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Definition
The concept of dehydration did not enter clinical medicine until the 1830s and was not
scientifically defined for some years after that. Although the word dehydration in general
English usage means loss of water, in physiology and medicine, the unmodified word
means a loss of water and salt or extracellular fluid (ECF), the most common of the
clinically recognized types of dehydration. Depending on the type of pathophysiologic
process, water and salts (primarily sodium chloride) may be lost in physiologic proportion
or lost disparately, with each type producing a somewhat different clinical picture. We have
found it useful to designate these types as isonatremic (classical), hypernatremic (hyper-
tonic), or hyponatremic (hypotonic). The differential losses produce different clinical
features because of the functional impermeability of the Na⫹ and Cl- ions of the ECF to
the adjacent intracellular fluid (ICF). We use sodium rather than chloride in the nomen-
clature because chloride ions are simultaneously involved in a reciprocal relationship with
bicarbonate ions. Such classification of the clinical entities has proved useful for under-
standing of the pathogenesis and especially for treatment.
Composition
The lean body mass (LBM) of humans is 70% water, with 25% of the LBM in infants in the
ECF and 45% in the ICF (Figs 1 and 2). Within the ECF is the plasma (about 6% of the
LBM at all ages), which is contained within its compartment by the small osmotic (oncotic)
concentration (1 to 2 mOsm/kg) of protein molecules that limits their permeability
*Clinical Professor of Pediatrics, University of California at San Francisco and Stanford University School of Medicine, San
Francisco, CA.
Requirements
To maintain a constant body temperature,
humans produce heat and lose it at a con-
trolled rate, in part by evaporation of water
from the skin (30 mL/100 kcal expended)
and from the lungs (15 mL/100 kcal ex-
pended), which is termed insensible water
loss. Both of these amounts increase during
hyperthermia, hyperventilation, and contin-
uous muscle contractions. The losses may
increase threefold if all three conditions oc-
cur simultaneously. Hyperthermia alone will
double insensible losses, as will a very warm
environment.
When dehydration occurs because of di-
arrhea, homeostatic mechanisms usually ad-
just so that water and sodium chloride are
lost in physiologic proportion, thus main-
taining the sodium concentration in serum
within the normal range. When vomiting
also occurs, water intake is curtailed, making
water loss proportionally greater than salt
losses and resulting in hypernatremia. When
massive stool loss of water and salt is ongoing
and the only intake is water, salt losses pre-
dominate, resulting in a hyponatremic state.
When dehydration occurs, several other
disturbances come into play. The process of
circulatory depletion from plasma loss and
concomitant starvation lead to excess hydro-
gen ion accumulation and reduced urine
output. Stool losses also contain intracellular
ions, particularly potassium, and uncom-
Figure 1. Composition of lean body mass (fat-free) of the infant. Reprinted monly, calcium homeostasis may be altered.
with permission from Finberg L, Kravath RE, Hellerstein S. Water and Electro- These combined disturbances may be
lytes in Pediatrics. 2nd ed. Philadelphia, Pa: WB Saunders; 1993.
summed up in five categories: volume, os-
molality (body space alterations), acid-base
markedly. The ECF and ICF compartments are main- or hydrogen ion, potassium losses, and calcium distur-
tained separately despite free permeability of water and bance.
Na⫹ and Cl- ions via the energy-dependent extrusion of
sodium from cells and the obligate phosphate and nega- Clinical Aspects
tively charged protein within cells. From 12 to 18 The first objective sign of dehydration is an increase in
months to about 5 years of age, the proportions gradu- pulse rate as a response to reduced plasma volume;
ally evolve into 20% ECF and 50% ICF. Thus, the com- subjectively, there may be increased thirst. When a hy-
positional maturity for body water components is com- pernatremic state is produced, tachycardia is less pro-
plete at approximately 5 years of age. For the first 6 to 12 nounced because ECF (hence plasma) is relatively pro-
months after birth and for all malnourished patients, the tected, although fever may offset this difference. Thirst
LBM and weight may be considered identical, with water may be intense. Changes in acute diarrhea usually are not
content comprising 70% of weight. In older and opti- noted until approximately 5% of the body weight (7% of
mally nourished children, about 10% of body weight is LBM) has been lost. If the process continues untreated,
fat, making body water content 60% of total weight. circulatory insufficiency predominates clinically. The
Laboratory Analysis
Very mildly dehydrated patients may be
managed without laboratory determina-
tions, but it is wise to confirm clinical im-
pressions in moderate losses and always in
Figure 2. Ionic profiles of body fluids: approximate representation of cations and
severe illness. Sodium, chloride, bicarbon-
anions of the three principal body fluid compartments. All are electrically neutral
ate, and urea nitrogen determinations are
and all have the same osmolality despite differences in total charges. The shaded
areas represent large molecules or bound ions whose osmolal contribution
the most essential. An arterial blood gas
(mOsm/kg) is quantitatively much less than their electric charge (mEq/kg), but may be helpful and may be obtained
which are of great importance to the distribution of ions because of their quickly in more severely ill patients. Potas-
impermeability. Reprinted with permission from Finberg L, Kravath RE, Hellerstein sium and calcium levels are occasionally
S. Water and Electrolytes in Pediatrics. 2nd ed. Philadelphia, Pa: WB Saunders; helpful. The urea nitrogen level gives a
1993. rough estimate of renal compromise. It is
the reduced renal function that produces
most useful clinical sign is the capillary refill time (tur- the acidemia rather than the loss of base in the stool for
gor): normal is less than 2 seconds, 2 to 2.9 seconds which compensation readily occurs.
corresponds to 50 to 90 mL/kg loss, 3.0 to 3.5 seconds
corresponds to 90 to 110 mL/kg, 3.5 to 3.9 seconds Management
corresponds to 110 to 120 mL/kg, and more than Treatment is based on the severity of dehydration and the
4 seconds corresponds to 150 mL/kg. Although not diagnosis of the differential losses of ECF and ICF (ie,
perfectly predictive, this is the only quantitatively useful isonatremic, hypernatremic, or hyponatremic).
sign. Even if the patient is febrile, the estimates are Severity and type of loss may be assessed best with a
reliable if room temperature is not excessively hot. five-point diagnostic analysis:
Other clinical signs of dehydration include mottled 1. Volume: That which has been and that which will
cool extremities, sunken fontanelle in infants, dry mu- continue to be lost. The first assessment is the deficit,
cous membranes, receded eyeballs, hyperpnea, and loss which may be determined roughly from the rate of
of skin elasticity in infants (the degree of loss does not capillary refill corresponding to ECF loss, as noted pre-
correlate with degree of volume loss). The sensorium viously. Estimating the volume begins by adding the
usually remains intact until dehydration becomes mod- obligatory daily replacement for each day of therapy. The
erate (⬎6% of weight). A weak cry and stupor suggest a Table shows the basal calorie expenditure at various ages
shock state (capillary refill ⬎4 sec). Hypotension is a late that determines the obligatory maintenance require-
manifestation of dehydration. ment. The usual patient expends about l.5 times the basal
PIR Quiz
Quiz also available online at www.pedsinreview.org.
6. A 6-week-old boy presents with vomiting for the past 2 weeks. Vomiting is described as forceful. It occurs
5 to 10 minutes after feeding and consists primarily of milk. Physical examination reveals: heart rate,
140 beats/min; respirations, 20 breaths/min; temperature, 98.2°F (36.8°C); and blood pressure, 90/50 mm
Hg. The anterior fontanelle is depressed. The infant is alert, responds appropriately to stimuli, and sucks
vigorously on a milk bottle. Skin turgor is diminished, with a capillary refill time of 2 to 3 seconds. The
abdomen is soft and nontender. Laboratory examination shows: serum sodium, 125 mEq/L (125 mmol/L);
potassium, 3.8 mEq/L (3.8 mmol/L); chloride, 85 mEq/L (85 mmol/L); and bicarbonate, 30 mEq/L (30 mmol/
L). Venous blood pH is 7.48 and PCO2 is 55 torr. Blood urea nitrogen (BUN) is 48 mg/dL (17.1 mmol/L).
Urine output is decreased. Which of the following is the most likely diagnosis?
A. Congenital adrenal hyperplasia.
B. Hypertrophic pyloric stenosis.
C. Malrotation of intestine.
D. Milk allergy.
E. Obstructive uropathy.
7. A 3-month-old boy presents with vomiting and diarrhea for the past 3 days. He recently was switched
from human milk to powdered milk formula. Physical examination shows a markedly irritable infant who
has a heart rate of 170 beats/min, respirations of 50 breaths/min, temperature of 99.7°F (37.6°C), and
blood pressure of 60/30 mm Hg. The anterior fontanelle is markedly depressed, and mucous membranes are
dry. The skin has diminished turgor, with tenting and a doughy feel. The capillary refill time is 4 to
5 seconds. Bladder catheterization yields no urine output. Laboratory values are: serum sodium, 172 mEq/L
(172 mmol/L); potassium, 5.3 mEq/L (5.3 mmol/L); chloride, 148 mEq/L (148 mmol/L); and bicarbonate,
8 mEq/L (8 mmol/L). BUN is 72 mg/dL (25.7 mmol/L). Which of the following is the best management
strategy for this child?
A. An intravenous bolus of 5% dextrose followed by rehydration over 48 hours.
B. An intravenous bolus of 5% dextrose followed by rehydration over 24 hours.
C. An intravenous bolus of 0.9% saline followed by rehydration over 48 hours.
D. An intravenous bolus of 0.9% saline followed by rehydration over 24 hours.
E. Rehydration over 48 hours without intravenous bolus.
8. Which of the following states is associated with greater fluid loss per kilogram of body weight for a given
severity of clinical manifestations of dehydration in children?
A. Fever.
B. Hypernatremia.
C. Male gender.
D. Obesity.
E. Older age.
Please note that the deadline for submission of your answer sheets
for the quizzes in the 2002 issues has been extended to January 31,
2003!