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Pediatric Dehydration

Pediatric Dehydration. Katharine Smart, MD, DTM&H, FRCPC Pediatric Emergency Medicine Alberta Children’s Hospital (special thanks to Marc Francis). Objectives. Review the epidemiology and impact of gastroenteritis in children Approach to the dehydrated patient

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Pediatric Dehydration

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  1. Pediatric Dehydration Katharine Smart, MD, DTM&H, FRCPC Pediatric Emergency Medicine Alberta Children’s Hospital (special thanks to Marc Francis)

  2. Objectives • Review the epidemiology and impact of gastroenteritis in children • Approach to the dehydrated patient • Review the evidence for clinical and laboratory determination of dehydration • Review Oral Rehydration Therapy and its indications • Discuss the concept of “fluid challenge” and the need for a paradigm shift

  3. Case 1 • A 20-month-old girl is brought to the emergency department (ED) after 2 days of vomiting and diarrhea. • Father reports no solid intake since the illness began and now child will not drink • Today- 8 stools and no diapers with urine in them • The child appears mildly ill but makes tears while crying • Her respiratory rate and quality are normal, VSS • Her mouth is somewhat dry • CRT is 1.5 seconds • Skin turgor is normal • BUN is 4.3 mmol/L; Bicarb 19 mmol/L

  4. Who Cares? • Dehydration is one of the leading causes of morbidity and mortality in children throughout the world • Causes 30% of worldwide deaths among infants and toddlers • Pre-ORT gastro was the number one killer of children in developing countries- it now falls behind LRTI’s • 8000 children younger than 5 years die each day due to gastroenteritis and dehydration • Almost 3 million/year!!

  5. Who cares? • In the US and Canada, children < 5 average 2 episodes of gastroenteritis/year • Gastro leads to 2 to 3 million office visits and 10% of all pediatric hospital admissions (US data) • The direct costs of outpatient and hospital visits are more than $2 billion per year (US data)

  6. Dehydration is not a disease 1) Decreased intake 2) Increased output • Insensible losses • Renal losses • GI losses 3) Translocation • Burns • Ascites

  7. Sick kids = decreased intake Higher percentage TBW Neonate 75% Child 65% Adult 60% Fever increases fluid needs Higher metabolic rate in kids less tolerance to fluid and electrolyte changes Poor renal concentration mechanisms at young age Why is this a peds problem?

  8. Causes of Dehydration • Diarrhea • Vomiting • Gastroenteritis • Stomatitis or pharyngitis • Febrile illness • DKA • DI • Burns

  9. Causes

  10. Diarrhea • DDx • Gastroenteritis • Malabsorption • IBD • IBS • Drug side effects • Thyrotoxicosis • Infections • Endocrine disorders

  11. Diarrhea • Indications for stool studies • Toxic appearance • Immunocompromised • Bloody or invasive • Duration > 7 days • Suspected parasites • Travel • Camping • Poor Water

  12. Vomiting “Vomiting without diarrhea should prompt a thorough search for another cause other than gastro”

  13. GI Obstruction Pancreatitis Appy Pyloric stenosis Volvulus Intussusseption GU UTI Pyelo RTA Toxic Drug ingestion Drug side effects ID Pneumonia Sepsis Endocrine Addisons CAH Neuro Meningitis/Encephalitis ↑ ICP Vomiting

  14. Case #1 • 5 mo Male • HPI • Non-bloody profuse watery stool 7 days • 10-15 stools per day – foul smelling • Child eager to take water until this AM • Now less interested in drinking and more lethargic • Exam • Quiet and tachypneic • Sunken eyes and a dry mouth • Tachycardic at 165 bpm • Cap refill is 3 seconds • Skin turgor prolonged

  15. Case #1 • How do you want to manage this patient? • What are some of the potential pitfalls in managing this patient? • Do you have an approach to this patient?

