Dehydration: Background, Pathophysiology, Epidemiology

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Dehydration
Author: Lennox H Huang, MD; Chief Editor: Timothy E Corden, MD more...
Updated: Sep 25, 2014

Background
Dehydration describes a state of negative fluid balance that may be caused by numerous disease entities. Diarrheal
illnesses are the most common etiologies. Worldwide, dehydration secondary to diarrheal illness is the leading cause
of infant and child mortality.

Pathophysiology
The negative fluid balance that causes dehydration results from decreased intake, increased output (renal, GI, or
insensible losses), or fluid shift (ascites, effusions, and capillary leak states such as burns and sepsis). The decrease
in total body water causes reductions in both the intracellular and extracellular fluid volumes. Clinical manifestations
of dehydration are most closely related to intravascular volume depletion. As dehydration progresses, hypovolemic
shock ultimately ensues, resulting in end organ failure and death.
Young children are more susceptible to dehydration due to larger body water content, renal immaturity, and inability
to meet their own needs independently. Older children show signs of dehydration sooner than infants due to lower
levels of extracellular fluid (ECF).
Dehydration can be categorized according to osmolarity and severity. Serum sodium is a good surrogate marker of
osmolarity assuming the patient has a normal serum glucose. Dehydration may be isonatremic (130-150 mEq/L),
hyponatremic (< 130 mEq/L), or hypernatremic (>150 mEq/L). Isonatremic dehydration is the most common (80%).
Hypernatremic and hyponatremic dehydration each comprise 5-10% of cases. Variations in serum sodium reflect the
composition of the fluids lost and have different pathophysiologic effects, as follows:
Isonatremic (isotonic) dehydration occurs when the lost fluid is similar in sodium concentration to the blood.
Sodium and water losses are of the same relative magnitude in both the intravascular and extravascular fluid
compartments.
Hyponatremic (hypotonic) dehydration occurs when the lost fluid contains more sodium than the blood (loss
of hypertonic fluid). Relatively more sodium than water is lost. Because the serum sodium is low, intravascular
water shifts to the extravascular space, exaggerating intravascular volume depletion for a given amount of
total body water loss. [1, 2]
Hypernatremic (hypertonic) dehydration occurs when the lost fluid contains less sodium than the blood (loss
of hypotonic fluid). Relatively less sodium than water is lost. Because the serum sodium is high, extravascular
water shifts to the intravascular space, minimizing intravascular volume depletion for a given amount of total
body water loss. [2, 3, 4]
Neurologic complications can occur in hyponatremic and hypernatremic states. Severe hyponatremia may lead to
intractable seizures, whereas rapid correction of chronic hyponatremia (>2 mEq/L/h) has been associated with
central pontine myelinolysis. During hypernatremic dehydration, water is osmotically pulled from cells into the
extracellular space. To compensate, cells can generate osmotically active particles (idiogenic osmoles) that pull
water back into the cell and maintain cellular fluid volume. During rapid rehydration of hypernatremia, the increased
osmotic activity of these cells can result in a large influx of water, causing cellular swelling and rupture; cerebral
edema is the most devastating consequence. Slow rehydration over 48 hours generally minimizes this risk.

Epidemiology
Frequency
United States
Diarrheal illnesses in children causes 3 million physician visits, 220,000 hospitalizations (10% of all children who
require hospitalization), and 400 deaths per year. On average, North American children younger than 5 years have 2
episodes of gastroenteritis per year.
International
Diarrheal illnesses with subsequent dehydration account for nearly 4 million deaths per year in infants and children.
The overwhelming majority of these deaths occur in developing nations.

Mortality/Morbidity
The prognosis is excellent if the child is promptly and effectively treated. However, the child with severe dehydration
and hypovolemic shock can have significant morbidity and mortality if treatment is delayed.
Mortality and morbidity generally depend on the severity of dehydration and the promptness of oral or intravenous
rehydration. If treatment is rapidly and appropriately obtained, morbidity and mortality are low.
Routine use of hypotonic parenteral fluids in hospitalized children has been associated with hyponatremia and
subsequent neurologic complications and death. Monitoring the efficacy and complications of parenteral rehydration
with accurate fluid balances and serum electrolytes is crucial.
Complications may include irreversible shock, sagittal or other venous sinus thrombosis, intractable seizures, and
renal failure.

Age
Children younger than 5 years are at the highest risk.

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Contributor Information and Disclosures

Author
Lennox H Huang, MD FAAP, Associate Professor and Chair, Department of Pediatrics, McMaster University
School of Medicine; Chief of Pediatrics, McMaster Children's Hospital
Lennox H Huang, MD is a member of the following medical societies: American Academy of Pediatrics, American
Association for Physician Leadership, Canadian Medical Association, Ontario Medical Association, Society of
Critical Care Medicine
Disclosure: Nothing to disclose.
Coauthor(s)
Dan L Ellsbury, MD Consulting Staff, Pediatrix Medical Group of Iowa; Consulting Staff, Department of
Pediatrics, Neonatology Intensive Care Unit, Mercy Medical Center of Des Moines
Dan L Ellsbury, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.
Caroline S George, MD Associate Professor, Consulting Staff, Department of Pediatrics, Division of Critical Care
Medicine, University of Minnesota Medical School
Caroline S George, MD is a member of the following medical societies: American Academy of Pediatrics, Society
of Critical Care Medicine
Disclosure: Nothing to disclose.
Krishnapriya R Anchala, MD, MS FAAP, Assistant Professor, Department of Pediatrics, Division of Pediatric
Emergency Medicine, McMaster University
Krishnapriya R Anchala, MD, MS is a member of the following medical societies: American Academy of
Pediatrics, Canadian Medical Association, Ontario Medical Association
Disclosure: Nothing to disclose.
Specialty Editor Board
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of
Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric
Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical
Center
Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American
College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine
Disclosure: Nothing to disclose.
Chief Editor
Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center,
Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta
Kappa, Society of Critical Care Medicine, Wisconsin Medical Society
Disclosure: Nothing to disclose.
Additional Contributors
G Patricia Cantwell, MD FCCM, Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care
Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team,
Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical
Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids
Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc
G Patricia Cantwell, MD is a member of the following medical societies: American Academy of Hospice and
Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society,
National Association of EMS Physicians, Society of Critical Care Medicine, Wilderness Medical Society
Disclosure: Nothing to disclose.

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