Vomiting, Diarrhea, Assessment of dehydration, Management of

shock and Fluid therapy

• Identify the causes of diarrhea and vomiting

• Differentiate between infective versus non-infective causes

• Classify the severity of dehydration

• Formulate the emergency management of hypovolemic shock

• Determine fluid therapy after initial resuscitation (type & volume)

Vomiting

• forceful expulsion of gastric contents

• Often preceded by nausea

Regurgitation

• passive, non-forceful ejection of gastric

contents due to reflux through a relaxed

esophageal sphincter

Physiology of Vomiting

Classification of Vomiting • According to nature:

1. Projectile---------- ↑ ICP or pyloric stenosis

2. Non Projectile------ GERD or any other causes.

• According to quality :

1. Bilious ( dark green) ----------- Always pathological and indicate obstruction beyond the ampulla of vater.

2. Bloody: red blood-------- Upper GI or massive lower GI bleed, coffee ground--------- old upper GI or lower GI bleeding

3. Non bloody, non bilious: usually clear or yellowish with remnants of previously ingested food--------most types of vomiting.

Clinical Clues to Diagnosis

a) Age of the patient

b) Duration of symptoms

- Acute onset: infective origin(AGE, meningitis, sepsis), acute gastrointestinal obstruction(pyloric stenosis)

- Chronic onset: partial mechanical obstruction, motility disturbance, metabolic etiology.

• . • According to quality : 1.Bilious ( dark green) ----------- Always

pathological and indicate obstruction beyond the ampulla of vater.

2.Bloody: red blood-------- Upper GI or massive lower GI bleed, coffee ground--------- old upper GI or lower GI bleeding

3.Non bloody, non bilious: usually clear or yellowish with remnants of previously ingested food--------most types of vomiting.

c) Nature: 1. Projectile---------- ↑ ICP or pyloric stenosis 2. Non Projectile------ GERD or any other causes d)Timing

- Nocturnal & morning : GERD

- Soon after meal : Hyperthrophic Pyloric Stenosis ( common in infants)

- Delayed vomiting( after more than 1 hour ingested

food) : motility disorder

- Cyclic vomiting***

Cyclic Vomiting: • stereotypic recurrent episodes of nausea and

vomiting without an identifiable organic cause

• Idiopathic, happened in early childhood, unknown pathogenesis.

• Characterized by I. Numerous of vomiting interspersed with well intervals

II. Intervals of normal health between episodes

III. Episodes that are stereotypic with regard to symptom onset and duration

IV. lack of laboratory or radiographic evidence to support an alternative diagnosis

V. high intensity

e) Vomitus 1.Bilious (dark green)- indicate obstruction

beyond the ampulla of vater (intussusceptions,malrotation… )

2.Fresh Blood: upper GI bleed (Esophagitis, Peptic ulceration, Oral/nasal bleeding)

3.Coffee ground color : old upper GI or lower GI bleeding

4.Non bloody, non bilious(ingested food) - pyloric stenosis …

5.Feaculent : Lower intestinal obstruction

f) Associated features : • GI symptoms

– Anorexia, nausea, retching, abdominal pain (common), diarrhoea

• Neurologic symptoms – Headache, photophobia, neck stiffness

• UTI symptoms – Dysuria, hematuria, incontinence

• Other systemic reviews

Physical examination

Assess hydration status

Abdominal examination eg: to look for tenderness, organomegaly, abdominal distension, presence of bowel sounds.

Look for signs of severe infection eg: tense anterior fontanelle, meningism for meningitis.

Examine for extraintestinal cause such as inflamed tympanic membrane in otitis media and renal punch in pyelonepritis and neurological examination

Investigation

• Laboratory Investigations

– FBC, electrolyte ,BUN, ESR, venous blood gases, amylase

– Urine, blood, stool C&S

• GI radiology – Barium swallow/ meal, AXR, ultrasound abdomen, endoscopy

• Metabolic investigations – blood gas,ammonia, blood and urine organic acids

Management

• Depends on specific cause

• While investigating/ treating underlying pathology – replace lost fluids, maintain hydration

Causes of vomiting Infant Child(pre-school) School-age & Adolescent

•GERD(most common) •Over feeding •Infection : - Gastroenteritis - meningitis - whooping cough - Otitis media - UTI •intestinal obstruction - pyloric stenosis - Duodenal atresia - intussusception - malrotation - volvulus - hirschsprung ds •Congenital adrenal hyperplasia •Renal failure

•Gastroenteritis(most common) •Systemic infection •Intestinal obstruction •Whooping cough •GERD •Coeliac disease •Otitis media •Meningitis •Raised ICP

•Gastroenteritis(most common) •Peptic ulcer •Systemic infection - pyelonephritis - meningitis -septicaemia •Coeliac ds •Appendicitis •Migraine •Pregnancy •Medication •Bulimia •Anorexia

Diarrhoea

WHO definition: diarrhoea is the passage of three or more loose or liquid stools per day, or more frequently than is normal for the individual.

