This document summarizes dehydration in children. It defines dehydration as a loss of fluid from the extracellular space at a rate exceeding intake. Children are more susceptible to dehydration due to their higher body water content and metabolic rates. Common causes of dehydration in children include viral and bacterial infections causing vomiting and diarrhea. Signs of dehydration include sunken eyes, decreased urination, and irritability. Treatment depends on the severity of dehydration and includes oral rehydration for mild to moderate cases and intravenous fluids for severe cases. Care must be taken with hyponatremic and hypernatremic dehydration to slowly correct electrolyte imbalances.

3. Dehydration:-
It mean volume depletion and
occurs when fluid loss from the
extracellular space at a rate that
exceeds intake.

5. Body fluid distribution
• The body contains 2 major fluid compartments: the intracellular
fluid (ICF) and the extracellular fluid (ECF). The ICF comprises of two
thirds of the total body water (TBW), while the ECF accounts for the
remaining third. The ECF is further divided into the interstitial fluid
(75%) and plasma (25%). The TBW comprises approximately 70% of
body weight in infants, 65% in children, and 60% in adults.
• Infants' and children’s higher body water content, along with their
higher metabolic rates and increased body surface area to mass
index, contribute to their higher turnover of fluids and solute.
Therefore, infants and children require proportionally greater
volumes of water than adults to maintain their fluid equilibrium and
are more susceptible to volume depletion. Significant fluid losses
may occur rapidly, leading to depletion of the intravascular volume.
•

6. Causes of dehydration in
children
1. Dehydration is most often caused by a viral infection that causes
fever, diarrhoea, vomiting and a decreased ability to drink or
eat.Common viral infections causing vomiting and diarrhoea
include rotavirus.
2. Sometimes sores in a child's mouth caused by a virus make it
painful to eat or drink, helping to cause or worsen dehydration.
3. More serious bacterial infections can make a child less likely to eat
and may cause vomiting and diarrhoea. Common bacterial
infections include Salmonella, E coli, CampylobacterandC.difficile.
4. Parasitic infections such as Giardia lamblia cause the condition
known as giardiasis.
5. Increased sweating from a very hot environment can cause
dehydration.
6. Excessive urination caused by unrecognised or poorly
treated diabetes (not taking insulin) and Diabetes insipidus.

7. 7-Third-space extravasation of intravascular fluid
(eg, pancreatitis, peritonitis, sepsis, heart
failure)
8-Hemorrhage
9-burn

8. Signs &Symptoms of dehydration
in children
You should be concerned if your child has an excessive loss of fluid
from vomiting or diarrhoea, or if the child refuses to eat or drink.
Signs of dehydration:
1. Sunken eyes
2. Decreased frequency of urination or dry nappies
3. Sunken soft spot on the top of the head in babies (called the
fontanelle)
4. No tears when the child cries
5. Dry or sticky mucous membranes (the lining of the mouth
or tongue)
6. Lethargy (less activity than normal)
7. Irritability (more crying, fussiness)
8. Abnormal capillary refill time
9. Abnormal skin turgor
10 .Abnormal respiratory pattern

11. investigation
• A full blood count may identify seriousness or type of
infection.
• Blood cultures may identify the type of bacterial
infection.
• Blood chemistry may identify
any electrolyte abnormality caused by vomiting and
diarrhoea, and may identify serious imbalances in body
chemistry caused by illness.
• Urinalysis may identify bladder infection, give evidence
of severity of dehydration and may identify sugar and
ketones in urine (evidence of uncontrolled diabetes).
• Stool examination

12. Evaluation the degree of
dehydration

13. CALCULATION OF THE DEFICIT:-
Determining the fluid deficit necessitates clinically determining the
percent dehydration and multiplying this percentage by the
patient's weight; a child who weighs 10 kg and is 10% dehydrated
has a fluid deficit of 1 L.
10kg x 10/100= 1L. .
CALCULATION OF MAINTENANCE:-
100 ml/kg for the first 10 kg body wt. = 1000 ml.
50 ml/kg for the second 10 kg body wt. = 500 ml.
25 ml/kg for the third 10 kg body wt. = 250 ml.
TOTAL FLUID REQUIRMENT:- equal to
Fluid deficit + maintenance within 24 hrs.

