Late Signs of Dehydration in Pediatric Patients: Critical Warning Signals

29.09.202302.07.2023 by alexxlab

What are the late signs of dehydration in children. How can healthcare providers recognize severe dehydration in pediatric patients. When does dehydration become life-threatening in infants and young children. What immediate interventions are needed for critically dehydrated pediatric patients.

Содержание

Understanding Pediatric Dehydration: Causes and Risk Factors

Pediatric dehydration occurs when a child loses more fluids than they take in, disrupting normal bodily functions. While mild dehydration is common and easily treatable, severe cases can be life-threatening if not addressed promptly.

The most frequent causes of dehydration in children include:

Acute gastroenteritis (vomiting and diarrhea)
Excessive sweating
Fever
Decreased fluid intake
Certain medical conditions (e.g., diabetes)

Children are particularly vulnerable to dehydration due to their higher metabolic rates, proportionally larger body surface area, and inability to communicate thirst effectively. Infants and young toddlers face the highest risk, as they rely entirely on caregivers for hydration.

Recognizing Early Warning Signs of Dehydration in Children

Identifying dehydration early is crucial for preventing progression to more severe stages. Common early signs include:

Decreased urine output or darker urine
Dry mouth and lips
Thirst
Irritability
Fatigue

Parents and healthcare providers should be vigilant for these symptoms, especially in children with ongoing fluid losses or decreased intake. Prompt rehydration at this stage can often prevent complications.

Assessing Urine Output in Dehydrated Children

Monitoring urine output is a valuable tool for assessing hydration status. In infants and toddlers still in diapers, caregivers should track the number of wet diapers over 24 hours. A significant decrease in wet diapers or no urine output for 6-8 hours warrants medical attention.

For older children, infrequent urination or very dark, concentrated urine indicates potential dehydration. Healthcare providers may use more precise measurements of urine specific gravity to quantify hydration status in clinical settings.

Late Signs of Dehydration: Critical Red Flags

As dehydration progresses, more severe symptoms emerge. These late signs indicate a medical emergency requiring immediate intervention:

Sunken fontanelles in infants
Sunken eyes
Absence of tears when crying
Skin that doesn’t bounce back quickly when pinched (poor skin turgor)
Rapid breathing
Rapid heart rate
Cool, mottled extremities
Lethargy or altered mental status
Very dry mouth and mucous membranes

The presence of these symptoms indicates severe dehydration, with the child potentially having lost 9% or more of their body weight in fluids. At this stage, oral rehydration is often insufficient, and intravenous fluid replacement becomes necessary.

Understanding Skin Turgor in Dehydrated Children

Skin turgor is a key clinical sign in assessing dehydration severity. To check skin turgor, gently pinch and release the skin on the abdomen or back of the hand. In a well-hydrated child, the skin should immediately return to its normal position. In dehydrated children, the skin may take longer to flatten out or remain “tented.”

It’s important to note that skin turgor can be less reliable in obese children or those with chronic malnutrition. In these cases, healthcare providers must rely on other clinical signs and laboratory values to assess hydration status accurately.

Neurological Manifestations of Severe Pediatric Dehydration

Severe dehydration can profoundly impact a child’s neurological function. Late-stage neurological signs include:

Extreme lethargy or unresponsiveness
Confusion or disorientation
Seizures
Coma

These symptoms indicate critical fluid and electrolyte imbalances affecting brain function. Rapid, appropriate rehydration is essential to prevent permanent neurological damage or death.

Recognizing Dehydration-Induced Seizures

Seizures in severely dehydrated children can result from electrolyte imbalances, particularly hyponatremia (low sodium levels) or hypoglycemia (low blood sugar). These seizures often present as generalized tonic-clonic activity and require immediate medical intervention.

Healthcare providers must address both the seizure activity and the underlying dehydration simultaneously. This typically involves administering anti-epileptic medications while initiating carefully controlled fluid resuscitation to correct electrolyte abnormalities.

Cardiovascular Complications in Late-Stage Pediatric Dehydration

As dehydration progresses, it can severely impact a child’s cardiovascular system. Late signs of cardiovascular compromise include:

Tachycardia (rapid heart rate)
Weak or thready pulse
Hypotension (low blood pressure)
Poor peripheral perfusion (cool, mottled extremities)
Delayed capillary refill (>2 seconds)

These signs indicate that the child’s circulatory system is struggling to maintain adequate blood flow to vital organs. Without prompt intervention, shock and organ failure may occur.

Assessing Capillary Refill Time in Dehydrated Children

Capillary refill time (CRT) is a quick, non-invasive way to assess peripheral perfusion. To perform this test:

Press firmly on the nail bed or sternum for 5 seconds
Release the pressure
Observe how quickly color returns to the blanched area

In well-hydrated children, color should return within 2 seconds. A CRT greater than 2 seconds suggests poor perfusion and may indicate significant dehydration or shock.

Laboratory Findings in Severe Pediatric Dehydration

While clinical assessment remains paramount, laboratory tests can provide valuable information in cases of severe dehydration. Key findings may include:

Elevated blood urea nitrogen (BUN) and creatinine
Electrolyte imbalances (e.g., hypernatremia or hyponatremia)
Metabolic acidosis
Elevated hematocrit (due to hemoconcentration)
Abnormal liver function tests

These laboratory abnormalities reflect the systemic impact of severe dehydration on multiple organ systems. Interpreting these results in conjunction with clinical findings guides appropriate rehydration strategies and helps monitor treatment response.

Understanding Metabolic Acidosis in Dehydrated Children

Metabolic acidosis is a common complication of severe dehydration, particularly in cases of diarrheal illness. It occurs due to:

Loss of bicarbonate in diarrheal stools
Lactic acid production from poor tissue perfusion
Ketone production from starvation
Impaired renal acid excretion

Severe metabolic acidosis can further compromise cardiac function and tissue perfusion, creating a vicious cycle. Addressing both fluid deficits and acid-base imbalances is crucial in managing these patients.

Immediate Interventions for Critically Dehydrated Pediatric Patients

When a child presents with late signs of dehydration, rapid and appropriate intervention is essential. Key steps include:

Establish intravenous access (two large-bore IVs if possible)
Initiate fluid resuscitation (typically 20 mL/kg bolus of isotonic crystalloid)
Continuously monitor vital signs and mental status
Obtain laboratory studies (electrolytes, blood gas, glucose)
Correct electrolyte imbalances and hypoglycemia if present
Consider antiemetics if persistent vomiting
Address the underlying cause of dehydration

The goal is to restore circulating volume, improve tissue perfusion, and correct metabolic derangements. Close monitoring during rehydration is crucial to prevent complications such as cerebral edema, particularly in cases of hypernatremic dehydration.

Fluid Resuscitation Strategies in Severe Pediatric Dehydration

The choice of rehydration fluid and rate depends on the severity of dehydration, electrolyte abnormalities, and underlying etiology. General principles include:

Use isotonic fluids for initial boluses (e.g., normal saline or Ringer’s lactate)
Avoid hypotonic fluids in the acute phase to prevent cerebral edema
Correct sodium abnormalities slowly (no more than 0.5 mEq/L/hour)
Consider adding dextrose if hypoglycemia is present
Reassess frequently and adjust therapy based on clinical response

In cases of shock, more aggressive fluid resuscitation may be necessary, potentially requiring inotropic support if hypotension persists despite adequate volume replacement.

Preventing Progression to Late-Stage Dehydration in Children

While recognizing and treating severe dehydration is critical, prevention remains the best approach. Strategies to prevent progression to late-stage dehydration include:

Early recognition of fluid losses (e.g., counting diapers, tracking vomiting episodes)
Prompt initiation of oral rehydration therapy for mild-moderate dehydration
Use of oral rehydration solutions (ORS) rather than sports drinks or juices
Encouraging small, frequent sips of fluid rather than large volumes
Continuing to offer breast milk or formula to infants
Educating caregivers on signs of worsening dehydration
Seeking medical attention if oral rehydration is unsuccessful or dehydration progresses

Healthcare providers play a crucial role in educating families about proper hydration practices and when to seek medical care. This proactive approach can significantly reduce the incidence of severe dehydration cases.

