Child with dehydration (1 month to 18 years)
Fluid loss or poor intake, most often gastroenteritis. Weigh the child (bare if possible).
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PediatricsManagement
Pediatric Dehydration and Fluid Resuscitation
Pediatric Dehydration and Fluid Resuscitation: Child with dehydration (1 month to 18 years) → Different fluid plan: DKA, malnutrition, heart or kidney d...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Warning Different fluid plan: DKA, malnutrition, heart or kidney disease, neonates
Use the specific guideline for DKA, severe acute malnutrition, burns or trauma, neonates under 28 days, heart, kidney or liver disease, and metabolic disorders. Rehydrate more slowly in meningitis, pneumonia or bronchiolitis.
- DKA: use the DKA pathway, not this one
- Severe acute malnutrition: WHO malnutrition protocol; standard boluses and rapid rehydration can cause heart failure
- Neonates, heart, kidney or liver disease: senior advice before boluses or rapid fluids
03Action Assess degree of dehydration
Best measure: weight loss against a weight from the last 2 weeks. Clinical signs are imprecise. If in doubt, manage as severe.
- Mild (<5%): alert; few or no signs; may be thirsty or pass less urine
- Moderate (5-9%): lethargic or irritable, tachycardia, fast breathing, sunken eyes, dry mucosa, reduced skin turgor, prolonged capillary refill
- Severe (10% or more): reduced conscious state, deep acidotic breathing, pale or mottled, cold, weak pulses, deeply sunken eyes, hypotension
- Check BGL in any drowsy or lethargic child (ketotic hypoglycaemia)
- Check Na, K, urea, creatinine and glucose if: IV fluids, severe dehydration, age <6 months with poor feeding or large losses, or signs of abnormal sodium
- Signs of high sodium: jittery movements, increased tone, hyperreflexia, doughy skin, seizures, drowsiness
04Decision Shock present?
Shock if one or more: reduced conscious state, tachycardia, tachypnoea, hypotension, weak peripheral pulses, mottled or cold peripheries, acidosis.
- If Yes
05Action Shock: 0.9% sodium chloride IV/IO bolus now
Child: 10-20 mL/kg as fast as possible (use ideal body weight; adult-size teenager: 500 mL per bolus). Reassess after each bolus. Consider sepsis. Heart disease: 10 mL/kg boluses and senior help early.
- Child: 0.9% sodium chloride 10-20 mL/kg IV or IO, as fast as possible (ideal body weight; adult-size teenager: 500 mL per bolus)
- Reassess heart rate, capillary refill, conscious state and BP after each bolus; repeat 10-20 mL/kg if still shocked
- After 20 mL/kg: call a senior clinician. Consider sepsis (give antibiotics), surgical or cardiac cause
- Still shocked after 40 mL/kg: consider inotropes; contact PICU or retrieval service
- Do not use glucose-containing fluid as a bolus
- BGL under 3.0 mmol/L with symptoms, or under 2.6 mmol/L: glucose 10% 2 mL/kg IV (max 200 mL); recheck BGL
- Take blood gas, Na, K, urea, creatinine and glucose when access is placed
06Action Severe, after shock, or enteral fluids failed: IV rehydration
Take Na, K, urea, creatinine and glucose when the cannula goes in. Na below 135 or above 145 mmol/L changes the plan (next step). Use isotonic fluid only.
- Fluid: 0.9% sodium chloride + 5% glucose
- Add potassium chloride 20 mmol/L (premixed bag) once K and renal function are known and the child passes urine
- Replace ongoing GI losses with 0.9% sodium chloride + KCl 20 mmol/L
- Start ORS early during IV therapy; stop IV when oral fluids are tolerated
07Decision Serum sodium?
Normal range 135-145 mmol/L.
- Na 135-145
08Action Na 135-145 mmol/L: maintenance + 5% deficit over 24 h
Hourly rate = full maintenance + 5% deficit (50 mL/kg) over 24 h. Deficit over 5%: replace the rest over the next 24 h after reassessment.
- Maintenance (4-2-1 rule): 3-10 kg: 4 mL/kg/h
- 10-20 kg: 40 mL/h + 2 mL/kg/h for each kg over 10 kg
- Over 20 kg: 60 mL/h + 1 mL/kg/h for each kg over 20 kg; usual maximum 100 mL/h (2400 mL/day)
- Plus 5% deficit: add 50 mL/kg spread over 24 h
- Use premorbid weight; consider ideal body weight in obese children
- Meningitis, pneumonia, bronchiolitis or CNS disease (high ADH risk): senior advice; consider 2/3 maintenance
09Action Monitor response
Strict fluid balance. Reassess hydration regularly.
