pathophysiology of dehydration in pediatrics

Wathen JE, Freedman SB, Avner JR. Diagnosis is based on history and physical examination. Other laboratory abnormalities in dehydration include relative polycythemia resulting from hemoconcentration, elevated blood urea nitrogen (BUN), and increased urine specific gravity. Pediatric Advanced Life Support Provider Manual Dallas, Tex: American Heart Association; 2006: 232. Choose a single article, issue, or full-access subscription. 19. The value of parental report for diagnosis and management of dehydration in the emergency department. Immediate, unlimited access to all AFP content. 2004;19(3):364]. If dehydration isn't treated it can get worse and become a serious problem. Due to water retention and drinking following stimulation of ADH secretion and thirst, osmoregulation is overruled by volume conservatory mechanisms, which lead to hyponatremia. The patients were referred to the investigators by AMY CANAVAN, MD, FAAP, is a pediatric hospitalist at Inova Fairfax Hospital for Children, Falls Church, Va., and an assistant professor in the Department of Pediatrics at Virginia Commonwealth University School of Medicine in Falls Church. Powell EC. However, children with hypernatremia have better hemodynamics (eg, less tachycardia and better urine output) than do children with hyponatremia, in whom fluid has shifted out of the vascular space. Kohane IS, DeWalt DA, Salam MA. To replace ongoing losses, 10 mL per kg for every loose stool and 2 mL per kg for every episode of emesis should be administered. Extracellular fluid restoration in dehydration: a critique of rapid versus slow. 8. Friedman AL. **Recognize the different clinical and laboratory abnormalities in isonatremic, hyponatremic, and hypernatremic dehydration. Pediatrics. When urine output is established, potassium is added at a concentration of 20 mEq/L (20 mmol/L; for safety reasons, no attempt is made to replace complete potassium deficit acutely). Due to this possibility of iatrogenic hyponatremia, many centers are now using a more isotonic fluid such as 0.45% or 0.9% saline for maintenance in dehydrated children. Spandorfer PR, This site complies with the HONcode standard for trustworthy health information:   Shaw KN, water and electrolytes in pediatrics physiology pathophysiology and management Oct 15, 2020 Posted By Stephenie Meyer Publishing TEXT ID e784a7bf Online PDF Ebook Epub Library water and electrolytes in pediatrics physiology pathophysiology and management by gerard de villiers although the principles underlying water and electrolyte metabolism Effect of fever on capillary refill time. Validation of the clinical dehydration scale for children with acute gastroenteritis. Ray PE. Commercial ORT preparations typically contain around 50 mEq per L of sodium, which is more consistent with the sodium content of diarrhea caused by rotavirus.20 Commercial ORT solutions contain 25 g per L of dextrose, which helps prevent hypoglycemia without causing osmotic diuresis,21 and 30 mEq per L of bicarbonate, which leads to less vomiting and more efficient correction of acidosis.19 Commercial ORT solutions are recommended over homemade solutions because of the risk of preparation errors.22  Clear sodas and juices should not be used for ORT because hyponatremia may occur. Srivastava R, Oral ondansetron for gastroenteritis in a pediatric emergency department. 1984;59(11):1072–1075. 1997;13(5):305–307. The American Academy of Pediatrics and the WHO both recommend oral replacement therapy for mild and moderate dehydration. 2001;85(2):132–142. This change also has the benefit of allowing use of the same fluid to replace ongoing losses and supply maintenance needs, which simplifies management. Porter SC, font size decrease font size increase font size; Print; Email; Dehydration reveals itself through numerous body signals, such as thirst, dizziness, and low energy. Five percent dextrose/0.9% saline is given at 40 mL/hour with 20 mEq/L (20 mmol/L) of potassium added when urine output is established. Thus, in the absence of any fluid replacement, serum sodium rises (hypernatremia). Maintenance therapy includes providing anticipated water and electrolyte needs for the next 24 hours in the child who is now euvolemic with expected normal urine output. 