Beat Silent Dehydration in Children with Fever: Fluid, Electrolytes, and Energy to Aid Faster Recovery

By Prof. Dr N. L. Sridhar, Safe Children’s Clinic, Secunderabad

Fever can lead to dehydration in your child

During the growing-up years, fever in infants and children is the most common reason for parents to seek medical care. Viral infections are by far the most common cause of fever in children. What tends to get missed during fever are the signs of dehydration. Dehydration during fever should not be taken lightly as it may delay the recovery process.

What is Dehydration: Dehydration means a significant reduction or depletion of body fluids due to either excessive losses, reduced intake, or both. All types of lost fluid contain electrolytes in varying quantities, so fluid loss is always accompanied by some degree of electrolyte loss. This is referred to as silent dehydration as it can be missed due to a lack of awareness. Silent dehydration is a widespread concern globally, and fever is one such occasion that may lead to dehydration.

Electrolytes are minerals that carry an electric charge. Electrolytes play an important role in the proper functioning of multiple organs of the body like nerves, muscles, brain and heart. Sodium and chloride help regulate the water levels in your body and acid-base balance. Calcium and potassium are involved in the contraction of muscles and transmission of nerve impulses. Magnesium is involved in muscular contraction and relaxation as well as the release of chemical messengers for the transmission of nerve impulses.

Why are children more prone to dehydration?

Dehydration can affect everyone, but certain individuals are more prone to it. Among these, infants and children are particularly vulnerable to dehydration. Due to their higher body surface area to volume ratio, children have a larger body surface to lose fluids through the skin when they have a high fever. The body surface area to volume ratio is the total surface area of the body in proportion to body size or volume. A higher value of this ratio means higher skin or body exposure to the environment. Young children often struggle to communicate their thirst or drink water on their own, which results in cases of dehydration.

The correlation between dehydration and fever is well established. Children with a high degree of fever >40°C (104°F) are at higher risk of dehydration. Children with fever may reduce fluid consumption, which makes them prone to further loss of fluids and electrolytes by increased sweating. With every degree Celsius increase in body temperature, fever causes fluid losses of more than 10%. A clinical study showed that over 25% of infants who visited the Pediatric Emergency Department due to fever were found to be dehydrated. Moreover, fever increases energy expenditure by 11% for every degree rise in temperature.

What about energy deficits?

Children have higher metabolic needs . In addition, a child being unwell has poor intake of food along with fluids, which further makes them more susceptible to dehydration and energy deficits.

Impact of Fluid, Electrolyte, and Energy Deficits:

Children with dehydration and energy deficits may show the following common symptoms in case of mild to moderate dehydration:
 Dry mouth/tongue
 Thirst  Weakness/ tiredness, headache
 Dizziness 1

In a subgroup of a knowledge, attitude, practices survey involving 123 paediatricians, it was found that these fluid, electrolyte, and energy deficits in fever have a high impact on recovery.

How can oral electrolyte drinks tackle dehydration during fever?

In the same study, it was found that 88% of paediatricians agreed that fluid, electrolyte, and energy advise given to patients with fever as adjuvants can help improve the speed of recovery. It is crucial to address fluid, electrolytes, and energy losses in children with fever as these deficits may impact the speed of recovery. Although water is essential for bodies, it may not be enough to address the fluid and electrolyte deficits in fever. Therefore, maintaining a proper balance of fluids, electrolytes, and energy is essential for recovering from fever.

Oral rehydration has been recommended for mild to moderate dehydration. Fluid intake should be increased by 20% during fever episodes regardless of the underlying cause. The Indian Academy of Pediatrics emphasizes keeping children well hydrated during fever as they may lose more fluids during fever. While electrolytes can be replenished with WHO ORS, it is best suited mainly for diarrheal conditions.

In conditions like fever and other non-diarrheal illnesses, electrolyte drinks with energy can play an important role in recovery. This is corroborated by an Indian Expert Panel whose recommendation suggests that the use of WHO ORS may not satisfy the energy goals in non-diarrheal conditions. The same panel also agreed that in patients with non-diarrheal conditions, electrolyte drinks (which are not based on the WHO formula), oral rehydration solutions do not lead to diarrhea. WHO ORS is the first line of treatment to address dehydration due to acute watery diarrhea. It contains electrolytes and an optimal amount of glucose in a specific ratio to replace the fluids that a child is losing because of diarrhea. WHO ORS can also be used to address dehydration in children with fever. However, considering increased energy requirements in a child with fever and reduced intake due to loss of appetite, energy needs should be addressed.

The addition of energy (glucose) to fluid and electrolyte drinks helps address the energy needs and also helps in improving palatability and thus patient compliance. Certain ready-to- serve electrolyte drinks may also contain additional electrolytes or ingredients like magnesium which can support muscle function.

For rehydration and energy needs in fever, the child can consume clear homemade fluids, coconut water, and ready-to-drink formats containing electrolytes and energy. These conventional rehydration methods like fruit juices contain more sugar and fewer electrolytes; the composition of coconut water and variations in homemade preparations may be inadequate to meet the requirements of fluids, electrolytes, and energy. It has been recommended that scientifically formulated ready-to-serve electrolyte drinks as adjuvants can address these deficits and facilitate holistic recovery in children. As per the Indian Expert Panel, ready-to-drink formats are preferable due to their quality standards and known concentration of electrolytes and energy content as compared to variable homemade preparations. They also offer the benefits of hygienic packaging and better taste for children to improve compliance.

To summarize, fever in children can lead to silent dehydration which, if not addressed, can impact their recovery. It would be advisable to address these losses with adjuvants like scientifically formulated fluids with electrolytes and energy due to their known quality, convenience, accuracy, and taste. It is recommended to consult a doctor when a child has fever and to identify if the child is dehydrated, showing signs like poor skin elasticity, dry tongue, dark-colored urine, etc.