Excessive daily stool liquid volume (>10 mL stool/kg body

weight/day (Nelson , Essential of Paediatrics,5th Edition)

Normally, a young infant has about 5 g/kg of stool output per day

Childhood diarrhea represents an excessive loss of fluid and

electrolytes in stools and is defined quantitatively as a total daily volume exceeding 20g/kg.

Classification

• Acute < 2 weeks.

• Persistent 2- 4 weeks

• Chronic > 4 weeks.

Types of Diarrhoea

Primary Mechanism:

• Secretory

• Osmotic

• Inflammatory

• Motility related diarrhea

- Increased motility

- Decreased motility

• Decreased surface area

Secretory Diarrhoea

• In this type of diarrhea there is both active intestinal secretion and decreased absorption of fluid and electrolytes.

• Little or no structural defects.

• Produce watery, normal osmalality stools. No stool leucocytes detected in the stool examination.

• Persists during fasting .

• Common cause: a. Infection-cholera,E.coli

b. Bile salt malabsorption following ileal resection

c. Laxative(docusate sodium)

Osmotic Diarrhoea • Involve secretion of fluid into the bowel.

• This occurs because:

a. Ingestion of non absorbable substance(Magnesium Sulphate)

b. Patient has generalized malabsorption so that high concentration of solute remain in the lumen.

c. Patient has transport defects such as disaccharide deficiency(lactase) or glucose-galactose malabsorption .

• Diarrhea stops when stop eating the malabsorptive substance or fasting.

• The stool is watery, acidic with the presence of reducing substances. There is an increase osmolality . No stool leucocytes detected.

Inflammatory Diarrhoea • There is damage of the intestinal mucosal cell • Leads to loss of fluid and blood. • In addition, there is defective absorption of fluid and

electrolytes. • In stool examination, there is presence of blood and

increased WBCs. • Common cause are infective conditions (Shigella,

Salmonella) and inflammatory conditions(UC and CD)

Motility related Diarrhoe • It occurs due to abnormal motility of intestine

which is increase or decrease in motility.

A. Increased Motility

• Decreased transit time and increase frequency of defecation.

• Stool produced is loose to normal appearing stool, stimulated by gastro-colic reflex.

• Examples: Irritable bowel syndrome, post-vagotomy ,hyperthyroid and dumping syndrome.

B. Decreased motility

• due to defect in neuromuscular unit or stasis due to bacterial overgrowth.

• Stool is loose to normal appearing.

• Examples: 1) pseudoobstruction

2) blind loop

Decreased Surface Area • When there is decreased functional capacity.

• Produce watery diarrhoea.

• Examples: 1) short bowel syndrome

2) celiac disease

3) Rotavirus enteritis

• May require elemental diet plus parenteral alimentation.

Stool Characteristics Small Bowel Large Bowel

Appearance Watery Mucoid and/or bloody

Volume Large Small

Frequency Increased Increased

Blood Possibly positive but never gross blood Possibly grossly bloody

pH Possibly <5.5 >5.5

Reducing substances Possibly positive Negative

WBCs <5/high power field Possibly >10/high power field

Serum WBCs Normal Possible leukocytosis,

Organisms Viral Rotavirus Adenovirus Calicivirus Astrovirus Norwalk virus

Invasive bacteria E Coli Shigella species Salmonella species Campylobacter species Yersinia species Aeromonas species Plesiomonas species

Toxic bacteria E coli Clostridium perfringens Cholera species Vibrio species

Toxic bacteria Clostridium difficile

Parasites Giardia species Cryptosporidium species

Parasites Entamoeba organisms

Stool Characteristics & Their Soures

Investigations: • Stool analysis

Macroscopic appearance Causes

Blood E.Coli (enterohaemorrhagic) Colitis

Blood , pus Salmonella Shigella

Blood, mucus Inflammatory bowel disease

Watery Giardiasis Cryptosporidiosis

Rice-water stool Cholera

Frothy Carbohyrate intolerance

Bloodstained Campylobacter infection

• Stool culture & sensitivity

• Stool for Ova and Cyst

- Giardiasis, crytospridiosis

• Stool PH level

- <5.5 or presence of reducing substances indicates carbohydrate malabsorption.

• FBC, CRP, ESR

• UFEME

• BUSE

• Colonoscopy and endoscopy

- Non-infectious etiology

Causes of acute diarrhoea

Infant Child Adolescent

•Gastroenteritis •Systemic infection •Antibiotic associated

•Gastroenteritis •Food poisoning •Systemic infection •Antibiotic associated

•Gastroenteritis •Food poisoning •Antibiotic associated

Causes of chronic diarrhoea

infant child adolescent

•Postinfectious secondary lactase deficiency •Cow’s milk/soy protein intolerance •Chronic nonspecific diarrhoea of infancy •Celiac disease •Cystic fibrosis •AIDS enteropathy

•Postinfectious secondary lactase deficiency •Toddlers diarhea •Irritable bowel syndrome •Celiac disease •Lactose intolerance •Giardiasis •Inflammatory bowel disease

•GIT infection •Inflammatory bowel disease •Celiac ds •Lactose intolerance •Giardiasis •Laxative abuse(anorexia nervosa)

Organisms Presentation

Viral Rotavirus (commonest, up to 60% of cases in <2years of age)

Calicivirus (norovirus)

Astrovirus

Adenovirus

Watery stool - no blood @ mucus low grade fever, Vomiting Dehydration prominent

Bacterial Salmonella sp Typhoid fever - Dysentry

Yersinia enterocolitica Differs from child vs adult Infants and child: diarrhea Adult: lesions of terminal ileum @ mesenteric lympadenitis

Campylobacter jejuni Enterocolitis

Shigella Dysentery , High fever → febrile convulsions

V. Cholera/ ET E. coli / Vibrio parahaemolyticus

Travelers diarrhea Profuse, rapidly dehydrating diarrhoea)

Organisms Presentation

Parasites Giardiasis

Entameoba histolytica Acute onset , Ameobic dysentry

Cryptosporidium

Mild watery diarrhea (healthy) Severe prolonged diarrhea (immunocompromised)

Chemicals

•Nonabsorb laxative •Laxative abuse (anorexia nervosa ) •Antibiotic associated •Toxic ingestion •Excess fruit juice (sorbitol) ingestion

Malabsorbed substance/

malabsorption

Inflammation

•Lactose intolerance •Post infectious secondary lacrase deficiency •Pancratic insufficiency (cystic fibrosis ) -Steatorrhea, - Failure to thrive(FTT) •Cow’s milk/ soy product insifficiency •Celiac ds - FTT after introduce gluten, - Abdominal distension - Buttock wasting •Short bowel syndrome

•Inflammatory bowel disease •Crohn disease •Ulcerative Colitis •Irritable bowel ds •Necrotizing enterocolitis

Causes Causetive agents Presentation

Gastroenteritis Viral Fever Diarrhea Sudden onset Absence of pain

Bacterial Fever +/- bloody diarrhea

Extra-GIT Infection

Local infection

Otitis media Fever Ear pain/ discharge

UTI Dysuria Frequency, incontinence

URTI Difficulty in swallow Swollen tonsil

Pneumonia / LRTI

Cough Fever Post-tussive vominting Sputum in vomitus

Systemic infection

Septicaemia Seizures, diarrhea

Meningitis Photophobia, LOC, neck stiffness

Causes Example Presentation

Gastrointestinal GERD Effortless not preceded by nausea chronic

Peptic ulcer or gastritis

Epigastric pain Blood @ coffee ground vomitus Pain relieved by acid blockade

Hepatitis Jaundice , Hx of exposure

Appendicitis Fever Abd pain migrating to right lower quadrant/ tenderness

Allergic Milk @ soy product protein intolerance

Particular formula/ food Blood in stool

Other food allergic In older children

Causes Example Presentation

Anatomical obstruction

Intestinal atresia Neonate, premature ~ polyhydromnious

Midgut malrotation Sudden onset pain, GI bleed Shock

Intussusception Colicky pain Lethargy Red currant jelly stool Mass occsionally

Duplication of cyst Colicky pain Mass

Pyloric stenosis <4 months old Nonbilious vomiting, postprandial Hunger state Visible peristalsis wave

Causes Example Presentation

CNS causes (↑ ICP)

Migraine syndrome Relieved by sleep, headache

Hydrocephalus Large head, altered mental status

Cyclic Vomiting Syndrome

Repetitive migraine headache @ Symptoms of irritable bowel (nausea,vomiting, abd pain)

Brain tumors Morning vomiting Acceleratig over time Headache, diplopia

Metabolic disorder

IEM Galactosemia Adrenogenital syndrome DKA Liver failure

Presentation early in life, worsens when catabolic or exposure to substance

Others Overfeeding

Poisons/drugs Lead, digoxin, theophyllin, erythromycin

Dehydration

Causes of dehydration

Assessment of dehydration (History)

• Assess the onset, frequency, quantity and character of both vomiting and diarrhoea

• Recent oral intake

• Urine output

• Weight before illness

• Associated symptoms (fever, change in mental status)

• Past medical history (underlying medical problems, history of other recent infections, medications, immune compromised states)

• Social history

Physical Examination

• Accurate body weight • Vital signs (temperature, heart rate, respiratory rate,

blood pressure) • General conditions • Eyes: sunken eyes, presence / absence of tears • Mucous membrane – moist or dry • Respiratory pattern • Bowel sounds • Extremities (perfusion, capillary filling time) • Skin turgor (anterior abdominal wall) • Inspection of stool (presence of blood or mucous)

Investigation

• Depends on clinical assessment

– Renal profile

– Stool culture and sensitivity

– Urinalysis

– Full blood count

Assessment of dehydration

• Is essential for appropriate fluid management. • Repeated assessment is often necessary. • Most useful signs for significant dehydration

– Prolonged capillary refill time (normal < 2 seconds) – Reduced skin turgor – Abnormal respiratory pattern

Percentage loss of body weight

Previous BW not available: Clinical signs for dehydration

Simplified ways of classifying the degree of dehydration

Classification Fluid deficit as % of BW Fluid deficit in ml/kg of BW

No signs of dehydration < 3% < 30 ml/kg

Some signs of dehydration 3-9% 30-90 ml/kg

Severe dehydration > 9% > 90 ml/kg

Adapted from WHO 2005

Assessment of dehydration Symptom No signs of

dehydration (<3% loss of BW)

Mild to moderate dehydration (3-9% loss of BW)

Severe dehydration (>9% loss of BW)

Mental status Well, alert Normal/ fatigue/ restless/ irritable

Apathetic, lethargic unconscious

Thirst Drinks normally, might refuse liquids

Thirsty, eager to drink

Drinks poorly, unable to drink

Heart rate Normal Normal to increased

Tachycardia, with bradycardia in most severe cases

Quality of pulse Normal Normal to decreased

Weak, thready, or impalpable

Breathing Normal Normal, fast Deep

Continue…

Symptom No signs of dehydration (<3% loss of BW)

Mild to moderate dehydration (3-9% loss of BW)

Severe dehydration (>9% loss of BW)

Eyes Normal Slightly sunken Deeply sunken

Tears Present Decreased Absent

Mouth and tongue Moist Dry Parched (very dry)

Skin fold Instant recoil Recoil in < 2 seconds

Recoil in > 2 seconds

Capillary refill Normal Prolonged Prolonged, minimal

Extremities Warm Cool Cool, mottled, cyanotic

Urine output Normal to decreased

Decreased Minimal

Adapted from WHO 2005, CDC 2003

Pinching the child's abdomen to test for decreased skin turgor

Slow return of skin pinch in severe dehydration

Diffuse mottled, bluish-gray appearance of this infant's skin suggestive of systemic poor perfusion

Sunken eyes

Dry tongue

A bit on hypernatraemic dehydration…

• Cause

– Predominantly breastfed and were given inadequate breastfeeding

– Given inappropriately prepared infant formula

• Common symptoms – Hyperpnoea

– Muscle weakness

– Restlessness

– A characteristic high-pitched cry

– Insomnia

– Lethargy

– And even coma

– Convulsions are typically absent except in cases of inadvertent sodium loading or aggressive rehydration

EMERGENCY MANAGEMENT

1) Initial resuscitation

-Secure airway, support breathing & restore

circulation

2) Fluid Resuscitation

• Rapid restoration of intravascular volume

• Complications of rapid fluid given : Cerebral edema, hyponatremia, osmotic demyelination, death.