14. Treatment
Mild Volume Depletion
• Patients with minimal to mild volume depletion
should be encouraged to continue an age-appropriate
diet and adequate intake of oral fluids.
Oral rehydration solution (ORS) should be used.
Children should be given sips of ORS (5 mL or 1
teaspoon) every 2 minutes . the goal should be to
drink 10 mL/kg body weight for each watery stool
and estimate volume of emesis for each episode of
vomiting .

15. • If commercially prepared ORS is not available, the
following recipe may be used:
• In 1 L of water, add 2 level tablespoons of sugar or
honey, a quarter teaspoon of table salt (NaCl), and a
quarter teaspoon of baking soda (bicarbonate of soda)
• If baking soda is not available, use another quarter
teaspoon of salt instead
• If available, add one-half cup of orange juice.
• The water is safer if boiled, but do not lose time doing
this if the child is very ill
• Inpatient therapy generally is not indicated for mild
volume depletion. However, it is prudent to arrange
outpatient follow-up evaluation within 48 hours, with
instructions to return sooner if symptoms worsen.

17. Oral Rehydration Solution
Composition:
NaCl: 3.5 gm, NaHCO3: 2.5 gm, KCl: 1.5 gm, Glucose: 20 gm, In
1000ml (1 litre) of water.
Some replace NaHCOs by 2 gm Tri-sodium Citrate Di-hydrate
which lessens vomiting, is tastier and more stable in humid
and hot areas.
Advantages of ORS:
Cheap, effective and easy to give at home by the mother. This is
why 95% of the cases are treated by ORS, as children will not
develop dehydration, when they get diarrhoea.
Limitations to oral rehydration therapy include shock, an ileus,
intussusception, carbohydrate intolerance (rare), severe
emesis, and high stool output (>10 mL/kg/hr).

18. Preparation of ORS:
The water should be boiled and cooled before the
powder is added to avoid the loss of bicarbonate,
and changes of concentration. In winter, warm
the solution to 40°C to increase acceptability,
increase the rate of absorption, decrease
vomiting & decrease the risk of a drop in the
body temperature when large volumes are
consumed.
Diarrhoea case fatality rate has decreased a lot
after the introduction of the ORS, due to the
prevention of dehydration.

19. Moderate Volume Depletion
• The literature supports use of oral rehydration for the
moderately dehydrated child. Similar outcomes have been
achieved in randomized studies comparing ORS with
intravenous fluid therapy with fewer complications and higher
parent satisfaction in the ORS groups. Moreover, ORS can
typically be initiated sooner than IV fluid therapy .
• With ORS, patients should receive approximately 50-100
mL/kg body weight over 2-4 hours, again starting with 5 mL
every 5 minutes. If the child can tolerate this amount and asks
for more fluids, the amount given can gradually be increased.
Once the fluid deficit has been corrected, parents should be
instructed on how to replace volume losses at home if the
child continues to have vomiting or diarrhea.

20. • Children in whom ORS fails should be given a
bolus (20 mL/kg) of isotonic fluid intravenously.
This may be followed by maintenance therapy.
Over the next few hours, the patient may be
transitioned to oral rehydration as tolerated, at
which point the intravenous therapy may be
discontinued.
• Children with moderate volume depletion may
require inpatient treatment if they are unable to
tolerate oral fluids despite rehydration.
Hospitalization may also be required for
treatment of the underlying cause of the fluid
deficit.

