Volume depletion in children

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

enteric losses

with mild or moderate volume depletion

1st line – oral rehydration solution (oral route)

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1st line –

oral rehydration solution (oral route)

Mild to moderate volume depletion is indicated by normal mental status, hemodynamic stability, and only mildly altered vital signs (e.g., minor degree of tachycardia).

Enteral replacement of fluid volume deficit and ongoing losses is appropriate for patients with mild or moderate dehydration.

Commercially available oral rehydration solutions (ORS) have a formulation close to that of the WHO-recommended ORS and may be used. Fluids such as carbonated beverages, fruit juice, or plain water should not be used.

Frequent small volumes, with gradual advancement as tolerated, is preferred. A general guideline is to give 50-100 mL/kg of ORS over 2-4 hours.[13][17]

Plus – age-appropriate diet

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Plus –

age-appropriate diet

Treatment recommended for ALL patients in selected patient group

"Gut rest" has no role in gastroenteritis. Breastfed infants should continue nursing in addition to receiving oral rehydration solution.

Age-appropriate diets should be instituted early in the course of gastroenteritis-associated mild or moderate volume depletion. Foods high in sugar and carbohydrates should be avoided.

Consider – antiemetic

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Consider –

antiemetic

Treatment recommended for SOME patients in selected patient group

Not commonly used in pediatric patients to treat vomiting related to acute gastroenteritis, but occasionally used in patients who are clinically stable and are unable to take adequate oral hydration.[31][32]

Ondansetron, in a disintegrating tablet formulation, has been studied for use in this clinical situation in a large, randomized, controlled study.[32]

Although other antiemetics are sometimes used in pediatric patients, they are generally not substantiated in the literature.

Primary options

ondansetron: children 8-15 kg: 2 mg orally (disintegrating tablet) as a single dose; children 16-30 kg: 4 mg orally (disintegrating tablet) as a single dose; children >30 kg: 6-8 mg orally (disintegrating tablet) as a single dose

2nd line – oral rehydration solution (nasogastric route)

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2nd line –

oral rehydration solution (nasogastric route)

Nasogastric administration of oral rehydration solution is rapid and efficacious for children who have mild to moderate volume depletion, and who are unable or unwilling to drink.

It may even be tolerated by many children with vomiting. Potential advantages of the nasogastric route include more rapid initiation of treatment, ease of nasogastric placement compared with intravenous placement (particularly in very young and dehydrated patients), and lower cost.

Potential disadvantages include risk for continued vomiting, ileus, displacement, and aspiration. Interestingly, parents are equally satisfied with nasogastric and intravenous treatments.[34]

Consider – antiemetic

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Consider –

antiemetic

Treatment recommended for SOME patients in selected patient group

Antiemetics may be indicated even in children receiving nasogastric therapy.

Ondansetron, in a disintegrating tablet formulation, has been studied for use in this clinical situation in a large, randomized, controlled study.[32]

Although other antiemetics are sometimes used in pediatric patients, they are generally not substantiated in the literature.

Primary options

with severe volume depletion or unable to tolerate enteral rehydration

1st line – intravenous isotonic crystalloid

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1st line –

intravenous isotonic crystalloid

Severe volume depletion, which is indicated by an altered mental status and hemodynamic instability, is a medical emergency and must be treated aggressively with intravenous isotonic crystalloid solutions. The intravenous route may be preferred if enteral administration is not tolerated.

If symptoms do not improve after 40-60 mL/kg of isotonic saline, other etiologies (e.g., anaphylaxis, hemorrhage, intoxication, concomitant cardiovascular dysfunction) should be considered. However, children presenting in hypovolemic shock may require additional fluid replacement before shock is reversed.[5][44][45]

Careful consideration of the individual circumstances of each patient and available resources should be part of the assessment of the risks versus the benefits of different strategies for volume repletion.

