untreated severe dehydration may lead to:DeathPermanent brain damage Seizures Cholera Gastroenteritis Shigellosis Fever Electrolyte disturbance

Hypernatremia (also caused by dehydration)Hyponatremia, especially from 

restricted salt diets

Let children

Thank you and God Bless