Hydration for Children, by ShaneTheNurse

One of the com­mon mis­takes that peo­ple make is to treat a dehy­drat­ed child in the same man­ner as a dehy­drat­ed adult. For a child that is severe­ly dehy­drat­ed this will most like­ly mean death. I have been an ER nurse since the 1990’s and I can­not tell you how many times I have treat­ed chil­dren for this con­di­tion. Sad­ly there are many occa­sions when a child may present to the ER only slight­ly dehy­drat­ed and by the time they are brought back to a room they have reached a mod­er­ate or even a severe state of dehy­dra­tion. This can hap­pen so quick­ly that dis­re­gard­ing the signs and symp­toms for even fif­teen min­utes could result in a Childs death. Now I do not expect to get every­one up to the lev­el of an EMT, ER RN or a physi­cian. Most of the time just rec­og­niz­ing the signs and act­ing quick­ly with the appro­pri­ate treat­ment will be all that is need­ed. I have to con­stant­ly remind med­ical pro­fes­sion­als to treat pedi­atric dehy­dra­tion as a life threat­en­ing con­di­tion and they have been trained as to the signs, symp­toms, and prop­er treat­ment.

Let’s look at the caus­es of pedi­atric dehy­dra­tion first.

• Vom­it­ing and diar­rhea are the num­ber one rea­son in my expe­ri­ence. Both are eas­i­ly treat­ed, but remem­ber there is a rea­son our bod­ies are doing this so do not run amok with the anti-diar­rhea or antiemet­ic med­ica­tions.

• Vom­it­ing – let the child vom­it until they have noth­ing left, then give them sips, not cups of juice or water not milk. See how they do, if they per­sist in vom­it­ing it may be time to con­sid­er some­thing like promet­hazine, ondansetron, meto­clo­pramide, or dimen­hy­dri­nate. Gin­ger and Aloe are nat­ur­al reme­dies known to be effec­tive.
• Diar­rhea – The last thing you want to have is some­thing like e‑coli start to grow expo­nen­tial­ly because you gave that child some lop­eramide and stopped the body from expelling what it knows to be bad. As long as the child can drink enough to keep up with what is com­ing out, yes you sort of have to mea­sure it, they will prob­a­bly be fine. Sev­er­al years ago a doc­tor gave his child an anti-diar­rhea med­ica­tion and the e‑coli grew like crazy for almost a week before it rup­tured the intesti­nal wall. At 10 years old who wants a piece of their stom­ach and intes­tine removed? So until there is noth­ing but clear liq­uid com­ing out avoid the anti-diar­rhea meds. One of my favorite bulk­ing agents is oat­meal, it is cheap and most kids will tol­er­ate it well.
• Heat relat­ed dehy­dra­tion – Usu­al­ly a result of some out­door activ­i­ty in which the child sweats out far more than they take in.This past sum­mer two chil­dren almost died because their irre­spon­si­ble par­ent s took them for a walk on the black­top with noth­ing to drink in 110F but a humidex of 138F.  They spent a day in the ICU and anoth­er 2 days in the pedi­atric unit recov­er­ing before child wel­fare took cus­tody. They were out for less than one hour before col­laps­ing. Again, to empha­size just how quick­ly this can go from darn good to fubar.
• Blood loss – there are a mul­ti­tude of rea­sons this can hap­pen includ­ing a bro­ken bone, so lets us not dwell on the caus­es and just go for the treat­ment. First thing after estab­lish­ing that they have a good air­way and can breathe, because if they can­not do those bleed­ing is the least of their con­cerns, con­trol the bleed­ing with direct pres­sure. No tourni­quets allowed. A childs cir­cu­lat­ing blood vol­ume is quite a bit less than an adults, even a small amount of blood loss can be life threat­en­ing.
• Burns – Bet most of you did not think of this one, and in a post shtf sit­u­a­tion with fires for heat­ing, or cook­ing the poten­tial risk will increase dra­mat­i­cal­ly.  Once the child is safe, cool the burned area until it is no longer hot to touch. Please do not put any but­ter, mar­garine, mus­tard, vine­gar, motor oil, may­on­naise (I have seen all of these applied to burns), or any­thing else that is not water on the burn. Remove all cloth­ing in the affect­ed area. Please be care­ful as the mod­ern fab­rics gen­er­al­ly have an oil base and will stick to the skin. Pulling it off may remove a large por­tion of healthy tis­sue also.

Signs and Symp­toms

Remem­ber to be age appro­pri­ate, a 2, 4, 6, and 8 year old will all have dif­fer­ent require­ments and assess­ment lev­els.

