Why is it essential for the nurse to obtain the height and weight of a severely dehydrated toddler?

Dehydration is a lack of water in your body. If your child loses a lot of body fluids or isn’t drinking enough, they might get dehydrated.

Table of Contents Show

Symptoms of dehydration
Does your child need to see a doctor about dehydration?
Treatment for dehydration
Prevention of dehydration

Gastroenteritis is the most common cause of dehydration. This is because it can make your child lose a lot of body fluids quickly. Any illness that causes persistent diarrhoea, vomiting or reduced fluid intake can result in dehydration.

A lot of sweating can also result in dehydration, particularly in babies in very hot weather, or in adolescent children who are doing vigorous activity.

Symptoms of dehydration

Children with mild dehydration might not have symptoms.

Children with severe dehydration might:

urinate less often
lose weight
look pale
be tired, lethargic or irritable
have fewer tears
be thirsty
have sunken and dark eyes
have a coated and dry tongue and mouth.

It can be hard to know whether younger children are weeing less often. The best way to tell is by checking their nappies. They might have fewer wet nappies, or their nappies might not be as wet as usual.

Does your child need to see a doctor about dehydration?

In some cases, yes.

You should see your GP if your child is under 6 months and has vomiting or diarrhoea.

If your child is older than 6 months, you should take them to the GP if they:

have been vomiting often, can’t keep any fluids down, or have been vomiting for more than 24 hours
have diarrhoea lasting longer than 2 weeks
aren’t gaining weight or are losing weight because of vomiting or diarrhoea.

Take your child to a hospital emergency department straight away if they:

have symptoms of severe dehydration – they are not urinating, are pale and thin, have sunken eyes, cold hands and feet, and are drowsy or cranky
seem very unwell.

You know your child best, so trust your instincts if your child doesn’t seem well. Signs that your child has a serious illness that needs urgent medical attention include severe pain, drowsiness, pale or blue skin, dehydration, troubled breathing, seizures and reduced responsiveness.

Treatment for dehydration

Mild dehydration
You can treat mild cases of dehydration by giving your child more fluid.

One option is oral rehydration fluid like Gastrolyte, Hydralyte, Pedialyte or Repalyte. You can buy these fluids over the counter from a pharmacy or supermarket . These products might come as premade liquid, soluble tablet, powder or icy poles for freezing. Make sure that you make up the liquid carefully according to the instructions on the packet.

If you can’t get oral rehydration fluid, you can use diluted lemonade, cordial or fruit juice. If you’re using a sugary drink, it’s important to dilute it – use one part of lemonade, cordial or juice to four parts of water.

Your child might not want to drink extra fluids. You can encourage them to drink more by giving them drinks with a syringe or spoon, or letting them suck icy poles.

If your child is vomiting, it’s usually better to offer small amounts of fluid, but more frequently. For example, give your child a few mouthfuls every 15 minutes.

If you have a breastfed baby, keep breastfeeding but feed more often. You can give your child extra oral rehydration fluid between feeds.

If your baby is bottle fed, give them oral rehydration fluid for the first 24 hours only and then reintroduce full-strength formula in smaller, more frequent feeds. You can still offer extra oral rehydration fluids between feeds.

Severe dehydration
In more severe cases of dehydration, your child might need to go to hospital to catch up on fluid loss. In many cases, the safest and quickest way to do this is by via a small tube that goes into your child’s nose and then into their stomach. The rehydrating fluids go through this tube. Less often, your child will be given fluids indirectly into a vein.

Prevention of dehydration

The best way to avoid severe dehydration is to see your doctor if your child has an illness that’s causing them to lose a lot of fluid or stop drinking.

On hot days or when your child is exercising, they need to stay hydrated. Make sure there’s plenty of water handy so your child can drink if they’re thirsty. You might need to remind some children to have regular drink breaks.

Principles of Fluid and Nutritional Management

Water is an important solvent in the body and represents a large percentage of body weight in term infants (75%) and an even larger percentage of weight in preterm infants. In the first year of life, total body water (TBW) decreases to about 60%. The percentage of TBW to body weight remains at 60% for males but decreases to 50% for females with puberty. TBW is composed of two main components: intracellular fluid (ICF) and extracellular fluid (ECF). The fetus and newborn have a larger ECF than ICF volume. This changes when the ICF volume increases and the ICF-to-ECF volume ratio reaches adult levels by 1 year of age (i.e., ECF is 20% to 25% of body weight compared with ICF at 30% to 40% of body weight).

The body seeks to maintain a steady state in the regulation of body water. Body water is provided through the intake of fluids and the oxidation of carbohydrates, fats, and protein. Thirst stimulates the intake of water. The kidneys, lungs, skin, and gastrointestinal tract excrete body water. Antidiuretic hormone (ADH) and renal tubular cell response to ADH are the two major mechanisms that affect renal water loss (Feher, 2012).

CALCULATION OF FLUID REQUIREMENTS

The maintenance of fluid balance and correcting imbalances are important in pediatric patients. The nurse should be familiar with the formulas used to calculate fluid requirements in infants and children to verify that the correct amount is ordered and administered.