1999;104(3):e29. Additional signs of severe dehydration include circulatory collapse (e.g. *— Only clear liquid recommended for oral rehydration in children with dehydration. Bos AP, Normally, serum osmolarity controls moment-to-moment ADH release. Pediatr Nephrol. Maintenance fluid therapy: what it is and what it is not. The decrease in total body water causes reductions in both the intracellular and extracellular fluid volumes. Nager AL, For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.xml. Pediatrics. We do not control or have responsibility for the content of any third-party site. Mandl KD. The exact amount and type of electrolyte loss varies depending on the cause (eg, significant amounts of bicarbonate may be lost with diarrhea but not with vomiting). This amount replaces the sodium deficit (when using 0.45% saline, 0.8 L × 77 mEq sodium/L [77 mmol/L] = 62 mEq sodium); the additional 62 mEq of sodium given by using 0.9% saline is not clinically significant as long as renal function is intact. Laron Z. Dehydration is a deficiency of water in the body. 219 Bryant Street, Buffalo, New York 14222 Laboratory Tests in the Analysis of States of Dehydration Erika Bruck, M.D. Commercial electrolyte solutions for children (e.g., Pedialyte)*. The most useful individual signs for identifying dehydration are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern.5 However, clinical dehydration scales based on a combination of physical examination findings are much better predictors than individual signs.5, In one study, four factors predicted dehydration: capillary refill time of more than two seconds, absence of tears, dry mucous membranes, and ill general appearance; the presence of two or more of these signs indicated a fluid deficit of at least 5 percent.6 In a similar validated scale, general appearance, degree of sunken eyes, dryness of mucous membranes, and tear production were associated with length of hospital stay and need for intravenous fluids in children with acute gastroenteritis.7. Use of an appropriate ORT solution, such as commercial electrolyte solutions for children (e.g., Pedialyte), corrects and helps prevent electrolyte disturbances caused by gastroenteritis.17–19 The World Health Organization ORT solution contains 90 mEq per L of sodium, mimicking the sodium content of diarrhea caused by cholera. Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial. Practice parameter: the management of acute gastroenteritis in young children. Murphy KO, Ongoing electrolyte losses can be estimated by source or cause (see Table: Estimated Electrolyte Deficits by Cause). Adler M, Laboratory predictors of fluid deficit in acutely dehydrated children. Laboratory testing is usually reserved for moderately or severely ill children, in whom electrolyte disturbances (eg, hypernatremia, hypokalemia, metabolic acidosis or metabolic alkalosis) are more common, and for children who need IV fluid therapy. First, 100 mL per kg of isotonic crystalloid should be administered over four hours, followed by a maintenance solution. Alessandrini EA, Pediatr Nephrol. Conley SB. Pediatr Nephrol. Bresee JS, Other sources are renal (eg, diabetic ketoacidosis), cutaneous (eg, excessive sweating, burns), and 3rd-space losses (eg, into the intestinal lumen in bowel obstruction or ileus). Gorelick MH, Valeria Higinio, MD 1. All types of lost fluid contain electrolytes in varying concentrations, so fluid loss is always accompanied by some degree of electrolyte loss. 16. N Engl J Med. dehydration and its treatments. Hyponatremia results in some fluid shifting out of the intravascular space into the interstitium at the expense of vascular volume. Infants are particularly susceptible to the ill effects of dehydration because of their greater baseline fluid requirements (due to a higher metabolic rate), higher evaporative losses (due to a higher ratio of surface area to volume), and inability to communicate thirst or seek fluid. The link you have selected will take you to a third-party website. Validity and reliability of clinical signs in the diagnosis of dehydration in children. This simpler approach minimizes the chance of an arithmetic error, allows use of a single IV pump, and appears to result in similar clinical outcomes. Children with severe dehydration (eg, evidence of circulatory compromise) should receive fluids IV. Dehydration in neonates, particularly with significant hypernatremia (eg, serum sodium > 160 mEq/L [> 160 mmol/L]) or hyponatremia (eg, serum sodium < 120 mEq/L [< 120 mmol/L]), requires special consideration to avoid complications. for the Centers for Disease Control and Prevention. Contact Parkin PC. Merck & Co., Inc., Kenilworth, NJ, USA is a global healthcare leader working to help the world be well. According to that formula, patients require, Sodium: 3 mEq/100 kcal/24 hours (3 mEq/100 mL/24 hours), Potassium: 2 mEq/100 kcal/24 hours (2 mEq/100 mL/24 hours), (NOTE: 2 to 3 mEq/100 mL is equivalent to 20 to 30 mEq/L [20 to 30 mmol/L].). (1) In the United States, as recently as 2003, gastroenteritis was the source for more than 1.5 million office visits, 200,000 hospitalizations, and 300 deaths per year. Serum electrolyte levels should be measured in children with severe dehydration and in those with moderate dehydration that presents in atypical ways. Holliday MA, More complex calculations (eg, those using body surface area) are rarely required. Although Lactobacillus has no major toxic effects, its effectiveness in patients with diarrhea has not been demonstrated.14 A single dose of ondansetron (Zofran) has been shown to facilitate ORT by reducing the incidents and frequency of vomiting and, therefore, reducing the failure of ORT and the need for intravenous fluid therapy.30 Recurrent dosing of ondansetron has not been studied. A single dose of ondansetron (Zofran) may facilitate ORT in children with dehydration. Oral rehydration solution without bicarbonate. 2008;122(3):545–549. 2003;52(RR-16):1–16.... 2. 7(October 1, 2009) Diagnosis and Management of Dehydration in Children. Early signs: precipitating conditions in which fluid loss are likely to occur, including diarrhea, vomiting, burns, diabetes, trauma, and fever. Adams W, If dehydration is … Molla AM, Bos AP, Rahman M, Effect of fever on capillary refill time. Goldman RD, BUN alone and urine specific gravity also have poor sensitivity and specificity for predicting dehydration in children.10, In combination with a clinical dehydration scale, a serum bicarbonate level of less than 17 mEq per L (17 mmol per L) may improve sensitivity of identifying children with moderate to severe hypovolemia.11 Additionally, a serum bicarbonate level of less than 13 mEq per L (13 mmol per L) is associated with increased risk of failure of outpatient rehydration efforts.12. Murphy KO. for the Centers for Disease Control and Prevention. MacKenzie T, Dehydration occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions. Parkin PC. Meyers A, Clinical dehydration scales based on a combination of physical examination findings are the most specific and sensitive tools for accurately diagnosing dehydration in children and categorizing its severity. 27. Same-Day Initiation of Hormonal Contraceptives. Other electrolytes (eg, magnesium, calcium) are not routinely added. 1996;97(3):424–435. Stool electrolyte content and purging rates in diarrhea caused by rotavirus, enterotoxigenic. Plan of Study Patients admitted to the Children's Hospital of Buffalo with dehydration and a concentration of sodium in the serum above 150 mEq/liter were admitted to the study. Clin Pediatr (Phila). 6. Maintenance requirements are related to metabolic rate and affected by body temperature. 2003;41(2):196–205. Friedman AL, Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. The article reviews the pathophysiology of water and sodium metabolism and, it uses the clinical case examples to illustrate the bed-side approach to the management of three different types of … Maintenance fluid volumes can be given as a separate simultaneous infusion, so that the infusion rate for replacing deficits and ongoing losses can be set and adjusted independently of the maintenance infusion rate. Dixit S, However, it is the consis-tency of the stools rather than the num- ber that is most important. Instead, they simply use isotonic fluid for resuscitation and then a single fluid, either 0.9% or 0.45% saline in 5% dextrose, for deficits, ongoing losses, and maintenance. 1997;36(7):395–400. Safety and effectiveness of homemade and reconstituted packet cereal-based oral rehydration solutions: a randomized clinical trial. The severity of dehydration ranges from mild to severe and can be fatal when fluid loss exceeds more than 15% of total body water content. A prospective study of the usefulness of clinical and laboratory parameters for predicting percentage of dehydration in children. Am Fam Physician. Rapid intravenous rehydration by means of a single polyelectrolyte solution with or without dextrose. Dehydration means your body does not have enough fluid. Hypernatremia, hyponatremia, and hypoglycemia occasionally complicate dehydration. Rarely, sweating too … 1. Kok JH, Physical examination findings during dehydration represent desiccation of tissue, the body's compensatory reaction to maintain perfusion, or both. Seshadri R, 1997;100(5):E3. Parents are also more satisfied with the visit when ORT had been used.16 With ORT, the same fluid can be used for rehydration, maintenance, and replacement of stool losses; and ORT can be initiated more quickly than intravenous fluid therapy.17, The principles of ORT to treat dehydration from gastroenteritis apply to the treatment of dehydration from other causes. For example, skin may feel parched or dry after hiking or spending time in the hot sun. Fluid therapy for children: facts, fashions and questions. Typically, half (400 mL) is given over the first 8 hours (400 ÷ 8 = 50 mL/hour) and the other half is given over the next 16 hours (25 mL/hour). Wang VJ. Please note that THE MANUAL is not responsible for the content of this resource. Islam MR, In … Rahman O, Teach SJ, Factors contributing to pathogenesis and pathophysiology of hypertonic dehydration were studied in individual patients. Saladino R, AMY CANAVAN, MD, Virginia Commonwealth University School of Medicine, Falls Church, Virginia, BILLY S. ARANT, JR., MD, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee. Severe dehydration: very slow; skin fold visible for longer than 2 seconds. 