The Role of Oral Rehydration Therapy in Preventing Severe Dehydration

Oral rehydration therapy (ORT) remains the cornerstone of managing mild to moderate dehydration in children. Key principles of effective ORT include:

Using properly formulated oral rehydration solutions
Administering small volumes frequently (e.g., 5 mL every 5 minutes)
Gradually increasing volume as tolerated
Continuing ORT even if some vomiting persists
Reintroducing age-appropriate diet once rehydration is achieved

When implemented early and correctly, ORT can prevent the progression to severe dehydration in most cases, reducing the need for intravenous fluids and hospitalization.

Long-Term Consequences of Severe Pediatric Dehydration

While most children recover fully from dehydration with appropriate treatment, severe cases can lead to long-term complications. Potential long-term effects include:

Renal injury or chronic kidney disease
Cognitive impairment (if cerebral hypoperfusion occurs)
Growth and developmental delays
Increased susceptibility to future dehydration episodes

These risks underscore the importance of prompt recognition and treatment of dehydration, as well as ongoing follow-up care for children who have experienced severe episodes.

Monitoring Renal Function After Severe Dehydration

Children who have experienced severe dehydration may be at risk for acute kidney injury (AKI) or long-term renal complications. Follow-up care should include:

Serial measurements of blood urea nitrogen and creatinine
Urinalysis to assess for proteinuria or hematuria
Blood pressure monitoring
Renal ultrasound if indicated
Referral to pediatric nephrology for cases with persistent abnormalities

Early detection and management of renal complications can help prevent progression to chronic kidney disease and improve long-term outcomes.

The Role of Healthcare Providers in Managing Pediatric Dehydration

Effectively managing pediatric dehydration requires a multidisciplinary approach involving various healthcare providers. Key roles include:

Primary care physicians: Early recognition, management of mild cases, and follow-up care
Emergency medicine physicians: Rapid assessment and treatment of severe cases
Pediatric intensivists: Management of complications and organ dysfunction in critical cases
Nurses: Continuous monitoring, fluid administration, and patient/family education
Nutritionists: Guidance on appropriate rehydration solutions and diet reintroduction
Social workers: Addressing social factors contributing to dehydration risk

Collaboration and clear communication among team members are essential for optimal patient outcomes. Regular training and protocol updates ensure all providers are equipped to recognize and manage dehydration at various stages of severity.

Improving Outcomes Through Standardized Dehydration Protocols

Implementing standardized assessment and treatment protocols for pediatric dehydration can significantly improve outcomes. Effective protocols typically include:

Validated clinical dehydration scales
Clear criteria for oral vs. intravenous rehydration
Evidence-based fluid resuscitation algorithms
Guidance on electrolyte correction and monitoring
Criteria for admission vs. discharge
Follow-up care recommendations

Regular review and updating of these protocols based on the latest evidence ensure that all children receive consistent, high-quality care regardless of the specific provider or setting.

Pediatric Dehydration – StatPearls – NCBI Bookshelf

Continuing Education Activity

The World Health Organization defines dehydration as a condition that results from excessive loss of body water. The most common causes of dehydration in children are vomiting and diarrhea. This activity describes the causes and pathophysiology of pediatric dehydration and highlights the role of the interprofessional team in its management.

Objectives:

Identify the etiology pediatric dehydration.
Recall the presentation of pediatric drhydration.
List the treatment and management options available for pediatric dehydration.
Explain interprofessional team strategies for improving care coordination and communication to advance the management of pediatric dehydration and improve outcomes.

Access free multiple choice questions on this topic.

Introduction

The World Health Organization defines dehydration as a condition that results from excessive loss of body water. The most common causes of dehydration in children are vomiting and diarrhea.

