Dehydration in children

Caring for a child with dehydration is a common occurrence in acute paediatric settings and as such, the ability to recognise and treat this condition is a vital skill for nurses who care for children. Failure to appropriately recognise dehydration when it occurs can lead to fast deterioration of the child's clinical condition and can be fatal. Children are more likely to become dehydrated than adults and often deteriorate quicker than adults when unwell, so the nurse caring for this patient group is required to respond with speed and skill to provide the appropriate care at the right time.

Nurses caring for children are likely to be required to treat numerous cases of dehydration throughout their careers as febrile illnesses and diarrhoea with or without vomiting are the second and third most commonly presented medical problems to emergency departments for children aged 0–15 years (Sands et al, 2012).

Inadequate treatment

Children are more likely to experience dehydration than adults because water constitutes a greater proportion of bodyweight in children than in adults (World Health Organization, 2009). Furthermore, the younger the child, the poorer the ability of their kidneys to conserve water, and children use more water over the course of 24 hours than adults due to their higher metabolic rates (World Health Organization, 2009).

A child or baby who ‘appears unwell’ because of dehydration may present with any of the following:

• increased irritability, lethargy or a change in normal behaviour
• sunken eyes or dark circles under the eyes
• dry mouth and lips
• low blood pressure
• high heart rate
• weak peripheral pulses
• reduced elasticity of skin
• capillary refill time of more than 2 seconds
• urine output less than 1 ml per hour in children or 2 ml per hour in infants
• loss of skin colour or mottled skin
• cooler than usual extremities

Recognition of the dehydrated child is a key skill for nurses caring for this patient group. Assessment of all deteriorating or critically ill patients should always follow the ABCDE approach:

• Airway
• Breathing
• Circulation
• Disability
• Exposure (Resuscitation Council UK, 2021)

During the ABCDE assessment, if the nurse suspects dehydration, they should consider whether the child appears unwell, has altered responsiveness (for example, is irritable or lethargic), has decreased urine output or has an increased heart or elevated respiratory rate (National Institute for Health and Care Excellence (NICE), 2009).

Recognition of the seriousness of the condition of a child with dehydration can sometimes be difficult on initial presentation as the child may at first appear to be quietly sleeping or undisturbed by assessment. Caution should be taken in these circumstances to ensure that the sleep is not a symptom of altered responsiveness and that the child receives a full and thorough assessment.

Treatment for dehydration in children is escalated according to the severity of the dehydration and may occur in one of the three following ways:

• oral rehydration
• maintenance fluids
• fluid resuscitation (NICE, 2020)

Any patient who requires treatment for dehydration should be monitored through the use of a fluid balance chart. This chart should include hourly documentation of the patient's input and output with 12-hourly fluid balance subtotals and 24-hourly totals (NICE, 2020). Weight should be measured before treatment and every 24 hours, with any difference between the two calculated (NICE, 2020).