2nd line – intraosseous isotonic crystalloid

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2nd line –

intraosseous isotonic crystalloid

If intravenous access cannot be obtained within the first 5 minutes, an intraosseous line should be placed. The proximal tibia and distal femur sites are frequently used.

Isotonic crystalloid is given in boluses of up to 20 mL/kg. This is repeated until the estimated deficit is restored or normal hemodynamic values, particularly heart rate and urine output, are well established. However, if symptoms do not improve after 40-60 mL/kg of isotonic saline, other etiologies (e.g., anaphylaxis, hemorrhage, intoxication, concomitant cardiovascular dysfunction) should be considered.

hemorrhagic losses

1st line – intravenous isotonic saline + surgical consultation

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1st line –

intravenous isotonic saline + surgical consultation

Initial treatment is with 20 mL/kg of isotonic crystalloid solution.[5][8] This can be repeated until signs of hemodynamic instability are improved with potential need for blood products/transfusion.

In addition, hemostasis is essential for correcting volume depletion. Occult bleeding is more common in children, due to patterns of trauma injury.[8]

Occult trauma should be considered in an infant or a young child presenting with altered mental status and signs of volume depletion who does not respond to crystalloid administration. A head and abdominal ultrasound or CT should be considered.

Consider – packed red blood cell transfusion

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Consider –

packed red blood cell transfusion

Treatment recommended for SOME patients in selected patient group

In cases of significant hemorrhagic losses when adequate oxygen delivery to vital organs is not maintained with crystalloid alone, blood products need to be repleted.

Generally, 5-10 mL/kg of cross-matched blood is given. In cases of active hemorrhage associated with hemodynamic instability, giving unmatched blood (trauma pack) may be necessary. Simultaneous consultation with a pediatric trauma team is indicated.

Attaining hemoglobin >10 mg/dL improves outcomes in children with shock.[24][47]

Consider – fresh frozen plasma + platelets

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Consider –

fresh frozen plasma + platelets

Treatment recommended for SOME patients in selected patient group

Coagulopathic patients with ongoing losses may require replacement of clotting factors for hemostasis. Platelets and fresh frozen plasma are given if bleeding is ongoing, blood loss is massive, or the patient has received massive transfusion (50% of total blood volume).

skin losses

exercise induced or heat stroke: mild to moderate and tolerating enteral rehydration

1st line – enteral oral rehydration solution + environmental control

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1st line –

enteral oral rehydration solution + environmental control

Mild to moderate volume depletion is indicated by normal mental status, hemodynamic stability, and only mildly altered vital signs (e.g., minor degree of tachycardia).

Initial management is with enteric replacement with oral rehydration solutions (ORS). Commercially available ORS have a formulation close to that of the WHO-recommended ORS and may be used.

Frequent small volumes, with gradual advancement as tolerated, is preferred. A general guideline is to give 50-100 mL/kg of ORS over 2-4 hours, similarly to treatment of mild to moderate volume depletion in children with enteral losses.[13][17]

In addition, environmental control is important. The patient should be moved to a neutral ambient temperature.

Consider – subsequent hypotonic oral solution

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Consider –

subsequent hypotonic oral solution

Treatment recommended for SOME patients in selected patient group

In cases of skin loss from excessive sweating, the fluid lost is relatively hypotonic. After intravascular volume is restored, relatively hypotonic solutions can be used to restore total body water deficit.

exercise induced or heat stroke: severe or unable to tolerate enteral rehydration

1st line – intravenous isotonic saline

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1st line –

intravenous isotonic saline

Severe volume depletion is indicated by an altered mental status and hemodynamic instability.

Initial treatment is with intravenous isotonic saline 20 mL/kg, repeated as necessary to restore normal hemodynamics.

