What is the treatment for severe dehydration in pediatric patients?

Treatment for Severe Dehydration in Pediatric Patients

Immediately administer intravenous isotonic crystalloid (normal saline or lactated Ringer's) at 20 mL/kg boluses rapidly until pulse, perfusion, and mental status normalize, then transition to oral rehydration solution once the child is stabilized. 1, 2

Initial Resuscitation Protocol

Immediate IV Fluid Administration

• Administer 20 mL/kg boluses of isotonic crystalloid (0.9% normal saline or lactated Ringer's) rapidly and repeatedly until clinical parameters normalize, including pulse strength, capillary refill time, perfusion, and mental status 3, 1, 2
• Children with severe dehydration commonly require 40-60 mL/kg of IV fluids in the first hour to achieve hemodynamic stability 1
• Continue boluses until the patient awakens, has no risk factors for aspiration, and shows no evidence of ileus 3

Special Populations

• For malnourished infants, use smaller-volume frequent boluses of 10 mL/kg due to reduced cardiac capacity to handle larger volume resuscitation 1, 2
• Add dextrose to IV fluids if hypoglycemia is present or suspected, particularly in young infants 1

Alternative Vascular Access

• If IV access cannot be secured rapidly (within 5 minutes), consider intraosseous (IO) route, which can be established more quickly (mean 67 seconds vs 129 seconds for IV) and is equally effective for fluid resuscitation 4

Definition and Recognition of Severe Dehydration

Severe dehydration is defined as ≥10% fluid deficit with clinical signs including: 1, 2

• Altered mental status or depressed consciousness
• Abnormal pulse (weak, absent, or tachycardic)
• Poor perfusion with prolonged capillary refill (>3 seconds)
• Decreased or absent urine output
• Signs of shock or pre-shock

Important caveat: Signs of dehydration may be masked in hypernatremic patients, so maintain high clinical suspicion even when classic signs are absent 2

Transition to Oral Rehydration

When to Transition

• Once pulse, perfusion, and mental status normalize, transition to oral rehydration solution (ORS) to replace the remaining fluid deficit 3, 1, 2
• This approach reduces total IV fluid requirements, allows for safer completion of rehydration, and enables earlier discharge in most cases 2

ORS Administration

• Use reduced osmolarity ORS (50-90 mEq/L sodium) such as Pedialyte 1, 5
• Do not use apple juice, Gatorade, or commercial soft drinks due to inappropriate electrolyte content and high osmolality 1

Replacement of Ongoing Losses

After initial stabilization, replace ongoing losses with ORS using: 1, 2

• 10 mL/kg ORS for each diarrheal stool
• 2 mL/kg ORS for each vomiting episode

Alternative WHO recommendations: 1

• 60-120 mL for children under 10 kg per episode
• 120-240 mL for children over 10 kg per episode

Monitoring During Resuscitation

Continuous Assessment Parameters

Monitor the following throughout resuscitation: 1, 2

• Pulse quality and rate
• Capillary refill time (goal ≤2 seconds)
• Mental status
• Perfusion parameters
• Urine output (goal >1 mL/kg/hour)
• Signs of fluid overload (increased work of breathing, rales, hepatomegaly)

Reassessment Timing

• Reassess hydration status after 2-4 hours, checking skin turgor, mucous membranes, urine output, and vital signs 1, 5
• Adjust therapy based on clinical response and laboratory values if obtained 1

Electrolyte Management

• Adjust electrolytes based on laboratory values obtained during initial assessment 1, 2
• Consider potassium supplementation once urine output is established 1
• Polyelectrolyte solutions may be superior to normal saline for correcting acidosis, showing increased bicarbonate levels (11.6 to 13.3 mmol/L) compared to decreased levels with normal saline (13.3 to 12.2 mmol/L) 6

Nutritional Management

During Treatment

• Breastfed infants should continue nursing throughout the illness, even during severe dehydration treatment 3, 2, 5
• Resume age-appropriate normal diet as soon as the child tolerates oral intake, during or immediately after rehydration is complete 3, 1, 2
• Do not "rest the bowel" - continue feeding throughout rehydration 5

Critical Pitfalls to Avoid

• Do not use hypotonic maintenance fluids during acute resuscitation of severe dehydration 2
• Do not delay IV access in truly severe dehydration attempting oral rehydration first 2
• Do not give antimotility drugs (e.g., loperamide) to children <18 years with acute diarrhea 3
• Do not use popular beverages for rehydration 2

Hospitalization Criteria

Admit patients with: 5

• Severe dehydration, shock, or altered mental status
• Inability to protect airway
• Ileus preventing oral intake
• Failed oral rehydration therapy despite adequate trial