Etiology

Infants and young children are particularly susceptible to diarrheal disease and dehydration. Reason include higher metabolic rate, inability to communicate their needs or hydrate themselves, and increased insensible losses. Other causes of dehydration may be the result of other disease processes resulting in fluid loss which includes: diabetic ketoacidosis (DKA), diabetes insipidus, burns, excessive sweating, and third spacing. Dehydration may also be the result of decreased intake along with ongoing losses. In addition to total body water losses, electrolyte abnormalities may exist. Infants and children have higher metabolic needs and that make them more susceptible to dehydration.[1]

Epidemiology

Dehydration is a major cause of morbidity and mortality in infants and young children worldwide. Each year approximately 760,000 children of diarrheal disease worldwide. Most cases of dehydration in children are the consequence of acute gastroenteritis.

Acute gastroenteritis in the United States is usually infectious in etiology. Viral infections, including rotavirus, norovirus, and enteroviruses cause 75 to 90 percent of infectious diarrhea cases. Bacterial pathogens cause less than 20 percent of cases. Common bacterial causes include Salmonella, Shigella, and Escherichia coli. Approximately 10 percent of bacterial disease occurs secondary to diarrheagenic Escherichia coli. Parasites such as Giardia and Cryptosporidium account for less than 5 percent of cases.

Pathophysiology

[1]Dehydration causes a decrease in total body water in both the intracellular and extracellular fluid volumes. Volume depletion closely correlates with the signs and symptoms of dehydration. The total body water (TBW) in humans is distributed in two major compartments. 2/3rd the of TBW is in the intracellular compartment and the other 1/3rd is distributed between interstitial space (75%) and plasma (25%). The total body water is higher in infants and children as compared to the adults. In infants, it is 70% of the total weight, whereas it is 65% and 60% respectively in children and adults. As indicated earlier dehydration is total water depletion with respect to the sodium and volume depletion is the decrease in the circulation volume. Volume depletion is seen in acute blood loss and burns, whereas distributive volume depletion is seen in sepsis and anaphylaxis. In much of the literature, the distinction between dehydration and volume depletion is a blur.

Metabolic acidosis is seen in infants and children with dehydration, the pathophysiology of which is multifactorial.

1. excess bicarbonate loss in the diarrhea stool or in the Urine is certain types of renal tubular acidosis

2. Ketosis secondary to the glycogen depletion seen in starvation which sets in infants and children much earlier when compared to adults.

3. Lactic acid production secondary to poor tissue perfusion

4. Hydrogen ion retention by the kidney from decreased renal perfusion and decreased glomerular filtration rate.

In children with pyloric stenosis have very unique electrolyte abnormalities from the excessive emesis of gastric contents. This is seen mostly in the older children. They loose chloride, sodium, potassium in addition to volume resulting in hypochloremic, hypokalemic metabolic alkalosis. Kidney excretes base in the form of Hco3 ion to maintain acid-base balance of loss of Hydrogen ion in the emesis in the form of hydrogen chloride. It is interesting to note that kidney also excretes hydrogen ion to save sodium and water, which could be the reason for aciduria. Recently published article has shown that many children with pyloric stenosis may not have metabolic alkalosis.

History and Physical

Various sign and symptoms can be present depending on the patient’s degree of dehydration. Dehydration is categorized as mild (3% to 5%), moderate (6% to 10%), and severe ( more than 10%). The table below can assist with categorizing the patient’s degree of dehydration. The degree of dehydration between an older child and infant are slightly different as the infant could have total body water (TBW) content of 70%-80% of the body weight and older children have TBW of 60% of the body weight. An infant has to lose more body weight than the older child to get to the same level of dehydration.[2]

Dehydration% Mild 3% to 5% Moderate 6% to 10% Severe >10%

Mental status Normal Listless, irritable Altered mental

Heart rate Normal Increased Increased

Pulses Normal Decreased Thready

Capillary refill Normal Prolonged Prolonged

Blood pressure Normal Normal Decreased

Respirations Normal Tachypnea Tachypnea

Eyes Normal Slightly sunken Fewer tears

Fontanelle Normal Sunken Sunken

Urine output Normal Decreased Oliguric

(see image below)

Evaluation

Dehydration could be associated with hypo or hyper or isonatremia. Most cases of dehydration are hyponatremic. In selected cases, electrolyte abnormalities may exist. This includes derangements in sodium levels, acidosis characterized by low bicarbonate levels or elevated lactate levels. For patients with vomiting, who have not been able to tolerate oral fluids hypoglycemia may be present. Evaluation of urine specific gravity and the presence of ketones can assist in the evaluation of dehydration.[3]

Children who were given free water when they have ongoing diarrhea disease can present with hyponatremic dehydration, the excess of free water concurrent to excess sodium and bicarbonate loss in diarrhea. This is also seen in the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). In these cases, the children appear to be more dehydrated and could also present with hyponatremic seizure activity.

