Treatment of hypovolemia (dehydration) in children
- Michael J Somers, MD
Michael J Somers, MD
- Associate Professor of Pediatrics
- Harvard Medical School
Fluid therapy maintains the normal volume and composition of body fluids and, if needed, corrects any existing abnormalities. In children, the most common abnormality requiring fluid therapy is hypovolemia or dehydration, often related to vomiting and diarrhea from gastroenteritis. Clinically, it is useful to divide fluid therapy into repletion therapy and maintenance therapy.
●Repletion therapy replaces any current existing water and electrolyte deficits, replaces any ongoing abnormal losses, and returns the patient to a normal volume and electrolyte status.
●Maintenance therapy replaces the expected ongoing losses of water and electrolytes from normal physiologic processes and maintains normal volume and electrolyte status (calculator 1). (See "Maintenance fluid therapy in children".)
Volume depletion reduces the effective arterial blood volume (also called effective circulating volume [ECV]), which refers to that part of the arterial volume that perfuses the tissues. If severe hypovolemia is not corrected in a timely fashion, ischemic end-organ damage may occur and, with profound or persistent hypovolemia, shock and death may ensue.
The treatment of hypovolemia in children will be reviewed here. The clinical assessment and diagnosis of hypovolemia, and the treatment of hemorrhagic and nonhemorrhagic hypovolemic shock are discussed separately. (See "Clinical assessment and diagnosis of hypovolemia (dehydration) in children" and "Hypovolemic shock in children: Initial evaluation and management".)
- Management of shock. In: Pediatric Advanced Life Support Provider Manual, Chameides L, Samson RA, Schexnayder SM, Hazinski MF (Eds), American Heart Association, Subcommittee on Pediatric Resuscitation, Dallas 2011. p.85.
- Freedman SB, Parkin PC, Willan AR, Schuh S. Rapid versus standard intravenous rehydration in paediatric gastroenteritis: pragmatic blinded randomised clinical trial. BMJ 2011; 343:d6976.
- Nager AL. Intravenous rehydration in paediatric gastroenteritis. BMJ 2011; 343:d7083.
- Rouhani S, Meloney L, Ahn R, et al. Alternative rehydration methods: a systematic review and lessons for resource-limited care. Pediatrics 2011; 127:e748.
- Jackson J, Bolte RG. Risks of intravenous administration of hypotonic fluids for pediatric patients in ED and prehospital settings: let's remove the handle from the pump. Am J Emerg Med 2000; 18:269.
- Ayus JC, Arieff AI. Hyponatremia and myelinolysis. Ann Intern Med 1997; 127:163.
- Levy JA, Bachur RG, Monuteaux MC, Waltzman M. Intravenous dextrose for children with gastroenteritis and dehydration: a double-blind randomized controlled trial. Ann Emerg Med 2013; 61:281.
- Rackow EC, Falk JL, Fein IA, et al. Fluid resuscitation in circulatory shock: a comparison of the cardiorespiratory effects of albumin, hetastarch, and saline solutions in patients with hypovolemic and septic shock. Crit Care Med 1983; 11:839.
- Wilkes MM, Navickis RJ. Patient survival after human albumin administration. A meta-analysis of randomized, controlled trials. Ann Intern Med 2001; 135:149.
- Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350:2247.
- Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2011; :CD000567.
- Moineau G, Newman J. Rapid intravenous rehydration in the pediatric emergency department. Pediatr Emerg Care 1990; 6:186.
- Rahman O, Bennish ML, Alam AN, Salam MA. Rapid intravenous rehydration by means of a single polyelectrolyte solution with or without dextrose. J Pediatr 1988; 113:654.
- Reid SR, Bonadio WA. Outpatient rapid intravenous rehydration to correct dehydration and resolve vomiting in children with acute gastroenteritis. Ann Emerg Med 1996; 28:318.
- Strange K. Regulation of solute and water balance and cell volume in the central nervous system. J Am Soc Nephrol 1992; 3:12.
- Neville KA, Verge CF, O'Meara MW, Walker JL. High antidiuretic hormone levels and hyponatremia in children with gastroenteritis. Pediatrics 2005; 116:1401.
- Berl T. Treating hyponatremia: damned if we do and damned if we don't. Kidney Int 1990; 37:1006.
- Karp BI, Laureno R. Pontine and extrapontine myelinolysis: a neurologic disorder following rapid correction of hyponatremia. Medicine (Baltimore) 1993; 72:359.
- Sterns RH. Severe symptomatic hyponatremia: treatment and outcome. A study of 64 cases. Ann Intern Med 1987; 107:656.
- Sterns RH, Cappuccio JD, Silver SM, Cohen EP. Neurologic sequelae after treatment of severe hyponatremia: a multicenter perspective. J Am Soc Nephrol 1994; 4:1522.
- Finberg L. Hypernatremic (hypertonic) dehydration in infants. N Engl J Med 1973; 289:196.
- Kahn A, Brachet E, Blum D. Controlled fall in natremia and risk of seizures in hypertonic dehydration. Intensive Care Med 1979; 5:27.
- Blum D, Brasseur D, Kahn A, Brachet E. Safe oral rehydration of hypertonic dehydration. J Pediatr Gastroenterol Nutr 1986; 5:232.
- Holliday MA, Friedman AL, Segar WE, et al. Acute hospital-induced hyponatremia in children: a physiologic approach. J Pediatr 2004; 145:584.
- Hoorn EJ, Geary D, Robb M, et al. Acute hyponatremia related to intravenous fluid administration in hospitalized children: an observational study. Pediatrics 2004; 113:1279.
- Moritz ML, Ayus JC. Prevention of hospital-acquired hyponatremia: a case for using isotonic saline. Pediatrics 2003; 111:227.
- Neville KA, Verge CF, Rosenberg AR, et al. Isotonic is better than hypotonic saline for intravenous rehydration of children with gastroenteritis: a prospective randomised study. Arch Dis Child 2006; 91:226.
- Schwartz R. Comments from another student of Gamble and Darrow on fluids. Pediatrics 1996; 98:314.
- Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics 1996; 97:424.
- Gavin N, Merrick N, Davidson B. Efficacy of glucose-based oral rehydration therapy. Pediatrics 1996; 98:45.
- GENERAL PRINCIPLES
- EMERGENT FLUID PHASE
- Type of fluid
- - Crystalloid versus colloid
- SECOND FLUID PHASE
- Intravenous rehydration therapy
- - Therapy according to serum sodium
- - Symptomatic hyponatremia
- - Therapy based on isotonic saline infusion
- Oral rehydration therapy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS