An Evidence-Based Review Of Dehydration In The Pediatric Patient
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An Evidence-Based Review Of Dehydration In The Pediatric Patient

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Table of Contents
 
Table of Contents
  1. Abstract
  2. Practice Recommendations (key points from the issue)
  3. Case Presentations
  4. Critical Appraisal Of The Literature
  5. Epidemiology, Etiology, And Pathophysiology
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
  9. Diagnostic Studies
  10. Treatment
    1. Mild Dehydration
    2. Moderate Dehydration
    3. Severe Dehydration
    4. General Rehydration Scheme
  11. Special Circumstances
    1. Hyponat remia ( Na)
      1. Management Of Hyponatremia
      2. Hypovolemic Hyponatremia
      3. Euvolemic Hyponatremia
      4. Hypervolemic Hyponatremia (Edema)
    2. Hypernatremia ( Na)
      1. Management Of Hypernatremia
      2. Hypovolemic Hypernatremia
      3. Euvolemic Hypernatremia
      4. Hypervolemic Hypernatremia
  12. Controversies And Cutting Edge
  13. Disposition
  14. Summary
  15. Time- And Cost-Effective Strategies
  16. Risk Management Pitfalls For The Treatment Of Pediatric Dehydration
  17. Case Conclusion
  18. References

Abstract

Dehydration is a physiologic response to a variety of diseases and conditions that results in a negative fluid balance due to decreased intake; increased output via renal, gastrointestinal, or insensible losses; or a systemic response to the specific disease state (eg, burns or sepsis). Dehydration causes total body water and electrolyte losses in the intracellular fluid (ICF) and extracellular fluid (ECF) compartments and can range from asymptomatic or mild to severe, with or without hypovolemic shock. As a result, a spectrum of signs and symptoms is seen.

Practice Recommendations (key points from the issue)

Click here to download a PDF of the Evidence-Based Practice Recommendations for this issue.

Case Presentations

During a busy shift in the emergency department, you obtain a history and perform a physical examination on a 3-month-old male patient. The mother states that her son has become progressively more listless over the past 3 days, has been drinking less than normal, and has only urinated once in the previous 12 hours. She also notes that the patient has had "tremors intermittently all day." In addition, he has had 3 episodes of vomiting without blood or bile and has a slight runny nose but no fever, diarrhea, or ill contacts.

The physical examination reveals a temperature of 37.9ºC (100.2ºF), a resting heart rate of 186 beats per minute, a respiratory rate of 56 breaths per minute, and a blood pressure reading of 78/50 mm Hg. The patient is visibly listless and has intermittent, erratic jerking in his arms and legs as well as a slightly sunken fontanel, no visible tears, and dry, sticky mucous membranes. Findings from an examination of his lungs, heart, and abdomen are normal, and further examination demonstrates slightly cool distal extremities, with a capillary refill time of 3 seconds.

This patient is clearly dehydrated, although the etiology of his signs and symptoms is unclear. As you evaluate the patient, you think about the following issues:

  1. Historically, are there other questions that should be asked?
  2. To what extent is the patient dehydrated (eg, mildly, moderately, severely)?
  3. What steps should be taken regarding treatment?
  4. Are laboratory tests required and if so, which ones?
  5. What differential diagnoses should be considered?

Critical Appraisal Of The Literature

The literature utilized for this article came from Ovid MEDLINE and PubMed searches using the key terms: pediatric, dehydration, assessment, clinical signs, symptoms, and treatment from 1990-2009. The article will focus on dehydration controversies in several areas, including the assessment of levels or severity of dehydration, the sensitivities of clinical signs and symptoms, and the utility of laboratory investigations.

Risk Management Pitfalls For The Treatment Of Pediatric Dehydration

  1. "I know acute gastroenteritis is treatable, so I can't imagine many pediatric patients die just from having diarrhea." Dehydration is a significant problem that causes death among patients in the United States and worldwide. In the United States, approximately 300 pediatric patients die from diarrhea and dehydration per year; worldwide, 1.5 to 2.5 million deaths occur annually in patients younger than 5 years.
  2. "I had a 3-month-old with a 40ºC (104ºF) temperature all day. He was drinking well, so it seemed strange that he looked so dehydrated." Even though this patient is drinking well, fever causes increased insensible losses. In addition, fever will increase the pediatric patient's respiratory rate, further contributing to insensible losses.
  3. "Taking a history is important, so I generally ask parents to tell me how many episodes of vomiting and diarrhea their child is having." The assessment regarding dehydration should be based on a very detailed and chronological history. Instead of asking solely for the number of episodes of vomiting and diarrhea, quantifying and qualifying questions should address specific amounts, frequency, timing, and consistency of input and output.
  4. "I perform a physical examination of my dehydrated patients, but I'm never quite sure which findings are most important." Multiple studies have shown the clinical characteristics most suggestive of dehydration include change in general appearance (eg, listless, sleepy, poorly responsive), absent tears, dry or sticky mucous membranes, sunken eyes, and delayed capillary refill. Although there is some variability in the literature, the aforementioned signs are most sensitive, along with other less important signs and symptoms found in dehydration tables.
  5. "I always get laboratory tests when I put in the IV. I put a lot of stock in a high SUN and low bicarbonate level." Guidelines from multiple organizations (eg, AAP, WHO) indicate that patients with mild or moderate dehydration do not routinely need laboratory testing. In general, no laboratory test results have been shown to predict levels of dehydration in lieu of an accurate physical examination. Laboratory testing should be performed if clinically indicated on the basis of dietary history or disease state and for all severely dehydrated patients. A high SUN and/or low bicarbonate level may suggest dehydration, but these results will not dictate the level of dehydration or the amount of fluid that should be administered.
  6. "Is it okay if I administer glucose along with an NS bolus? I've heard it's helpful." Most clinicians bolus with NS. One study found that unscheduled returns and hospitalizations were lower among patients who received IV dextrose, even after controlling for volume of fluid received, age, antiemetics, and duration of symptoms. However, in the absence of prospective trials, the significance of this study remains unclear.
  7. "I usually treat mildly dehydrated patients with oral fluids and moderately dehydrated patients with IV. Are there other options?" Pediatric patients with mild dehydration are usually able to drink orally with the aid of a teaspoon, syringe, bottle, cup, etc. Even patients with moderate dehydration are often able to overcome the disorder after receiving an oral rehydration regimen (ie, small amounts spaced at short intervals). If oral rehydration fails, additional IV or NG rehydration can occur.
  8. "Sometimes I get surprisingly low or high sodium levels in patients when I don't expect it. I never have really understood what conditions could cause such laboratory abnormalities." Depending on total body water and sodium levels, patients who have a variety of diseases may suffer from hyponatremia or hypernatremia.
  9. "I'm always reluctant to give too much fluid to a patient with hypovolemic shock, as I don't want to cause pulmonary edema." Patients who have hypovolemic shock should be aggressively treated with NS 20 mL/kg boluses, aiming for 60 mL/kg over the first hour. The primary goals are to restore intravascular volume, provide hemodynamic support, and ultimately to achieve euvolemia with correction of electrolyte abnormalities. Although pulmonary edema rarely occurs with large volume fluid administration, more often than not, a careful physical examination and close monitoring should prevent this.
  10. "Sammy, a 6-month-old patient, has jitteriness and has been vomiting for 3 days. The history suggests a strange diet. I gave a bolus of fluid because he looked dry, but now his sodium level is 162 mEq/L. What do I do now?" In this instance, a history and physical examination will help to decipher the underlying diagnosis. Normal saline 20-mL/kg boluses should be given until the patient's vital signs are stable and his sodium level begins to drop (usually with bedside testing or, if necessary, formal laboratory testing). Sodium correction should occur over 24 to 48 hours. After the patient is stabilized, fluids should be changed to D5 ¼ NS, D5 1/3 NS, or D5 ½ NS. Fluids should also provide for maintenance requirements and ongoing losses.

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.

  1. * King CK, Glass R, Bresee JS, Duggan C; Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1-16. (Systematic review)
  2. Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997;99(5):E6. (Prospective, cohort; 186 patients)
  3. Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics. 1996;97(3):424-435. (Systematic review)
  4. * World Health Organization. The Treatment of Diarrhea: A Manual for Physicians and Other Senior Health Workers. WHO/CDD/SER/80.2. Geneva, Switzerland: World Health Organization; 1995. (Systematic Review) ) http://whqlibdoc.who.int/hq/2003/WHO_FCH_CAH_03.7.pdf. Accessed November 23, 2009.
  5. Vega RM, Avner JR. A prospective study of the usefulness of clinical and laboratory parameters for predicting percentage of dehydration in children. Pediatr Emerg Care. 1997;13(3):179-182. (Prospective; 97 patients)
  6. Friedman JN, Goldman RD, Srivastava R, Parkin PC. Development of a clinical dehydration scale for use in children between 1 and 36 months of age. J Pediatr. 2004;145(2):201-207. (Retrospective; 141 patients)
  7. Goldman RD, Friedman JN, Parkin PC. Validation of the clinical dehydration scale for children with acute gastroenteritis. Pediatrics. 2008;122(3);545-549. (Prospective, randomized, controlled trial; 205 patients)
  8. Duggan C, Refat M, Hashem M, Wolff M, Fayad I, Santosham M. How valid are clinical signs of dehydration in infants? J Pediatr Gastroenterol Nutr. 1996;22(1):56-61. (Prospective; 150 patients)
  9. Gorelick MH, Shaw KN, Baker MD. Effect of ambient temperature on capillary refill in healthy children. Pediatrics. 1993;92(5):699-702. (Prospective, interventional; 32 patients)
  10. Saavedra JM, Harris GD, Li S, Finberg L. Capillary refill (skin turgor) in the assessment of dehydration. Am J Dis Child. 1991;145(3):296-298. (Descriptive analysis; 30 patients)
  11. Gorelick MH, Shaw KN, Murphy KO, Baker MD. Effect of fever on capillary refill time. Pediatr Emerg Care. 1997;13(5):305-307. (Prospective; 234 patients)
  12. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA. 2004;291(22):2746-2754. (Meta-analysis; 26 of 1603 articles)
  13. * United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Data Services. 1999-2000 National Ambulatory Medical Care Survey Dataset. Hyattsville, MD: United States Department of Health and Human Services; 2000. (Systematic review)
  14. Narchi H. Serum bicarbonate and dehydration severity in gastroenteritis. Arch Dis Child. 1998;78(1):70-71. (Prospective, descriptive; 106 patients)
  15. Rothrock SG, Green SM, McArthur CL, DelDuca K. Detection of electrolyte abnormalities in children presenting to the emergency department: multicenter, prospective analysis. Acad Emerg Med. 1997;4(11):1025-1031. (Prospective, multicenter; 715 patients)
  16. Teach SJ, Yates EW, Feld LG. Laboratory predictors of fluid deficit in acutely dehydrated children. Clin Pediatr (Phila). 1997;36(7):395-400. (Prospective; 40 patients)
  17. Steiner MJ, Nager AL, Wang VJ. Urine specific gravity and other urinary indices: inaccurate tests for dehydration. Pediatr Emerg Care. 2007;23(5):298-303. (Retrospective; 79 patients)
  18. Wathen JE, MacKenzie T, Bothner JP. Usefulness of the serum electrolyte panel in the management of pediatric dehydration treated with intravenously administered fluids. Pediatrics. 2004;114(5):1227-1234. (Prospective; 182 patients)
  19. Reid S, Bonadio WA. Outpatient rapid intravenous rehydration to correct dehydration and resolve vomiting in children with acute gastroenteritis. Ann Emerg Med. 1996;28(3):318-323. (Prospective; 58 patients)
  20. Ramsook C, Sahagun-Carreon I, Kozinetz CA, Moro-Sutherland D. A randomized clinical trial comparing oral ondansetron with placebo in children with vomiting from acute gastroenteritis. Ann Emerg Med. 2002;39(4):397-403. (Prospective, randomized, double-blind; 145 patients)
  21. Reeves JJ, Shannon MW, Fleisher GR. Ondansetron decreases vomiting associated with acute gastroenteritis: a randomized, controlled trial. Pediatrics. 2002;109(4):e62. (Prospective, placebo controlled; 172 patients)
  22. Freedman SB, Adler M, Seshadri R, Powell EC. Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med. 2006;354(16):1698-1705. (Prospective, double-blind; 215 patients)
  23. Fonseca BK, Holdgate A, Craig, JC. Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch Pediatr Adolesc Med. 2004;158(5):483-490. (Meta-analysis; 16 articles)
  24. * Duggan C, Santosham M, Glass RI. The management of acute diarrhea in children: oral rehydration, maintenance and nutritional therapy. MMWR Recomm Rep. 1992;41(RR-16):1-20. (Descriptive review)
  25. * Nager AL, Wang VJ. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Pediatrics. 2002;109(4):566-572. (Prospective, randomized, controlled trial; 90 patients)
  26. Thomas NJ, Carcillo JA. Hypovolemic shock in pediatric patients. New Horiz. 1998;6(2):120-129. (Descriptive analysis)
  27. Carcillo J, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA. 1991;266(9):1242-1245. (Retrospective; 34 patients)
  28. Pizzaro D, Posada G, Villavicencio N, Mohs E, Levine MM. Oral rehydration in hypernatremic and hyponatremic diarrheal dehydration. Am J Dis Child. 1983;137(8):730-734. (Prospective; 94 patients)
  29. Hoover B, Gebara BM. Hypertonic 3% saline infusion by nasogastric tube for the treatment of severe symptomatic hyponatremia. Clin Pediatr (Phila). 1999;38(1):55-57. (Case report)
  30. Todd SR, Malinoski D, Muller PJ, Schreiber MA. Lactated Ringer's is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock. J Trauma. 2007;62(3):636-639. (Prospective, randomized, blind; 20 swine)
  31. Levy JA, Bachur RG. Intravenous dextrose during outpatient rehydration in pediatric gastroenteritis. Acad Emerg Med. 2007;14(4):324-331. (Case controlled; 56 patients, 112 controls)
  32. Nagler J, Wright RO, Krauss B. End-tidal carbon dioxide as a measure of acidosis among children with gastroenteritis. Pediatrics. 2006;118(1):260-267. (Prospective; 146 patients)
  33. Nager AL, Wang VJ. Comparison of ultra rapid intravenous hydration and rapid intravenous hydration in pediatric patients with acute dehydration. Amer J Emerg Med. In press. 10.1016/j.ajem.2008.09.046 (Prospective, randomized; 92 patients)
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Publication Information
Authors

Alan L. Nager

Publication Date

January 1, 2010

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