Andi Irhamnia Sakinah

Program Studi Pendidikan Dokter

UIN Alauddin Makassar
2019

PEDIATRIC
DEHYDRATION
Learning Objectives
• Understanding how to diagnose Pediatric Dehydration
• Understanding how to treat Pediatric Dehydration as an Emergency
Status
Definition
• The World Health Organization defines dehydration as a condition
that results from excessive loss of body water.
• This decrease in total body water occurs in excess of sodium (also
called “free water loss”), resulting in a hypertonic and hypernatremic
state.

https://www.ncbi.nlm.nih.gov/books/NBK436022/
Etiology
• Infants and young children are particularly susceptible to diarrheal
disease and dehydration.
• The most common causes of dehydration in children are vomiting
and diarrhea.
• Dehydration may also be the result of decreased intake along with
ongoing losses. In addition to total body water losses, electrolyte
abnormalities may exist.

https://www.ncbi.nlm.nih.gov/books/NBK436022/
Epidemiology
• Dehydration is a major cause of morbidity and mortality in infants and
young children worldwide.
• Each year approximately 760.000 children of diarrheal disease worldwide.
• Diarrheal diseases and resulting severe dehydration are the leading cause
of infant mortality worldwide especially in children < 5years of age
• Most cases of dehydration in children are the consequence of acute
gastroenteritis.
• Viral 75-90% rotavirus, norovirus, and enteroviruses
• Bacterial 20% Salmonella, Shigella, and Escherichia coli.
• Other <5% Giardia and Cryptosporidium

https://www.ncbi.nlm.nih.gov/books/NBK436022/
Understanding the disturbances of dehydration requires
knowledge about body composition and the continuing
requirements for water and electrolytes.

• BODY COMPOSITION
• Infants: 70% of water (25% ECF, 45% ICF)
• Older and optimally nourished children: 6o% of water (70% water – 10% fat
deposit)
• REQUIREMENTS
• To maintain constant body temperature Insensible Water Loss (IWL)
• Increased during hyperthermia, hyperventilation, continuous muscle contraction.

https://pedsinreview.aappublications.org/content/23/8/277#T1
Pathophysiology
• Dehydration causes a decrease in total body water in both the intracellular
and extracellular fluid volumes.
• Volume depletion closely correlates with the signs and symptoms of
dehydration.
• Volume depletion is seen in acute blood loss and burns, whereas
distributive volume depletion is seen in sepsis and anaphylaxis
• Dehydration b/o diarrhea, homeostatic mechanisms usually adjust so that
water and sodium chloride are lost in physiologic proportion – isonatremic
state
• When vomiting also occurs, water intake is curtailed, making water loss
proportionally greater than salt losses hypernatremia.
• When massive stool loss of water and salt is ongoing and the only intake is water,
salt losses predominate, resulting in a hyponatremic state.
https://pedsinreview.aappublications.org/content/23/8/277#T1
https://www.ncbi.nlm.nih.gov/books/NBK436022/
Metabolic Acidosis
• Excess bicarbonate loss in the diarrhea stool or in the urine is certain
types of renal tubular acidosis
• Ketosis secondary to the glycogen depletion seen in starvation which
sets in infants and children much earlier when compared to adults.
• Lactic acid production secondary to poor tissue perfusion
• Hydrogen ion retention by the kidney from decreased renal
perfusion and decreased glomerular filtration rate.

https://www.ncbi.nlm.nih.gov/books/NBK436022/
Pediatric Normal Vital Sign

https://www.emedicinehealth.com/pediatric_vital_signs/article_em.htm#what_are_normal_ranges_of_vital_signs_for_various_ages
Pediatric Normal Vital Sign

https://www.emedicinehealth.com/pediatric_vital_signs/article_em.htm#what_are_normal_ranges_of_vital_signs_for_various_ages
Pediatric Body Weight Estimation
• The Best Guess method was the most accurate for children older
than 1 year (mean difference between measured and estimated
weight, 0.43 kg)
• The new APLS formula was the most accurate for children younger
than 1 year (mean difference, 0.51 kg).

https://www.jwatch.org/na33389/2014/01/24/pediatric-weight-estimates-which-method-best
History and Physical

https://www.ncbi.nlm.nih.gov/books/NBK436022/
Rapid Assessment
 • The first objective sign of
dehydration is an increase in
pulse rate as a response to
reduced plasma volume;
subjectively, there may be
increased thirst.
• The most useful clinical sign is
the capillary refill time (turgor):
• Normal is <2 seconds
• 2-2.9 seconds corresponds
to 50 to 90 mL/kg loss
• 3.0-3.5 seconds corresponds
to 90-110 mL/kg
• 3.5-3.9 seconds corresponds
to 110-120 mL/kg
• > 4 seconds corresponds to
150 mL/kg.

