Correction of Severe Dehydration in Children
Children with severe dehydration (≥10% fluid deficit) require immediate intravenous resuscitation with isotonic crystalloid boluses of 20 mL/kg (lactated Ringer's or normal saline) until pulse, perfusion, and mental status normalize, followed by transition to oral rehydration solution once the child can tolerate oral intake. 1
Initial Assessment and Recognition
Severe dehydration constitutes a medical emergency requiring immediate intervention. 1 Clinical signs indicating severe dehydration include:
- Altered mental status or decreased level of consciousness 1
- Abnormal pulse and poor perfusion 1
- Shock or near-shock state 1
- Estimated fluid deficit ≥10% of body weight 1
Critical pitfall: Signs of dehydration may be masked in hypernatremic children, requiring heightened clinical suspicion. 1
Immediate Resuscitation Phase
Standard Approach for Most Children
Administer intravenous isotonic crystalloid boluses of 20 mL/kg body weight using lactated Ringer's solution or normal saline. 1 This represents a strong, high-quality recommendation from the Infectious Diseases Society of America. 1
- Continue boluses until pulse, perfusion, and mental status return to normal 1
- May require two IV lines or alternate access sites (venous cutdown, femoral vein, or intraosseous infusion) 1
- Adjust electrolytes and administer dextrose based on chemistry values 1
Recent evidence suggests balanced crystalloid solutions (lactated Ringer's) may offer advantages over 0.9% saline, including slightly reduced hospital stay and lower risk of hypokalaemia, though both are acceptable. 2
Special Consideration for Malnourished Infants
Malnourished infants benefit from smaller-volume, frequent boluses of 10 mL/kg body weight due to reduced cardiac capacity to handle larger volume resuscitation. 1 This is a critical modification to prevent fluid overload in this vulnerable population.
Transition to Oral Rehydration
Once the patient's level of consciousness returns to normal and they can tolerate oral intake, transition to oral rehydration solution (ORS) to replace the remaining estimated deficit. 1
Criteria for Transition
Continue IV rehydration until: 1
- Pulse, perfusion, and mental status normalize
- Patient awakens and has no altered consciousness
- No risk factors for aspiration present
- No evidence of ileus
ORS Dosing After Stabilization
For children <10 kg: 60-120 mL ORS for each diarrheal stool or vomiting episode, up to ~500 mL/day 1
For children >10 kg: 120-240 mL ORS for each diarrheal stool or vomiting episode, up to ~1 L/day 1
Alternative if unable to drink: Administer through nasogastric tube or give 5% dextrose in 0.25 normal saline with 20 mEq/L potassium chloride intravenously. 1
Ongoing Management and Monitoring
Replacement of Ongoing Losses
Replace ongoing stool and vomit losses with ORS throughout treatment until diarrhea and vomiting resolve. 1 Administer approximately 10 mL/kg for each watery stool and 2 mL/kg for each vomiting episode. 1
Nutritional Therapy
- Breastfed infants should continue nursing throughout the illness 1
- Resume age-appropriate normal diet once rehydration is complete 1
- Offer food every 3-4 hours 1
- Lactose-containing formulas can be tolerated in most instances; diluted formula offers no benefit 1
Monitoring Parameters
Reassess hydration status frequently during treatment: 3
- Monitor pulse, perfusion, and mental status continuously during IV phase 1
- Reassess after 3-4 hours of ORS therapy 3
- Continue treatment according to degree of dehydration at reassessment 3
Critical Pitfalls to Avoid
Do not use apple juice, Gatorade, or commercial soft drinks for rehydration - these lack appropriate electrolyte composition and may worsen dehydration. 1
Do not delay IV access attempts - severe dehydration is a medical emergency requiring immediate vascular access, using alternate sites if needed. 1
Do not continue IV fluids unnecessarily - transition to ORS as soon as clinically appropriate to reduce complications and hospitalization time. 1
Do not use standard volume boluses in malnourished infants - reduce to 10 mL/kg to prevent cardiac overload. 1