28. The maintenance need for water in parenteral fluid therapy. The most common acid-base derangement that occurs with volume depletion, especially in infants, is metabolic acidosis. 5. Copelovitch L. The measurement is not affected by fever and should be less than two seconds.8 Assessment of skin turgor is performed by pinching skin on the lateral abdominal wall at the level of the umbilicus. Ray PE, Copyright © 2009 by the American Academy of Family Physicians. 2009 Oct 1;80(7):692-696. 2nd ed. This development is likely due to volume-related ADH release as well as to significant amounts of stimuli-related ADH release (eg, from stress, vomiting, dehydration, hypoglycemia). Sack DA, MacFaul R, Oral rehydration solution for acute diarrhea prevents subsequent unscheduled follow-up visits. Pediatrics. Previous: Same-Day Initiation of Hormonal Contraceptives, Home Dehydration is one of the leading causes of pediatric morbidity and mortality throughout the world. Segar WE. Dehydration is a frequent reason for emergency room visits and affects at least 2 million children annually.1 Frequently caused by gastroenteritis, dehydration may result in serious morbidity and mortality. It may also be a sign of neglect. Bennish ML, Simplified treatment strategies to fluid therapy in diarrhea [published correction appears in Pediatr Nephrol. Extracellular fluid restoration in dehydration: a critique of rapid versus slow. Murphy KO. Offringa M. Bollen CW, If ORT fails after initial resuscitation of a child with severe dehydration, intravenous fluid therapy should be initiated. Hypernatremia. 2003;18(11):1152–1156. Reid SR, Vega RM, 13. Definition of Diarrhea Diarrhea is the passage of loose or watery stools at least 3 times in a 24- hour period. Among children in the United States, fluid and electrolyte disturbances from acute gastroenteritis result in 1.5 million outpatient visits, 200,000 hospitalizations, and 300 deaths per year.1 Additionally, children may become dehydrated because of a variety of other illnesses that cause vomiting, diarrhea, or poor fluid intake. Skin turgor as a quantitative index of dehydration in children. If severe dehydration is present, a child with hypernatremia or hyponatremia should receive isotonic crystalloid until stabilized. et al. The trusted provider of medical information since 1899, Dehydration and Fluid Therapy in Children, Obsessive-Compulsive Disorder (OCD) and Related Disorders in Children and Adolescents, Adolescent patients who have obsessive-compulsive disorder (OCD) are most likely to also have which of the following. Molla AM, Laboratory predictors of fluid deficit in acutely dehydrated children. Adler M, Severe hypernatremic dehydration induces brain shrinkage, which can tear cerebral blood vessels, leading to cerebral hemorrhage, seizures, paralysis, and encephalopathy. Dehydration is a common complication of illness observed in pediatric patients presenting to the emergency department (ED). This may occur in hypovolemic children with low ECF volume, normovolemic patients with inappropriately increased ADH secretion, and also in hypervolemic individuals with decreased effective circulating volume and … However, clinical dehydration scales based on a combination of physical examination findings are better predictors than individual signs. Dehydration is a general state in which there is a total-body fluid deficit. Bothner JP. Reprints are not available from the authors. Diarrheal disease and dehydration account for 14% to 30% of worldwide deaths among infants and toddlers. A randomized trial of oral vs intravenous rehydration in a pediatric emergency department. 2007;92(6):546–550. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Watery diarrhoea results from disordered water and electrolyte transport in the small intestine. Potassium replacement (usually by adding 20 to 40 mEq potassium per liter [20 to 40 mmol/L] of replacement fluid) should not begin until adequate urine output is established. That a child with moderate dehydration fails ORT fluid, 75 % ). Third is extracellular fluid electrolyte loss hypernatremia and hyponatremia pathophysiology of dehydration in pediatrics contents, GR. The American Academy of Pediatrics at the University of Tennessee College of Medicine Chattanooga also occur response! Free water this great resource continues as the Merck Manual in the management of dehydration circulatory... T, MacFaul R, Shaw KN & Co., Inc., Kenilworth, NJ, USA a! 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