Maintenance fluids can be calculated using a formula based on body weight:

Weight (kg)	Fluid Per Day
0-10	100 mL/kg/day
11-20	1,000 mL + 50 mL/kg for each kg >10 kg
>20	1,500 mL + 20 mL/kg for each kg >20 kga
a Maximum total fluids are normally 2,400 mL/day.

A quick method to calculate approximate hourly rate per kilogram weight for maintenance fluid needs is as follows:

Weight (kg)	Approximate Hourly Rate
0-10	4 mL/kg/hour
10-20	40 mL/hour + 2 mL/kg/hour for each kg >10kg
>20	60 mL/hour + 1 mL/kg/hour for each kg >20kga
a Maximum rate of fluids per hour is 100 mL.

Two examples illustrate how this formula is used:

A 13-kg child would need 1,000 mL + (50 mL × 3 = 150 mL) = 1,150 mL/day, or 47.9 or 48 mL/hour. Using the quick method for calculation of hourly rate, it is 40 mL + (2 mL × 3 = 6), or 46 mL/hour.
A 36.5-kg child would need 1,500 mL + (20 mL × 16.5 = 330) = 1,830 mL/day, or 76.25 mL/hour. Using the quick method for calculation of hourly rate, it is 60 mL + (1 mL × 16.5), or 76.5 mL/hour.

Water is normally lost through urine, insensible loss (skin and lungs), and stool. Maintenance needs may be decreased or increased based on clinical situations. Examples of situations causing increased needs are fever, burns, tachypnea, tracheostomy, diarrhea, vomiting, nasal gastric suction, polyuria, and third space losses (shifts of fluids from intravascular space to interstitial space). Oliguria, anuria, and hypothyroidism are associated with decreased maintenance needs.

LOSS OF BODY WEIGHT DUE TO DEHYDRATION

Clinical signs of dehydration depend on the severity of fluid loss and type of dehydration. Level of dehydration is typically classified as mild, moderate, or severe. Table 5-1 provides an outline for the clinical evaluation of dehydration. Fluid loss can be calculated based on the child’s weight. Divide the weight when dehydrated by weight when healthy and calculate the percent change; then calculate the amount lost by subtracting from 100%. For example, the child’s weight when
healthy is 4.5 kg and current weight is 4.1 kg; divide 4.1 by 4.5 = 0.91 = 91% of healthy weight; 100 – 91 = 9% weight loss.

TABLE 5-1 Clinical Manifestations of Dehydration

Loss of Body Weight (%)	Clinical Manifestations	Severity
3-5	Slightly dry mucous membranes	Mild
Increased thirst
Decreased urine output
Normal or slightly increased pulse
7-10	Tachycardia	Moderate
Decreased skin turgor
Sunken eyes and fontanel
Oliguria
Poor tear production and dry mucous membranes
Restless, irritable to lethargic
Delayed capillary refill
Cool and pale
10-15	Rapid, weak pulse	Severe
Low blood pressure
Anuric
Very sunken eyes and fontanel
No tears, parched mucus membranes, and tenting of skin
Very delayed capillary refill
Lethargic to comatose

Quick restoration of circulatory volume is critical for infants and children who are severely dehydrated (10% to 15% dehydration estimate). In these instances, fluid imbalance must be quickly corrected. Fluid boluses of 20 mL/kg of isotonic solution (e.g., 0.9% normal saline or Ringer’s lactate) over 20 minutes intravenously is used to restore circulatory volume (Kleinman et al., 2010).

The child with severe dehydration may need multiple fluid boluses of normal saline at a faster rate. Such boluses should be given as rapidly as possible and repeated until there are signs of improvement in circulation, such as warm skin, improved capillary refill time, and restored urine output. Reassess the child’s status after each fluid bolus. Watch for signs of renal or cardiac failure while administering fluid boluses.

Children who are dehydrated must have their fluid and electrolyte deficits replaced and maintenance fluid needs met. The classification of dehydration based on serum sodium concentration is important in estimating water deficits. Type of dehydration and serum sodium levels is as follows:

Type	Sodium Level (mEq/L)
Isotonic	130-150
Hypotonic	<130
Hypertonic	>150

Most children have isotonic dehydration. The fluid management of severe isotonic dehydration is done in a stepped approach, as outlined below.

Intravascular volume is restored.
- Receives 20 mL/kg of normal saline bolus(es) over 20 minutes or less until intravascular volume is restored.
Determine 24-hour water needs.
- Calculate maintenance water needs per kg PLUS deficit water.
Determine 24-hour electrolyte needs.
- Calculate maintenance sodium and potassium.
- Calculate deficit sodium and potassium.
Deliver appropriate fluid based on water and electrolyte needs as above.
- Administer 1/2 calculated fluid in the first 8 hours after amount delivered as bolus(es) is subtracted.
- Administer the remainder of the fluid (second 1/2) over the next 16 hours.

The appropriate fluid for a child with isotonic dehydration is generally D5 1/2 normal saline with 20 mEq/KCl. Children weighing 10 to 20 kg with only mild dehydration typically only need D5 1/4 normal saline. The management of the child with hyponatremic dehydration is generally the same as for the child with isotonic dehydration.

