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How to manage the care of the dehydrated child

1366 British Journal of Nursing, 2019, Vol 28, No 21

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C aring 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

How to manage the care of the dehydrated child Leah Rosengarten, Lecturer in Children’s Nursing, Department of Health and Life Sciences, University of Northumbria, Newcastle upon Tyne, Leah.rosengarten@northumbria.ac.uk

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).

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:

■ Increased irritability, lethargy or a change in normal behaviour

■ Sunken eyes or dark circles under the eyes ■ Dry mouth and lips ■ Low blood pressure ■ High heart rate ■ Weak peripheral pulses ■ Reduced elasticity of skin ■ Capillary refill time of more than 2 seconds

■ Urine output less than 1 ml per hour in children or 2 ml per hour in infants

■ Loss of skin colour or mottled skin ■ Cooler than usual extremities.

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):

■ Children younger than 1 year, particularly those younger than 6 months

■ Infants who were of low birthweight ■ Children who have had more than five

episodes of diarrhoea in the previous 24 hours

■ Children who have vomited more than twice in the past 24 hours

■ Children who have not been offered or have not been able to tolerate supplementary fluids to maintain hydration (see Box 1 and Box 2)

■ Infants who have stopped breast or bottle feeding during the illness

■ Children with signs of malnutrition.

AT A GLANCE

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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

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):

■ Oral rehydration ■ Maintenance fluids ■ Fluid resuscitation. 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

Table 1. Clinical signs of dehydration and hypovolaemic shock (‘red flags’ shown in red)

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

Box 1. Holliday-Segar formula to calculate route maintenance fluids

■ 100 ml/kg/day for the first 10 kg of weight ■ 50 ml/kg/day for the next 10 kg ■ 20 ml/kg/day for the remaining weight over 20 kg

Source: Holliday and Segar, 1957; National Institute for Health and Care Excellence, 2015

Box 2. Routine fluid maintenance formula for full-term neonates

■ From birth to day 1: 50–60 ml/kg/day ■ Day 2: 70–80 ml/kg/day ■ Day 3: 80–100 ml/kg/day ■ Day 4: 100–120 ml/kg/day ■ Days 5–28: 120–150 ml/kg/day

Source: National Institute for Health and Care Excellence, 2015

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