Similarly, infants who are fed oral rehydration solution prepared from excess salt or who lost excess free water as in diabetes incipidus could have hypernatraemic dehydration

End-tidal carbon dioxide measurements have been studied in an attempt to assess degrees of dehydration greater than five percent in children. This non-invasive approach has promise, but as of now has not proven to be an effective tool in determining the degree of dehydration in children. [4]

Treatment / Management

Priorities in the management of dehydration include early recognition of symptoms, identifying the degree of dehydration, stabilization, and rehydration strategies. [2][5][3]

Symptoms include vomiting, diarrhea, fever, decreased oral intake, inability to keep up with ongoing losses, decreased urine output, progressing to lethargy, and hypovolemic shock.

Mild Dehydration

The American Academy of Pediatrics recommends oral rehydration for patients with mild dehydration. Breastfed infants should continue to nurse. Fluids with high sugar content may worsen diarrhea and should be avoided. Children can be fed age-appropriate foods frequently but in small amounts.

Moderate Dehydration

The Morbidity and Mortality Weekly Report recommends administering 50 mL to 100 mL of oral rehydration solutions per kilogram per body weight during two to four hours to replace the estimated fluid deficit, with additional oral rehydration solution, administered to replace ongoing losses.

Severe Dehydration

For patients who are severely dehydrated, rapid restorations of fluids are required.

Patients who are severely dehydrated can present with altered mental status, lethargy, tachycardia, hypotension, signs of poor perfusion, weak thread pulses, and delayed capillary refill.

Intravenous fluids, starting with 20 ml/kg boluses of normal saline are required. Multiple boluses may be needed for children in hypovolemic shock. Additional priorities include obtaining a point of care glucose test, electrolytes, and urinalysis assessing for elevated specific gravity and ketones. [6]

Hypoglycemia should be assessed at the point of care testing via glucometer, and venous blood gas with electrolytes or serum chemistries. It should be treated with intravenous glucose. The dose is 0.5 gm/km to 1 gm/km. This translates to 5 ml/kg to 10 ml/kg of D10, 2ml/kg to 4 ml/kg of D25, or 1 ml/kg to- 2 ml/kg of D50. The use of D50 is usually reserved for an adolescent or adult-sized patients using a large bore intravenous line. [7]

Replacement of Fluids

An assessment of the degree of dehydration will determine the fluid replacement. Using tables that can predict the degree of dehydration is helpful. If a previous “well weight” is available, that can be subtracted from the patient’s “sick weight” to calculate total weight loss. One kilogram weight loss equates to one liter of fluid lost.

The rate of replacement is based on the severity of the dehydration. Patients with hypovolemic shock need rapid boluses of isotonic fluid either normal saline or ringer lactate at 20ml/kg body weight. This could be repeated 3 times with reassessment in-between the boluses. Ringer lactate is superior to normal saline in hemorrhagic shock requiring rapid resuscitation with isotonic fluids.[8] This difference is not found in the children with severe dehydration from acute diarrheal disease. In these children, the replacement with normal saline and ringer lactate did show similar clinical improvement.[9]

Rapid infusion can cause cardiac insufficiency, congestive heart failure, and pulmonary edema. Rapid correction in patients with diabetic ketoacidosis can cause cerebral edema in adolescent and children.

The rate of replacement fluids is calculated after taking into account for the maintenance, replacement and deficit requirement of the patient. Sodium requirements of the children in the hospital are higher than that of the adults. The children have high metabolic needs, has higher insensible lose as they have a higher body surface area. They also have higher respiratory and heart rates, requiring the use of an intravenous solution containing high sodium like D5NS. The deficit is determined by the degree of dehydration as outlined earlier. The second phase of fluid replacement therapy lasts for 8 hours, during which the child requires 1/2 of the remaining deficit in addition 1/3rd of the maintenance fluid. The remaining half of the deficit and the 2/3rd of the daily maintenance therapy is given during the third phase of the therapy which spans the following 16 hours.

