My student presentation on the causes, diagnosis and treatment of dehydration in children.

1. MANAGEMENT OF SEVERE
DEHYDRATION
DR YAKUBU, AHAB
SUPERVISED BY DR. MADUBUKO C.

2. CASE SCENARIO
• M.A is a 7month old girl that presented to the EPU with 5 bouts of vomiting and 8
bouts of passage of non-bloody, non-mucoid loose stools over 2 days. she was
commenced on complementary feeds barely 3 weeks prior to symptom onset and
is still being breastfed. However, in the past 2 days, has had poor suck. Mother is
unsure of urine output in the past 24 hours as diaper is always soaked with stool.
• Examination reveals an afebrile child with very depressed AF, he is lethargic and
cries without tears. PR=140bpm, reg, small volume. RR = 56bpm, cap refill
>4sec wt= 6kg .
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3. QUESTIONS
1. List 4 signs of dehydration in this child?
2. What is the estimated degree/severity of dehydration in this child?
3. How would you manage this pt?
4. What 4 possible complications could arise?
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4. OBJECTIVES
• To identify children at risk of dehydration
• To know the types of dehydration
• To be able to identify a child with dehydration
• To be able to treat dehydration (especially the severe form)
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5. OUTLINE
• INTRODUCTION
• CAUSES OF DEHYDRATION
• CLASSIFICATION OF DEHYDRATION
• TYPES OF DEHYDRATION
• CLINICAL FEATURES OF DEHYDRATION
• TREATMENT
• COMPLICATIONS
• CONCLUSION
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6. INTRODUCTION
• Dehydration is the excessive loss of body water resulting in a decrease in
total body water.
• It is a state of negative fluid balance that can be caused by various diseases.
• Many clinical conditions lead to this abnormal water balance in children
and depending on the relative effects of intake and loss either dehydration
or overhydration may result.
• Total fluid loss > Total fluid intake
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7. • Fluid loss from both intravascular and extravascular compartments
can result to dehydration.
• Extravascular loss- impairment of cellular function and loss of tissue
laxity
• Often there is an associated electrolyte loss with diarrhoea
• Sodium is the most affected electrolyte- Hyponatremia or
hypernatremia
• If not properly treated, morbidity and mortality rates increase.
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8. Body water distribution
• Although a smaller percentage of body water is in the ECF( except in
the newborn) , it is more prone to fluctuation compared to the ICF, as
such, dehydration and overhydration are associated with changes in
the ECF volume.
• The newborn is made up of 70-80% water
• Adults 50-60% water
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9. Body water distribution
• Infants are at higher risk of dehydration due to:
• High surface area to body ratio
• High basal fluid requirement
• Immature renal tubular reabsorbtion
• Inability to gain access to fluids when thirsty
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10. Water balance
• The amount of water in the body is influenced by input and output
• Input – water, breastmilk, food
• Output – insensible loss- about 30ml/kg/day
- renal water loss – about 60ml/kg/day
- stool water loss – 10ml/kg/day
However, insensible loss vary with age.
it is more in preterm and reduces as the child gets older
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11. Causes of Dehydration
1. REDUCED INTAKE – poor maternal lactation, GI malformations
(oesophageal atresia), poorly mixed baby formular
2. INCREASED LOSS -
 True volume depletion
• Increased insensible loss – persistent fever, phototherapy , burns,
hyperhidrosis, heat stroke, ventilator use
• Renal loss – DKA, DI, polyuric phase of AKI, adrenal insufficiency
• GI loss – diarrhea, vomiting, NG tube drainage
 Decreased intravascular volume with increased total body water
• Third space loss- peritonitis, nephrotic syndrome
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12. CLASSIFICATION
Based on severity
1. Mild – loss of <5% body weight
2. Moderate – loss of 5-10% body weight
3. Severe – loss of >10% body weight
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13. CLINICAL FEATURES
PARAMETERS MILD (5%) MODERATE (7.5%) SEVERE (10%)
TEARS NORMAL REDUCED ABSENT
THIRST THIRSTY VERY THIRSTY UNABLE TO DRINK
FONTANELLES NORMAL SUNKEN VERY SUNKEN
EYES NORMAL SUNKEN VERY SUNKEN
BUCCAL MUCOSA NORMAL- DRY VERY DRY PARCHED
PULSE NORMAL RAPID RAPID BUT WEAK /
ABSENT
CAPILLARY REFILL IMMEDIATE >1.5 SEC >3SEC
