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Fluid and fluid management in

children
Case
• Newborn, 10 days old

• Admitted in your hospital for pneumonia

• Needs naso-gastric tube feeding


Question
The daily fluid intake of a neonate is:

3. 90 ml/kg
4. 120 ml/kg
5. 150 ml/kg
6. Depends on the urine output
Fluid management children I
• Neonates
– 1st 5 days of life: start with 30 ml/kg/24 h and
increase with 30 ml/day: i.e.: 30 – 60 – 90 –
120 – 150 ml/kg/24 h
– Beyond day 5: 150-180 ml/kg/24 h
– 8 feedings
Question
A. Neonates need relatively more fluid than older children
because their urine output is relatively higher

B. Infants and children need more fluid than adults


because their insensible loss is higher

• A is true
• B is true
• A and B are true
• A and B are false
Surface in relation to bodymass

6 cm2/cell 1.5 cm2/cell 0.75 cm2/cell


Question
A. Neonates need relatively more fluid than older children
because their urine output is relatively higher

B. Infants and children need more fluid than adults


because their insensible loss is higher

• A is true
• B is true
• A and B are true
• A and B are false
Case
• Boy, 5 yr
• Admitted to clinic for elective surgery, 1st
24 h no oral intake

• The experienced nurse says you should


give 1500 ml/24 h DW5% i.v.
Question
A. The experienced nurse is right (as is always
the case with experienced nurses)

C. The experienced nurse ‘knows’ the intake, but


is probably unable to calculate it

5. A is true
6. B is true
7. A and B are true
8. A and B are false
Fluid management children II
• Neonates
– 150-180 ml/kg/24 h

• Children fluid maintenance per 24 h:


– first 10 kg: 100 ml/kg/24 h
– 10-20 kg: +50 ml/kg/24 h
– 20-30 kg: +20 ml/kg/24 h
– > 40 kg: as in adults: ± 2000 ml/24 hr
Examples
• Body weight 8 kg: 8*100 = 800 ml/24 h

• Bodyweight 16 kg: (10*100)+(6*50)=1300 ml/24 h

• Bodyweight 24 kg: (10*100)+(10*50)+(4*20)=1580 ml/24 h

• Bodyweight 40 kg: (10*100)+(10*50)+(20*20)=1900 ml/24 h

• Bodyweight 80 kg ≠ (10*100)+(10*50)+(60*20)=3700 ml/24 h

• A rule of thumb: bodyweight = (2*age)+8


Case
• Boy, 5 yr
• Admitted to clinic for elective surgery, 1st 24 h no
oral intake

• The experienced nurse says you should give


1500 ml/24 h DW5% i.v.

• BW= (2*5)+8= 18 kg
• Intake: (10*100)+(8*50)=1400 ml
Question
A. The experienced nurse is right (as is always
the case with experienced nurses)

C. The experienced nurse ‘knows’ the intake, but


is probably unable to calculate it

• A is true
• B is true
• A and B are true
• A and B are false
Case, boy 3 yr
• History/
– previous healthy, no malnutrition
– Since 2 d diarrhea, 5 watery stools/day
– Decrease urine output, thirsty

• PE/
– BW 8 kg, PR 140/min, skin turgor↓ dry mucosa

• Diagnosis/
– 5-10% dehydration

• Treatment: ORS
Break
Question about ORS
A. The combination of salt and sugar enhances fluid absorption
because sodium and glucose transport in the small intestine are
coupled, and glucose promotes absorption of both sodium ions
and water

B. Standard ORS is solution has osmolality 311 mosmol/l (90


mmol/l
Na, 111 mmol/l glucose) is better than low osmolarity ORS for
non-malnourished children

7. A is true
8. B is true
9. A and B are true
10. A and B are false
Question about ORS
A. The combination of salt and sugar enhances fluid absorption
because sodium and glucose transport in the small intestine are
coupled, and glucose promotes absorption of both sodium ions
and water

B. Standard ORS is solution has osmolarity 311 mOsmol/l (90


mmol/l Na, 111 mmol/l glucose) is better than low osmolarity ORS
for non-malnourished children

• A is true
• B is true
• A and B are true
• A and B are false
Case
• Girl, 6 year

• History
– Since 2 days: profound diarrhea due to shigella
dysentery
– Decreased urine output

• PE/
– Bodyweight: 21.5 kg
– Irritable, dry membranes, deep set eyes, decreased skin
turgor
Question
The total fluid this patient needs in the 1st 24 h is:

1. 3.5 liter
2. 4 liter
3. 4.5 liter
4. 6 liter
Rehydration schedule
3 pillars:
2. daily intake
3. estimated deficit
4. ongoing losses

Half of total 0- 8 h, half in 8-24 h


Estimation of dehydration
Mild Moderate Severe/shock

% Weight loss <5 5-10 >10

Behavior consolable irritable lethargic

Heart rate -/↑ ↑↑ ↑↑↑

Mucous membranes normal dry Parched/crack

Tears present decrease Absent

Eyes normal Deep set sunken

Skin turgor normal decrease tenting

Fontanel flat Slightly depressed sunken

Capillar refill normal 3-5 sec >5 sec

Urine output normal decreased anuric


Rehydration schedule
5-10% dehydration, current weight 21.5 kg
3 pillars:

daily intake: (10*100)+(10*50)+(3*20)= 1560


estimated deficit 7%= (0.07*23)= 1600
ongoing losses: 750(?) 750
Total 3810

Half of total (1900 ml) 0- 8 h, half in 8-24 h


Question
The total fluid this patient needs in the 1st 24 h is:

• 3.5 liter
• 4 liter
• 4.5 liter
• 6 liter
Case, boy 3 yr
• History/
– Severe diarhoea, no malnutrition
• PE/
– Lethargic, BW 7.6 kg, PR 140/min, skin turgor ↓ ↓ dry
mucosa, no tears

• Diagnosis/
– 10% dehydration

• What would be rehydration schedule?


What would be rehydration schedule?
3 pillars:

daily intake 8.5*100 850 ml


estimated deficit 10% 850 ml
ongoing losses:500 500 ml
Total 2200 ml

1100 ml in 1st 8 h, 1100 ml in 2nd 16 h 3


Case continued

Due to miscommunication the nurse gives


2200 ml in the first 8 h!
Question
A. Hypertension is a symptom of overhydration in
healthy children, whereas congestive heart
failure is a more prominent feature in adults

C. Malnourished children are at risk for


overhydration and congestive heart failure

5. A is true
6. B is true
7. A and B are true
8. A and B are false
Malnutrition and fluid
pathophysiological concepts
• Malnourished children may have cardiomyopathy

• Malnourished children may less easily deal with


fluid and thus be at risk for congestive heart
failure

• Therefore sodium overload may be dangerous

• Therefore ReSoMal (low osmolarity ORS) is


thought to be better than standard ORS in
malnourished children
Malnutrition and fluid
the evidence
• 2 RCT evaluating the beneficial effects of ReSoMal in malnourished
children
– Dutta 2001, Alam 2003

• 1 trial (Dutta) overall overhydration 8% (5% in ReSoMal group, 12%


in standard ORS group, p=0.2)

• 1 trial (Alam) no patients with overhydration

• Definition of overhydration very vague or not given

• Conclusion:
– The risk of overhydration and congestive heartfailure in malnourished
children may be overemphasized
– ReSoMal does not prevent overhydration
Question
A. In healthy children overhydration easily leads to
hypertension, whereas congestive heart failure is a
more prominent feature in adults

C. Malnourished children are at risk for overhydration and


congestive heart failure

• A is true
• B is true
• A and B are true?
• A and B are false
QUESTIONS?

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