• Sweat­ing – Is the child sweat­ing? Sweat is good it means they have enough hydra­tion to expend cool­ing them­selves, though they are active­ly dehy­drat­ing. If the child stops sweat­ing you will need to act fast
• Skin Tur­gor – if you pinch their skin does it stay in the shape of a lit­tle pup tent or rapid­ly return to nor­mal? Rapid return is good, pup tent is bad.
• Col­or – are they red, do they look flushed? Are they pale with clam­my skin? Either one may be an indi­ca­tor of dehy­dra­tion
• Eyes – are the eyes moist or do they look like they are dry and start­ing to wrin­kle? Wrin­kles in the eye­ball are a freaky site and require imme­di­ate inter­ven­tion
• Lev­el of con­scious­ness, LOC – Is the child alert and ori­ent­ed to their usu­al state? Do they know their name?  If not con­sid­er dehy­dra­tion if there has been no head injury.
• Motor skills and coor­di­na­tion – Are they able to do tasks they can usu­al­ly do or walk with­out stum­bling? While fatigue or a head injury may be a fac­tor, they may also be dehy­drat­ed
• Mucous Mem­branes – are they moist or dry? Dry mouth and nasal pas­sages indi­cate the child is prob­a­bly dehy­drat­ed.
• Urine Out­put — Is the child uri­nat­ing? How often? How much?  What col­or is it? The med­ical stan­dard is to pro­duce 1mL/kg/hr. So a 10kg, 22lb child should pro­duce 10mL, 2 tsp. per hour. What­ev­er they take in the same amount, rough­ly, should be com­ing out. Most chil­dren have to uri­nate once every 2 hours, so that same 10kg child should pro­duce 20mL or 4tsp of urine.  As for col­or, when ide­al­ly hydrat­ed the urine is essen­tial­ly clear. There are many things that can give col­or to the urine. Aspara­gus turns it green, Beets red, Car­rots orange, so col­or is not tru­ly an indi­ca­tor of the lev­el of dehy­dra­tion.

Now we need to hydrate these lit­tle guys.

• Drink it – The pre­ferred method because it is the eas­i­est and the least inva­sive, all the oth­er meth­ods will not be enjoyed by the child. Pedi­alyte, have you ever tried this stuff? Not so yum­my, but it does con­tain the elec­trolytes the child needs and they even come as pop­si­cles. Reg­u­lar pop­si­cles, ice chips, water, juice are all good. What­ev­er the child will take in and keep down. Avoid giv­ing soda, milk, acidic juices or juices with spices; these will gen­er­al­ly make them start puk­ing again.
• Rec­tal tube, Proc­to­clysis – not so much fun but if they are puk­ing their guts out they prob­a­bly will not mind. Try to use a tube no larg­er than the Childs pinkie fin­ger. Remem­ber to expel the air from the tube before insert­ing it of they will get a tube full of air first.  It is ok to lube the tube, petro­le­um jel­ly, water based lubri­cants such as K‑Y, even but­ter or mar­garine will be ok here. Use a small fun­nel or at least one appro­pri­ate to the size of the child. Do not use the half gal­lon fun­nel for the one year old. Fill the fun­nel until it is topped off then let it absorb slow­ly. This is a pas­sive way to get the flu­id in, remem­ber that grav­i­ty works and have the fun­nel above the child.

These next three meth­ods should only be done by some­body that has prop­er med­ical train­ing!

• Sub­cu­ta­neous Line, SC, Hypo­der­mo­clysis – This one is for those with a lit­tle more med­ical skill. It involves insert­ing a nee­dle under the skin and slow­ly insert­ing ster­ile intra­venous flu­id.
• Intra­venous, IV – This involves the inser­tion of an IV catheter into the vein of the child and then infus­ing a ster­ile intra­venous flu­id, gen­er­al­ly 0.9% Sodi­um Chlo­ride in water also known as nor­mal saline or NS. This is by far the quick­est way to rehy­drate the child and it is also the most dif­fi­cult if the child is already severe­ly dehy­drat­ed. Also there is a poten­tial to infuse too much flu­id which would cre­ate a whole oth­er prob­lem which may be just as dead­ly
• Intraosseus, IO – This is one that a lot of doc­tors will not try because of the risk for infec­tion and tis­sue dam­age, and their own fears. Done cor­rect­ly it will save chil­dren and adult alike. It is one of my favorites in a severe dehy­dra­tion case of if there is anoth­er rea­son I can­not find a vein. The IO nee­dle is insert­ed into the Tib­ia 1cm below the Tib­ial Tuberos­i­ty., see this is why it is best left to pros. Once insert­ed and mar­row removed via syringe to con­firm place­ment the flu­id can be infused.

Well how much flu­id do I need?

If the child can drink, let them have as much as they want if they are not already com­pro­mised. Once com­pro­mised, steps must be tak­en to ensure ade­quate hydra­tion with­out putting the child at risk. For exam­ple giv­ing the vom­it­ing child a glass of milk will almost always lead to more vom­it­ing and an increase in dehy­dra­tion.

There are stan­dards we use in the ER and I try to use these when pos­si­ble. Remem­ber to be age, weight, and dehy­dra­tion lev­el appro­pri­ate.

• Oral

• mild dehy­dra­tion 50mL/kg over 4 hours
• Mod­er­ate dehy­dra­tion 100mL/kg over 4 hours
• Increase by 10mL/kg for each episode of vom­it­ing or diar­rhea.
• Rec­tal Tube – as much as the child will tol­er­ate up to 200mL per hour. Start out slow say 20mL per hour and increase the vol­ume grad­u­al­ly as the child may tol­er­ate or until the flu­id is bypass­ing the tube and being expelled.

• SC – 20mL/kg over 4 – 24 hours up to 1mL per minute
• IV / IO – 20mL/kg over 4 hours. Once the child has sta­bi­lized pro­ceed with oral rehy­dra­tion. Use your best judg­ment as the lev­el of dehy­dra­tion.

There are many oral elec­trolyte solu­tions. They are essen­tial­ly water, salts, and sug­ar in a spe­cif­ic ratio. Pedi­alyte, Gatorade, Pow­er­ade are great ready to drink elec­trolyte replace­ment drinks. Herbal­ife H3O, Sqwinch­er are excel­lent iso­ton­ic pow­der mix­es that are eas­i­ly stored and trans­port­ed in the field, they store for years. There are of course oth­er oral rehy­dra­tion solu­tions made by oth­er com­pa­nies.