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Pediatric Dehydration

Key considerations: Severe dehydration with shock, DKA, Intussusception

Cannot miss

  • Severe dehydration with shock
  • DKA
  • Intussusception
  • HUS

Likely diagnoses

  • Viral gastroenteritis
  • Bacterial gastroenteritis
  • Poor oral intake from illness
  • Pyloric stenosis (infants)

Red flags

  • Altered mental status
  • Absent tears
  • Sunken fontanelle
  • Capillary refill >3 seconds
  • Tachycardia with weak pulses
  • No urine output >8 hours

Workup

  • history: Vomiting/diarrhea frequency and duration, urine output, oral intake, fever; exam: Weight (compare to recent weight if available), mucous membranes, skin turgor, fontanelle, tears, cap refill; labs: BMP if moderate-severe or IV fluids needed; Not needed for mild dehydration managed with ORT; imaging: Not typically needed unless alternative diagnosis suspected; bedside: Weight comparison to recent well-weight (most accurate assessment)

Management

  • immediate: Severe dehydration (>10%): 20mL/kg NS bolus, repeat as needed, then replacement over 24hr; Moderate (5-10%): ORT trial first, IV if unable to tolerate PO; general: Mild (3-5%): oral rehydration therapy (ORS) 50mL/kg over 4 hours; Continue breastfeeding/regular diet — do NOT withhold food; Ondansetron 0.15mg/kg (max 4mg) ODT to facilitate ORT; Avoid fruit juice, sports drinks (high osmolarity)

Disposition

  • admit: Severe dehydration, failed ORT, altered mental status, concern for surgical abdomen; Infants <3 months with significant dehydration; discharge: Mild-moderate dehydration responding to ORT with reliable caregivers and return precautions; consults: Surgery if surgical cause suspected (intussusception, pyloric stenosis)

Clinical pearls

  • Oral rehydration is as effective as IV for mild-moderate dehydration and is preferred
  • Ondansetron significantly reduces the need for IV fluids in pediatric gastroenteritis
  • The best indicator of dehydration severity is percentage weight loss compared to recent well-weight

Source and review

  • AAP Gastroenteritis Guidelines 2019. Last reviewed: 2024-11-01