Pediatric Dehydration Management

Aka: Pediatric Dehydration Management, Dehydration Management in Children, Intravenous Therapy Protocol in Pediatric Dehydration, Severe Pediatric Dehydration Management

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II. Indications

  1. Severe Pediatric Dehydration
  2. Treat Mild to Moderate Dehydration with Oral Rehydration Therapy Protocol in Pediatric Dehydration

III. Labs

  1. Indications
    1. Severe Pediatric Dehydration
    2. Altered Mental Status
    3. Age <6 months
  2. Serum Electrolytes
    1. Obtain in all cases of severe Dehydration (not typically needed in mild to moderate Dehydration)
    2. Correct serious Electrolyte abnormalities prior to starting phase 2 (maintenance replacement)
    3. Serum bicarbonate
      1. Serum bicarbonate >15-17 mEq/L decreases the likelihood of Clinically SignificantDehydration
      2. Serum bicarbonate <13 mEq/L increases the likelihood that Oral Rehydration Solution will fail
      3. Teach (1997) Clin Pediatr 36(7): 395-400 [PubMed]
    4. Blood Urea Nitrogen (BUN) and BUN to Creatinine Ratio
      1. Unreliable marker in Pediatric Dehydration
  3. Serum Glucose
    1. Monitor in infants and toddlers with Diarrhea
    2. Serum Glucose <40 mg/dl is also a trigger for initiating IV fluid management
  4. Other testing only as indicated by history
    1. Complete Blood Count
    2. Urinalysis
      1. Specific gravity is an unreliable marker
    3. Stool Cultures
      1. Consider NAT Stool testing in Immunocompromised children, bloody Diarrhea (Dysentery)

IV. Management: General

  1. Treat Mild to Moderate Dehydration with Oral Rehydration Therapy Protocol in Pediatric Dehydration instead
    1. This protocol is intended for severe Dehydration requiring IV Resuscitation
  2. See ABC Management
  3. Treat Hypoglycemia independent of initial fluid boluses
    1. See Intravenous Dextrose
    2. Add dextrose to maintenance fluids
  4. Obtain early IV Access in severe Dehydration
    1. Obtain Intraosseous Access if unable to obtain IV Access
  5. Ondansetron (Zofran)
    1. Aids transition to Oral Rehydration Therapy

V. Management: Initial Replacement (Phase 1 Acute Resuscitation)

  1. Give 20 ml/kg Normal Saline or Lactated Ringers over 10-15 minutes
  2. May repeat bolus until circulation stable
    1. May require up to 60 ml/kg within the first 1-2 hours
    2. Consider other causes of shock (e.g. Septic Shock) if refractory to fluid boluses
    3. Stabilization criteria include
      1. Improved Sinus Tachycardia
      2. Capillary Refill <2 seconds
      3. Intact mental status
      4. Adequate Urine Output (>1 ml/kg/h)
  3. After fluid boluses until circulation stable
    1. Administer 100 ml/kg of fluid
      1. Option 1: Oral Rehydration Solution
        1. See Oral Rehydration Therapy Protocol in Pediatric Dehydration
      2. Option 2: Intravenous Normal Saline or Lactated Ringers
    2. Initiate maintenance fluids
      1. Option 1: Oral Rehydration Solution
        1. See Oral Rehydration Therapy Protocol in Pediatric Dehydration
      2. Option 2: Continue intravenous hydration as below

VI. Management: Maintenance Replacement with IV fluids (Phase 2 Resuscitation)

  1. See Oral Rehydration Therapy Protocol in Pediatric Dehydration (mild to moderate Dehydration)
    1. Start the oral rehydration protocol (see above)
  2. Calculate 24 hour maintenance requirements
    1. See Maintenance Fluid Requirements in Children (Holliday-Segar Formula)
  3. Calculate Deficit (See Pediatric Dehydration)
    1. Mild Dehydration: 3-5% deficit (50 ml/kg deficit, 30 ml/kg if >10 kg)
    2. Moderate Dehydration: 6-10% deficit (100 ml/kg deficit, 60 ml/kg if >10 kg)
    3. Severe Dehydration: >10% deficit (120 ml/kg deficit)
  4. Calculate remaining deficit
    1. Subtract fluid resucitation given in Phase 1
    2. Some guidelines recommend replacement of deficit in 4 hours followed by oral maintenance
  5. Calculate Replacement over 24 hours
    1. First 8 hours: 50% Deficit + Maintenance
    2. Next 16 hours: 50% Deficit + Maintenance
  6. Determine Serum Sodium Concentration
    1. Pediatric Hypertonic Dehydration (Serum Sodium > 150)
    2. Pediatric Hypotonic Dehydration (Serum Sodium < 130)
    3. Pediatric Isotonic Dehydration
      1. Add Dextrose to maintenance fluids
      2. Use D5 NS instead of Hypotonic Saline
        1. Exercise caution with hypotonic solutions (Hyponatremia)
        2. Use D5 NS as maintenance fluid instead of D5 1/2NS
        3. McNab (2015) Lancet [PubMed]
      3. Weight <28 kg: D5 1/2NS (prior recommendation D5 1/4NS)
      4. Weight >28 kg: D5 NS
  7. Add Potassium to Intravenous Fluids after patient voids
    1. Potassium source
      1. Potassium Chloride
      2. Potassium Acetate for Metabolic Acidosis
    2. Potassium dosing
      1. Weight <10 kilograms: 10 meq/liter KCl
      2. Weight >10 Kilograms: 20 meq/liter KCl
  8. Correct for ongoing losses
    1. Reassess intakes and outputs every 4 hours
      1. Adjust fluids to maintain adequate Urine Output and Vital Signs
    2. Replace stool outputs
      1. Indicated if stool >30/ml/kg/day
      2. Replace equal volume of stool losses with 1/2NS with 20 kcl (in addition to maintenance volume)
    3. Replace ongoing fever-related losses
      1. Replace 1 ml/kg/hour per degree increase above normal (in celsius)

VII. Resources

  1. Vega and Bhimji (2017) Pediatric Dehydration in Stat Pearls
    1. https://www.ncbi.nlm.nih.gov/books/NBK436022/

VIII. References

  1. Walton (2020) Crit Dec Emerg Med 34(6): 3-9
  2. Canavan (2009) Am Fam Physician 80(7):692-6 [PubMed]

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