Maintenance Fluid requirement & Diarrhoea management Children😊

Fluids and Electrolytes

Fluid Requirement in Neonate

• Based on birth Weight & day of life (in ml/kg/day)
• <1500 gm: 80ml /kg/day
• >1500 gm: 60ml /kg/day
• By the end of 1st week — 150 ml/kg/day

• Example:
• Neonate of weight 3 kg:
• Day 1 — 3x60=180ml— 12 feeds — 15 ml/feed

• Important Information
• Q. Which fluid to give?
• 1st 48hrs. of life:
• 10% dextrose alone
• After 48 hrs.:
• NS in 5% dextrose with 1ml KCL/100 ml

Management of Shock in Children

• Medical emergency

• Airway, Breathing, Circulation, Disability, Exposure

• Start oxygen

• Wide bore IV access

• Wide-spectrum IV antibiotics

• Fluid Boluses of Crystalloids
• Eg: RL >> NS
• 20ml/kg up to 3 times
• If not having cardiac problems

• If not improving
• Start inotropes
• Epinephrine/Norepinephrine
• If not improving
• IV hydrocortisone
• Mechanical ventilation
• ECMO (Extra Corporeal Membrane Oxygenation)

• Recent Updates
• Protocolised approach not preferred.
• Individualized approach to suit patient physiology & settings.
• Crystalloids Are Preferred
• Deresuscitation
• Restricting Maintenance fluid after initial resuscitation
• Use of diuretics
• Advantage:
• More ventilation-free days \& shorter ICU stays (Faster recovery)
• Decreases complications of fluid overload

Fluid Resuscitation in a Child with Burns

Diarrhea management PSM

• Definition: ≥3 loose/watery stools in 24 hrs.

• Based on consistency, not quantity.

• Mothers often detect abnormal stools early.

• Dangers:
• Dehydration
• Electrolyte imbalance

Enteroviral diarrhea

• Causes Isotonic dehydration with acidosis

Acute Diarrhea in Children

• Definition:
• Passage of 3 or more loose liquid or watery stools in a day.

• Rotavirus
• M/c/c of diarrhoea in children
• M/c/c of death by diarrhoea in children < 5 years (29%)
• Most common cause of diarrhea in adults is Norovirus

• Most common cause of constipation in children
• Functional or habitual due to improper toilet training.

• MC metabolic abnormality:
• Isonatremic dehydration +
• metabolic acidosis +
• hypokalemia.

• Altered sensorium/Seizures in a child with diarrhea:
• Severe dehydration,
• Hypo/Hypernatremia
• Cerebral sinus thrombosis.

Clinical Types

Acute Watery Diarrhea

• Duration:
• hours to days

• Dangers:
• Dehydration
• Weight loss (if feeding stops)

• Pathogens:
• V. cholerae
• E. coli
• Rotavirus (most common in children)

Acute Bloody Diarrhea (Dysentery)

• Dangers:
• Intestinal mucosal damage
• Sepsis
• Malnutrition
• Dehydration

• Visible blood in stool

• Most common cause: Shigella

Acute (< 6 hrs)

• Chinese food (emetic): B. cereus

• Dairy: S. aureus

Acute (> 6 hrs)

Bloody diarrhea

• Poultry, eggs: Salmonella

• Severe dehydration: Shigella

• Reiter syndrome, rashes in knees: Shigella
• She () was Right ()

• GBS, Reiter syndrome: Campylobacter
• Camp- giardia
• Campylobacter- gbs

• Uremia, anemia: EHEC O157:H7

• Longitudinal ulcer: Typhoid

• Transverse ulcer: TB

• Flask-shaped ulcer: Amoebic

CHRONIC Diarrhea:

• Stool osmotic gap = 290 - 2 x (stool Na + stool K)

• < 50 → Secretory diarrhea → Causes:
1. Gastrinoma (ZES)
2. Carcinoid → Serotonin

• > 50 → Osmotic diarrhea → Resolve upon fasting

Oral Rehydration Solution (ORS)

ORS Contents

Component	Standard (mEq/L)	Reduced Osmolarity (mmol/L)
Glucose	111	75
Sodium	90	75
Chloride	80	65
Potassium	20	20
Citrate	10	10
Osmolarity	311	245 mOsm/L
ㅤ	ㅤ	Sodium (75) chloride (65) Potassium (20) Citrate (10)

Reduced Osmolarity ORS Ingredients (g per 1L)

Component	g/L
Glucose (anhydrous)	13.5
Trisodium citrate hydrate	2.9
Sodium chloride	2.6
Potassium chloride	1.5
Total	20.5 g

• Use 1 packet in 1L water.

