Marginal or deficient fluid balance may be present in children with severe cerebral palsy and oromotor problems, particularly if gastrostomy tube feedings are not in place. When the child with failure to thrive and a limited fluid status develops a routine gastroenteritis, dehydration and nutritional status become major difficulties. Some children dehydrate with minimal diarrhea or vomiting and have difficulty maintaining hydration until the diarrhea or vomiting resolves. Hypernatremia or hyponatremic dehydration with seizure activity may result if the sodium load is very high or low. Hospitalization decisions should be based on the history of diarrhea, hydration status of the patient in relation to the amount of diarrhea reported, and baseline nutritional status. The further below the 5th percentile for weight a child is, the greater is the concern that the child cannot be orally hydrated if diarrhea or vomiting persists. Obtaining a premorbid weight from the family will assist the physician in estimating fluid loss. Monitoring urine output also will provide information, as will the traditional signs of dry mucous membranes, tachycardia, skin tenting, and sunken eyes. When rapid dehydration occurs in the malnourished child with limited hydration as the baseline, intravenous access may be a problem. If an intravenous line cannot be placed successfully, interosseus line placement should be considered. In addition to treatment with fluid boluses, full feeds should be continued.
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