Hypernatremic dehydration is a dangerous situation and puts the child at risk for neurologic hemorrhages and thrombosis. It requires a slower correction of the fluid deficit, usually over 48 to 72 hours. Rapid correction of hypernatremic dehydration can cause rapid fluid shifts, leading to cerebral edema.

Electrolyte replacement is calculated and determines the amount of sodium and potassium that is ordered.

FACTORS THAT AFFECT MAINTENANCE FLUID REQUIREMENTS

Factors that cause alterations in maintenance fluid requirements include the following:

Factor	Fluid Needs
Fever	Increased
Hyperventilation	Increased
Sweating	Increased
Hyperthyroidism	Variable—may be increased
Renal failure	Maintenance fluids equal to insensible losses (limit to 400 mL/m2/24 hours) plus mL/mL of urine replacement (100% of urine replacement)

PRINCIPLES OF ORAL REHYDRATION

Oral rehydration is an acceptable method to replace fluid loss and deliver maintenance fluids in children with mild-to-moderate dehydration from vomiting and diarrhea (Colletti, Brown, Sharieff, et al., 2010; Piescik-Lech, Sharmin, Guarino, et al., 2013; Spandorfer, Alessandrini, Joffe, et al., 2005). Diarrhea can lead to large losses of water and electrolytes and is associated with isotonic dehydration in most patients. Mildto-moderate diarrheal dehydration can be treated in most children with simple oral solutions of glucoseelectrolytes (e.g., World Health Organization oral rehydration salts; Rehydralyte [Ross Products, Abbott Laboratories]) and adequate supervision. For children who are vomiting, oral rehydration solutions (ORS) should begin after 1 to 2 hours of the child or infant having nothing by mouth. Antiemetics are administered to control nausea and vomiting (Niescierenko & Bachur, 2013). Key considerations in oral rehydration therapy include the following (King, Glass, Bresee, et al., 2003; Colletti et al., 2010):

Administer appropriate solution to provide replacement of needed sugars and electrolytes as ordered by the healthcare provider.
For oral rehydration divide the total volume deficit by 4 and aim to deliver this volume of fluid during each of the 4 hours of the rehydration phase. The following amounts of ORS are generally ordered, depending on amount of fluid deficit.
- 50 to 100 mL/kg—mild-to-moderate dehydration (approximately 12 to 25 mL/kg/hour).
- Plus (for both mild and moderate dehydrate) an additional 10 mL/kg for each diarrheal stool and 2 mL/kg for each episode of vomiting.
Begin rehydration with small amounts of the prescribed rehydration solution.
For children younger than 2 years, give 120 mL; for children older than 2 years, give 120 mL to 240 mL slowly every hour, divided into small amounts every 15 to 20 minutes.
If vomiting occurs, give 5 to 10 mL every few minutes until vomiting stops and then greater amounts as above; repeat unless emesis consistently occurs in amounts that exceed intake. A teaspoon or 5-mL syringe can be used for the initial administration of fluid, especially if the child is vomiting. Administer at least 5 mL of solution each minute (5 mL × 60 = 300 mL). In a 10-kg infant this is equivalent to 30 mL/kg. Children larger than 15 to 20 kg can receive 10 mL/minute.
After rehydration, begin feeding immediately. Give infants their regular full-strength formula. If this is not tolerated, the healthcare prescriber may switch the child to a lactose-free formula. Breast-fed infants should continue breast-feeding during rehydration with shorter duration and more frequent feedings. Reintroduce age-appropriate bland solids as soon as tolerated avoiding foods high in simple sugars and fatty foods.

Maintenance solutions with lower sodium concentrations (e.g., Pedialyte, Infalyte) should not be used as rehydrating solutions. Decrease ORS intake if the child appears to be well hydrated or shows signs of fluid overload.

The energy needs of children vary depending on age and other conditions. Nutrients (carbohydrates, proteins, and fats) and minerals and vitamins are needed for growth and tissue repair. The energy content of food is referred to as its kilocalorie (kcal) value. Estimated energy requirements are based on basic body metabolism, growth, and
activity. The average kilocalorie requirements for children up to age 3 years are as follows:

Age (months)	Formula
0-3	(89 × weight [kg] – 100) + 175
4-6	(89 × weight [kg] – 100) + 56
7-12	(89 × weight [kg] – 100) + 22
13-35	(89 × weight [kg] – 100) + 20
Information from Otten, J.J., Hellwig, J.P., & Meyers, L.D. (Eds.). (2006). Dietary references intakes: The essential guide to nutrient requirements. Washington, D.C.: National Academies Press.

An adequate nutritional intake should result in increased weight, height, and head circumference (in infants). Commonly used and easy to remember general rules of weight gain are that infants generally double their birth weight by 4 to 6 months of life, triple their birth weight, and double their length by 12 months of age. The adolescent growth spurt occurs over 24 to 36 months. Growth peaks in females around 12 years and in males around 14 years decelerating by the end of puberty and ceases soon after due to epiphyseal fusion (Lazar & Phillip, 2012).

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