Buku Saku Lintas Diare, 2011; https://pedsinreview.aappublications.org/content/23/8/277#T1

Evaluation
• Very mildly dehydrated patients may be managed without laboratory
determinations, but it is wise to confirm clinical impressions in moderate
losses and always in severe illness.
• Sodium, chloride, bicarbonate, and urea nitrogen determinations are the
most essential.
• An arterial blood gas may be helpful and may be obtained quickly in more
severely ill patients.
• Potassium and calcium levels are occasionally helpful.
• The urea nitrogen level gives a rough estimate of renal compromise. It is
the reduced renal function that produces the acidemia rather than the loss
of base in the stool for which compensation readily occurs.

https://pedsinreview.aappublications.org/content/23/8/277
Management/Treatment
• Priorities in the management of dehydration include
• early recognition of symptoms
• identifying the degree of dehydration,
• stabilization, and
• rehydration strategies.

https://www.ncbi.nlm.nih.gov/books/NBK436022/
Oral Rehydration Solution
• Recipe
• 1 L water
• 2 tablespoon sugar/honey
• ¼ teaspoon of table salt
• ¼ teaspoon of baking soda
• Flavor: ½ cup of orange juice or coconut water
Mild Dehydration
• The American Academy of Pediatrics recommends oral rehydration
for patients with mild dehydration.
• Breastfed infants should continue to nurse.
• Fluids with high sugar content may worsen diarrhea and should be
avoided.
• Children can be fed age-appropriate foods frequently but in small
amounts.

https://www.ncbi.nlm.nih.gov/books/NBK436022/
Moderate Dehydration
• The Morbidity and Mortality Weekly Report recommends
administering 50 mL to 100 mL of oral rehydration solutions per
kilogram per body weight during two to four hours to replace the
estimated fluid deficit, with additional oral rehydration solution,
administered to replace ongoing losses.

https://www.ncbi.nlm.nih.gov/books/NBK436022/
 • Dalam 4 jam pertama ORS/Oralit (sesuai BB atau umur)
75 cc x BB anak

• Lanjutkan ASI on demand!

• Bila bayi <6 bulan tidak menyusu, tambahkan air matang 100-200cc pada
masa ini
• Makan bila anak mau makan
• Muntah? Tunggu 10 menit lalu perlambat pemberian oralit (1 sendok per
2-3 menit)
• Bila kelopak mata bengkak, stop oralit dan berikan air masak/ASI
• Bila ibu tidak bisa tinggal di fasilitas layanan kesehatan hingga 3 jam,
ajari ibu cara menyiapkan oralit dan berikan oralit secukupnya hingga 2
hari berikutnya (+ 6 bungkus)
• Ajari 5 langkah rencana terapi A untuk mengobati anak dengan diare di rumah

https://apps.who.int/iris/bitstream/handle/10665/81170/9789241548373_eng.pdf?sequence=1; http://www.ichrc.org/522-diare-dengan-dehidrasi-sedangringan
5 Langkah Terapi Diare di Rumah
(Rencana Terapi A)
• Beri cairan lebih banyak dari biasanya
• Beri Zinc
• Beri anak makanan untuk mencegah kurang gizi
• Antibiotik sesuai indikasi
• Nasihati Ibu/Pengasuh

Buku Saku Lintas Diare, 2011;

• Follow-up 3 jam kemudian (atau sebelum 3 jam bila anak tidak bisa
minum oralit atau terjadi perburukan) dan klasifikasikan kembali
• Tidak dehidrasi: beri cairan, (Zinc selama 10 hari bila diare), lanjut
minum/makan, kunjungan ulang
• Dehidrasi ringan/sedang, ulangi pemberian oralit selama 3 jam, mulai beri
anak makanan/susu/jus, ASI sesering mungkin.
• Dehidrasi berat atau anak sama sekali tidak bisa minum oralit (muntah
profuse) Pasang IV line
• Berikan 100cc/kgBB (Ringer Laktat atau Ringer Asetat, atau NaCl 0.9%, dengan
aturan

Buku Saku Lintas Diare, 2011;

