Nursing Care of Children with Fluid

and Electrolvte Disorders

Julie Davis Lander, R. N., B.S., M. A?

Nursing care of the pediatric patient requires a fouhdation of specific knowledge. A difficult and sometimes baffling component of nursing care of children is fluid and electrolyte management. It is essential for nurses to understand major principles regarding fluid and electrolyte balance to enhance their observation and intervention skills. Major principles guiding nurses who care for pediatric populations are:

1. Infants and small children have different proportions of body water and body fat than do adults. a. The body water of newborns approaches 80 percent of body

weight compared to that of average adult males, which approaches 60 percent.

b. Normal infants demonstrate rapid physiological decline in the ratio of body weight t o body water during the immediate post- partum period.

c. Proportions of body water decrease more slowly throughout in- fancy and reach the value for adults by approximately 2 yearsof age.

2. The percentage of body water contained in the extracellular com- partment is greater for infants and small children than for adults. a. Infants retain one-half of their body water in the cell.

*Assistant Professor, College of Nursing, University of Tulsa, Tulsa, Oklahoma.

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42 Issues in Comprehensive Pediatric Nursing

b. Adults retain two-thirds of their body water in the cell. 3. The water turnover rate per unit of body weight is three times

greater in infants and small children, than it is in adults. a. The metabolic rate of children is about three times that of adults. b. The immaturity of the kidney in infants may impair their ability

4. In sum, infants and children are more vulnerable to disorders of hy- dration than adults (e.g., children are prone to severe disturbances of the GI tract that result in diarrhea and vomiting).‘

to conserve water.

UNIQUENESS OF THE CHILD

The body fluids are a heterogeneous mixture of fluids differing in quan- tity, quality, reaction to change, and response to disorders that threaten homeostasis. Total body water is a term used to indicate all the fluids of the body except those that exist within the gastrointestinal (GI) and genito- urinary (GU) tracts.2 Total body water can be divided into fluid within the cells (intracellular) and fluid external to the cells (extracellular). Extra- cellular fluid can be further broken down into fluid within the vascular system (blood volume) and fluid outside the blood vessels (interstitial fluid).

To understand the pediatric conditions of fluid management, five major concepts must be emphasized. First, the total body water in infants is about 750 ml/kg body weight as compared to 550 ml/kg in adult^.^ The additional body water in children under 2 years of age does not provide a safety factor because the turnover of water is higher than in adults.

Second, because weight increases more rapidly than surface area over the growth period, there is a proportionate increase in the volume of the extracellular fluid with respect to the rate of water expenditure4 Although infants have relatively more body water than adults, they also have a rela- tively greater surface area.

More of the infant’s body is on the surface and less inside as compared to the adult’s body.4 As the bones, muscles, and internal organs of the child develop, the surface of the body makes up a smaller proportion of the total body structure. Because an infant has a greater surface area, basal heat production per kg of body weight is about twice as rapid as that of an adult.4 Insensible losses per kg are also about twice as great. An adult has greater amounts of bone and other connective tissues that consume less oxygen, thus creating less body heat p r o d ~ c t i o n . ~

Table 1 illustrates how much more rapidly body weight increases than does surface area.4 At 10 years of age, weight has increased ten times compared to surface area, which has increased five times. Since insensible water losses are determined by surface area, the infant is more vulnerable to abnormal water losses than the adult.

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Fluid and Electrolyte Disorders 43

Table 1. Relationship of Growth Parameters

Weight vs . Surface area Infant 6 mo 1 Yr 10 yr Adult

Weight (kg) 3.4 7.4 10.0 31.0 70.0

Height (cm) 50.0 66.0 75.0 139.0 170.0

Surface area (m) 0.21 0.36 0.45 1.12 1.75

Reprinted with permission from Burke, S.: The Composition of Body Fluids. St. Louis, C.V. Mosby, 1976.

Third, the infant's greater energy metabolism also requires increased water expenditure by the kidneys. In comparison, minimal urine output for a 70 kg adult is about 500 m1/24 hours and minimal output for a 7 kg child is 100 ml versus 50 m1/24 hours (table 2).4 2

Fourth, the plasma Na' (sodium) in the newborn infant is almost 10 mEq/L higher than that of the adult, although this difference disappears by the end of the first week of life.3 K' (potassium) is about 5.5 mEq/L at birth, becoming normal by the third or fourth day.3' Mg" (magnesium) and Ca'" (calcium) are both low in the first 24 hours; after birth, they gradually rise.3 Phosphate is high at birth and falls slowly over the first year to normal adult level^.^

Finally, infants and young children have higher metabolic rates and

Table 2. Daily Fluid Losses in Males Weighing 7 and 70 kg

Average Loss

Type of Loss 7 kg Male (ml/kg)

Insensible loss 45 .O 22.5

Renal loss 40.0 20.0

Loss in stools 10-15 2.5

Average totals 95-100 45.0

Reprinted with permission from Graef, J.: Manual of Pediarric Therapeutics. Boston, Little Brown, 1974, p. 90.

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44 Issues in Comprehensive Pediatric Nursing

different fluid requirements than adults. Adults as well as infants require about 100 in1 of water per 100 calories metabolized, but an infant expends 100 calories per kg of body weight and an adult expends only 40 calories per kg. Adults can go without food for several days without developing ketosis, but fasting infants can develop ketonuria very quickly.

DEHYDRATION

Because the fluid and electrolyte balance of infants and young children is very labile, nurses can frequently care for children manifesting some degree of dehydration. Dehydration refers to a reduction in the volume of body fluids. In the most common situations, this reduction is distributed throughout the total body water in such a way that blood volume, extra- cellular fluid, and intracellular fluid are all decreased. Dehydration can be caused by a primary reduction i n intake of fluids that cannot be balanced by sufficient reduction in output, by an increase in output that cannot be offset by increased intake, or by a combination of both decreased in- take and increased output.' It should be stressed that if intake ceases and output is not modified, the infant will lose his total extracellular fluid in less than 3 days, but the adolescent will not reach that loss until 6 days.7 With absence of intake, infants dehydrate approximately twice as rapidly as adolescents. Dehydration can be categorized in relation to seventy as ( 1 ) mild, (2) moderate, or (3) severe, and to tonicity as (1) isotonic, ( 2 ) hypertonic, or ( 3 ) hypotonic.

Five percent mild dehydration, a loss of 50 ml of body fluid per kg of body weight, is considered to be the mildest level at which clinical signs of dehydration appear.' Observable signs of dehydration may take the form of tachycardia and dry mucous membrane^.^ Since this is not a reliable indication in all infants, the mucous membranes need to be in- spected carefully between the gums and cheek. In the presence of fluid volume deficit, an infant can have a drawn facial expression with the appearance of sunken eyes, a depressed anterior fontanel, and pallor indicating poor peripheral circulation.'O

Body temperature and respirations are important observations in evaluating an infant's state of hydration." In the presence of fever, there is an increase in insensible water loss. The higher the fever, the greater is the fluid loss. Subnormal temperatures are often present in dehydrated infants because they have a decreased energy output. Accelerated re- spirations can also deplete body water and lead to dehydration.

Ten percent moderate dehydration, a loss of 100 ml of body fluid per kg of body weight, is hazardous.12 Dry mucous membranes, poor skin turgor, cyanosis of the extremities, sunken eyes, absence of tearing, and a depressed anterior fontanel become apparent. Renal function is suf- ficiently reduced and metabolic acidpsis is present. Accurate monitoring

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Fluid and Electrolyte Disorders 45

of intake and output as well as of body weight is required. The child should be weighed on the same scale and at the same time each day. Weighing should be done before the child has eaten and after voiding.

Fifteen percent severe dehydration, loss of 150 ml of body fluid per kg of body weight, produces the occurrence of shock.12 The sensorium is depressed, blood pressure is decreased, the pulse is rapid and weak, and cardiac sounds are distant and faint. Renal function is impaired, produc- ing elevated creatinine and urea nitrogen levels. Potassium levels are elevated with high, pointed T waves, an absence of P waves, and a widening QRS complex.12

When the net deficit of water is greater than the net deficit of solute, fluids become concentrated or hypertonic. When loss of solute exceeds loss of water, the body fluids become more dilute or hypotonic. When loss of solute and loss of water are proportional, the body fluids retain their usual concentration and isotonicity.

Isotonic Dehydration In the first stage of most forms of dehydration, the body fluids remain

isotonic since the kidney is able to compensate for any disparity between water and solute loss by producing urine of opposite composition." It is only at the second stage of dehydration, when the kidney no longer has the capacity to make this adjustment or when other factors have inter- vened to prevent further renal compensation, that hypertonicity or hypo- tonicity ensues.

Hypertonic Dehydration Conservation of water by the kidneys is limited in a young child; thus, a

hypotonic fluid loss can lead to hypertonic dehydration. Na' levels rise to 150 mEq/L thus initially increasing serum osmolarity. In addition to the fact that the kidney is unable to create urine that is hypertonic, hypotonic intake may not be sufficient.

Another problem that has increased the incidence and severity of hyper- tonic dehydration is misuse of high solute feedings in the treatment of diarrhea.' These consist of improperly diluted commercial and prescrip- tion salt and carbohydrate solutions for home treatment of gastroenteritis.

Nurses need to be aware of several clinical manifestations of hypertonic dehydration:

1. Doughiness of the subcutaneous tissue has frequently been reported as a sign of hypertonicity, but it is highly variable in frequency and onset such that little reliance is placed on the absence of this finding."

2. Shock occurs less frequently because of the better maintenance of extracellular fluid volume in hypertonic dehydration.'

3. Nevertheless, it is essential to remember that the actual extent of de- hydration is greater than that suggested by loss of skin turgor, dry-

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46 Issues in Comprehensive Pediatric Nursing

ness of mucous membranes, absence of tearing, or depression of an- terior fontanel.

4. The brain volume shrinks away from the skull as cellular fluid is lost.' The greater tension on bridging vessels between the skull and brain cause brain hemorrhage and central nervous system depression. Unusual irritability, twitching, or seizure activity reflect central ner- vous system impairment.

Hypotonic Dehydration Hypotonic dehydration occurs primarily when intake is more hypo-

tonic than output. Low plasma Na' concentration, less than 130 mEq/L, may result from water intoxication due to overadministration of nonelec- trolyte fluids.

Clinical observations that need to be noted by the nurse are: 1 . Decreased skin turgor, dryness o f the mucous membranes, depression

o f the anterior fontanel, and a sunken appearance of the eyes. 2. Shock. Due to the diminished vascular volume, shock is easily mani-

fested. I t can happen with less total body water loss than in any other form of dehydration.' With the relatively greater reduction in blood volume, the urine output soon decreases.

3. Changes in the central nervous system. These changes, apparent in water intoxication,' * are a result of intracellular hypotonicity that appears to alter the conductivity of the cells and increase the cell water. Water moves into the brain faster than Na' moves out, causing acute nausea, vomiting, headaches, and convulsions.

CONTROL OF EXTRACELLULAR FLUID

When the extracellular fluid volume is decreased, thirst may develop, but the child may be unable to swallow owing to dry mucous membranes. Communicating the desire to drink is an additional problem in caring for a young child or infant.

Plasma tonicity can stimulate antidiuretic hormone (ADH) release. ADH increases reabsorption of water in the distal tubules and collecting ducts. This action decreases urine output, increases urine osmolarity, elevates specific gravity, increases urine Na' concentration, decreases plasma osmo- larity, and decreases plasma Na' Concentration.' Aldosterone can be re- leased to enhance tubular resorption of Na'. Aldosterone secretion plays an important role in the control of extracellular fluid (ECF) volume, as this volume depends mainly on the amount of Na' that the secretion c o n tains.'

NURSING RESPONSIBILITY IN ADMINISTRATION OF INTRAVENOUS FLUIDS

Great responsibility and extreme caution need to be exercised while

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Fluid and Electrolyte Disorders 47

delivering parenteral fluids to a child. The child's condition must be re- assessed at frequent intervals to reevaluate the fluid requirements. The clinical status of infants can deteriorate or improve remarkably in a few hours. Because of the danger of overtransfusion, the nurse must watch carefully for signs of tachypnea, rapid pulse, elevated central venous pres- sure (CVP), distended neck veins, and peripheral edema." Pediatric in- fusion sets with a graduated chamber must be used to make titration of the fluid safer and to facilitate accurate hourly recording of the infused amount. To ensure safety, a hemostat should be placed between the large reservoir bottle and the increment chamber. Quantities of less than 150 ml should be used with children under 2 years of age, quantities of less than 250 ml used with children under 5, and quantities of less than 500 ml used with children under Nurses are encouraged to use microdrop ap- paratus which delivers 60 drops/ml. Since microdrops per minute equal ml per hour, nurses can easily check the infusion rate of the IV. Infusion pumps (e.g., IVAC) also assist in delivering small amounts to a child. It is important, however, not to become dependent upon infusion pumps be- cause machinery may fail.

Rapid injection of certain substances can be fatal. Potassium induced ventricular fibrillation can occur or rapid Ca++ infusion may cause cardiac arrest, which is preceded by bradycardia.20 Cat' infusions should never be given without monitoring the pulse.

Nurses must routinely unwrap dressings over IV sites to check for infil- tration and infection. If an IV or cut down site becomes infected, the site should be changed and appropriate therapy begun. Sloughing can occur due to extravasation of hypertonic fluids, inadvertent administration into an artery, or pressure necrosis.20 Adequate padding is essential, especially beneath the heel, when veins in the dorsum of the foot are used.

COMPLICATIONS OF FLUID AND ELECTROLYTE IMBALANCE

Electrolyte derangement may occur in association with fluid loss; how- ever, many times the critical problem is acidosis.21 Potassium loss from diarrhea may potentiate the development of shock by decreasing the ef- ficiency of cardiac muscle contractility, thereby lessening cardiac output. Although loss of body fluid may produce changes in Na' concentration, many pediatric patients with dehydration do not have these changes; that is, only 20 to 25 percent have hypernatremic changes.22 The appearance of Na' imbalance is related to the age of the child, the cause of fluid loss, the length of time over which the loss has occurred, and the type of fluid intake during the time of A high incidence of hypematremia in the young infant is associated with an abrupt decrease in fluid intake. Loss of fluid by fever in older children will also produce dehydration with an increase in blood Na+.23

Hyponatremic dehydration, which constitutes 10 percent of all diarrhea

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48 Issues in Comprehensive Pediatric Nursing

cases, may occur when the child has prolonged diarrhea accompanied by intake of large amounts of water without electrolytes. The infant who has a history of diarrhea, refuses formula, and drinks only water is a prime candidate for this form of d e h y d r a t i ~ n . ~ ~ Diarrhea containing bicarbonate will usually precipitate metabolic acidosis. This is true even if the fluid losses are not sufficient to lead to shock.

Vomiting may produce a loss of acids, which in turn may promote alka- losis leading to convulsions. For infants in this situation, the fluid loss may still outweigh the H' ion loss.2s Infants experience a decrease in blood volume from moderate losses of extracellular fluid. Electrolyte Replacement

Maintenance electrolyte therapy is always necessary to replace the normal urinary, fecal, and skin losses of sodium, chloride, and potassium. The appropriate requirements can also be determined on the basis of caloric expenditure. One can assume that children usually need 3 mEq Na, 2 niEq C1, and 2 mEq K per 100 K calories per day to meet their electrolyte main- tenance requirements.26 These electrolyte requirements usually do not need to be altered when the maintenance water requirement is varied. This quantity of sodium should not be given to patients with heart failure or liver disease. Because surgical procedures may cause excessive tissue loss of' K', potassium should be omitted if the child is oliguric, in shock, sus- pected of having adrenal insufficiency, or in the immediate postoperative pcnod. Glucose must also be included to prevent acidosis and ketosis and t o lessen protein catabolism.

SUMMARY

I n sum, parenteral fluids are used whenever a child is unable to ingest the amount o f water and electrolytes needed to meet the ongoing daily physiological losses of water and electrolytes. Many infants and children with diarrhea do not require parenteral fluid therapy. The decision for the use of oral rather than parenteral therapy rests on clinical appraisal of the patient. If there are signs of circulatory insufficiency, lethargy, vomiting, or GI distention, an IV must be instituted. In the absence of these findings and with only mild signs of dehydration, mixtures of sugar and electrolytes as described above may be fed. Parenteral therapy is indicated for infants when amounts in excess of 1.5 L per day are required to meet continued stool losses.'

With complete omission of oral feedings to infants with moderately severe diarrhea, frequency and volume of stools will usually subside rapidly (within 48 hours). When this occurs, and if gastric distention and vomiting are absent, oral feedings of glucose, carbohydrate, and electrolyte mixtures may be initiated. Commercial mixtures such as Lytren are available. Mix-

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Fluid and Electrolyte Disorders 49

tures must be compounded exactly as prescribed since hyperosmolarity may result from a more concentrated solution. It is also important not to overload the child with electrolyte free solutions because water intoxica- tion may result. When the infant tolerates the carbohydrate and electro- lytes by mouth, calories can be increased gradually along with fat and protein (tables 3 and 4).27,28

In young infants with a family history of allergies, the use of hypo- allergenic feeding mixtures such as Nutramigen or soybean is recommended

Table 3. Composition of Oral Fluids

Fluid Na' K' c1- Solute Calories (mEq/L) (mOsm/L) (kcal/L)

Water 0 0

Sugar water (5%)" 0

Lytren 25

Pedialyte 30

Coca-Cola 0.5

Pepsi Cola 7

Ginger Ale 3

Seven-Up 7.5

Orange juice 2

Gatorade .23

Boiled skimmed milk? 27

One-half boiled skimmed milk$ 13

0

0

25

20

13

1

1

0.5

48

2.5

43

21

0

0

30

30

0

0

1

0

2

31

15

0 0

0 200

135 280

115 280

27 435

15 480

1 0 380

15 420

100 410

50 167

350 410

175 205

Note.-This table presents the electrolyte, solute, and caloric content of commonly used fluids given to infants who are unable to take their usual food intake. Reprinted with permission from Weil, W.: New York, GNne and Stratton, 1977, p. 111.

Fluid and Electrolyte Metabolism in Infants and Children.

*Prepared at home by using 3 tablespoons/quart of water.

?Assuming no evaporation. In practice, boiling creates an evaporative loss, producing higher values than those shown.

$This term refers to equal amounts of water and skimmed milk.

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50 Issues in Comprehensive Pediatric Nursing

Table 4. Compositions of Milks and Milk-type Formulas

Solution Solute Concentrations

Pro- tein” Na’ K+ Ca* MgX Cl PO

Cow’s milk

IIurnaii’s milk

En famil (20 kcalloz)

Isomil (20 kcal/oz)

Meat base

Mull-Soy

Nut raniigen

Sirnilac 13 (1 3 kcal/oz)

Sirnilac 20 (20 kcal/oz)

Similac PM 60/40

SMA (20 kcal/oz)

Sobee

Soyalac liquid -~

3.3

1.2

1.5

2 .o 2.8

3.1

2.2

1.2

1.8

1.6

1.5

3.2

2.1 -

25

7

11

13

17

16

20

10

11

7

6.4

22

14 __

35

14

19

18

12

40

27

15

19

14.8

14.1

32

23 __

65

16.5

27

35

53

64

54

22.4

35

17.5

22

54

21

10

3.2

. . .

...

. . .

. . .

. . .

2.2

3.4

3.3

4.3

...