21. Severe Volume Depletion
• Patients with severe volume depletion should receive intravenous
isotonic fluid boluses (20-60 mL/kg). In children with difficult
peripheral access, perform intraosseous or central access promptly.
Fluid boluses should be repeated until vital signs, perfusion, and
capillary refill have normalized.
• If a patient reaches 60-80 mL/kg in isotonic crystalloid boluses and
is not significantly improved, consider other causes of shock (eg,
sepsis, hemorrhage, cardiac disease). In addition, consider
administering vasopressors and instituting advanced monitoring,
such as a bladder catheter, central venous pressure, and measuring
mixed venous oxygen saturation.
• Although physicians typically give normal saline for these initial
boluses, it is important to remember to check a bedside glucose
level for patients who appear lethargic or altered. Treat
hypoglycemia promptly. The appropriate dose is 0.25 g/kg IV (2.5
mL/kg of 10% dextrose or 1 mL/kg of 25% dextrose).

22. • Once vital sign abnormalities are corrected,
initiate maintenance fluid therapy plus
additional fluid to make up for any continued
losses.
• Daily fluid requirements may be met using
dextrose 5% in half-normal saline solution.
• The emergency physician also should consider
daily sodium and potassium requirements as
follows:
• Sodium 2-3 mEq/kg/d
• Potassium 2-3 mEq/kg/d

23. Fluid management of dehydration

24. During Therapy Monitor:
1- Vital sign :
pulse , blood pressure
2- Intake and output:
fluid balance and urine output
3-Physical examination:
weight
sign of volume depletion or overload
4-Electrolytes

25. ADDITIONAL THERAPIES.
• Antimotility agents
• are contraindicated in children with dysentery and probably have no role in
the management of acute watery diarrhea in otherwise healthy children.
• Antiemetic
• ANTIBIOTIC THERAPY
• Timely antibiotic therapy in select cases of diarrhea may reduce the
duration and severity of diarrhea and prevent complications
• ZINC SUPPLEMENTATION
• There is strong evidence that zinc supplementation in children with
diarrhea in developing countries leads to reduced duration and
severity of diarrhea WHO and UNICEF recommend that all children
with acute diarrhea in at-risk areas should receive oral zinc in some
form for 10–14 days during and after diarrhea (10 mg/day for infants
<6 mo of age and 20 mg/day for those >6 mo).

26. HYPONATREMIC DEHYDRATION.
• The pathogenesis of hyponatremic
dehydration is usually due to a combination of
sodium and water loss and water retention to
compensate for the volume depletion. The
patient has a pathologic increase in fluid loss,
and this fluid contains sodium. Most fluid that
is lost has a lower sodium concentration, so
patients with only fluid loss would have
hypernatremia

27. • Diarrhea has, on average, a sodium concentration of 50
mEq/L. By replacing diarrheal fluid with water, which
has almost no sodium, there is a reduction in the
serum sodium concentration. The volume depletion
stimulates synthesis of antidiuretic hormone, resulting
in reduced renal water excretion. Hence, the body's
usual mechanism for preventing hyponatremia, renal
water excretion, is blocked. The risk of hyponatremia is
further increased if the volume depletion is due to loss
of fluid with a higher sodium concentration, as may
occur with renal salt wasting, third space losses, or
diarrhea with a high sodium content (cholera).

28. • Hyponatremic dehydration produces more substantial
intravascular volume depletion due to the shift of water from
the extracellular space into the intracellular space. In addition,
some patients have symptoms, predominantly neurologic, as
a result of hyponatremia .
• The initial goal in treating hyponatremia is correction of
intravascular volume depletion with isotonic fluid (NS or RL).
An overcorrection in the serum sodium concentration (>135
mEq/L) is associated with an increased risk of central pontine
myelinolysis (CPM). The risk of CPM also increases with overly
rapid correction of the serum sodium concentration, so it is
best to avoid increasing the sodium by >12 mEq/L each 24 hr. .
Again, potassium delivery is adjusted based on the initial
serum potassium level and the patient's renal function.
Potassium is not given until the patient voids.

29. • The patient's sodium concentration is monitored closely to
ensure appropriate correction, and the sodium concentration
of the fluid is adjusted accordingly. Patients with ongoing
losses require an appropriate replacement solution. Patients
with neurologic symptoms (seizures) as a result of
hyponatremia need to receive an acute infusion of hypertonic
(3%) saline to increase the serum sodium concentration
rapidly.

