Caring for a child with dehydration is a common occurrence in acute paediatric settings and as such the ability to recognise and treat this condition is a vital skill for nurses who care for children. Failure to appropriately recognise dehydration when it occurs can lead to fast deterioration of the child's clinical condition and can be fatal. Children are more likely to become dehydrated than adults and often deteriorate quicker than adults when unwell, so the nurse caring for this patient group is required to respond with speed and skill to provide the appropriate care at the right time.
Dehydration in children: how and why
The NHS defines dehydration as the body losing more fluid than it is taking in (NHS website, 2019). Dehydration in children is usually caused by diarrhoea and vomiting or systemic infection, but can also be the result of a number of other underlying conditions (Forman et al, 2012).
Nurses caring for children are likely to be required to treat numerous cases of dehydration throughout their careers as febrile illnesses and diarrhoea with or without vomiting are the second and third most commonly presented medical problems to emergency departments for children aged 0–15 years (Sands et al, 2012).
Inadequate treatment of dehydration in children can lead to acidosis, electrolyte disturbances, kidney damage or hypovolaemic shock (Mecham, 2006; Pringle et al, 2011). Hypovolaemic shock is the clinical state in which the loss of blood volume causes inadequate tissue perfusion in the body; it is the most common cause of shock in children and can be fatal if not detected early and treated appropriately (Mecham, 2006; Nolan and Pullinger, 2014).
Children are more likely to experience dehydration than adults because water constitutes a greater proportion of bodyweight in children than in adults (World Health Organization (WHO), 2009). Furthermore, the younger the child, the poorer the ability of their kidneys to conserve water, and children use more water over the course of 24 hours than adults due to their higher metabolic rates (WHO, 2009).
This article aims to aid nurses caring for children with dehydration in recognising and treating dehydrated children.
Recognition
Recognition of the dehydrated child is a key skill for nurses caring for this patient group. Assessment of all deteriorating or critically ill patients should always follow the ABCDE approach: airway, breathing, circulation, disability, exposure (Resuscitation Council UK, 2019).
During ABCDE assessment, if the nurse suspects dehydration, they should consider whether the child appears unwell, has altered responsiveness (for example, is irritable or lethargic), has decreased urine output or has an increased heart or elevated respiratory rate (National Institute for Health and Care Excellence (NICE), 2009).
Recognition of the seriousness of the condition of a child with dehydration can sometimes be difficult on initial presentation as the child may at first appear to be quietly sleeping or undisturbed by assessment. Caution should be taken in these circumstances to ensure that the sleep is not a symptom of altered responsiveness and that the child receives a full and thorough assessment.
Table 1 displays the clinical features of dehydration and hypovolaemic shock, which can be used to aid in the assessment and differentiation of these conditions (NICE, 2015). The clinical features in red are ‘red flags’ for medical professionals and should prompt an escalation in treatment (NICE, 2015).
| No clinically detectable dehydration | Clinical dehydration | Hypovolaemic shock |
|---|---|---|
| Alert and responsive | Altered responsiveness (irritable, lethargic etc) | Decreased level of consciousness |
| Appears well | Appears to be unwell or deteriorating | |
| Eyes not sunken | Sunken eyes | |
| Moist mucous membranes (except after drinking) | Dry mucous membranes (consider excluding children who are ‘mouth breathers’) | |
| Normal blood pressure | Normal blood pressure | Hypotension (decompensated shock) |
| Normal breathing pattern | Tachypnoea | Tachypnoea |
| Normal capillary refill time | Normal capillary refill time | Prolonged capillary refill time |
| Normal heart rate | Tachycardia | Tachycardia |
| Normal peripheral pulses | Normal peripheral pulses | Weak peripheral pulses |
| Normal skin turgor | Reduced skin turgor | |
| Normal urine output | Decreased urine output | |
| Skin colour unchanged | Skin colour unchanged | Pale or mottled skin |
| Warm extremities | Warm extremities | Cold extremities |
Source: adapted from National Institute for Health and Care Excellence, 2015
When assessing dehydration it is important to note that the severity of the dehydration can be judged by an increased number of or an escalation in any of the clinical features (NICE, 2015).
Symptoms to note
A child or baby who ‘appears unwell’ due to dehydration may present with any of the following:
Children particularly at risk
It is important that nurses caring for children recognise that the following groups are at increased risk of dehydration (NICE, 2009):
Treatment
Treatment for dehydration in children is escalated according to the severity of the dehydration and may occur in one of the three following ways (NICE, 2015):
Any patient who requires treatment for dehydration should be monitored through the use of a fluid balance chart. This chart should include hourly documentation of the patient's input and output with 12-hourly fluid balance subtotals and 24-hourly totals (NICE, 2015). Weight should be measured before treatment and every 24 hours, with any difference between the two calculated (NICE, 2015).
Oral rehydration
Oral rehydration is advocated for use in all children showing signs of clinical dehydration as shown in Table 1 (NICE, 2009). IV rehydration may be indicated as an alternative to oral rehydration in children who have ‘red flag’ symptoms, are showing signs of clinical deterioration or who cannot tolerate oral rehydration (NICE, 2009; 2015).
In children who can tolerate oral rehydration, the use of a low-osmolarity oral rehydration solution (ORS) 240-250 mOsm/litre is recommended (NICE, 2009). Children should be given 50 ml/kg of ORS over 4 hours followed by ORS for maintenance in small, frequent volumes until reassessment shows an improvement in the signs of clinical deterioration (NICE, 2009). For example, a 10 kg child should be given an initial 500 ml of ORS over 4 hours, then 42 ml/hour of maintenance ORS and then reassessed hourly to ensure further deterioration is not missed.