Consider – subsequent intravenous hypotonic saline

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Consider –

subsequent intravenous hypotonic saline

Treatment recommended for SOME patients in selected patient group

After intravascular volume is restored, in cases of skin loss from excessive sweating, relatively hypotonic solutions (e.g., 0.45% normal saline) can be used with caution to restore total body water deficit if indicated by persistent hypernatremia. Whenever hypotonic fluids are delivered, frequent monitoring of electrolytes to ensure detection of rapid changes in serum sodium is recommended.

with burns

1st line – intravenous isotonic saline

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1st line –

intravenous isotonic saline

Volume losses can be extremely high in patients with significant burns, requiring urgent hemodynamic stabilization and transfer to highly specialized burn centers.[51]

All patients with burns >10% total body surface area (TBSA) should be resuscitated with isotonic saline solution delivered intravenously.

Advanced Burn Life Support (ABLS) Guidelines state that pediatric patients (12 years or younger) with nonelectrical burns should receive 3mL/kg/%TBSA of isotonic crystalloid (ideally lactated Ringer’s solution) in the first 24 hours. Pediatric electrical burns should receive 4mL/kg/%TBSA.[52] One half of this total volume should be delivered in the first 8 hours, and the remainder over the next 16 hours in addition to maintenance intravenous fluids.[53] Maintenance fluids should include dextrose; 5% dextrose in lactated Ringer’s solution is recommended by ABLS Guidelines. Resuscitation should be titrated hourly to urine output (0.5 mL/kg/hour for children weighing >30 kg or 1 mL/kg/hour for children weighing ≤30 kg) until the fluid rate is decreased down to the maintenance rate.[52] Children with larger burns or who are hemodynamically unstable may require resuscitation in excess of these amounts.

Consultation with burn specialists and transfer to a burn unit for optimal care should be considered.

Plus – appropriate wound care

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Plus –

appropriate wound care

Treatment recommended for ALL patients in selected patient group

Appropriate wound care is required.

renal losses

with diabetic ketoacidosis

1st line – intravenous isotonic saline

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1st line –

intravenous isotonic saline

In these patients, volume depletion is mostly due to renal water loss associated with glycosuria. A reasonable approach is to administer 10-20 mL/kg of normal saline intravenously over the first 20-30 minutes, and the remaining fluid deficit plus the weight-based maintenance fluid requirement, with either 0.45% or 0.90% normal saline, over the next 24-48 hours while monitoring closely for signs of cerebral edema.[9][55][56]

Cerebral injury occurs frequently and with varying severity in children with DKA; however, evidence suggests that this is due to cerebral hypoperfusion and the hyperinflammatory state caused by DKA, rather than rapid fluid administration.[9][57]

Managing a young child in DKA can be complicated by late presentation, new diagnosis, underestimated degree of illness, and high insulin sensitivity leading to hypoglycemia.

Plus – intravenous insulin therapy

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Plus –

intravenous insulin therapy

Treatment recommended for ALL patients in selected patient group

Insulin therapy guided by specialist protocols is required. Giving insulin subcutaneously to young children presenting in DKA, particularly with a new diagnosis of diabetes mellitus, is not advised.

Primary options

insulin regular: consult specialist for guidance on dose

with central diabetes insipidus

1st line – enteral hypotonic oral rehydration

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1st line –

enteral hypotonic oral rehydration

Volume depletion from renal losses other than DKA is uncommon. Of other rare causes, an unlikely but possible presentation is in children with central diabetes insipidus.

Volume depletion may present in children with known central diabetes insipidus because of interrupted normal treatment. Rarely, patients with history of head trauma or brain tumor are at risk of developing new central diabetes insipidus, which results in dehydration, sometimes associated with volume depletion.

Enteral replacement is generally sufficient. As water losses are primary, hypotonic solutions may be used.

Consider – desmopressin

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Consider –

desmopressin

Treatment recommended for SOME patients in selected patient group

The safety and efficacy of desmopressin injection for treating diabetes insipidus have not been established in children <12 years old. However, intranasal desmopressin therapy is given to patients previously known to have diabetes insipidus who present in hypovolemic shock that is clearly attributable to or complicated by unregulated diabetes insipidus.

