Keep It Down Now
Answer: D
Dehydration (volume depletion) in the pediatric population is a complicated matter: although common, it encompasses a broad clinical spectrum from mild and manageable at home to severe and life-threatening.
Even in a resource-rich setting such as the US, on an annual basis approximately 30 million children are affected by dehydration, 1.5 million seek outpatient care, 200,000 are hospitalized, and 300 die from this common
condition.
The world stage sees much more morbidity and mortality: the Centers for Disease Control and Prevention (CDC) and the United Nations Children’s Fund report that in children 5 years and younger, the annual incidence of diarrheal illness is 1.5 billion. Approximately 2 million children die each year worldwide from diarrheal illness alone.
Although the following findings have variable sensitivities, specificities, and reliability scores, the constellation of symptoms and signs informs the clinician as to the severity of dehydration:
Physical Examination Findings in Pediatric Dehydration:
Dehydration (volume depletion) in the pediatric population is a complicated matter: although common, it encompasses a broad clinical spectrum from mild and manageable at home to severe and life-threatening.
Even in a resource-rich setting such as the US, on an annual basis approximately 30 million children are affected by dehydration, 1.5 million seek outpatient care, 200,000 are hospitalized, and 300 die from this common
condition.
The world stage sees much more morbidity and mortality: the Centers for Disease Control and Prevention (CDC) and the United Nations Children’s Fund report that in children 5 years and younger, the annual incidence of diarrheal illness is 1.5 billion. Approximately 2 million children die each year worldwide from diarrheal illness alone.
Although the following findings have variable sensitivities, specificities, and reliability scores, the constellation of symptoms and signs informs the clinician as to the severity of dehydration:
Physical Examination Findings in Pediatric Dehydration:
Oral rehydration remains the recommended route for mild and moderate dehydration. However, it is not always possible to rely on the PO route and the emergency provider must have an array of approaches
at his disposal. The clinician will weigh specific factors that influence the decision. Depending on the particular patient situation, the resources available, and the shared decision making with caregivers, any of the above (A-D) are viable options.
With the introduction of newer, safer, and less expensive anti-emetics as adjunct therapy, oral rehydration continues to make strides in its use in emergency departments. The process of rehydration can begin in the ED, and after a reasonable observation time, rehydration can continue at home. Institutions vary in specific protocols to give parents to follow at home, but in the appropriate home setting, for moderate dehydration, an abbreviated rule of thumb:
For standard replacement in mild dehydration, the goal is to give 50 mL/kg over 4 hours. This is
equivalent to:
● 1 mL/kg of oral rehydration solution every 5 minutes for 4 hours
Or:
● 3 mL/kg of oral rehydration solution every 15 minutes for 4 hours
The instructions should be tailored to the parents’ understanding, ability, and parenting style.
Recall that one teaspoon is 5 mL. Instruct parents to give ORS as teaspoons per 5 minutes or give a
syringe, mark the volume with a permanent marker, and have them slowly drip this in against the child’s buccal mucosa.
For accelerated replacement, the goal is to give 100 mL/kg of oral rehydration solution over 4 hours. To be exact, calculate and clearly outline in writing the amount and frequency to give for this child based on weight.
Infants: this will be approximately 30 mL/hour (or one ounce/hour) of ORS; instructions can be to give 5-10 mL (1-2 tsp) every 15 minutes
Toddlers: this will be approximately 60 mL/hour (or two ounces/hour) of ORS; instructions can be to give 15 mL (3 tsp) every 15 minutes
Children: this will be approximately 90 mL/hour (or three ounces/hour) of ORS; instructions can be to give 20-25 mL (one half to one ounce) every 15 minutes
In this child’s case, the parents “have tried everything” – an anti-emetic, reassurance, education, and a trial of PO hydration can still save the day. Oral rehydration solution may be commercial or based on the WHO recipe.
If this fails, other routes are at our disposal.
The clinical pearl here is to match the degree of invasiveness with the severity of illness and the resources available.
In a recent literature review, Rouhani et al concluded that hydration through the nasogastric route (B) had a similar success profile to intravenous hydration. In resource-poor environments, this may be preferable to using an IV. The downside, of course, is the obvious discomfort of an NG tube (which may be mitigated by the proper use of topical anesthetics). A fitting scenario would be the child with moderate dehydration who fails a PO challenge and whose caregivers refuse an IV. NG tube would not be an appropriate option for the child with severe dehydration or shock.
