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Pediatric Dehydration

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Pediatric Dehydration, Dehydration in Children

  • Epidemiology
  1. Pediatric Dehydration is responsible for 200,000 hospitalizations and 300 deaths in the U.S. per year
  • 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 [PubMed]
  • Precautions
  1. Markers of dehydration have low accuracy as single measures, but useful in combination
    1. Hoxha (2015) Med Arch 69(1): 10–2 [PubMed]
  • 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 of lateral abdominal wall
    2. Skin Tenting with a >2 second delay in return to normal suggests dehydration
  3. Capillary Refill
    1. Perform in a warm room
    2. Press on Sternum or pad of foot in infants
    3. Press on finger tuft in children (held at heart level)
    4. Capillary Refill Time over 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 [PubMed]
  • Efficacy
  • Poor markers of pediatric hydration status (low sensitivity and Specificity)
  • Findings
  • Minimal or subclinical Dehydration
  1. Deficit: 1-2% (10-20 ml/kg)
  2. Symptoms and signs
    1. Increased Thirst
    2. Mild Oliguria
  • Findings
  • Mild Dehydration
  1. Deficit <5% loss
    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
  • Findings
  • Moderate Dehydration
  1. Deficit 5-9% loss
    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 (Tachycardia)
    6. Tachypnea
      1. Compensatory Tachypnea for Metabolic Acidosis without respiratory distress
    7. Skin turgur is prolonged (Skin slowly retracts or tents for 2 sec)
    8. Delayed Capillary Refill (2-4 seconds)
    9. Listless and Irritable
    10. 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)
    11. Blood Urea Nitrogen (BUN) increased (low Test Sensitivity and Specificity)
    12. 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)
  • Findings
  • Severe Dehydration
  1. Deficit >10% loss
    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. Toxic appearance
    4. Sunken eyes
    5. Very dry mucous membranes
    6. Acrocyanosis
    7. Thready and rapid pulse (severe Tachycardia)
    8. Grunting
    9. Deep and rapid Respiratory Rate
      1. Compensatory Tachypnea for Metabolic Acidosis without respiratory distress
    10. Decreased Blood Pressure
      1. Children compensate and maintain Blood Pressure with Sinus Tachycardia and vascular constriction
      2. Hypotension is an ominous late marker of severe Dehydration in Children and heralds cardiovascular collapse
    11. Skin turgur is very prolonged (Skin slowly retracts or tents for >4 sec)
    12. Skin retracts >2 sec
    13. Oliguria or Anuria
    14. Specific Gravity >1.035
    15. Capillary Refill >4 seconds
    16. Blood Urea Nitrogen (BUN) markedly increased
    17. Severe Metabolic Acidosis
      1. Arterial pH <7.10
  • References
  1. Walton (2020) Crit Dec Emerg Med 34(6): 3-9
  2. Canavan (2009) Am Fam Physician 80(7):692-6 [PubMed]