Holliday-Segar calculation is used for calculation of maintenance fluid in children, which is 100ml/kg/day for first 10 kg body weight (BW), then 50 ml/kg/day for the next 10 kg BW and then 20 ml/kg /day for any BW over and above. [10]

For patients where intravenous access can not be achieved or maintained, other methods can be employed. They include continuous nasogastric hydration and subcutaneous hydration.[11]]

Hypodermoclysis refers to hydrating the subcutaneous space with fluid which can be absorbed systemically. Hypodermoclysis is best reserved for the stable child or infant with mild to moderate dehydration who either fails a trial of fluids by mouth or who needs some degree of rehydration to facilitate gaining intravenous access after a slow subcutaneous fluid bolus has been given.

The process begins with:

The placement of topical anesthetic cream, such as EMLA, cover with an occlusive dressing, wait for 15 to 20 minutes.“Pinch an inch” of skin anywhere, but the most practical site for young children is between the scapulae.Insert a 25-gauge butterfly needle or 24-gauge angiocatheterInject 150 units hyaluronidase SC (if available).Infuse 20 mL/kg isotonic solution over one hour, repeat as needed or use this technique as a bridge to intravenous access.

Differential Diagnosis

Hypovolemic shock

Pearls and Other Issues

Once the patient’s condition has stabilized, hydration therapy continues to replace existing and ongoing losses. Fluid therapy should include maintenance fluids plus replacement of the existing fluid deficit.

Deficit calculation can be determined in several ways. If the patient’s weight before the illness is known, it can be subtracted from the current weight. Each kilogram lost would be equivalent to one liter of fluid lost. If the prior weight is not known, multiply the weight in kilograms by the dehydration percent.

For a 10 kg patient who is 10% dehydrated, 0.1 represents 10%

Maintenance fluids can be calculated as follows:

For a patient weighing less than 10 kg, they should receive 100 mL/kg/day.

If the patient weighs less than 20 kg, fluids will include the 1000 mL/day plus 50 mL/kg/day for each kilogram between 10 kg and 20 kg.

For patients weighing more than 20 kg, give 1500 mL/day, plus 20 mL/kg/day for each kilogram over 20 kg. Divide the total by 24 to determine the hourly rate.

In hyponatremic dehydration, half of the deficit can be replaced over eight hours with the remaining half the following sixteen hours. Severe hyponatremia (< 130 mEq/L) or hypernatremic dehydration (> 150 mEq/L) is corrected over 24 to 48 hours. Symptomatic hyponatremia (seizures, lethargy) can be acutely managed with hypertonic saline (3% sodium chloride). The deficit may be calculated to restore the sodium to 130 mEq/L and administered over 48 hours, as follows:

Sodium deficit = (sodium desired – sodium actual) x volume of distribution x weight (kg))

Example: Sodium = 123, weight = 10 kg, assumed volume of distribution of 0.6; Sodium deficit = (130-123) X 0.6 X 10 kg = 42 mEq sodium. Hypertonic saline (3%) which contains 0.5 mEq/mL may be used for rapid partial correction of symptomatic hyponatremia. A bolus dose of 4 mL/kg raises the serum sodium by 3 mEq/L to 4 mEq/L.

Rapid correction of hypernatremia may result in cerebral edema, as a result of intracellular swelling occurs. Osmotic demyelination syndrome, also known as central pontine myelinolytic, can occur as a result of rapid correction of hyponatremia. Symptoms include a headache, confusion, altered consciousness, gait disturbance, and may lead to respiratory arrest.

Enhancing Healthcare Team Outcomes

Diarrheal diseases and resulting severe dehydration are the leading cause of infant mortality worldwide especially in children < 5years of age.[12]. This burden is even higher among children in developing countries. To improve the outcome and decrease the morbidity and mortality from the diarrhea diseases especially Rotaviral disease which is the leading cause of death in children we need cooperation between various different agencies and countries.

