What are the steps for managing dehydration?

Management of Dehydration

The management of dehydration should begin with assessment of dehydration severity, followed by appropriate rehydration therapy with oral rehydration solution (ORS) for mild to moderate cases and intravenous fluids for severe cases, while maintaining nutrition throughout the treatment process. 1, 2

Assessment of Dehydration

• Determine the degree of dehydration through careful physical examination, categorizing as mild (3-5% fluid deficit), moderate (6-9% fluid deficit), or severe (≥10% fluid deficit) 2
• Evaluate for signs including:
  • Mild dehydration: increased thirst, slightly dry mucous membranes 2
  • Moderate dehydration: loss of skin turgor, dry mucous membranes 2
  • Severe dehydration: severe lethargy or altered consciousness, prolonged skin tenting, hypovolemic shock 1, 2
• Rapid breathing, prolonged skin retraction time, and decreased perfusion are reliable indicators of dehydration 2
• Monitor patient's weight and signs of dehydration throughout therapy to assess adequacy of rehydration 1

Treatment Based on Severity

Mild to Moderate Dehydration

• Use reduced osmolarity oral rehydration solution (ORS) as first-line therapy 1, 2
• For mild dehydration (3-5% fluid deficit), administer ORS at 50 mL/kg over 2-4 hours 2
• For moderate dehydration (6-9% fluid deficit), administer ORS at 100 mL/kg over 2-4 hours 2
• Specific ORS dosing after each stool:
  • Children <2 years: 50-100 mL of ORS solution 1
  • Older children: 100-200 mL of ORS solution 1
  • Adults: As much as desired 1
• If patient cannot tolerate oral intake, consider nasogastric administration of ORS 1
• For infants unable to drink but not in shock, use nasogastric tube to administer ORS at 15 mL/kg body weight/hour 1

Severe Dehydration

• Administer isotonic intravenous fluids (lactated Ringer's or normal saline) immediately 1, 2
• Continue IV rehydration until pulse, perfusion, and mental status normalize 1
• Once stabilized, remaining fluid deficit can be replaced using ORS 1
• For infants in shock, use nasogastric tube only if IV equipment and fluids are not available 1

Ongoing Management

• After initial rehydration, provide maintenance fluids and replace ongoing losses with ORS until diarrhea and vomiting resolve 1
• Encourage increased intake of locally available fluids that can prevent dehydration (e.g., cereal-based gruels, soup, rice water) 1
• Avoid soft drinks for rehydration due to their high osmolality 1, 2
• Reassess hydration status after 3-4 hours and continue treatment according to degree of dehydration 1
• Advise caregivers to return to healthcare facility if patient continues to pass many stools, is very thirsty, has sunken eyes, has fever, or does not seem to be improving 1

Nutritional Support

• Continue breastfeeding throughout the diarrheal episode for infants 1, 2
• If an infant is receiving formula, dilute with equal volume of clean water until diarrhea stops 1
• Resume age-appropriate diet during or immediately after rehydration 1
• For children >4-6 months:
  • Provide freshly prepared foods including cereal-bean or cereal-meat mixes with vegetable oil 1
  • Offer food every 3-4 hours (more frequently for younger children) 1
  • After diarrhea stops, provide one extra meal daily for a week 1

Adjunctive Therapies

• Consider antimotility, antinausea, or antiemetic agents only after adequate hydration is achieved 1
• Avoid antimotility drugs (e.g., loperamide) in children <18 years 1
• Ondansetron may be given to facilitate oral rehydration tolerance in children >4 years with vomiting 1
• Probiotic preparations may help reduce symptom severity and duration 1
• Consider oral zinc supplementation for children 6 months to 5 years in areas with high zinc deficiency prevalence 1

Common Pitfalls to Avoid

• Do not "rest the bowel" through fasting - this delays recovery 2
• Do not use popular beverages like apple juice, Gatorade, or commercial soft drinks for rehydration 1, 2
• Avoid assuming dehydration is due to neglect - it typically results from physiological and disease processes 3
• Do not delay treatment for severe dehydration - it constitutes a medical emergency 2
• Avoid confusing "dehydration" with "hypovolemia" - they are often incorrectly used interchangeably 4