Children who are ill-appearing or critically ill clearly need intravascular access, and peripheral intravenous lines are appropriate. In the critical patient, after two IV attempts, rapidly move to intraosseous access (C). In this child’s case, other modalities may be tried before this more invasive (but in the proper context life-saving) approach.
Hypodermoclysis is an alternative technique to intravenous hydration: IV fluids are given by gravity into the
subcutaneous space. First used in pediatrics is the 1940s then in the geriatric population, it has risen and
fallen from favor throughout the years. Now with commercially available hyaluronidase (which temporarily
depolymerizes hyaluronan, a viscous component of the interstitial space that inhibits bulk fluid flow) the rate of administration and total volume given is enhanced. The advantages to hypodermoclysis are that it is safe, rapidly performed, requires little skill, and gives similar volumes of IV fluids to the non-critically ill patient.
Procedure
Various protocols are described, some of which are as simple as topical anesthetic (as in gaining IV access), insertion of an age-appropriate angiocath into the subcutaneous space, and starting IV fluids at gravity (or pump-assisted if the clinician injects 150 IU of hyaluronidase into the subcutaneous space via the angiocath 10 minutes before starting fluids).
Allen et al (2009) found that hyaluronidase-facilitated subcutaneous hydration to be safe and effective for
children with mild to moderate dehydration. In their prospective study of 51 patients, in 46/51 (90.2%) patients access was gained on first attempt and rehydration was successful in 43/51 (84.3%) patients. No systemic adverse events were reported, but one child developed cellulitis at the infusion site.
In their protocol, they inserted a 24-gauge angiocatheter or needle in the mid-anterior thigh or interscapular area, gave 150 U (1 mL) of recombinant human hyaluronidase, and administered 20 mL/kg of isotonic fluid over one hour. In some cases where the child was admitted, the infusion was continued up to three days as needed.
Below is their illustrative figure of an interscapular infusion site before infusion (A), 4 minutes after initiation of infusion (B), and 44 minutes after initiation of infusion (C):
at his disposal. The clinician will weigh specific factors that influence the decision. Depending on the particular patient situation, the resources available, and the shared decision making with caregivers, any of the above (A-D) are viable options.
With the introduction of newer, safer, and less expensive anti-emetics as adjunct therapy, oral rehydration continues to make strides in its use in emergency departments. The process of rehydration can begin in the ED, and after a reasonable observation time, rehydration can continue at home. Institutions vary in specific protocols to give parents to follow at home, but in the appropriate home setting, for moderate dehydration, an abbreviated rule of thumb:
For standard replacement in mild dehydration, the goal is to give 50 mL/kg over 4 hours. This is
equivalent to:
● 1 mL/kg of oral rehydration solution every 5 minutes for 4 hours
Or:
● 3 mL/kg of oral rehydration solution every 15 minutes for 4 hours
The instructions should be tailored to the parents’ understanding, ability, and parenting style.
Recall that one teaspoon is 5 mL. Instruct parents to give ORS as teaspoons per 5 minutes or give a
syringe, mark the volume with a permanent marker, and have them slowly drip this in against the child’s buccal mucosa.
For accelerated replacement, the goal is to give 100 mL/kg of oral rehydration solution over 4 hours. To be exact, calculate and clearly outline in writing the amount and frequency to give for this child based on weight.
Infants: this will be approximately 30 mL/hour (or one ounce/hour) of ORS; instructions can be to give 5-10 mL (1-2 tsp) every 15 minutes
Toddlers: this will be approximately 60 mL/hour (or two ounces/hour) of ORS; instructions can be to give 15 mL (3 tsp) every 15 minutes
Children: this will be approximately 90 mL/hour (or three ounces/hour) of ORS; instructions can be to give 20-25 mL (one half to one ounce) every 15 minutes
In this child’s case, the parents “have tried everything” – an anti-emetic, reassurance, education, and a trial of PO hydration can still save the day. Oral rehydration solution may be commercial or based on the WHO recipe.
If this fails, other routes are at our disposal.
The clinical pearl here is to match the degree of invasiveness with the severity of illness and the resources available.
