Pediatric Dehydration

1. History: Triage
   1. History from parents can help rule-out dehydration
   2. Findings correlated with adequate hydration
      1. No decreased oral intake
      2. No decrease in urine output
      3. No history of Vomiting
      4. Normal tear production
   3. References
      1. Porter (2003) Ann Emerg Med 41:196-205
2. Efficacy: Best markers of pediatric hydration status
   1. Increased Respiratory Rate (rapid deep breathing)
      1. May be a sign of Metabolic Acidosis
   2. Abnormal skin turgur
      1. Pinch skin at umbilical level and lateral abdominal wall
      2. Skin Tenting with a delay in return to normal suggests dehydration
   3. Capillary Refill
      1. Press on Sternum in infants or finger tuft in children
      2. Capillary Refill Time over 1.5 to 2 seconds suggests dehydration
   4. Serum bicarbonate
      1. Serum bicarbonate >15-17 mEq/L decreases the likelihood of Clinically Significant dehydration
      2. Serum bicarbonate <13 mEq/L increases the likelihood that Oral Rehydration Solution will fail
      3. Teach (1997) Clin Pediatr 36(7): 395-400
3. Efficacy: Poor markers of pediatric hydration status (low sensitivity and Specificity)
   1. Urine Specific Gravity
   2. Blood Urea Nitrogen
4. Signs and symptoms: Minimal or subclinical Dehydration
   1. Deficit: 1-2% (10-20 ml/kg)
   2. Symptoms and signs
      1. Increased Thirst
      2. Mild Oliguria
5. Signs and symptoms: Mild Dehydration
   1. Deficit
      1. Child: 3% deficit (30 ml/kg)
      2. Infant: 5% deficit (50 ml/kg)
   2. Signs and Symptoms
      1. Dry lips
      2. Thick Saliva
      3. Decreased Tears
      4. Anterior Fontanelle flat
      5. Decreased Urine output
6. Signs and symptoms: Moderate Dehydration
   1. Deficit
      1. Child: 6% deficit (60 ml/kg)
      2. Infant: 9% deficit (90 ml/kg)
   2. Signs and symptoms
      1. Eyes sunken
      2. Tears absent
      3. Dry mucus membranes
      4. Sunken Fontanelle
      5. Pulse weak and rapid
      6. Skin turgur is prolonged (Skin slowly retracts or tents)
      7. Delayed Capillary Refill (>2 seconds)
      8. Listless and Irritable
      9. Urine characteristics
         1. Dark color
         2. Oliguria (Urine output <1-2 cc/kg/hour)
         3. Urine Specific Gravity = 1.030 (low Test Sensitivity and Specificity)
      10. Blood Urea Nitrogen (BUN) increased (low Test Sensitivity and Specificity)
      11. Metabolic Acidosis
          1. Arterial pH <7.30
          2. Serum bicarbonate <17 meq/L (failure to respond to ORS is associated with serum bicarbonate <13 meq/L)
7. Signs and symptoms: Severe Dehydration
   1. Deficit
      1. Child: 10% deficit (100 ml/kg)
      2. Infant: 15% deficit (150 ml/kg)
   2. Signs and symptoms
      1. Limp and cold
      2. Lethargy or coma
      3. Acrocyanosis
      4. Thready pulse
      5. Grunting
      6. Deep and rapid Respiratory Rate
      7. Decreased Blood Pressure
      8. Skin retracts >2 sec
      9. Oliguria or Anuria
      10. Specific Gravity >1.035
      11. Capillary Refill >4 seconds
      12. Blood Urea Nitrogen (BUN) markedly increased
      13. Severe Metabolic Acidosis
          1. Arterial pH <7.10
8. Management
   1. See Pediatric Dehydration Management