• Bolus 20 ml/kg of isotonic crystalloid over 5-10 minutes

• Assess vital signs and perfusion

1) Blood pressure

2) Quality of central and peripheral pulses

3) Skin perfusion

4) Mental status

5) Urine output

• If not improve, 20 ml/kg boluses to a total 60 ml/kg, ideally within first 30 to 60 minutes of treatment.

Further management

• Once the patient stable, find and treat the cause

• Continue fluid therapy

• Assess the sodium level

1) Normal isotonic saline

2) Mild to moderate hyponatremia isotonic saline

3) Severe serum sodium at rate 0.5 mEq/L per hour

FLUID THERAPY AFTER INITIAL RESUSCITATION

ORAL REHYDRATION THERAPY (ORT)

Process of replacing essential body fluids and salts that a child loses in critical quantities during attacks of diarrhoea.

Most often, diarrhoea kills a child by dehydration, which means that too much liquid has been drained out of the child's body. So as soon as diarrhoea starts, it is essential to give the child extra drinks to replace the liquid being lost.

ORT is the giving of fluid by mouth to prevent and/or correct the dehydration that is a result of diarrhoea. As soon as diarrhoea begins, treatment using home remedies to prevent dehydration must be started.

ORAL REHYDRATION SOLUTION (ORS)

• Commonly, Oral Rehydration Salts (ORS) solution is given to treat dehydration resulting from all types of acute diarrhoeal diseases.

• Glucose- electrolytes (salt) mixed solution.

• Used to treat mild and moderate dehydration.

• To treat low concentrations of electrolytes in the blood

(severe electrolyte depletion).

• Cheaper than IV therapy and has lower risk of complication.

•The New Reduced Osmolarity formula for the ORS packet recommended by WHO and UNICEF contains:

Osmolarity (ORS) mmol/litre

Sodium 75

Chloride 65

Glucose, anhydrous 75

Potassium 20

Citrate 10

Total Osmolarity 245

INTRAVENOUS FLUID Indication:-

• Severely dehydrated.

• Moderate dehydration if there is no improvement after ORS

• Unconscious child

• Continuing rapid stool loss (> 15-20ml/kg/h)

• Frequent, severe vomiting, drinking poorly

• Abdominal distension with paralytic ileus, usually caused by some anti-diarrhea drug ( eg; codeine, loperamide) and hypokalaemia

• Glucose malabsorption

Types of solution

Solution (mmol/L) Na K Ca Cl lactate

NS 0.9% 150 - - 150 -

0.45%NS in 5% dextrose (children) 77 - - 77 -

0.18 % NS in 4.0% dextrose (up to 2 year) 30 - - 30 -

Hartmann ‘s solution (Ringer’s lactate) 130 5 4 112 27

PLAN A: TREAT DIARRHOEA AT HOME Counsel mother on 3 rules :- 1. Give extra fluid

Breastfeed frequently Give 8 packets ORS to used at home

• Up to 2 years : 50-100ml after each loose stool • ≥ 2 : 100-200ml after each loose stool

Give frequent small sips from a cup or spoon If chlid vomit, wait 10 minutes then continue but more slowly Continue giving extra fluid until diarrhea stop

2. Continue feeding But avoid food with high simple sugar (osmotic load may worsen

diarrhea)

3. When to return to the health facility Not able to drink, breastfeed or drinking poorly Becomes sicker Fever Blood in stool

PLAN B: TREAT SOME DEHYDRATION WITH ORS

1. Give recommended amount of ORS over first 4-hour period:-

2. Inform mother to:- • Give frequent small sips from cup or spoon

• If child vomit, wait 10 minutes then continue but more slowly

• Continue breastfeeding whenever child wants

3. After 4 hours:- • Reassess child and classify child for dehydration

• Select appropriate plan to continue (Plan A, B or C)

4. If mother must leave before completing treatment:- • Give her enough ORS packets to complete rehydration and 8 packets as

recommended in Plan A

• Explain the 3 Rules (Plan A)

