Pediatric Dehydration

What is Pediatric Dehydration?

Dehydration is a serious issue around the world and is a top cause of sickness and death in children. Diarrhea and dehydration cause between 14% to 30% of deaths in infants and toddlers globally. The biggest cause of gastroenteritis (a condition causing diarrhea and vomiting) is usually viruses. The rotavirus was once the main cause of gastroenteritis worldwide. However, in developed countries and some middle-income countries, including the United States, the cases of hospitalization due to rotavirus have decreased since the introduction of the rotavirus oral vaccine in 2006. Now, norovirus and other types of enteroviruses are leading causes of gastroenteritis more than rotavirus.

Dehydration is defined by the World Health Organization (WHO) as a condition where the body loses too much water. Infants and children’s bodies contain more water (between 65% to 80%) compared to adults. This makes young children particularly prone to dehydration as they can’t express their thirst or get drinks on their own. Infants need more fluids due to the higher rate of insensible fluid loss, which means the loss of body fluids that we are usually unaware of, caused by the larger surface area of their bodies relative to their weight.

Dehydration has three categories based on the level of sodium in the serum: isotonic, hypotonic, and hypertonic, each with different causes and treatments. All treatment aims to replace water and electrolytes, satisfy daily fluid needs, and replenish any additional losses.

What Causes Pediatric Dehydration?

Babies and young kids are especially vulnerable to diarrhea and dehydration because their bodies work faster, they can’t communicate their need for water, they can’t hydrate themselves, and they lose more water through things like sweat. Dehydration happens when the body loses more fluid than it takes in. This can happen because of several things such as having a stomach bug, diabetes, burn injuries, sweating excessively, and fluid accumulating in parts of the body where it can’t be used.

Typically, dehydration happens because of a sudden stomach bug. Viruses, including the rotavirus, norovirus, and enteroviruses, cause 75% to 90% of cases of infectious diarrhea worldwide, while bacteria cause fewer than 20%. In kids younger than 2, the most common cause is rotavirus. Ever since a vaccine was developed for rotavirus in 2006, there’s been a drop in hospitalizations due to dehydration, and cases of gastroenteritis caused by norovirus and other stomach viruses have gone up. In countries with fewer resources, some studies have shown that bacteria cause more than 25% of cases in children with gastroenteritis, most commonly the bacteria Escherichia coli and Shigella. Other common culprits include the organisms Cryptosporidium, Aeromonas, Campylobacter jejuni, and Vibrio cholera.

Sometimes, the terms dehydration and hypovolemia are used interchangeably by healthcare professionals. Dehydration refers to a loss of total body water (TBW), which mainly affects the parts of your body’s cells that hold water, leading to an imbalance in your body’s fluid and electrolyte levels. You can get dehydrated from not drinking enough water, losing too much fluid through sweat, vomiting, diarrhea, or medical conditions like certain types of diabetes. Dehydration makes you feel thirsty, gives you a dry mouth, makes your urine darker, reduces urine output, and can cause dizziness, confusion, and an increased heart rate. Hypovolemia refers to a decrease in the volume of blood circulating in your body, particularly a reduction in blood plasma, which is the liquid part of blood. This can happen because of bleeding, sweating too much, severe burns, or losing fluid from your digestive system. If not treated quickly, hypovolemia can cause low blood pressure, poor blood circulation to your body’s tissues, and shock. Both conditions involve losing fluids, but hypovolemia refers to a reduction in blood volume, while dehydration is a general lack of TBW. These two terms are sometimes used interchangeably because these conditions often occur at the same time.

Risk Factors and Frequency for Pediatric Dehydration

Diarrhea and dehydration are major health issues for infants and young children around the world. Each year, these illnesses cause 700,000 to 800,000 child deaths, which makes up nearly 16% of child deaths across the globe. Most of these diarrhea cases happen in South Asia and Sub-Saharan Africa. The World Health Organization (WHO) has managed to significantly reduce deaths from diarrhea by about 75% between the 1980s and 2008. However, since 2008, this decrease has stopped.

In Ethiopia, diarrhea is estimated to cause about 10,000 deaths among children under 5 years old each year. Most of these cases are due to poor sanitation, unsafe water, and a lack of access to basic hygiene products. In Pakistan, diarrhea is a major cause of death among infants, causing around 60% of child and infant deaths. The illnesses responsible for these deaths mainly include gastroenteritis and dehydration.