• Periksa kembali anak setiap 15 - 30 menit. Jika status hidrasi belum
membaik, beri tetesan intravena lebih cepat.
• Juga beri oralit (kira-kira 5 ml/kg/jam) segera setelah anak mau
minum: biasanya sesudah 3-4 jam (bayi) atau 1-2 jam (anak)
• Periksa kembali bayi sesudah 6 jam atau anak sesudah 3 jam.
• Klasifikasikan Dehidrasi. Kemudian pilih rencana terapi yang sesuai
(A, B, atau C) untuk melanjutkan penanganan.
Contraindication for ORS
• Shock
• Fecal volume more than 10ml/kg/hours
• Ileus
• Monosaccharide intolerance

For patients who cannot or do not want to drink, ORS can be given via NGT or
gastrostomy. Although vomiting often occurs in diarrhea patients, vomiting is not a
contraindication to ORS and does not reduce ORS success rates

Rudolph’s Pediatrics 20th ed, 2014

Severe Dehydration
• Rapid restorations of fluids are required.
• Intravenous fluids, starting with 20 ml/kg boluses of normal saline are
required. Multiple boluses may be needed for children in hypovolemic
shock.
• Additional priorities include obtaining a point of care glucose test,
electrolytes, and urinalysis assessing for elevated specific gravity and
ketones.
• Ringer lactate is superior to normal saline in hemorrhagic shock requiring
rapid resuscitation with isotonic fluids.[7] This difference is not found in
the children with severe dehydration from acute diarrheal disease. In these
children, the replacement with normal saline and ringer lactate did show
similar clinical improvement.
Maintenance Fluid
• Holliday-Segar calculation is used for calculation of maintenance
fluid in children,
• 100ml/kg/day for first 10 kg body weight (BW)
• 50 ml/kg/day for the next 10 kg BW
• 20 ml/kg /day for any BW over and above.
WASSALAM,
JAZAAKUMULLAH KHAYR ☺
Studi Kasus (1)
• Seorang anak laki-laki 1.5 tahun dibawa ibunya ke IGD dengan BAB
encer sejak 2 jam sebelum MRS. Frekuensi BAB ±10kali, tidak ada
ampas, lendir (-), darah (-). Anak juga muntah sebanyak 5 kali dan malas
minum. Riwayat makan selama ini baik, anak minum ASI eksklusif
selama 6 bulan. Pada pemeriksaan tanda vital didapatkan anak tampak
lemas, TD 85/60mmHg, denyut nadi 130x/menit, frekuensi napas
34x/menit, suhu tubuh 37.5C. Pada pemeriksaan fisik didapatkan
fontanella mayor cekung, mata cekung, tidak terdengar ronkhi ataupun
wheezing, peristaltik terdengar kesan meningkat, turgor kembali lambat,
CRT <3”.

• Bagaimana status hidrasi pasien?

• Lakukan tatalaksana kegawatdaruratan pada pasien ini!
Setelah 30 menit observasi
• KU: belum membaik
• Status hidrasi masih sama

• Lakukan tatalaksana kegawatdaruratan pada pasien ini!

Setelah 6 jam masa observasi setelah
MRS
• KU: Mulai membaik
• Anak mulai minta minum dan rewel. Frekuensi BAB 5x. Muntah
tidak ada
• Pada pemeriksaan tanda vital didapatkan TD 100/70mmHg, denyut
nadi 120x/menit, frekuensi napas 30x/menit, suhu tubuh 37.5C. Pada
pemeriksaan fisik didapatkan fontanella mayor agak cekung, mata
agak cekung, turgor kembali cukup lambat, CRT <2”.

• Bagaimana status hidrasi pasien saat ini?

• Lakukan tatalaksana pada pasien!
Setelah 6 jam 20 menit masa observasi
setelah MRS
• Anak muntah 1x, isi cairan bening.

• Lakukan tatalaksana pada pasien!

Setelah 3 jam kemudian, Ibu meminta
membawa pulang anaknya
• KU Membaik
• Anak sejak beberapa menit menangis dan saat ini tertidur.
• Frekuensi BAB 1x, muntah tidak ada
• TD 100/70mmHg, denyut nadi 120x/menit, frekuensi napas
26x/menit, temperatur 37.5C

• Lakukan tatalaksana pada pasien ini!

Studi Kasus (2)
• Seorang anak laki-laki 3 tahun dirujuk dari puskesmas dengan pasca
resusitasi syok akibat dehidrasi berat.
• Tiba di IGD, didapatkan CRT 1”
• Dari pemeriksaan fisik didapatkan BB 14kg

• Lakukan tatalaksana pada pasien ini hingga pasien membaik dan

diperbolehkan rawat jalan!