What is the treatment for a child with fever and dehydration, without a history of pharyngitis or symptoms of urinary tract infection (UTI)?

Treatment of Febrile Child with Dehydration (No Pharyngitis or UTI Symptoms)

Initiate oral rehydration therapy immediately with 50-100 mL/kg of oral rehydration solution (ORS) containing 50-90 mEq/L sodium over 2-4 hours, based on the degree of dehydration, and begin age-appropriate feeding as soon as rehydration is achieved. 1

Assessment of Dehydration Severity

First, clinically assess the degree of dehydration to determine the appropriate rehydration volume 1:

• Mild dehydration (3-5% fluid deficit): Administer 50 mL/kg ORS over 2-4 hours 1
• Moderate dehydration (6-9% fluid deficit): Administer 100 mL/kg ORS over 2-4 hours 1
• Severe dehydration (≥10% fluid deficit, shock): This is a medical emergency requiring immediate IV rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize 1

The most useful physical findings for identifying dehydration include prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern 2. Clinical dehydration scales combining multiple examination findings are more accurate than individual signs 2.

Oral Rehydration Technique

Administer ORS using small, frequent volumes initially 1:

• Start with one teaspoon (5 mL) using a teaspoon, syringe, or medicine dropper 1
• Gradually increase the amount as tolerated 1
• After 2-4 hours, reassess hydration status 1
• If still dehydrated, reestimate the fluid deficit and restart rehydration therapy 1

Most children with dehydration can be successfully rehydrated via the oral route, though oral rehydration therapy remains underutilized in the United States 3.

Replacement of Ongoing Losses

Replace ongoing fluid losses during both rehydration and maintenance phases 1:

• Administer 10 mL/kg ORS for each watery or loose stool 1
• Administer 2 mL/kg ORS for each episode of vomiting 1
• If losses can be measured accurately, give 1 mL of ORS for each gram of diarrheal stool 1

Dietary Management

Resume normal feeding immediately upon achieving rehydration 1:

• Breast-fed infants: Continue nursing on demand throughout rehydration 1
• Formula-fed infants: Offer full-strength, lactose-free or lactose-reduced formula immediately after rehydration in amounts sufficient to meet energy and nutrient requirements 1
• If lactose-free formula is unavailable, full-strength lactose-containing formula can be used under supervision 1
• Older children: Resume normal age-appropriate diet once rehydrated 2

Fever Management Considerations

Use antipyretics (acetaminophen or ibuprofen) only when fever causes discomfort 4:

• Dose antipyretics based on the child's weight, not age 4
• Avoid ibuprofen in dehydrated children 4
• Physical methods of reducing fever are discouraged except in hyperthermia 4
• Combined or alternating antipyretics are discouraged 4

When to Use Parenteral Therapy

Switch to IV rehydration if 1, 3:

• The child has severe dehydration (≥10% fluid deficit) or shock 1
• The child cannot retain oral fluids due to persistent vomiting 3
• Oral rehydration fails after appropriate attempts 3

Critical Pitfalls to Avoid

• Do not delay rehydration while searching for fever source: Begin oral rehydration immediately based on clinical assessment of dehydration 1
• Do not withhold feeding: Resume normal diet as soon as rehydration is achieved; continued feeding does not worsen diarrhea and supports recovery 1
• Do not use ibuprofen in dehydrated children: This increases risk of renal complications 4
• Do not rely solely on fever height: The degree of dehydration, not fever severity, determines the rehydration approach 1, 2
• Do not use physical cooling methods: These are ineffective and may cause discomfort 4

Follow-Up Monitoring

Reassess hydration status after 2-4 hours of oral rehydration therapy 1. If the child remains dehydrated despite appropriate oral rehydration attempts, consider parenteral therapy 1, 3.