Additional fluid therapy is discontinued as soon as volume is adequately replaced.

Primary options

desmopressin nasal: children 3 months to 12 years: 5-30 micrograms/day intranasally given in 1-2 divided doses; children ≥12 years: 10-40 micrograms/day intranasally given in 1-2 divided doses

2nd line – intravenous hypotonic solution

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2nd line –

intravenous hypotonic solution

If patients cannot tolerate oral replacement, intravenous hypotonic solution (e.g., one quarter normal saline) may be used.

Consider – desmopressin

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Consider –

desmopressin

Treatment recommended for SOME patients in selected patient group

Additional fluid therapy is discontinued as soon as volume is adequately replaced.

Primary options

desmopressin nasal: children 3 months to 12 years: 5-30 micrograms/day intranasally given in 1-2 divided doses; children ≥12 years: 10-40 micrograms/day intranasally given in 1-2 divided doses

diuretic overuse

1st line – enteral oral rehydration solution

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1st line –

enteral oral rehydration solution

Diuretic overuse can result from accidental ingestions in toddlers or rarely, Munchausen by proxy. These patients should be treated with enteral oral rehydration solution (ORS) (as for enteral losses).

Commercially available ORS have a formulation close to that of the WHO-recommended ORS and may be used.

Diuretic overdose may result in electrolyte abnormalities that require correction. Serum electrolytes should be monitored.

septic shock

1st line – intravenous isotonic crystalloid

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1st line –

intravenous isotonic crystalloid

Sepsis is usually associated with elements of hypovolemia from decreased intake, increased insensible losses, gastrointestinal losses, and third spacing (loss to the extravascular space).

Pediatric Surviving Sepsis Campaign guidelines recommend that if a critical care facility is available initial fluid resuscitation should be provided with intravenous isotonic crystalloid fluids in boluses of 10-20 mL/kg administered over the first hour until the patient has reversal of shock (i.e., a normal heart rate and BP for age, capillary refill less than 2 seconds, normal mental status, and adequate urinary output). If fluid resuscitation results in new hepatomegaly or pulmonary edema, or if there are persistent signs of shock after 40-60 mL/kg of isotonic fluid has been given, vasoactive therapy should be initiated.[22]

If a critical care facility is not available and hypotension is present, pediatric Surviving Sepsis Campaign guidelines recommend that up to 40 mL/kg in bolus fluid (10-20 mL/kg per bolus) should be administered over the first hour with titration to clinical markers of cardiac output. Fluid boluses should be discontinued if signs of fluid overload develop. In the absence of hypotension, bolus fluid administration is not recommended and maintenance fluids should be started.[22]

Plus – broad-spectrum antibiotics

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Plus –

broad-spectrum antibiotics

Treatment recommended for ALL patients in selected patient group

After obtaining blood cultures, empiric broad-spectrum antibiotics, which take into account local susceptibility and infectious patterns, should be given promptly. It is important to give broad-spectrum antibiotics as soon as possible and always within 1 hour of recognition of septic shock.[22]

Common regimens include ampicillin and gentamicin in neonates, and third-generation cephalosporins, such as ceftriaxone plus vancomycin, in older children. Additional coverage for gram-negative organisms, Pseudomonas species, fungal pathogens, and resistant Staphylococcus aureus will be guided by the patient's medical history and clinical presentation.

Primary options

ampicillin: consult specialist for guidance on neonatal doses

and

gentamicin: consult specialist for guidance on neonatal doses

vancomycin: infants and children: 15 mg/kg intravenously every 6 hours

and

ceftriaxone: infants and children: 100 mg/kg intravenously every 24 hours

Consider – vasopressor + blood products + advanced monitoring

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Consider –

vasopressor + blood products + advanced monitoring

Treatment recommended for SOME patients in selected patient group

Hemodynamic support with infusion of vasopressor agents may be required. There is no adequate evidence that any one vasopressor agent is a superior choice compared with another and specific choice may be individualized.[59] Consult a specialist for guidance on choice of vasopressor and dose.