Oral rehydration solutions
The oral rehydration solutions that meet the above recommended 240-250 mOsm/litre are Dioralyte, Dioralyte Relief, Electrolade and Rapolyte (NICE, 2009). If children refuse to drink the ORS solution, supplementation of the ORS with normal fluids, including milk or water, could be considered, but not fruit juice or carbonated drinks (NICE, 2009). Insertion of a nasogastric tube may also be considered for children who cannot tolerate the taste of the ORS as an alternative to the need for cannulation and IV fluids (NICE, 2009).
Maintenance fluids
For children who have any red flag symptoms (Table 1) or children who persistently vomit the ORS, intravenous (IV) rehydration is recommended (NICE, 2009). It is advised that IV rehydration should initially use isotonic crystalloids that contain sodium in the range of 131-154 mmol/litre (NICE, 2015).
Routine maintenance IV fluid rates for children and young people can be calculated using the Holliday–Segar formula (Holliday and Segar, 1957) in Box 1. It is important to be aware that over a 24-hour period, males rarely need more than 2500 ml of fluid and females rarely need more than 2000 ml of fluid (NICE, 2009). When seeking to use IV fluids for rehydration in children, it is necessary to calculate their routine maintenance requirements, then add 50 ml/kg to this total and deliver this volume over 24 hours (NICE, 2009). For example, a 15 kg child would receive 1250 ml maintenance volume then 750 ml extra to counteract their dehydration so a total of 2000 ml over 24 hours.
Children who require rehydration with IV hydration should have their urea, electrolytes and blood glucose monitored at the start of the hydration and every 24 hours thereafter (NICE, 2009). This monitoring will dictate whether the child requires an increase or decrease in fluid volumes or any additional treatment for altered electrolyte or glucose levels, and therefore more frequent monitoring. Following IV rehydration, the child's clinical condition should be reassessed and ORS or normal food and drink slowly introduced as tolerated (NICE, 2009).
Intravenous fluid
NICE (2009) guidance recommends the use of an isotonic crystalloid fluid, with sodium in the range of 131-154 mmol/litre, to rehydrate patients who require IV fluids. The most commonly used fluid that fits this criteria is sodium chloride 0.9% with glucose 5%, but this may vary across different practice settings.
Fluid resuscitation
IV fluid resuscitation should be delivered in children who show signs of hypovolaemic shock or children with red flag symptoms who show signs of clinical deterioration as in Table 1 (NICE, 2015).
Children and young people who require IV fluid resuscitation should be given 20 ml/kg of glucose free crystalloids that contain sodium in the range of 131-154 mmol/litre over less than 10 minutes (Moritz and Ayus, 2011; NICE, 2015). The most commonly used glucose-free crystalloid is sodium chloride 0.9% but other solutions such as Hartmann's solution may be used (NICE, 2015).
Fluid bolus
The administration of IV fluids for fluid resuscitation over less than 10 minutes is usually referred to as a fluid bolus and delivered as quickly as the venous access device will allow.
It is important to consider whether the child has any pre-existing conditions such as cardiac or kidney disease as this may require reduced fluid volumes for resuscitation (NICE, 2015).
Once a child has received IV fluid resuscitation of 20 ml/kg, their condition should be reassessed for clinical improvement, as they may require further fluid boluses (NICE, 2015). Children who no longer show clinical indication for the need for further fluid boluses should commence on maintenance fluids (calculated as in Box 1) with 100 ml/kg extra volume added and continue to be monitored (NICE, 2009). Children who have not shown improvement in their condition may have the fluid bolus repeated once or twice as required but it is vital to note that if 40–60 ml/kg or more IV fluid resuscitation is required then expert advice is needed to assess the child and for continuing fluid management advice (for example, the paediatric intensive care team) (NICE, 2015).
Calculating fluid maintenance
In some practice settings, body surface area may be used to calculate fluid maintenance requirements for children. In this instance the calculation can occur through estimating ‘insensible losses’ (this is the estimated amount of fluid that a child will lose on a daily basis from the lungs, skin, and respiratory tract) within the range of 300–400 ml/m²/24 hours plus urine output (NICE, 2009). For example, a child weighing 28 kg will have an estimated body surface area of 1 m², so the child's fluid management needs would be calculated on the basis of 1x300 ml + urine output.
Nutritional management
Once rehydration has been achieved, the child may drink full-strength milk straight away and the child's usual solid food can be reintroduced. Fruit juices and carbonated drinks should be avoided until any diarrhoea has stopped (NICE, 2009:7).
Summary
It is common for young children to show a decrease in normal fluid and dietary input when they are feeling unwell. Although this decrease in oral intake does not dictate that dehydration will always follow, this is a risk that should be considered in any children presenting to healthcare settings.
Recognition of dehydration in children is a necessary skill for nurses. Treatment of dehydration in children is tiered according to the severity of the dehydration and will consist of either oral rehydration, IV rehydration or IV fluid resuscitation. Infants, children and young adults with conditions such as diabetic ketoacidosis or cardiac conditions will require different management to that outlined in this article, and management of these conditions should follow clinical guidance. Early recognition of dehydration and effective treatment of the condition will prevent further clinical deterioration or additional complications.