Pediatric Dehydration and Fluid Resuscitation (AAP/WHO)

Algorithm Steps

1. ▶

   Start

   Pediatric Dehydration Assessment

   Child with fluid loss or decreased intake

   1. ●

      Action

      Assess Degree of Dehydration

      Clinical assessment

      • MILD (3-5%):
      • • Slightly dry mucous membranes
      • • Normal capillary refill, good skin turgor
      • • Normal mental status, alert
      • MODERATE (6-9%):
      • • Dry mucous membranes, decreased tears
      • • Delayed capillary refill (2-3 sec)
      • • Decreased skin turgor (1-2 sec tenting)
      • • Irritable or lethargic
      • SEVERE (≥10%):
      • • Very dry mucous membranes
      • • Cap refill >3 sec, tenting >2 sec
      • • Tachycardia, weak pulses
      • • Lethargy, sunken eyes, sunken fontanelle
      1. ◆

         Decision

         Signs of Shock?

         Hypovolemic shock assessment

         • SHOCK PRESENT IF:
         • • Tachycardia with weak/absent pulses
         • • Hypotension (late sign)
         • • Delayed capillary refill >4 sec
         • • Altered mental status
         • • Cold, mottled extremities
         1. ●

            Action

            Bolus Resuscitation for Shock

            Rapid IV/IO fluid resuscitation

            • NS or LR 20 mL/kg IV bolus over 5-20 min
            • Reassess after each bolus
            • May repeat x2-3 if needed
            • Max typically 60 mL/kg in first hour
            • REASSESS AFTER EACH BOLUS:
            • • HR, BP, cap refill, mental status
            • • Avoid fluid overload (pulmonary edema)
            1. ●

               Action

               Severe Dehydration - IV Fluids

               IV rehydration required

               • PHASE 1: Deficit replacement
               • NS 20 mL/kg bolus, then assess
               • PHASE 2: Replace deficit
               • Calculate: Weight × % deficit × 10 = mL deficit
               • Replace over 24-48 hours
               • Use isotonic fluids (NS or LR)
               • Add dextrose if hypoglycemic
               1. ●

                  Action

                  Maintenance Fluids

                  Use isotonic fluids for maintenance

                  • USE ISOTONIC FLUIDS:
                  • NS (0.9% NaCl) or LR with dextrose
                  • HOLLIDAY-SEGAR (4-2-1 rule):
                  • • First 10 kg: 4 mL/kg/hr
                  • • Next 10 kg: 2 mL/kg/hr
                  • • Each kg >20: 1 mL/kg/hr
                  • Add KCl 20-40 mEq/L once urinating
                  • Check electrolytes q6-12h
                  1. ●

                     Action

                     Monitor Response

                     Reassess frequently

                     • Track I/O strictly
                     • Weigh daily (same scale)
                     • Monitor for hyponatremia
                     • Target urine output 1-2 mL/kg/hr
                     • IMPROVING:
                     • • HR normalizing
                     • • Mental status improving
                     • • Urine output increasing
                     • • Weight stabilizing
                     1. ✓

                        Outcome

                        Discharge When

                        Safe for home

                        • Tolerating oral fluids
                        • Urine output adequate
                        • Mental status normal
                        • Parents understand ORS use
                        • Follow-up plan in place
         2. ●

            Action

            Mild Dehydration - ORS

            Oral rehydration therapy at home

            • ORAL REHYDRATION SOLUTION (ORS)
            • 50 mL/kg over 3-4 hours
            • Small, frequent sips
            • Continue breastfeeding
            • Avoid sugary drinks (juice, soda)
            • Follow up if not improving in 24h
         3. ●

            Action

            Moderate Dehydration - ORS Trial

            Supervised ORS with backup plan

            • ORAL REHYDRATION:
            • 100 mL/kg over 3-4 hours
            • Supervised in ED/clinic
            • If vomiting: Give small amounts frequently (5mL q1-2min)
            • Ondansetron may help: 0.15 mg/kg (max 8mg)
            • If ORS fails → IV fluids