Correcting coagulopathy and anemia may also be necessary for optimal management.

Patients requiring vasopressors or deteriorating despite crystalloid need to be transferred to ICU for advanced monitoring.

anaphylactic shock

1st line – epinephrine (adrenaline) + intravenous or intraosseous isotonic saline

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1st line –

epinephrine (adrenaline) + intravenous or intraosseous isotonic saline

Patients with anaphylaxis classically manifest in distributive shock, in which severe systemic vasodilation and capillary leak causes underperfusion of vital organs despite normal total body volume status. While not technically volume depletion, the clinical presentation of a child in anaphylaxis has some overlap with patients presenting in hypovolemic shock, with altered mental status, tachycardia, and low BP. Infants and toddlers may report age-specific symptoms of anaphylaxis that are different from older children and adults. For example, skin symptoms and subtle behavioral signs (pulling/scratching/fingers in ear, withdrawal, inconsolable crying, irritability, or clinging) may be more common in infants and younger children, while respiratory symptoms may be more common in older children.[60]

Initial acute therapy is with intramuscular epinephrine. This may be given by a self-injectable device.[60][61]

In addition, intravenous saline 10 mL/kg is given (repeated as necessary to restore intravascular volume and hemodynamic stability).[61][62] The intraosseous route may be used if gaining intravenous access is not possible.

Corticosteroids and/or antihistamines are no longer recommended for the initial emergency treatment of anaphylaxis.[63]

Primary options

epinephrine (adrenaline): 0.01 mg/kg (1 mg/mL solution) intramuscularly every 5-10 minutes according to response, maximum 0.3 mg/dose

epinephrine (adrenaline): (auto-injector) children 7.5 to <15 kg body weight: 0.1 mg intramuscularly as a single dose, may repeat once after 5-15 minutes; children 15-30 kg body weight: 0.15 mg intramuscularly as a single dose, may repeat once after 5-15 minutes; children ≥30 kg body weight: 0.3 mg intramuscularly as a single dose, may repeat once after 5-15 minutes

Consider – vasopressor + transfer to intensive care unit (ICU)

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Consider –

vasopressor + transfer to intensive care unit (ICU)

Treatment recommended for SOME patients in selected patient group

Refractory anaphylaxis may require ongoing vasopressor support. There is no adequate evidence that any one vasopressor agent is a superior choice compared with another.[59] Consult a specialist for guidance on choice of vasopressor and dose. The patient is transferred to the ICU.

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Volume depletion in children

Treatment algorithm

enteric losses

oral rehydration solution (oral route)

age-appropriate diet

antiemetic

Primary options

oral rehydration solution (nasogastric route)

antiemetic

Primary options

intravenous isotonic crystalloid

intraosseous isotonic crystalloid

hemorrhagic losses

intravenous isotonic saline + surgical consultation

packed red blood cell transfusion

fresh frozen plasma + platelets

skin losses

enteral oral rehydration solution + environmental control

subsequent hypotonic oral solution

intravenous isotonic saline

subsequent intravenous hypotonic saline

intravenous isotonic saline

appropriate wound care

renal losses

intravenous isotonic saline

intravenous insulin therapy

Primary options

enteral hypotonic oral rehydration

desmopressin

Primary options

intravenous hypotonic solution

desmopressin

Primary options

enteral oral rehydration solution

septic shock

intravenous isotonic crystalloid

broad-spectrum antibiotics

Primary options

vasopressor + blood products + advanced monitoring

anaphylactic shock

epinephrine (adrenaline) + intravenous or intraosseous isotonic saline

Primary options

vasopressor + transfer to intensive care unit (ICU)