In a recent literature review, Rouhani et al concluded that hydration through the nasogastric route (B) had a similar success profile to intravenous hydration. In resource-poor environments, this may be preferable to using an IV. The downside, of course, is the obvious discomfort of an NG tube (which may be mitigated by the proper use of topical anesthetics). A fitting scenario would be the child with moderate dehydration who fails a PO challenge and whose caregivers refuse an IV. NG tube would not be an appropriate option for the child with severe dehydration or shock.
Children who are ill-appearing or critically ill clearly need intravascular access, and peripheral intravenous lines are appropriate. In the critical patient, after two IV attempts, rapidly move to intraosseous access (C). In this child’s case, other modalities may be tried before this more invasive (but in the proper context life-saving) approach.
Hypodermoclysis is an alternative technique to intravenous hydration: IV fluids are given by gravity into the
subcutaneous space. First used in pediatrics is the 1940s then in the geriatric population, it has risen and
fallen from favor throughout the years. Now with commercially available hyaluronidase (which temporarily
depolymerizes hyaluronan, a viscous component of the interstitial space that inhibits bulk fluid flow) the rate of administration and total volume given is enhanced. The advantages to hypodermoclysis are that it is safe, rapidly performed, requires little skill, and gives similar volumes of IV fluids to the non-critically ill patient.
Procedure
Various protocols are described, some of which are as simple as topical anesthetic (as in gaining IV access), insertion of an age-appropriate angiocath into the subcutaneous space, and starting IV fluids at gravity (or pump-assisted if the clinician injects 150 IU of hyaluronidase into the subcutaneous space via the angiocath 10 minutes before starting fluids).
Allen et al (2009) found that hyaluronidase-facilitated subcutaneous hydration to be safe and effective for
children with mild to moderate dehydration. In their prospective study of 51 patients, in 46/51 (90.2%) patients access was gained on first attempt and rehydration was successful in 43/51 (84.3%) patients. No systemic adverse events were reported, but one child developed cellulitis at the infusion site.
In their protocol, they inserted a 24-gauge angiocatheter or needle in the mid-anterior thigh or interscapular area, gave 150 U (1 mL) of recombinant human hyaluronidase, and administered 20 mL/kg of isotonic fluid over one hour. In some cases where the child was admitted, the infusion was continued up to three days as needed.
Below is their illustrative figure of an interscapular infusion site before infusion (A), 4 minutes after initiation of infusion (B), and 44 minutes after initiation of infusion (C):
Summary of treatment of the stable dehydrated child:
● With the proper adjuncts, timing, and education, oral hydration can be given successfully in the ED
and continued at home
● For mild dehydration: 1 mL/kg of oral rehydration solution every 5 minutes for 4 hours
● Tailor the alternative route to the clinical scenario, family’s input and ability to continue therapy, and the
resources available
● Hypodermoclysis is making a comeback – be on the lookout for more mention of it
References
Allen CH et al. Recombinant Human Hyaluronidase-Enabled Subcutaneous Pediatric Rehydration. Pediatrics. 2009;124:e858–e867.
Barker LT. Systematic Review: In the Child With Gastroenteritis Who Is Unable to Tolerate Oral Fluids, Are There Effective Alternatives to Intravenous Hydration? Ann Emerg Med. 2012; 60(5):607-8.
King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. Nov 21 2003;52(RR-16):1-16.
Rouhani S et al. Alternative Rehydration Methods: A Systematic Review and Lessons for Resource-Limited Care. Pediatrics. 2011;127;e748.
● With the proper adjuncts, timing, and education, oral hydration can be given successfully in the ED
and continued at home
● For mild dehydration: 1 mL/kg of oral rehydration solution every 5 minutes for 4 hours
● Tailor the alternative route to the clinical scenario, family’s input and ability to continue therapy, and the
resources available
● Hypodermoclysis is making a comeback – be on the lookout for more mention of it
References
Allen CH et al. Recombinant Human Hyaluronidase-Enabled Subcutaneous Pediatric Rehydration. Pediatrics. 2009;124:e858–e867.
Barker LT. Systematic Review: In the Child With Gastroenteritis Who Is Unable to Tolerate Oral Fluids, Are There Effective Alternatives to Intravenous Hydration? Ann Emerg Med. 2012; 60(5):607-8.
King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. Nov 21 2003;52(RR-16):1-16.
Rouhani S et al. Alternative Rehydration Methods: A Systematic Review and Lessons for Resource-Limited Care. Pediatrics. 2011;127;e748.