Assessment and Correction of

Dehydration in a child

Viral GASTROENTERITIS

Yogesh Nataly
RL Hospital, ED
Reg/PHO Teaching 18/04/2018
UPSM Oct 2023
 What we covering in this talk!

• Get the diagnosis right

• Assess the hydration of the child

• Fluid Management
• Orals
• NGT
• IV or even IO fluids
QCH, Brisbane/RCH, Melbourne Guidelines!
Viral GASTROENTERITIS
 Viral GASTROENTERITIS

KEY CONSIDERATIONS:

• Diagnosis ?

• How dehydrated (how much fluids req.) ?

• What Fluid ?

• What Route?
• What Rate ?

• Admit or Discharge ?
 Mimics!!

❑ SURGICAL
Appendicitis, SBO, Intussusception, Mal-rotation
with volvulus, hernias, Pyloric Stenosis (HPS)

❑ NON-ENTERIC
UTI, Meningitis, Pneumonia, Otitis Media, IBS

❑ METABOLIC
DKA, inborn errors, Hemolytic Uraemic Syndrome
Assessment of Hydration?
Viral GASTROENTERITIS
 Increasing Severity ----------------------------- →

None Clinical Dehydration Shock (> 10%)

(5-10%)
Appearance well Unwell Unwell
LOC Alert Altered  LOC

Skin Colour unchanged Unchanged Pale or mottled

Extremities warm Warm Cold
Eyes Not sunken Sunken -
Mucous Memb. moist Dry -
HR Normal Normal 
Breathing Normal  
Peripheral Pulse Normal Normal Weak
CRT Normal Normal > 2 sec
Skin Tugor Normal  -
BP Normal Normal  (decomp. shock)
Source: National Collaborating Centre for Women's and Children's Health
 Assessment of Hydration?
HIGH RISK FOR DEHYDRATION
• < 6 months
• > 5 diarrheal motions or > 2 vomits in 24h
• Infants with LBW or failure to thrive
• Underlying chronic medical conditions
• Immuno-compromised
• Stopped breast feeding during the illness
• Not being able to tolerate supplementary fluids
 Assessment of Hydration?

BLOOD TESTS

Routine blood tests best

avoided

# heel prick BSL

# heel prick Ketones

When would you do bloods?

 Assessment of Hydration?

STOOL TEST

Routine testing avoided

When would you do stool testing?

immuno-compromised, sepsis, recent
overseas travel, diarrhoea > 7 days,
recent use of antibiotics
What clinical signs do you see?
 FLUID MANAGEMENT

QCH GUIDELINE FOR THE TREATMENT OF A

CHILD WITH GASTROENTERITIS

Three groups of patients:

no dehydration

clinically dehydrated

clinically shocked
 NO CLINICAL DEHYDRATION

ORAL Rehydration; “small frequent fluid”

the focus is on preventing dehydration and to be able to
ensure that the child goes home (Gastro Pack) tolerating orals!

• Document TOFs and output

• 5-10 mls every 5-10 mins of Gastrolyte or Icy poles
(Hydralyte, 62mls) for the older kids
• Ondansetron for > 6 months, > 8 kg (Dose: 2 - 4 mg)
• Avoid antibiotics and anti-diarrhoeal (Lomotil)
• Continue with breast and formula feeds as usual
• Observe high risk kids for 1- 4 hrs in ED
CLINICAL DEHYDRATION (5 - <10%)

Options are Oral/NG/IV

Rapid Rehydration using NG

(Phin SJ, et al. Clinical pathway using rapid rehydration for children with gastroenteritis.
J Paediatr Child health 2003)

1. Best suited for children 6 months to 3 yrs

2. NG is the route of choice if oral rehydration fails (after 1 h)
3. 50ml/kg of ORS via NG diarrhoea using an infusion pump
over 4 hrs (RCH, Melb 25ml/kg/h X 4 hrs)
4. Large vomit or diarrhoea is a further 5ml/kg
5. After rehydration, return to normal feeds as tolerated
CLINICAL DEHYDRATION (5 - <10%)

RAPID NG Rehydration
50ml/kg over 4 h
Best under the age of 3 yrs
• Fewer complications when compared to IV
replacement
• cost effective
• Decreased length of stay in ED and/or
Hospitalisation
• Quicker return to normal age-appropriate diet
• Use an infusion pump with either Gastrolyte/
Paedialyte/ Hydralyte
 CLINICAL DEHYDRATION (>10%): SHOCK!

INTRAVENOUS or INTRAOSSEOUS HYDRATION

Rapid IV or IO access

10-20 ml/kg 0.9% saline bolus, repeat

If circulatory volume re-established, then the child requires both

maintenance and deficit fluid
plus DEFICIT: @10%

100ml/kg 0.9% Saline + Dextrose 5% over the next 8 hrs

MAINTENNANCE

according to the weight of the child (using the 4ml/kg,2ml/kg and

ml/kg rule)

Look for other causes of shock i.e. sepsis

 Question 1

A 3yo child recently unwell with cough and coryza is sent home
from a childcare with Ds and Vs. There have been several kids
unwell at the childcare with similar symptoms.

OE: afebrile, RR 40 (n: 20-40), HR 140 (n: 100-150), BSL 6.0

Weight 15 kg
The child is irritable, CRT 2 s, with dry mucous membranes and
the peripheries are warm

You diagnose the child with Gastroenteritis. How would you

manage the fluid requirements?
 Question 2
You see a 4 yo unwell child with Ds and Vs in ED. The child has
been sick for 2 days. Mum has been hydrating the child with
home-made rehydration solution and topping this up with double
strength formula feeds.
OE: afebrile, RR 30 (n: 20-40), HR 130 (n: 100-150), BSL 6.0
Weight 16 kg
The child is lethargic, CRT 2 s, with dry mucous membranes and
normal skin tugor with a “doughy” feel

VBG/Electrolytes:

pH 7.45, pCO2 40, HCO3 28, BE +1, Na 165, K 3.9, Chloride

102 (97-109)

How would you manage this child?

 Question 3

Jackson is a 6 wk old brought into ED with his mum. He has been vomiting for
the past 4 days and today seems lethargic, not been able to keep anything down
for the past 24 h and has had only one slightly wet nappy.

OE: pallor, afebrile, HR 180 (n: 110-170), RR 45 (n: 25-60), BSL 6.0, CRT 3s

Weight 3kg

VBG/Electrolytes:

pH 7.50, pCO2 50, HCO3 38, BE +5, Na 129, K 3.6, Chloride 92 (97-109)

How would you manage this child’s fluid requirements?

Viral GASTROENTERITIS

Take Home Messages

o get your diagnosis right!

o assess hydration using clinical signs/symptoms (nil

dehydration, dehydration or shock). Weight of the child
is the best guide

o Choose the route and rate with caution; where possible

enteral methods of fluid administration are preferred over
IV
o for younger children, an error in the fluid prescription can
be unforgiving!!