What is the recommended treatment protocol for pediatric dehydration?

Pediatric Dehydration Treatment Protocol

For mild to moderate dehydration in children, oral rehydration solution (ORS) is the first-line treatment, with 50 mL/kg for mild dehydration and 100 mL/kg for moderate dehydration administered over 2-4 hours, while severe dehydration requires immediate IV isotonic crystalloid boluses of 20 mL/kg until vital signs normalize. 1, 2

Assessment of Dehydration Severity

The clinical assessment determines treatment approach:

• Mild dehydration (3-5% fluid deficit): Increased thirst, slightly dry mucous membranes 2
• Moderate dehydration (6-9% fluid deficit): Loss of skin turgor, dry mucous membranes, decreased urine output 2
• Severe dehydration (≥10% fluid deficit): Severe lethargy or altered consciousness, prolonged skin tenting, signs of shock 2

The most reliable physical findings are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern 3. Clinical dehydration scales combining multiple findings are more accurate than individual signs 3.

Treatment Algorithm by Severity

Mild Dehydration (3-5% deficit)

• Administer 50 mL/kg of ORS over 2-4 hours 1, 2
• Start with small volumes (5 mL using a teaspoon or syringe) and gradually increase as tolerated 1
• For children <10 kg: give 60-120 mL ORS for each diarrheal stool or vomiting episode 4, 1
• For children >10 kg: give 120-240 mL ORS for each diarrheal stool or vomiting episode 4, 1

Moderate Dehydration (6-9% deficit)

• Administer 100 mL/kg of ORS over 2-4 hours 1, 2
• Use the same gradual administration approach as mild dehydration 1
• If the child cannot drink but is not in shock, consider nasogastric administration at 15 mL/kg/hour 1, 5
• Replace ongoing losses using the same volumes as mild dehydration 4, 1

Severe Dehydration (≥10% deficit)

This is a medical emergency requiring immediate IV therapy 2:

• Administer isotonic crystalloid (lactated Ringer's or normal saline) boluses of 20 mL/kg until pulse, perfusion, and mental status normalize 4, 1
• Important caveat for malnourished infants: Use smaller-volume, frequent boluses of 10 mL/kg due to reduced cardiac capacity 4, 1
• Adjust electrolytes and administer dextrose based on laboratory values 4
• Once stabilized, transition to ORS to complete rehydration 4, 1

Choice of Rehydration Solution

Use only commercially available low-osmolarity ORS formulations 1, 5:

• Acceptable products: Pedialyte, CeraLyte, Enfalac Lytren (containing 75-90 mEq/L sodium) 4, 5
• These solutions are safe in both hypernatremia and hyponatremia (except when edema is present) 4

Critical Pitfall to Avoid

Never use apple juice, Gatorade, sports drinks, or commercial soft drinks for rehydration 4, 1, 5. These beverages have inappropriate electrolyte content and excessive osmolality that can worsen diarrhea 5.

Maintenance Phase

Once rehydration is achieved (typically after 2-4 hours):

• Resume age-appropriate normal diet within 3-4 hours 4, 1
• Breastfed infants should continue nursing throughout the illness 4, 1
• Children previously on lactose-containing formula can tolerate the same product in most instances 4
• Continue replacing ongoing losses with ORS until diarrhea and vomiting resolve 4, 1

When to Escalate to IV Therapy

Switch from oral to IV rehydration if 4, 5:

• Severe dehydration with shock or altered mental status
• Failure of ORS therapy after appropriate trial
• Presence of ileus
• Persistent inability to tolerate oral intake despite nasogastric attempts

Monitoring Response

• Reassess hydration status after 2-4 hours by checking skin turgor, mucous membranes, urine output, and vital signs 1, 2
• If dehydration persists after the initial rehydration period, reassess the fluid deficit and restart rehydration therapy 1
• Successful progress is judged by hemodynamic monitoring, fluid input/output measurement, and clinical examination 2

Additional Clinical Considerations

• Do not use anti-diarrheal medications in children with acute diarrhea 1, 5
• Avoid "resting the bowel" through fasting—feeding should begin as soon as appetite returns 2
• For young infants receiving IV therapy, add dextrose to prevent hypoglycemia and consider potassium supplementation once urine output is established 1
• In patients with renal or cardiac compromise, monitor serum osmolality and frequently assess cardiac, renal, and mental status to avoid fluid overload 2