Pediatric Dehydration

ACHIEVING*A*FLUID*BALANCE
By Nita Kumar, MSN, RN

Nurses have long recognized the importance of maintaining fluid and electrolyte balance.
Florence Nightingale wrote of the benefits of giving patients beef tea, and today we know
a major benefit of bouillon is its high sodium content, which helps increase extracellular
fluid volume. Continued research has further shown that beef tea may in fact have too
much sodium and better products are now available that are more beneficial and safe to
use even in children with
dehydration
(see Table 1).

Being alert for developing dehydration is an important aspect of caring for infants and
children. Dehydration often is characterized as mild, moderate or severe. In children,
dehydration usually is attributable to vomiting or an acute viral or bacterial diarrhea.

FLUID BALANCE
Fluid balance refers to total body water, which stays constant with consistent distribution
among the main fluid compartments. Water and electrolytes are equally important.
Children and infants present unique problems in managing fluids and electrolytes. In a
healthy state, premature infants are approximately 90 percent water; newborns, 70
percent-80 percent water; a 3-year-old child is 60 percent water; and an adult is
approximately 90 percent water.
An infant may exchange half his extracellular fluid daily, whereas an adult may exchange
only one-sixth in the same period. Compared to an older child, a premature infant has
almost five times as much body surface area in relation to its weight; the newborn has
three times the body surface area. This increase in body surface area increases
insensible water losses, which in turn makes infants more susceptible to dehydration than
older children and adults. A child’s fluid requirements are listed in Table 2.

ELECTROLYTE OVERVIEW
To effectively monitor infants and children, the nurse needs a basic knowledge of
important electrolytes and signs and symptoms of imbalances. Table 3 presents normal
fluid expenditures. The most crucial electrolytes for all cell life are K+, Na+ and Cl-.
Another electrolyte to closely monitor is Ca+. Although not an electrolyte, serum glucose
plays an important role in the hemodynamic monitoring of the pediatric patient.

BASAL METABOLIC RATE

The BMR, or basal metabolic rate, for infants and children is higher than for adults
because of larger body surface area in relation to the mass of active tissue. BMR is higher
in infants to support growth. Infants expend 100 calories per kilogram of body weight and
adults expend 40 calories per kilogram. Infant kidneys are also not mature enough to
concentrate urine efficiently. Thus, the infant needs more water to excrete a given amount
of solute.
Insensible water losses may increase as much as 50-70 mL for each degree Celsius
above normal body temperature in an infant. Fever increases insensible water losses by
about 0.42 mL/kg/degree Celsius for each degree above 37 degrees C. Radiant heat
warmers and phototherapy lights can also increase fluid losses.
Increased respiratory rate in infants and children (> 60-80 breaths per minute) when they
are sick (for example with respiratory syncytial virus can also contribute to increased
insensible water losses, resulting in severe dehydration (see Table 4).

For each 1 percent weight loss, 10 mL/kg of fluid have been lost. For example, if a child
weighing 10 kg lost 12 percent body weight, the child lost 1200 mL of fluid (12 percent x
10 mL percent x 10 kg). Weight loss of 1 kg is approximately equivalent to body fluid loss
in the amount of 1 L.

ASSESSMENT
Good assessment skills will help the nurse recognize subtle clues before an infant or child
gets into serious fluid and electrolyte problems. Assessing physical data, the results of
lab tests, body weight and intake and output are important aspects of care to monitor.
The following are signs of a dehydrated child:
* decrease in extracellular fluid volume leading to decrease in peripheral circulation;
* change in skin color to pale or gray;
* decreased capillary refill;
* dry skin turgor;
* decrease in tear production;
* vasoconstriction of small arterioles to keep blood flow going to vital organs, resulting in
cool extremities, even if the child is febrile;
* decrease in saliva, dry lips and nares, cracked membranes, and tongue may become
red, rough, dry and wrinkled;
* increase in pulse rate (>160 bpm for infants and >120 bpm for children) resulting from
hypovolemia;
* fluid deficit causing mild metabolic; acidosis; and
* hyperventilation, resulting in increased insensible fluid losses.
Blood pressure is the last vital sign to show changes and should not be relied on as an
assessment indicator of dehydration. Fontanels of infants will be depressed with a
moderate fluid deficit.

REHYDRATION
IV fluids remain a treatment of choice for volume deficit in severely dehydrated children
as well as adults. Oral solutions are successful in treating children with isotonic, hypotonic
or hypertonic dehydration. Vomiting is not a contraindication. A

child who is vomiting should be given frequent, small doses of oral rehydration solutions.
Alternating an IV solution with a low-sodium fluid, such as water, breast milk, lactose-free
formula or half-strength lactose containing formula, is an effective treatment plan.
Signs of moderate dehydration plus one or more of the following: rapid thready pulse,
cyanosis, rapid breathing, delayed capillary refill, lethargy or coma, necessitate the need
for IV rehydration therapy. Isotonic solutions such as Ringer’s Lactate or 0.9 percent
saline can be administered IV or intraosseous (IO) at a rate of 40 mL/kg/h until pulse and
state of consciousness return to normal, then 50-100 mL/kg of oral rehydration solutions
(ORS) based on remaining degree of dehydration.
Replacement of ongoing stool losses and vomitus may be done with ORS, 10 mL/kg for
each diarrheal stool and 5 mL/kg for each episode of vomitus. While parenteral access is
being sought, nasogastric infusion of ORS may be begun at 30 cc/kg/hr, provided airway
protective reflexes remain intact.
Maintenance requirements include giving enough water and electrolytes to prevent
deterioration of body stores (see Table 5). When short-term (2-3 days) parenteral therapy
is given, enough calories are given to blunt hunger and inhibit protein breakdown and
ketosis. In general, all intravenous fluids should have at least 5 percent glucose.
Reasonable initial approximations for maintenance needs are 3 mEq Na+/100 kcal and
2.5 mEq K+/100 kcal.

Corrections are also made for temperatures above 38 degrees C. For every degree
(centigrade) of temperature, fluid needs increase by 12.5 percent. A fever of 39 degrees
C would require maintenance fluid to be increased by 25 percent.

REFEEDING
As soon as possible, children can be given breast milk with added libitum, full-strength
formula, complex carbohydrates (rice, wheat, potatoes, bread, cereals), lean meats
(chicken), yogurts, fruits and vegetables. Avoid foods that are high in fats or simple sugars
and avoid highly restrictive diets (i.e., the BRAT diet).

NEW RESEARCH
Frozen oral hydration (FS) has been studied as an alternative to conventional
solution (CS) of enteral fluids. Results show that children with mild or moderate
dehydration are more likely to tolerate FS than CS. Conventional solution failures crossed
over to FS had a greater tolerance rate than the reverse.

CONCLUSIONS
Accurate assessment of the degree of dehydration in children is important in helping
make decisions on which children should receive oral vs. intravenous hydration, the
length of treatment, and the need for prolonged observation or hospitalization. Laboratory
tests alone cannot reliably assess mild to moderate dehydration in children due to various
factors and should be used as an adjunctive tool only. Oral rehydration solutions should
be the mainstay therapy for mildly to moderately dehydrated children. Rapid intravenous
rehydration therapy offers an alternative modality that ultimately may offer more efficient
and cost-effective management for the moderately to severely dehydrated child. *