Contents

07 EVALUATION 10 TREATMENT

08 DIAGNOSIS 11 PREVENTION

DIFFERENTIAL
09 DIAGNOSIS
  Severity assessment
• The best individual signs of hypovolemia:
 Degree of volume depletion
Weight loss, dry mucous membranes, prolonged capillary refill time, loss of skin turgor, and
increased and deep respiratory pattern
increased pulse diminished systolic and/or diastolic blood pressure,
and sunken fontanel

• Indications for hospitalization

Shock
Severe volume depletion
Moderate volume depletion with a refusal of oral fluids
Clinical deterioration
Intractable or bilious vomiting
Failure of oral rehydration
Neurologic abnormalities (eg, lethargy, seizures)
Clinical Evaluation of Dehydration
• Mild dehydration (<5% in an infant; <3% in an older child or adult):
Normal or increased pulse; decreased urine output; thirst; normal
physical findings.

• Moderate dehydration (5–10% in an infant; 3–6% in an older child or adult):

Tachycardia; little or no urine output; irritable/lethargic; sunken
eyes and fontanel; decreased tears; dry mucous membranes; mild delay in
elasticity (skin turgor); delayed capillary refill (>1.5 sec); cool and pale

• Severe dehydration (>10% in an infant; >6% in an older child or adult):

Peripheral pulses either rapid and weak or absent; decreased
blood pressure; no urine output; very sunken eyes and fontanel; no tears;
parched mucous membranes; delayed elasticity (poor skin turgor); very
delayed capillary refill (>3 sec); cold and mottled; limp, depressed
consciousness
  Supportive treatment
Fluid repletion and replacement of ongoing fluid losses are the goals of therapy

• Fluid repletion and maintenance

 Initial therapy is directed toward correcting fluid deficit and electrolyte imbalance.
 Fluid repletion is based upon the degree of hypovolemia (dehydration)
 Intravenous (IV) fluids should be administered if dehydration is severe or if the patient is
unable to take oral solutions.

 Mild to moderate dehydration

Oral rehydration therapy (ORT) is the preferred first-line treatment for
fluid and electrolyte losses
 Approach to Severe Dehydration

• The child is given a fluid bolus, usually 20 mL/kg of the

isotonic fluid, over approximately 20 min

• In a child with a known or probable metabolic

alkalosis (e.g., the child with isolated vomiting),
LR or PlasmaLyte should not be used because the
lactate or acetate would worsen the alkalosis.
• Isotonic fluid (NS or LR): 20 mL/kg over 20 min
• Repeat as needed

• Isotonic
Calculatefluid
24 hr(NS
fluidor LR):maintenance
needs: 20 mL/kg +over 20volume
deficit min
Repeat as needed
• Calculate 24 hr fluid
Subtract isotonic fluidalready
needs:administered
maintenance + deficit
from 24 hr fluid volume
needs
Subtract isotonic fluid already administered from 24 hr
• fluid
Administer
needs remaining volume over 24 hr using 5% dextrose NS +
20 mEq/L KCl
Administer remaining volume over 24 hr using 5%
• dextrose NS + 20
Replace ongoing mEq/L
losses KCl
as they occur LR, Ringer lactate; NS,
Replace ongoing losses as they occur LR, Ringer
normal saline.
lactate; NS, normal saline.
 Monitoring Therapy

• Vital signs:
Pulse Blood pressure

• Intake and output:

Fluid balance Urine output

• Physical examination:
Weight Clinical signs of depletion or overload

• Electrolytes
Diet
 We recommend resumption of an age-appropriate diet as tolerated as soon as
rehydration is complete

 Within the age-appropriate diet, complex carbohydrates, lean meats, yogurt, fruits,
and vegetables are better tolerated than foods containing high levels of fats and
simple sugars.

 The lactose intolerance associated with acute viral gastroenteritis usually is

mild and self-limiting, although a lactose-free diet may reduce the duration of
diarrhea and the risk of treatment failure among children who are not
breastfed.