In the US, diarrhea and dehydration cause more than 200,000 hospitalizations among young children every year. However, these conditions are not a leading cause of death. Around the world, areas where breastfeeding rates are high, and there is access to safe water, good sanitation, and rotavirus vaccines, there are lower rates of diarrhea and dehydration needing medical attention.

Signs and Symptoms of Pediatric Dehydration

Dehydration severity can range from mild to severe, and the symptoms differ based on this. The degree of dehydration can be classified as mild (3% to 5%), moderate (6% to 10%), or severe (more than 10%). Infants can be more affected by dehydration due to their higher body water percentage. Basic symptoms to mild dehydration include a decrease in urine output. As dehydration becomes moderate, symptoms could include a dry mouth, skin that doesn’t bounce back when pinched, delayed time for blood to refill the small vessels, a faster heart rate, and irritability. Severe dehydration is more critical, with symptoms like altered mental status, difficulty in breathing, low blood pressure, and skin color changes. Those severely dehydrated might need emergency fluid resuscitation. If abdominal pain accompanies dehydration, an urgent evaluation is necessary as it could signal an underlying problem.

Additionally, diseases that lead to dehydration must be identified and treated. For instance, yellowish skin or eyes in someone with hepatitis, or children with stomach upset and a widespread, spotty red rash might indicate typhoid fever.

The table provided shows a breakdown of the signs and symptoms experienced depending on the percentage of dehydration:

Testing for Pediatric Dehydration

If your child needs intravenous fluid, blood tests are crucial. These tests help doctors identify the level of dehydration your child is experiencing. Kids with mild dehydration usually have normal electrolytes (minerals in the body needed for proper cell function) and acid/base balance (which keeps our body’s pH level stable). Their pee might be more concentrated (a specific gravity greater than 1.015) as the body tries to hold onto water. The presence of ketones (a kind of chemical) in the urine may indicate severe dehydration. If the blood test shows high levels of a substance called blood urea nitrogen (BUN), it may suggest your child is more dehydrated. However, high levels of BUN can also come from high protein in the diet, heavy protein breakdown in the body, or bleeding in the digestive system.

The bicarbonate (substances that keep our blood from becoming too acidic or too alkaline) level in the blood can help show how dehydrated your child is. Bicarbonate levels less than 17 mEq/L suggest moderate to severe dehydration.

Checking the blood sodium helps doctors to classify the type of dehydration and helps guide which IV fluids your child needs. Isonatremic dehydration means the body has lost water and salt in equal amounts, with a blood sodium value of 130 to 150 mEq/L. Hyponatremic dehydration occurs when the body has lost more salt than water, with a blood sodium value below 130 mEq/L. This condition can cause seizures and is commonly due to the body secreting too much of a hormone that prevents urination. Hypernatremic dehydration means the body has lost more water than salt, and the blood sodium value is above 150 mEq/L. This type of dehydration can occur with severe viral gastroenteritis, certain medical conditions or when children drink rehydration solutions that are not properly mixed.

Serum potassium levels are important to check, as they can be abnormal in dehydrated kids. Low potassium is common because of diarrhea. However, ongoing issues relating to dehydration, like bicarbonate loss from the body, can lead to a condition known as metabolic acidosis, and could increase potassium levels in the blood. High potassium may affect your child’s heart rhythm.

Severe vomiting in children can cause metabolic alkalosis, which is an imbalance that makes your body too alkaline. This is usually seen in infants with a stomach condition called pyloric stenosis. Tests may also show low blood sugar levels and abnormal electrolyte balances. Research is ongoing to discover new ways to assess how dehydrated a child is, including the measurement of carbon dioxide in exhaled air. But at this time, no proven tool exists to determine the degree of dehydration in pediatric patients.

Treatment Options for Pediatric Dehydration

Managing dehydration involves recognizing the signs early, understanding the severity of the dehydration, restoring water and electrolyte levels, replacing ongoing fluid loss, and keeping fluid levels stable. It’s important to measure the volume of vomit and stool as these contribute to the overall fluid loss in the body. This can help medical professionals decide on the best method, volume and speed of rehydration. There are two main phases of treatment: replacing the deficit of fluid and electrolytes, which continues until the symptoms of dehydration have lessened and the patient has urinated. This is followed by the maintenance phase, around 4 hours later, where extra fluids are given to meet the patient’s metabolic needs and to replace ongoing losses.