• Consume within 24 hours.

Special ORS Types

• Resomal (for malnourished): Na 45, K 40
• For SAM children
• Not freely available (costly)
• more potassium
• less sodium
• some minerals.

• Super ORS:
• Uses rice/non-starch sugars (glycine, alanine)
• Low shelf life

Which and how much maintenance fluid to use?

• In children
• NS with 5% dextrose
• + 1 ml KCl/100 ml
• (20 meq/L of K+)
• 1 mL KCl = 2 meq KCL
• For 1st 10 kg:
• 100 ml/kg
• Next 10 kg:
• 50 ml/kg
• Beyond 20 kg:
• 20 ml/kg

• Example:
• Weight of child = 18kg
• For 1st 10kg = 10x100=1000ml
• For next 8kg = 8x50=400ml
• So, child needs 1400 ml of IV fluid in 24 hours

Degree of Dehydration

• ≥ 2 signs of some dehydration or severe dehydration
• ≥ 1 of the signs of
• sensorium,
• thirst
• skin pinch
• Falsely slow in malnutrition
• it indicates dehydration.

Treatment Plans

Plan A: No Dehydration

• Home management

• 4 rules of home treatment:
• Extra fluid
• Zinc
• Continue feeding
• Return if danger signs

• Replacement of ongoing losses by WHO ORS
• 5-10 ml/kg/loose stool
• <2 years: 50–100 ml
• ≥2 years: 100–200 ml

Zinc supplementation (for 14 days):

• Duration is 10-14 days.

• How to give:
• Infants: Dissolve in breast milk, ORS, or clean water.
• Older: Chew or dissolve in water.
• If vomiting, wait 10 min, resume slowly.

Plan B: Some Dehydration

• Treat with ORS at clinic over 4 hours.

• Amount for first 4 hours:
• 75 ml/kg over 4 hours
• [If cannot accept orally, give IV fluid].
• 0 or New born → 200ml
• New born till 1 year → 200ml + 50ml per month
• After 1 year till 5 years → 800ml + 200ml per year

Age	ORS (ml)
Up to 4 months <6 kg	200–450
4–12 months 6 – < 10 kg	450–800
12 months–2 years 10–< 12 kg	800–960
2–5 years 12–19 kg	960–1600

• Infants <6 months (not breastfed):
• Give 100–200 ml clean water additionally.

Plan C: Severe Dehydration

• Start IV fluids immediately.

• 100 ml/kg extra fluid:
• Fluids:
• Ringer lactate or NS
• For children,
• Ringer lactate in 5% Dextrose> Ringer lactate/Normal Saline.

• Allow breastfeeding and semi-solid diet.

• IV Fluid Rate:

Age	30 ml/kg (initial)	70 ml/kg (follow-up)	Total (100ml/kg)
<12 months	Over 1 hour	Over 5 hours	6 hours
12 mo – 5 years	Over 30 minutes	Over 2.5 hours	3 hours

• Monitor and replace ongoing losses.

Treatment of Acute Diarrhea in Children

• Treatment or prevention of dehydration.

• Maintain Normal Diet.

• No role of antibiotics.
• Except
• Dysentry
• Cholera
• Systemic sepsis

• Dextrose containing fluid alone should not be used.

Persistent Diarrhea in Children

• Definition:
• Acute diarrhea at least 14 days.

• Management:
1. Correction of dehydration.
2. Supplement Zinc, Vit A.
3. Dietary modification.
• Diet A (Reduced lactose diet).
• Diet B (Lactose-free diet with reduced starch).
• Diet C (Monosaccharide-based diet).

• Osmotic diarrhea:
• Diarrhoea improves when the child is not fed for 24 hours.

Antibiotic Guidelines

Key Public Health Facts

• 📌 National ORS Day: 29th July