- Weigh at start and at least daily (same scale)
- Check electrolytes and glucose 4-6 h after starting IV fluids if unwell or abnormal, then at least every 24 h
- Na change over 0.5 mmol/L/h, or Na outside 135-145 mmol/L: senior clinician
- Improving: heart rate settles, alert, passing urine, weight rising
10Outcome Discharge when rehydrated and drinking
Tolerating oral fluids, vomiting reduced, nil or mild dehydration, passing urine, alert. Give an ORS plan and clear return advice. Young infants: review within 48 h.
- Resume usual diet and milk feeds; no need to dilute milk
- Parents know how to give ORS and replace losses
- Return if: refuses fluids, keeps vomiting, less urine, drowsy, blood in stool or bilious vomit
- Young infants: review within 48 h
- Na >145
11Action Na over 145 mmol/L: senior advice; Na 150 or more: deficit over 48 h
Treat shock first. Then lower Na by no more than 0.5 mmol/L/h (10-12 mmol/L per day). Fast correction causes cerebral oedema and seizures.
- Na 146-149: standard plan; repeat Na, K, urea, creatinine in 4-6 h
- Na 150-169: 0.9% sodium chloride + 5% glucose, maintenance + deficit over 48 h (eg 10 kg: 55 mL/h; 20 kg: 90 mL/h); add ongoing losses
- Repeat Na 1-2 h after starting, then every 4-6 h; senior advice
- Na falls faster than 0.5 mmol/L/h: reduce or stop fluids; seek expert advice
- Na 170 or more: emergency; contact ICU and tertiary centre
- Seizures during correction: contact ICU; consider cerebral oedema or venous sinus thrombosis
- Restrict and record oral intake; stop feed fortification; add potassium once passing urine
- Path rejoins step 09Shared downstream outcome
- Na <135
12Action Na below 135 mmol/L: isotonic fluid only; senior advice
Use 0.9% sodium chloride + 5% glucose at maintenance + 5% deficit over 24 h. No hypotonic fluids. Target Na rise 6-8 mmol/L in 24 h; never over 8 mmol/L unless seizing.
- Seizures or reduced conscious state: emergency. 3% sodium chloride 3 mL/kg IV over 20 min (max 150 mL) without delay; repeat if still seizing, Na under 125 mmol/L and rise under 5 mmol/L; contact ICU
- Na below 130 mmol/L or symptoms: discuss with paediatric team
- Na below 125 mmol/L: consider transfer
- Repeat Na 4-6 hourly; strict fluid balance and weight
- Path rejoins step 09Shared downstream outcome
If No13Warning No shock: check red flags for another diagnosis
Vomiting without diarrhoea, bilious vomiting, blood in stool, severe abdominal pain, age under 6 months, diarrhoea over 10 days, or immunocompromise need senior review.
- Bilious vomiting, severe abdominal pain or distension: possible bowel obstruction; no NG fluids; senior and surgical review
- Vomiting without diarrhoea: think of other causes (eg sepsis, UTI, DKA, raised intracranial pressure)
- Drowsy or lethargic: check BGL now. Under 3.0 mmol/L: glucose 10% 2 mL/kg IV (max 200 mL) or oral glucose if alert (not ORS); then glucose-containing fluids
14Decision No shock: how dehydrated?
Use the signs in the assessment step. If in doubt, manage as the more severe grade.
- Mild
15Action Mild (<5%): oral fluids, usually at home
Continue breastfeeding and milk feeds. Offer ORS in small, frequent amounts.
- ORS about 10 mL/kg/h, in small frequent amounts, if thirsty or losses continue
- Replace losses: 5 mL/kg ORS after each large watery stool if at higher risk
- Avoid fruit juice and fizzy drinks until diarrhoea stops
- Stop feed fortification (extra formula scoops, glucose polymer)
- Tell parents when to return: refuses ORS, keeps vomiting, less urine, drowsy, red flags
- Young infants: review within 48 h
- Path rejoins step 10Shared downstream outcome
- Moderate
16Action Moderate (5-9%): supervised ORS; NG if oral fails
ORS 50 mL/kg over 4 h plus maintenance, small frequent amounts. Ondansetron only if 6 months or older and not in long QT syndrome.