30. Treatment of hyponatremic dehydration Dehydration
Restore intravascular volume
Normal saline: 20 mL/kg over 20 min
Repeat as needed
Rapid volume repletion: 20 mL/kg normal saline or Ringer Lactate (maximum = 1 L) over 2 hr
Calculate 24-hr fluid needs: maintenance + deficit volume
Subtract isotonic fluid already administered from 24 hr fluid needs
Administer remaining volume over 24 hr using D5 ½ normal saline + 20 mEq/L KCl
Replace ongoing losses as they occur

31. HYPERNATREMIC DEHYDRATION.
• Hypernatremic dehydration is the most dangerous
form of dehydration due to complications of
hypernatremia and of therapy. Hypernatremia can
cause serious neurologic damage, including central
nervous system hemorrhages and thrombosis. This
appears to be secondary to the movement of water
from the brain cells into the hypertonic extracellular
fluid, causing brain cell shrinkage and tearing blood
vessels within the brain .

32. • The movement of water from the intracellular space to
the extracellular space during hypernatremic
dehydration partially protects the intravascular
volume. Thus, children with hypernatremia often
appear less ill than children with a similar degree of
isotonic dehydration. Urine output may be preserved
longer, and there may be less tachycardia.
Unfortunately, because the initial manifestations are
milder, children with hypernatremic dehydration are
often brought for medical attention with more
profound dehydration.
• Children with hypernatremic dehydration are often
lethargic, and they may be irritable when touched.
Hypernatremia may cause fever, hypertonicity, and
hyperreflexia. More severe neurologic symptoms may
develop if cerebral bleeding or thrombosis occurs.

33. • Overly rapid treatment of hypernatremic dehydration may
cause significant morbidity and mortality. Idiogenic osmoles
are generated within the brain during the development of
hypernatremia. These idiogenic osmoles increase the
osmolality within the cells of the brain, providing
protection against brain cell shrinkage caused by
movement of water out of the cells and into the hypertonic
extracellular fluid. They dissipate slowly during the
correction of hypernatremia. With overly rapid lowering of
the extracellular osmolality during the correction of
hypernatremia, there may be an osmotic gradient created
that causes water movement from the extracellular space
into the cells of the brain, producing cerebral edema.
Symptoms of the resultant cerebral edema can range from
seizures to brain herniation and death.

34. • To minimize the risk of cerebral edema during
the correction of hypernatremic dehydration,
the serum sodium concentration should not
decrease by >12 mEq/L every 24 hr. The
deficits in severe hypernatremic dehydration
may need to be corrected over 2–4 days .

35. Treatment of Hypernatremic Dehydration

37. • The initial resuscitation of hypernatremic dehydration requires
restoration of the intravascular volume with NS. LR should not be
used because it is more hypotonic than NS and may cause too rapid
a decrease in the serum sodium concentration, especially if
multiple fluid boluses are necessary.
• To avoid cerebral edema when correcting hypernatremic
dehydration, the fluid deficit is corrected slowly. The rate of
correction depends on the initial sodium concentration .There is no
general agreement on the choice or the rate of fluid for correcting
hypernatremic dehydration. The choice and the rate of fluid
administration are not nearly as important as vigilant monitoring of
the serum sodium concentration and adjustment of the therapy
based on the result .

38. • Seizures are the most common manifestation of cerebral edema
from an overly rapid decrease of the serum sodium concentration
during correction of hypernatremic dehydration. Acutely, increasing
the serum concentration via an infusion of 3% sodium chloride can
reverse the cerebral edema. Each 1 mL/kg of 3% sodium chloride
increases the serum sodium concentration by approximately 1
mEq/L. An infusion of 4–6 mL/kg often results in resolution of the
symptoms. This is similar to the strategy used for treating
symptomatic hyponatremia .
• In patients with severe hypernatremia, oral fluids must be used
cautiously. Infant formula, because of its low sodium concentration,
has a high free water content, and especially if added to
intravenous therapy, it may contribute to a rapid decrease in the
serum sodium concentration. Less hypotonic fluid, such as an oral
rehydration solution, may be more appropriate initially.