Age Up to 4 months 4-12 months 1-2 years 2-5 years

Weight <6kg 6 - <10kg 10 - <12kg 12-19kg

In ml 200-400 400-700 700-900 900-1400

PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

Start IV/IO immediately

• if child can drink, give ORS by mouth while drip is being set up

• give 100ml/kg Ringer lactate or normal saline :-

1st give 20ml/kg ASAP (repeat fluid boluses until perfusion improved)

then give 80ml/kg over 5 h(age ≤ 12 m) or 2h 30 mnt (age >12m)

• reassess child after every bolus and stop bolus once perfusion improve or when fluid overload suspected

• reassess child every 1-2 h during rehydration

• give ORS (5ml/kg/h) as soon as child can drink

• reassess an infant after 6h and child after 3h. Classify dehydration and choose appropriate plan

If IV/IO line fail to set up

arrange for the child to be sent to nearest centre

meanwhile as arrangements are made to send the child, try further attempts :-

• try to rehydrate child with ORS (20ml/kg/h over 6h orally/orogastric tube. Continue to give ORS along the journey

• reassess child every 1-2 h

• give fluid more slowly if repeated vomiting or increasing abdominal distension

• reassess child after 6h classify dehydration choose appropriate plan

Fluid Therapy Calculation Fluid deficit (ml) = % dehydartion X BW in grams

Type of fluid solution:

1/5 normal saline 5 % dextrose solution or 1/2 normal saline 5 % dextrose with or without added KCl in the drip

Maintenance fluid:

Total fluid required (ml) = fluid deficit + maintenance fluid given over 24 hours

Age Maintenance Fluid Required

< 6 months 150 ml/kg/day

6 months to 1 year 120 ml/kg/day

> 1 year

a)first 10 kg

b)Second 10 kg

c)Subsequent kg

100 ml/kg

50 ml/kg

20 ml/kg

EXAMPLE 8 months old child weighing 5kg is 5% dehydrated and not tolerate oral intake.

Rehydrating over 24 hours

1. Fluid deficit 5% x 5000 = 250ml

2. Fluid maintenance 120ml/kg/24h

120ml x 5kg = 600ml /24 h

3. Total fluids in first 24 hours 250ml + 600ml = 850ml

4. Rate of infusion 850ml/24h = 35ml /h

Age Maintenance Fluid Required

< 6 months 150 ml/kg/day

6 months to 1

year

120 ml/kg/day

> 1 year

a)first 10 kg

b)10 – 20 kg

c)> 20 kg

100 ml/kg

+ 50 ml/kg for next 10 subsequent kg

+ 20 ml/kg for any subsequent kg

EXAMPLE 12 years old child weighing 30kg is 5% dehydrated and not tolerate oral intake.

Rehydrating over 24 hours

1. Fluid deficit 5% x 30000 = 1500ml

2. Fluid maintenance First 10kg = 100ml/kg x 10kg = 1000ml

Second 10kg = 50ml/kg x 10kg = 500ml

Next 10kg = 20ml/kg x 10kg = 200ml

Total = 1700ml

3. Total fluids in first 24 hours 1500ml + 1700ml = 3200ml

4. Rate of infusion =3200ml/24h = 133ml /h

Age Maintenance Fluid Required

< 6 months 150 ml/kg/day

6 months to 1 year 120 ml/kg/day

> 1 year

a)first 10 kg

b)Second 10 kg

c)Subsequent kg

100 ml/kg

50 ml/kg

20 ml/kg

Hyponatraemic Dehydration

Definition = serum Na⁺ <130 mmol/l

ORS solution is a safe and effective therapy for nearly all children with hyponatraemia

1/2 normal saline 5 % dextrose with 20 mEq/L KCl

Daily Na+ requirement 2 – 3 mmol/kg/day

Na+ deficit (140 – serum Na+) x 0.6 x weight (kg)

Hypernatraemic Dehydration

Definition = serum Na⁺ > 150mmol/l If child shock, first resuscitation then rehydrate with ORS over 48 to 72

hours If fluid has been given to resuscitate, amount given should be

subtracted from the fluid deficit (important to avoid giving too much fluid)

Reduce serum Na+ slowly and not exceed 10 mmol/L per 24 hours (dramatic fall lead to cerebral oedema and seizures)

Use normal saline 5 % dextrose for the duration of fluid replacement until serum Na+ is < 145 mmol/L

Then use 1/2 NS 5 % dextrose or 1/5 NS 5 % dextrose Add KCl after the child passes urine Monitor blood urea serum electrolytes 6 hourly