What is the best method of assessing dehydration in a toddler?

Fluid and electrolyte needs from basal metabolism must also be accounted for. Maintenance requirements are related to metabolic rate and affected by body temperature. Insensible losses (evaporative free water losses from the skin and respiratory tract) account for about one third of total maintenance water (slightly more in infants and less in adolescents and adults).

Maintenance fluid volumes can be given as a separate simultaneous infusion, so that the infusion rate for replacing deficits and ongoing losses can be set and adjusted independently of the maintenance infusion rate.

Baseline estimates are affected by fever (increasing by 12% for each degree > 37.8° C), hypothermia, and activity (eg, increased for hyperthyroidism or status epilepticus, decreased for coma).

The traditional approach to calculating the composition of maintenance fluids was also based on the Holliday-Segar formula. According to that formula, patients require

• Sodium: 3 mEq/100 kcal/24 hours (3 mEq/100 mL/24 hours)

• Potassium: 2 mEq/100 kcal/24 hours (2 mEq/100 mL/24 hours)

(NOTE: 2 to 3 mEq/100 mL is equivalent to 20 to 30 mEq/L [20 to 30 mmol/L].)

Due to this possibility of iatrogenic hyponatremia, many centers are now using a more isotonic fluid such as 0.45% or 0.9% saline for maintenance in dehydrated children. The most recent American Academy of Pediatrics' clinical practice guideline (2018) recommends all patients 28 days to 18 years of age receive isotonic solutions with appropriate potassium chloride and dextrose as maintenance IV fluids. This change also has the benefit of allowing use of the same fluid to replace ongoing losses and supply maintenance needs, which simplifies management. Although practice variation still exists in choosing appropriate maintenance IV fluids, all clinicians agree the important point is to closely monitor dehydrated patients receiving IV fluids, which includes monitoring of serum electrolyte levels.

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