For mild to moderate dehydration, oral rehydration is recommended by the World Health Organisation and the American Academy of Pediatrics. The goal is to return patients to a normal state of hydration. Oral rehydration therapy (ORT) is a less expensive method than direct fluid administration into a vein (intravenous or IV), it requires fewer technical skills, and avoids complications like phlebitis (inflammation of a vein) and infection. It also means non-medical caregivers can contribute to the treatment. It’s important that ORT is given in small amounts to avoid triggering vomiting. This can be administered with a nasogastric tube if patients refuse fluids or can’t drink. However, ORT is not suitable for patients with altered mental status, abdominal ileus (a type of bowel obstruction), malabsorption, persistent vomiting, or severe dehydration.

The World Health Organisation recommend ORT solutions with a certain balanced mixture of electrolyte salts and glucose. These come as a pharmaceutical product, distributed in packets. They can also come in powdered, liquid or “ice-pop” forms. Drinks with high sugar content like juice, soda, or sports drinks might make diarrhea worse. Broths with excessive salt can lead to hypernatremia (high sodium levels in the blood). In severe cases of dehydration, it’s important to assess the patient and decide the best treatment options, such as emergency management using IV fluids. Severe dehydration can lead to low blood volume (hypovolemia), and requires quick fluid replacement. Further management includes testing blood glucose levels, serum electrolytes, and urine for ketones, which provides helpful information to guide further medical therapy.

If oral rehydration doesn’t work, intravenous (IV) fluids may be selected, this is a more direct way to get fluid back into the body. It is important to calculate the rehydration volume and infusion rate. The fluids delivered should normally contain saline and glucose to correct hypoglycemia (low blood sugar levels). In the second phase of fluid administration, the types of fluid given will be based on the patient’s serum sodium concentration. The quantity of fluid to be replaced might be calculated using different formulas, providing an estimate of what fluids will be needed to replace ongoing losses from vomiting and diarrhea. In some cases, isotonic saline solutions could be useful to replace both water and sodium.

There are alternative methods for children who are unable to take fluids orally, such as nasogastric hydration, where a tube is inserted through the nose into the stomach. There is also subcutaneous fluid administration, where fluids are administered under the skin, used when intravenous access cannot be achieved. Hypodermoclysis is another method used in older adults, which is not contraindicated in children and involves injecting fluids under the skin. While these methods may not be commonly used, they can be beneficial alternatives in cases where needed.

What else can Pediatric Dehydration be?

Doctors need to consider many potential causes when they see a child who is dehydrated. Dehydration is often due to loss of fluid from vomiting, diarrhea, or not drinking enough liquids. However, it can also be a sign of other medical conditions, which need to be identified and treated. Here are some of the possible underlying causes:

• Infections that can make the body lose fluids. These can include stomach bugs caused by viruses or bacteria, bladder infections, or more serious infections that can shock the body, disrupt the balance of minerals in the blood, and cause dehydration.
• Metabolic disorders. These are conditions that affect how the body regulates water and minerals. Examples include diabetes insipidus, a type of diabetes that can cause extreme thirst and frequent urination, ketoacidosis, a serious complication of diabetes mellitus that occurs when your body produces high levels of blood acids called ketones, and a rare genetic condition called congenital adrenal hyperplasia where the body can’t maintain the right balance of certain vital substances in the blood and tissue. All of these conditions can lead to dehydration.
• Structural problems in the digestive system. Some babies are born with conditions such as pyloric stenosis, which is a narrowing of the opening from the stomach into the small intestine, or malrotation with volvulus, which is a twisting of the intestines. These problems can make it hard for the body to absorb enough fluids, leading to dehydration.

When a child is dehydrated, doctors need to gather a lot of information, including the child’s medical history and the results of a physical examination and lab tests. This helps them find out what’s causing the dehydration and decide on the best treatment.

What to expect with Pediatric Dehydration

Dehydration can be a serious health issue for children, particularly in parts of the world where there is limited access to clean water and healthcare facilities. The overall prognosis, or likely outcome of dehydration, depends on several factors.

Early recognition and correct management of dehydration, using methods like ORS (an oral rehydration solution) and intravenous fluids, can massively improve the situation. However, in areas where the healthcare resources are not sufficient, severe dehydration can be very risky. This can lead to a variety of serious complications, such as imbalances of the body’s electrolytes, organ failure, and even death.

Children who repeatedly become dehydrated, often due to recurrent gastrointestinal infections, may suffer from long-term health problems and stunted growth. It’s crucial to address the underlying factors that can lead to dehydration, such as access to clean water, sanitation, immunizations, and preventive healthcare. This is vital in reducing the global impact of dehydration on children and the associated illnesses and mortality that can result.

Possible Complications When Diagnosed with Pediatric Dehydration

: It’s important for healthcare professionals who work with children to know what might go wrong if kids get dehydrated. Dehydration in kids can cause dangerous health problems. These can include electrolyte imbalances like hypernatremia or hyponatremia, which can lead to neurological issues like confusion, seizures, and coma. Acute kidney injury can happen when dehydration leads to decreased blood flow to the kidneys. This can result in no urine output and the body holding onto waste products it usually gets rid of. Severe cases of dehydration can lead to a life-threatening condition called hypovolemic shock, which involves low blood pressure and impaired blood flow to the body’s tissues. If treatment for dehydration is delayed, this could lead to metabolic acidosis, heart rhythm problems, and even death. Kids who keep getting severely dehydrated from repeated bouts of diarrhea are at risk of malnutrition, which can lead to cognitive and physical development delays and higher rates of illness and death from dehydration.

Treating dehydration can also carry risks. For example, oral rehydration solutions that aren’t prepared correctly can cause imbalances in electrolytes like sodium. There have been rare occurrences of gastrointestinal issues like bleeding from stomach and duodenal ulcers after people have drunk incorrectly made oral rehydration solutions. Intravenous (IV) hydration treatment necessitates frequent checking of blood glucose and electrolyte levels in order to prevent or correct imbalances and to guide ongoing clinical evaluation. Fixing hypernatremia too quickly could result in brain swelling and seizures.

One disorder that can happen when hyponatremia is fixed too quickly is called osmotic demyelination syndrome or central pontine myelinolysis. Symptoms often include headache, confusion, change in level of consciousness, and a hard time walking, and this disorder can even lead to respiratory failure. Other possible risks of giving IV fluids too quickly are heart failure and fluid in the lungs. IV treatment in general comes with the risk of vein inflammation, swelling from fluid leaking out of the vein, large bruises, skin inflammation, and sepsis from a catheter-related infection. To avoid these serious complications, healthcare professionals must be ready to quickly spot signs and symptoms of dehydration and start the appropriate oral or IV hydration treatment with careful monitoring.

Common Issues with Dehydration:

• Electrolyte imbalances (hyponatremia or hypernatremia)
• Neurological issues (confusion, seizures, coma)
• Acute kidney injury
• Hypovolemic shock
• Metabolic acidosis
• Heart rhythm problems
• Death
• Effects of repeated severe dehydration (malnutrition, development delays)

Possible Risks of Treatment:

• Electrolyte imbalances from incorrect oral rehydration solutions
• Gastrointestinal issues
• Quick correction of hypernatremia (brain swelling, seizures)
• Osmotic demyelination syndrome or central pontine myelinolysis
• Complications of IV hydration too quickly (heart failure, fluid in the lungs)
• Risks of IV treatment (vein inflammation, fluid leakage and swelling, large bruises, skin inflation, catheter-related sepsis)

Preventing Pediatric Dehydration

Making sure that children do not become dehydrated is extremely important, especially in areas with fewer resources. Some key ways to prevent dehydration include getting children vaccinated against illness like rotavirus, measles, and cholera, which can cause diarrhea and lead to dehydration. One great way to keep infants healthy and stave off dehydration is to feed them only breast milk for the first six months of their lives, before introducing other foods while continuing to breastfeed for up to two years. This method, recommended by the World Health Organization, supplies vital nutrients and helps protect against diseases.

Access to clean water, good hygiene practices, and proper sanitation systems are also crucial in preventing dehydration from diarrhea-related diseases. Things like using safe methods of waste disposal and washing hands regularly are simple yet powerful actions that can drastically lower the risk of dehydration.

Oral Rehydration Therapy (ORT), a treatment for dehydration, has been proven to work well, but there can be issues with people knowing about it, using it correctly, or medical professionals not following the guidelines set by organizations like the American Academy of Pediatrics (AAP), World Health Organization (WHO), and the Centers for Disease Control and Prevention (CDC). Also, the cost of ORT bought in stores might be too much for some families to afford.

Therefore, it’s important to tackle these issues through education and training, and by making affordable ORT solutions available. This would greatly help to improve the health of children across the world.