Fluid Therapy for Severe Dehydration in a 1-Year-Old Child
For this 9 kg child with severe dehydration from acute diarrhea, immediately administer intravenous isotonic crystalloid (lactated Ringer's or normal saline) at 20 mL/kg boluses (180 mL per bolus) until pulse, perfusion, and mental status normalize, then transition to oral rehydration solution (ORS) to complete rehydration. 1
Initial Resuscitation Phase
Intravenous fluid administration is mandatory for severe dehydration:
- Administer isotonic crystalloid boluses of 20 mL/kg (180 mL for this 9 kg child) using either lactated Ringer's solution or 0.9% normal saline 1
- Repeat boluses until clinical signs normalize: pulse rate, perfusion (capillary refill), and mental status return to normal 1
- This typically requires 60-100 mL/kg over the first 2-4 hours (540-900 mL total for this child) 2
- Balanced crystalloid solutions like lactated Ringer's likely reduce hospital stay slightly compared to normal saline and may reduce risk of hypokalaemia 3
Transition to Oral Rehydration
Once circulation is restored and the child is alert without aspiration risk:
- Switch to oral rehydration solution (ORS) to replace the remaining fluid deficit 1
- For children <10 kg, administer 60-120 mL ORS for each diarrheal stool or vomiting episode, up to approximately 500 mL/day 1
- Give ORS in small, frequent amounts (5-10 mL every 1-2 minutes initially if vomiting present) to avoid triggering further vomiting 4
Maintenance and Ongoing Loss Replacement
After complete rehydration:
- Replace ongoing losses with 10 mL/kg ORS (90 mL) for each watery stool 4, 5
- Replace 2 mL/kg ORS (18 mL) for each vomiting episode 4, 5
- Continue replacement until diarrhea and vomiting resolve 1
Critical Monitoring Parameters
Reassess clinical status frequently:
- Monitor pulse, perfusion, capillary refill time, mental status, and urine output 1
- Adjust electrolytes and administer dextrose based on laboratory values if available 1
- If the child has severe acidosis with oliguria, consider physiological bicarbonate dosing to correct pH to 7.25 2
Nutritional Management
Resume feeding as soon as tolerated:
- Continue breastfeeding throughout the illness if applicable 1, 4
- Resume age-appropriate diet during or immediately after rehydration is complete 1, 4
- Do not dilute formula or restrict diet unnecessarily 1
Common Pitfalls to Avoid
Critical errors that worsen outcomes:
- Never use antimotility drugs (like loperamide) in children under 18 years—these are contraindicated and can cause serious adverse effects including respiratory depression 1, 5
- Avoid allowing the thirsty child to drink large volumes of ORS rapidly (ad libitum), which worsens vomiting 4
- Do not use inappropriate fluids like apple juice, Gatorade, or soft drinks for rehydration 1
- Do not delay IV fluids in severe dehydration attempting oral rehydration first 1
Warning Signs Requiring Immediate Attention
Indicators of treatment failure or complications:
- Persistent shock or failure to normalize pulse and perfusion despite adequate IV fluids 4
- Intractable vomiting preventing successful oral rehydration 4
- Very high stool output (>10 mL/kg/hour or >90 mL/hour for this child) 4
- Signs of glucose malabsorption (increased stool output with ORS administration) 4
- Development of altered mental status or seizures suggesting electrolyte abnormalities 1
Adjunctive Considerations
Additional supportive measures: