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, gastrointestinal [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 and the physiologic
compensation attempts that takes place. 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. (Osmolarity =
[2 × sodium] + [glucose/18] + [blood urea nitrogen/2.8]) 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 (not to exceed 0.5 mEq/L per hour; 10-12 mEq/L in 24 hours).

Etiology

Determination of the cause of dehydration is essential. Poor fluid intake, excessive fluid output,
increased insensible fluid losses, or a combination of the above may cause intravascular
volume depletion. Successful treatment requires identification of the underlying disease state.

Common causes of dehydration include the following:

Gastroenteritis: This is the most common cause of dehydration. If both vomiting and diarrhea
are present, dehydration may rapidly progress. [5, 6] Rotaviruses are the most common global
causes for dehydration and severe diarrheal disease in infants and young children. [7]
Stomatitis: Pain may severely limit oral intake.

Diabetic ketoacidosis (DKA): Dehydration is caused by osmotic diuresis. Weight loss is caused
by both excessive fluid losses and tissue catabolism. Rapid rehydration, especially rapid initial
volume resuscitation, may be associated with a poor neurologic outcome. DKA requires very
specific and controlled treatment (see Diabetic Ketoacidosis).

Febrile illness: Fever causes increased insensible fluid losses and may affect appetite.

Pharyngitis: This may decrease oral intake.

Life-threatening causes of dehydration include the following:

Gastroenteritis

Diabetic ketoacidosis (DKA)

Burns: Fluid losses may be extreme. Very aggressive fluid management is required (see
Emergent Management of Thermal Burns).

Congenital adrenal hyperplasia: This may have associated hypoglycemia, hypotension,

hyperkalemia, and hyponatremia.

GI obstruction: This is often associated with poor intake and emesis. Bowel ischemia can result
in extensive capillary leak and shock.

Heat stroke: Hyperpyrexia, dry skin, and mental status changes may occur. [8]

Cystic fibrosis: This results in excessive sodium and chloride losses in sweat, placing patients at
risk for severe hyponatremic hypochloremic dehydration.

Diabetes insipidus: Excessive output of very dilute urine can result in large free water losses
and severe hypernatremic dehydration, especially when the child is unable to self-regulate
water intake in response to thirst (eg, the very young or the developmentally or physically
challenged).

Thyrotoxicosis: Weight loss is observed, despite increased appetite. Diarrhea occurs.

Procedures

Orogastric/nasogastric tube

An orogastric/nasogastric tube may be inserted to facilitate enteral rehydration in children with

mild-to-moderate dehydration. These tubes should be considered to assist in the nutritional
recovery of children who are critically ill or severely dehydrated.

Prevent or manage dehydration in your child:

 Offer your child liquids as directed. Ask his or her healthcare provider how much liquid to
offer each day and which liquids are best. During sports or exercise, and on warm days,
your child needs to drink more often than usual. He or she may need to drink up to 8
ounces (1 cup) of water every 20 minutes. Breastfeed your baby more often, or offer him
or her extra formula.
 Continue to breastfeed your baby or offer him or her formula even if he or she drinks
ORS. Give your child bland foods, such as bananas, rice, apples, or toast. Do not give
him or her dairy products or spicy foods until he or she feels better. Do not give him or
her soft drinks or fruit juices. These drinks can make his or her condition worse.
 Keep your child cool. Limit the time he or she spends outdoors during the hottest part of
the day. Dress him or her in lightweight clothes.
 Keep track of how often your child urinates. If he or she urinates less than usual or his or
her urine is darker, give him or her more liquids. Babies should have 4 to 6 wet diapers
each day.
If you suspect dehydration, call your healthcare provider. You can treat mild dehydration at
home by doing the following:

 Keep track of how much fluid your child drinks and how often he or she urinates.
 Breastfeed or bottle-feed a sick infant more often, but for shorter periods of time.
 For vomiting or diarrhea, give your child 1 to 2 teaspoons of an oral rehydration solution
(ORS) every 10 minutes. Continue until your child can drink larger amounts of fluid
without vomiting or passing stool.
 Avoid soft drinks, tea, juice, broth, or sports drinks like electrolyte solutions. These may
make symptoms worse.
 Do not use medicines for vomiting and diarrhea, unless your healthcare provider tells
you to.
 If your child has a hard time keeping fluids down and becomes very dehydrated, your
healthcare provider may decide to treat him or her in a hospital. There, a healthcare
provider can make your child comfortable. Your child will be given fluids and
nourishment by mouth or through an intravenous (IV) line. Medicine may be given to
stop the vomiting and allow your child to drink enough fluid to stay hydrated.