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14. PARAMETERS MILD MODERATE SEVERE
BLOOD PRESSURE NORMAL NORMAL – ORTHOSTATIC
HYPOTENSION
HYPOTENSION
RESPIRATORY RATE NORMAL INCREASED INCREASED
SKIN TUGOR NORMAL SLOW TO RETURN TENTING
URINE OUTPUT NORMAL REDUCED VERY REDUCED/ABSSENT
BODY TEMPERATURE NORMAL NORMAL-RAISED RAISED
MENTAL STATE INTACT IRRITABLE LETHARGIC/ COMA
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15. CONFOUNDERS
MALNUTRITION – sunken eyeballs , skin turgor, mental state
More objective indicators should be used
• BP
• URINE OUTPUT
• PULSE
OEDEMATOUS CHILD –
HYPERTONIC DEHYDRATION- may not look dehydrated
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16. MANAGEMENT
PRIMARY SURVEY AND RESUSCITATION
• QUICK History – diarrhea, vomiting, excessive urination
• FOCUSED Physical examination – to classify the degree of dehydration
SECONDARY SURVEY AND DIAGNOSTIC EVALUATION
• MORE DETAILED HX –
• DETAILED examination – acetone breath, hyperpigmentation,
oedema, ascites
• INVESTIGATION – E/U/Cr , RBG, URINALYSIS, STOOL MICROSCOPY
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17. PRINCIPLES OF MANAGEMENT
1. Expand ECF – ANTI-SHOCK
2. Correct fluid deficit
3. Replace ongoing losses
4. Correct any associated electrolyte derangement
5. Address the cause of dehydration
6. Monitor
7. Other supportive care
8. Counselling
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18. MILD (ORAL)
• 50ml/kg of ORS over 4 hours then 10ml/kg per loose stool
• Re-asses during and after therapy
MODERATE (ORAL)
• 75ml/kg of ORS over 4 hours then 10ml/kg per loose stool
NB: IN CHILDREN WITH SAM CORRECTION IS OVER 6 HOURS
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19. SEVERE ( IV THERAPY): it is an emergency
deficit – 100ml/kg
maintenance – Holliday – Segar formular 100ml for first 10kg, 50ml for the
next 10kg and 20ml for every kg.
ADMINISTRATION
1. ANTI-SHOCK – give 20-30ml/kg of deficit over 30mins (15ml/kg in 1 hour
for SAM )
2. Then – over the next 8hours
½ deficit + 1/3 maintenance
3. Over the remaining 16 hours
½ deficit + 2/3 maintenance
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20. Example
A 15kg child with severe dehydration
DEFICIT – 1500ml MAINTENANCE – 1250ml
• anti shock – 300ml over 30mins ( remnant 1200mls)
• Then – over 8 hours
600ml +417ml = 1017ml
over 16 hours
600ml + 833ml = 1433ml
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21. NEXT STEPS AFTER CORRECTING
DEHYDRATION- MONITORING
• Check and monitor for rehydration –
• Avoid overhydration
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22. Principles of Treatment of Diarrhea
• Diarrhea disease is one of the commonest causes of dehydration
1. Correct dehydration
2. Replace ongoing losses (per loose stools)
3. Nutritional consideration
4. Additional therapy
• Antibiotics if indicated
• Zinc
• Vitamin A
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23. Indications for IV Fluid Therapy in Diarrhea
1. Severe dehydration
2. Child <6 months
3. Prematurity
4. Bloody diarrhea
5. Persistent vomiting
6. Reduced urine output
7. Depressed consciousness
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24. COMPLICATIONS
Before therapy Following therapy
SHOCK OVERHYDRATION
AKI CENTRAL PONTINE MYELINOLYSIS ( HYPOTONIC)
CEREBRAL OEDEMA ( HYPOTONIC ) CEREBRAL OEDEMA ( HYPERTONIC)
CEREBRAL HEMORRHAGE (HYPERTONIC)
CENTRAL PONTINE MYELINOLYSIS ( HYPERTONIC)
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25. Prevention of dehydration
• Primary prevention: aimed at reducing exposure to hazards that leads to
disease eg contaminated feeds
• Education about healthy habits e.g. hand washing and environmental sanitation
• immunization against dieased
• Secondary prevention: aimed at reducing the impact of disease , halting or
slowing its progression and preventing recurrence; it includes detection and
treatment
• Tertiary prevention: aims to reduce the impact of ongoing illness and its
lasting effects. It is done to improve function, quality of life and life
expectancy
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26. CONCLUSION
Dehydration is the excessive loss of body water resulting in a decrease
in total body water.
Infants are at higher risk of dehydration
Early detection and proper management of dehydration reduces
morbidity and mortality rates
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27. •THANK YOU
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28. REFERENCES
• PAEDIATRICS AND CHILD HEALTH IN A TROPICAL REGION – AZUBUIKE
AND NKANGINIEME
• NELSON TEXTBOOK OF PAEDIATRICS
• Medscape
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