. . . -

30

12

13

15

. . .

. . .

22

. . .

15

13

10.3

. . .

. . . __

60

8.7

27

. . .

40

48

42

20.3

32

10.5

19

30

18 -.

Note. - Adapted by permission from Committee on Nutrition, American Academy of Pediatrics: Commentary on breast-feeding and infant formulas including proposed standard for formulas. Pediatrics 57:278, 1976. Reprinted with permission from Weil, W.: Fluid and Electroiyte Metab- olism in Infants and Chiidren. New York, Gmne and Stratton, 1977, p. 291.

*Protein in g/dl: all others in mEq/liter.

because of the permeability of the GI tract to whole protein at this age. Nurses have great responsibility in caring for children with fluid and

electrolyte imbalances. Because of the physiological differences previously discussed, the margin for error in nursing observation and intervention is greatly diminished. An understanding of basic fluid and electrolyte dif- ferences between the adult and child should assist the nursing team in sharpening observation skills. Only then can appropriate nursing interven- tion be implemented.

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Fluid and Electrolyte Disorders 51

REFERENCES

1. The Lippincott Manual o f Nursing Practice, 2nd ed. Philadelphia, J.B. Lippincott, 1978, p. 1404.

2. Weil, W.: Fluid and Electrolyte Metabolism in Infants and Children. New York, Grune and Stratton, 1977, p. 3.

3. Shoemaker, W.: Fluid and Electrolyte Therapy in Acute Illness. Chicago, Year Book Medical Publishers, 1970, p. 185.

4. Burke, S.: The Composition and Function of Body Fluids. St. Louis, C.V. Mosby, 1976, p. 2.

5. Graef, J.: Manual of Pediatric Therapeutics. Boston, Little Brown, 1974, p. 90.

6. Weil, op. cit., p. 90. 7. Ibid., p . 91. 8. Ibid., p. 96. 9. Nelson, W.E., et al.:

10. Burke, op. cit., p. 87. 1 1. Haddow, J. : Understanding and managing hypernatremic dehydration.

12. Weil, op. cit., p. 97. 13. Nelson, op. cit., pp. 220-222. 14. Kemp, H.: Current Pediatric Diagnosis and Treatment. Los Altos,

15. Weil, op. cit., p. 113. 16. Gellis, S. : Current Pediatric Therapy. Philadelphia, W.B. Saunders,

17. Dube, S.: Immediate Care of the Sick and Injured Child. St. Louis,

18. Weil, op. cit., p. 125. 19. Kemp, op. cit., p. 992. 20. Ibid., p. 1007. 2 1. Burgess, A. : The Nurse’s Guide to Fluid and Electrolyte Balance. New

York, McGraw-Hill, 1970, p. 383. 22. Finberg, L.: Dehydration secondary to diarrhea. In The Critically Ill

Child, edited by Smith, C.A., Philadelphia, W.B. Saunders, 1972, pp.

Textbook o f Pediatrics, 9th ed. Philadelphia, W.B. Saunders, 1969, p. 228.

Pediatr. Clin. North Am. 21(2):436, 1974.

Calif., Lange Medical Publications, 1978, p. 998.

1976, p. 757.

C.V. Mosby, 1978, p. 131.

2 14-2 1 5.

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52 Issues in Comprehensive Pediatric Nursing

23. Burgess, op. cit., p. 384. 24. Dube, op. cit., p. 130. 2.5. Scipien, G. : Comprehensive Pediatric Nursing. New York, McCraw-

26. Smith, 11.: Introduction to Clinical Pediatrics. Philadelphia, W.B.

1'7. Weil, op. cit., p. 11 1. 28. (hid., p. 291.

Hill. 1979, pp. 75 1-754.

Saunders, 1977, p. 381.

BIBLIOGRAPHY

I . Davis, D.: The declining incidence of infantile hypernatremic dehydra- tion in Great Britain. Am J. Disabled Child 133: 148-150, 1979.

2. Odland, J.: Hyponatrernia. Heart and Lung : 587-592, 1978.

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