Dehydrated Child

Question 1

Describe clinical assessment of dehydration and initial treatment

Answer 1

Question 2

Aspects to consider when assessing dehydration?

Answer 2

• “No single symptom or clinical sign reliably predicts the degree of dehydration”
  
  • Wet nappies
  • Fontanelle
  • Skin turgor
  • Capillary refill
  • Tachycardia
  • Ongoing interval observation

Question 3

Can you use apple juice, soft drinks or sports drinks for oral rehydration therapy?

Answer 3

• Not ideal. Add 1 part drink and 4-5 parts water
• Low sodium, high osmolality, therefore would worsen diarrhoea

Question 4

What solution should be used for nasogastric rehydration?

Answer 4

Fluid with sodium concentration of 60mmol/L e.g. gastrolyte (not hydrolyte)

Question 5

Contraindications to NG rehydration?

Answer 5

• an ileus (check for bowel sounds)
• significantly reduced level of consciousness

Question 6

Contraindications to rapid NG rehydration?

Answer 6

• younger than 6 months
• medical condition which increases risk of fluid overload

Question 7

What IV fluid rehydration is available?

Answer 7

• Standard IV rehydration (usually over 24-48 hrs)
  
  • 0.9% saline + 5% glucose + 20mmol/l KCl
• or Rapid IV rehydration (over 4 hours then cease)
  
  • 0.9% saline + 5% glucose (NO added potassium)
• Do not use fluid with < 0.9% NaCl [can cause cerebral oedema]

Question 8

How do you calculate maintenance IV fluid requirements?

Answer 8

Question 9

How do you calculate hydration deficit and how do you determine rate of IV fluids?

Answer 9

• Kg x (% loss) x 10 = hydration deficit
• IV fluid rate is (deficit + maintenance)/24 hours
• E.g. 12kg with moderate dehydration (5%)
  
  • Rehydration = 12 x 5 x 10 = 600mL
  • Maintenance = 1100mL
  • Total in 24 hours = 1700mL

Question 10

Contraindications to rapid IV hydration?

Answer 10

• child <6m
• child has altered LOC
• child shocked or severely dehydrated
• child has abnormal Na

Question 11

What to do when a child has hypernatraemia (Na > 149mmol/L) and dehydrated?

Answer 11

• Do not follow standard Acute Gastroenteritis guideline
• Consult paediatrician
• Hypernatraemic dehydration is uncommon
• Increased risk of cerebral oedema, seizures and brain damage
• Clinically, degree of dehydration may be underestimated
• If shock is present -> fluid bolus 20mL/kg, using 0.9% NaCl + 5% glucose +/- 20mmol/L KCl

Question 12

What to do when a child has hyponatraemia (Na < 135mmol/L) and dehydrated?

Answer 12

• Do not use fluid with less than 0.9% NaCl
• If there is severe hyponatraemia (Na <130mmol/L)
  
  • Use 0.9% NaCl + 5% glucose
  • Urgent Paediatrician consult

Question 13

What is the role of medication in gastroenteritis management?

Answer 13

• No role for anti-motility or anti-diarrhoeal meds
• Many antiemetics have side effects e.g. dystonic reactions and sedation and should be avoided (e.g. promethazine, prochlorperazine)
  
  • 5HT-3 receptor meds (ondansetron) may have some clinical benefit but limit to one dose
• Pro-biotics and zinc may have some benefit (OTC or yoghurt) as adjuncts to oral rehydration or when diet is reintroduced
• Antibiotics rarely indicated even in bacterial causes