- ORS 50 mL/kg over 4 h plus maintenance; give small amounts often
- Persistent vomiting, age 6 months or more: ondansetron single oral dose: under 8 kg 0.15 mg/kg; 8-15 kg 2 mg; 15-30 kg 4 mg; over 30 kg 8 mg (off-label in Australia). Avoid in congenital long QT syndrome
- Oral fails: rapid NG ORS 10-25 mL/kg/h for 4 h
- Slow NG instead (5% deficit over 6 h, then maintenance) if: age <6 months, LRTI, meningitis, abnormal Na, abdominal pain or significant comorbidity
- No NG if: shock, altered conscious state, bilious vomiting or distension, facial or base of skull trauma
- Replace ongoing losses mL for mL with ORS
- Reassess hydration after 4 h
17Decision Rehydrated and tolerating ORS or NG?
Reassess after the rehydration phase (about 4 h).
- If Yes
- Path rejoins step 10Shared downstream outcome
If No- Path rejoins step 06Shared downstream outcome
- Severe
- Path rejoins step 06Shared downstream outcome
Guideline Source
RCH Melbourne Clinical Practice Guideline: Dehydration (April 2026), with RCH Gastroenteritis, Nasogastric fluids and Intravenous fluids CPGs
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Not for DKA, severe acute malnutrition, neonates under 28 days, burns or trauma, or heart, kidney or liver disease: use the specific guideline
- Rates are starting points: reassess hydration, weight and sodium often; Na under 135 or over 145 mmol/L needs senior advice
- Severe hypernatraemia (170 mmol/L or more) and hyponatraemic seizures need ICU care beyond this pathway
- Low-resource settings and cholera: follow WHO Treatment Plans B and C
Contraindicated Populations
neonates_under_28_daysdiabetic_ketoacidosissevere_acute_malnutritionheart_failure_or_significant_cardiac_diseasechronic_kidney_disease_or_renal_impairmentliver_diseaseburns_or_traumainborn_errors_of_metabolism
Applicable Regions
AUUSEUUK
AU: Hartmann's = compound sodium lactate (Ringer's lactate). Premixed 0.9% sodium chloride + 5% glucose with KCl 20 mmol/L is standard. Oral ondansetron for gastroenteritis is off-label in Australia. Retrieval: state paediatric retrieval service.
UK: NICE CG84 (under 5s) uses 10 mL/kg 0.9% sodium chloride boluses for shock and 50 mL/kg ORS over 4 h for clinical dehydration.
Global: Based on RCH Melbourne CPGs (Dehydration 2026, Gastroenteritis 2025, Nasogastric fluids 2026, Intravenous fluids 2026, Hypernatraemia 2020, Hyponatraemia 2023), NICE CG84 (2009) and AAP maintenance IV fluids CPG (Feld 2018, isotonic fluids).
Low-resource: WHO Treatment of diarrhoea (2005): Plan B ORS 75 mL/kg over 4 h; Plan C IV Ringer's lactate 100 mL/kg for severe dehydration; severe malnutrition needs a separate slow protocol.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Pediatric Dehydration and Fluid Resuscitation?
The Pediatric Dehydration and Fluid Resuscitation is a management clinical algorithm for Pediatrics. It provides a structured decision tree to guide clinical decision-making, based on RCH Melbourne Clinical Practice Guideline: Dehydration (April 2026), with RCH Gastroenteritis, Nasogastric fluids and Intravenous fluids CPGs.
What guideline is the Pediatric Dehydration and Fluid Resuscitation based on?
This algorithm is based on RCH Melbourne Clinical Practice Guideline: Dehydration (April 2026), with RCH Gastroenteritis, Nasogastric fluids and Intravenous fluids CPGs.
What are the limitations of the Pediatric Dehydration and Fluid Resuscitation?
Known limitations include: Not for DKA, severe acute malnutrition, neonates under 28 days, burns or trauma, or heart, kidney or liver disease: use the specific guideline; Rates are starting points: reassess hydration, weight and sodium often; Na under 135 or over 145 mmol/L needs senior advice; Severe hypernatraemia (170 mmol/L or more) and hyponatraemic seizures need ICU care beyond this pathway; Low-resource settings and cholera: follow WHO Treatment Plans B and C. Individual patient factors may require deviation from these recommendations.
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