  16. Approach to Peds Dehydration • Initial Resuscitation • Determine % dehydration • Define the type of dehydration • Determine the type and rate of rehydration fluids • Final considerations

  17. Approach to Peds Dehydration • Initial Resuscitation • Determine % dehydration • Define the type of dehydration • Determine the type and rate of rehydration fluids • Final considerations

  18. Initial Resuscitation • ABCs • Initial fluid bolus • 20cc/kg of NS or Ringers • Appropriate in all types of dehydration • Reassess q5mins and repeat x 3 • Initial hypoglycemia • 5cc/kg of D10W in infants • 2cc/kg of D25W in children • Think about Shock DDx if unresponsive to 3 attempts at NS bolus

  19. Approach to Peds Dehydration • Initial Resuscitation • Determine % dehydration • Define the type of dehydration • Determine the type and rate of rehydration fluids • Final considerations

  20. Case #2 • 20 mo F • HPI • 2 days of vomiting and diarrhea • Not eating and will not drink • 8 stools today but dad does not think there were any diapers with urine in them • Afebrile • Exam • Appears mildly ill • Tears + • Vitals are normal including RR • Mouth is Dry • Cap Refill time is 2.0 seconds

  21. Survey • How dehydrated is this child? 3-5% 6-9% >10% • Who wants to do bloodwork? • Who wants to start an IV to rehydrate?

  22. AAP Guideline • The AAP guideline states that “the treatment of a child with diarrhea is directed primarily by the degree of dehydration present” • Mild (3%-5%) • Moderate (6%-9%) • Severe (>9%) • Mild to Moderate- ORT • Severe- IV fluids • CDC uses a similar assessment and scale

  23. WHO Classification • None (3-5%) • Some (5-10%) • Severe (>10%) • Treatment recommendations are the same • None- maintain hydration • None-Some- ORT • Severe- IV fluids

  24. So what’s up?? • Despite recommendations for oral rehydration in mild or moderate dehydration, ORT is used in < 30% of the cases of gastro for which it is indicated • Clinicians tend to overestimate the degree of dehydration • May result in more invasive intravenous rehydration • What do you think?

  25. Determine % Dehydration • Gold standard is pre and post weight • What are the markers that we use to assess this? • Clinical • Laboratory • How reliable and precise are these markers?

  26. Is this Child Dehydrated?Michael J. Steiner; Darren A. DeWalt; Julie S. Byerley, JAMA. 2004;291(22):2746-2754 • Quantifying dehydration is important and common • Utility of the clinical history, physical examination, and laboratory tests had not previously been systematically reviewed • Teaching the assessment of dehydration often based on clinical experience and medical tradition • Steiner et al, conducted a systematic review of the literature on the precision and accuracy of history, physical examination, and laboratory tests in identifying dehydration in children between 1 month and 5 years old

  27. Clinical Signs

  28. Capillary Refill Time- what is normal? • Although many practitioners use other sites to measure capillary refill time, most studies of this sign use the palmar surface of the distal fingertip • Using this approach, values for non-dehydrated children are less than 1.5 to 2 seconds • Gorelick et al, found that fever did not affect the test characteristics in children with vomiting, diarrhea, or poor oral intake

  29. Laboratory Signs BUN >8= >2.9 mmol/L >18= >6.4 mmol/L >27= >9.6 mmol/L >45= >16 mmol/L

  30. Scale gave equal weight to 10 commonly elicited signs: Decreased skin elasticity CRT > 2 seconds General appearance Absence of tears Abnormal respirations Dry mucous membranes Sunken eyes Abnormal radial pulse Tachycardia (heart rate150/min) Decreased urine output 3 of the 10 signs 87% sensitive and 82% specific in detecting 5% dehydration LR positive, 4.9 7 of 10 signs 82% sensitive and 90% specific in detecting 10% dehydration LR positive of 8.4 Validity and Reliability of Clinical Signs in the Diagnosis of Dehydration inChildren, Marc H. Gorelick, Kathy N. Shaw and Kathleen O. Murphy, Pediatrics 1997;99;e6

  31. Logistic regression analysis showed 4 signs contained most of the predictive power: Capillary refill time Dry mucous membranes Absence of tears Abnormal overall appearance 2 of 4 signs was 79% sensitive and 87% specific for diagnosing 5% dehydration LR positive of 6.1 3 of 4 signs was 82% sensitive and 83% specific for diagnosing 10% dehydration LR positive of 5.1 Gorelick, cont’d * Not statistically different than 10 sign model

  32. History- “they haven’t peed all day!” • Steiner pooled 3 studies to evaluate the accuracy of history taking in assessing dehydration • All 3 of these studies evaluated history of low urine output as a test for dehydration • Low urine output did not increase the likelihood of 5% dehydration (LR, 1.3; 95% CI, 0.9-1.9) • Also NOT predictive of dehydration: • A history of vomiting, diarrhea, decreased oral intake, reported low urine output, a previous trial of clear liquids, and having seen another clinician during the illness prior to presenting to the ED