World health organization while working with member countries and other agencies promotes national policies and investments to have access to safe drinking water, to improve sanitation, to research in diarrhea prevention like vaccination, to implement preventive measures like source water treatments, safe storage and to help train the health care workers who could go into communities to bring the change at local level.

Review Questions

Access free multiple choice questions on this topic.
Comment on this article.

Figure

Dehydration Scale. Contributed by Roy M. Vega MD

References

1.: Tutay GJ, Capraro G, Spirko B, Garb J, Smithline H. Electrolyte profile of pediatric patients with hypertrophic pyloric stenosis. Pediatr Emerg Care. 2013 Apr;29(4):465-8. [PubMed: 23528507]
2.: Falszewska A, Szajewska H, Dziechciarz P. Diagnostic accuracy of three clinical dehydration scales: a systematic review. Arch Dis Child. 2018 Apr;103(4):383-388. [PubMed: 29089317]
3.: Vega RM, Avner JR. A prospective study of the usefulness of clinical and laboratory parameters for predicting percentage of dehydration in children. Pediatr Emerg Care. 1997 Jun;13(3):179-82. [PubMed: 9220501]
4.: Freedman SB, Johnson DW, Nettel-Aguirre A, Mikrogianakis A, Williamson-Urquhart S, Monfries N, Cheng A. Assessing Dehydration Employing End-Tidal Carbon Dioxide in Children With Vomiting and Diarrhea. Pediatr Emerg Care. 2018 Aug;34(8):564-569. [PubMed: 28538608]
5.: Yang HW, Jeon W, Min YG, Lee JS. Usefulness of end-tidal carbon dioxide as an indicator of dehydration in pediatric emergency departments: A retrospective observational study. Medicine (Baltimore). 2017 Sep;96(35):e7881. [PMC free article: PMC5585495] [PubMed: 28858101]
6.: Geurts D, Steyerberg EW, Moll H, Oostenbrink R. How to Predict Oral Rehydration Failure in Children With Gastroenteritis. J Pediatr Gastroenterol Nutr. 2017 Nov;65(5):503-508. [PubMed: 28248796]
7.: Sendarrubias M, Carrón M, Molina JC, Pérez MÁ, Marañón R, Mora A. Clinical Impact of Rapid Intravenous Rehydration With Dextrose Serum in Children With Acute Gastroenteritis. Pediatr Emerg Care. 2018 Dec;34(12):832-836. [PubMed: 28463940]
8.: Martini WZ, Cortez DS, Dubick MA. Comparisons of normal saline and lactated Ringer’s resuscitation on hemodynamics, metabolic responses, and coagulation in pigs after severe hemorrhagic shock. Scand J Trauma Resusc Emerg Med. 2013 Dec 11;21:86. [PMC free article: PMC4029282] [PubMed: 24330733]
9.: Kartha GB, Rameshkumar R, Mahadevan S. Randomized Double-blind Trial of Ringer Lactate Versus Normal Saline in Pediatric Acute Severe Diarrheal Dehydration. J Pediatr Gastroenterol Nutr. 2017 Dec;65(6):621-626. [PubMed: 28422812]
10.: Meyers RS. Pediatric fluid and electrolyte therapy. J Pediatr Pharmacol Ther. 2009 Oct;14(4):204-11. [PMC free article: PMC3460795] [PubMed: 23055905]
11.: Rébeillé-Borgella B, Barbier C, Moussaoui R, Faisant A, Michard-Lenoir AP, Rubio A. [Nasogastric rehydration for treating children with gastroenteritis]. Arch Pediatr. 2017 Jun;24(6):527-533. [PubMed: 28416428]
12.: GBD Diarrhoeal Diseases Collaborators. Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Infect Dis. 2017 Sep;17(9):909-948. [PMC free article: PMC5589208] [PubMed: 28579426]

: Disclosure: Roy Vega declares no relevant financial relationships with ineligible companies.
: Disclosure: Usha Avva declares no relevant financial relationships with ineligible companies.