Hyponatremia can lead to serious neurologic sequelae, and thus hypotonic fluids should initially be avoided. Hyponatremia also frequently occurs when parents or other caregivers attempt to rehydrate children with fluids with inadequate amounts of sodium, such as water, juice, soda and Gatorade.7 Caretakers should be advised against giving inappropriate oral rehydration solutions on scene or en route to the hospital.
A Cochrane Library database review found no significant clinical differences between ORT and IV therapy for treating dehydration secondary to gastroenteritis in children. ORT did have a higher rate of paralytic ileus; however, the IV group has all the risks related to IV placement and therapy. For every 25 children who received ORT, one failed and needed IV hydration.11 Other rehydration methods include nasogastric, intraperitoneal, subcutaneous, intraosseous and rectal rehydration. Unfortunately, there are few clinical trials that evaluate the efficacy and long-term safety of some of these techniques. Nasogastric rehydration has been adequately studied. It is a safe technique with minimal adverse effects and has been found in four different clinical trials to have efficacy similar to IV therapy.1 NG rehydration can be performed using nonsterile oral rehydration solution.
Intraosseous rehydration is also as effective as IV therapy.1 Furthermore, IO access is sometimes faster and more reliable than IV access; however, it should only be reserved for crisis situations.
Case 1: According to all scales for the evaluation of dehydration, this baby classifies as severely dehydrated. His mental status is poor, and he has multiple signs on exam indicating the severity of his dehydration.
Additionally, his vital signs show mild tachycardia, corresponding with low intravascular volume. His respiratory rate and blood pressure are appropriate for his age. This baby should receive a 20 ml/kg bolus of isotonic crystalloid fluid either IV or IO (if IV access fails) and be transported to the hospital immediately. As for the etiology of his dehydration, he likely suffered from acute viral gastroenteritis. He may have been infected with a virus at daycare and subsequently developed symptoms. The organism is unlikely bacterial given the baby’s lack of fever, lack of blood in the stool and relatively short duration of symptoms.
Case 2: This child is dehydrated, though clinically less dehydrated than the infant in case 1. She is mildly lethargic and has dry and sticky mucous membranes; however, her capillary refill and skin turgor are normal.
Additionally, she has a normal respiratory pattern. With the exception of a fever, the rest of her vital signs are appropriate for her age. According to the WHO and Gorelick scales (the appropriate scales for the age of 4 years), she can be categorized as mildly dehydrated given her mental status and dry mucous membranes. She does not require IV therapy unless she does not tolerate ORT. As for the etiology of her mild dehydration, her presentation is suspicious for meningitis. Transport her promptly to the hospital for further evaluation.
Dehydration occurs frequently, and young children are at increased risk. Recognize key clinical signs such as abnormal capillary refill, abnormal skin turgor and irregular respiratory pattern. If in doubt about the severity of dehydration, give a 20 ml/kg bolus of normal saline and transport the child to the hospital.