  33. Development of a Clinical Dehydration Scale for use in Children between 1 and 36 months of age. J. Friedman, et al. J Peds, Aug 2004 pp.201-207 • Developed a clinical score to assess severity and response to treatment in children aged 1-36 months • Score not intended to be diagnostic • Found 4 of 9 items to be the most valid and reliable • General appearance • Mucous membranes • Sunken eyes • Absent tears • Of 137 patients only 1 had severe dehydration (>10% weight loss) but 94 (69%) received IV fluids; 9 patients had moderate dehydration (6-9% weight loss)

  34. Steiner conclusions • Data suggest that signs of dehydration can be imprecise and inaccurate • Difficult for clinicians to predict the exact degree of dehydration • Combination of clinical symptoms better than individual signs or lab findings • Steiner et al agrees with WHO and other groups that recommend using the physical examination to classify dehydration as none, some, or severe • This general assessment can then be used to guide clinical management

  35. What does it mean for us? • We can classify children as: • Not dehydrated- need advice on how to maintain hydration • Some dehydration- need ORT and if successful advice on how to maintain hydration • Severe dehydration- need fluid resuscitation followed by rehydration

  36. Approach to Peds Dehydration • Initial Resuscitation • Determine % dehydration • Define the type of dehydration • Determine the type and rate of rehydration fluids • Final considerations

  37. Case #4 • 6 day old Female • First child born at term • GBS negative mother • Normal preg and delivery D/C’d within 24 hrs • Exclusively breastfed • HPI • Mom says child is a “poor feeder” • Not sure if her breastmilk has come in fully • Child much more listless today • Having to wake to feed • No urine output or stools noted in the last 48hrs

  38. Case #4 con’t • Exam • Vitals = HR 160, RR 38, T36.9°C, Sats 94%, BG4.1 • Generally – difficult to rouse but irritable upon awakening • CVS – normal pulse and cap refill • Resp – clear • Hydration – MM dry, no tears noted, skin is noted to be very soft and doughy

  39. Labs CBC WBC 4.8 Hgb 179 Plt 433 Lytes Na 167 K 6.8 Cl 132 Bicarb 16 BUN = 7mmol/L Creatinine = 90umol/L What type of dehydration is this? What is the most likely cause? Case #4 con’t

  40. Define the type of dehydration • Three major classes of dehydration based on relative losses of Na and Water • Isonatremic dehydration (80%) • Hypernatremic dehydration (15%) • Hyponatremic dehydration (5%) Thanks to Marc Francis for upcoming slides

  41. Body Fluids ICF (mEq/L) ECF (mEq/L) • Sodium 20 135-145 • Potassium 150 3-5 • Chloride --- 98-110 • Bicarbonate 10 20-25 • Phosphate 110-115 5 • Protein 75 10

  42. Isonatremic dehydration • By far the most common • Equal losses of Na and Water • Na = 130-150 • No significant change between fluid compartments • No need to correct slowly

  43. Hypernatremic Dehydration • Water loss > sodium loss • Na >150mmol/L • Water shifts from ICF to ECF • Child appears relatively less ill • More intravascular volume • Less physical signs • Alternating between lethargy and hyperirritability

  44. Hypernatremic Dehydration • Physical findings • Dry doughy skin • Increased muscle tone • Correction • Correct Na slowly • If lowered to quickly causes • massive cerebral edema • intractable seizures

  45. Hyponatremic Dehydration • Sodium loss > Water loss • Na <130mmol/L • Water shifts from ECF to ICF • Child appears relatively more ill • Less intravascular volume • More clinical signs • Cerebral edema • Seizure and Coma with Na <120

  46. Hyponatremic Dehydration • Correction • Must again be performed slowly unless actively seizing • Rapid correction of chronic hyponatremia thought to contribute to…. Central Pontine Myelinolysis • Fluctuating LOC • Pseudobulbar palsy • Quadraparesis

  47. Approach to Peds Dehydration • Initial Resuscitation • Determine % dehydration • Define the type of dehydration • Determine the type and rate of rehydration fluids • Final considerations

  48. Case #4 • 18 mo M • previously heatlhy • HPI • Diarrhea and vomiting for 3 days • Mom says stools are liquid and foul smelling with no mucous or blood • 6 episodes of diarrhea and 4 episodes of vomiting per day • not feeding well and activity level ↓ • He seems weak and tired • Decreased number of wet diapers

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