1. Premature neonate (<37 weeks gestation at delivery; also called preterm or premature infant)

a. Body water content: ratio of fluid to body mass is greater

1) Total body water (TBW) distribution is quantitatively and qualitatively different

a) Rapid changes take place at birth

b) Thin layer of subcutaneous fat; special care is needed to prevent insensible water losses

2) By 24 weeks of gestation, the TBW of a fetus is approximately 90%; by 32 weeks it is 80%

a) TBW and extracellular fluid (ECF) are larger at younger gestational ages

b) With continued growth and development, the proportion of ECF decreases as the intracellular fluid (ICF) increases

3) Water requirements vary with birth weight, age, and disease process

b. Body surface area (BSA)

1) Approximately two times greater than body weight (BW)

2) Higher BSA: body mass may cause very high insensible water losses that affect fluid balance

c. Acid-base regulation

1) Significantly larger BSA affects the route of metabolism by increasing the production of metabolic waste that must be excreted by the kidneys

2) Buffers help to maintain a constant pH by removing or releasing hydrogen ions

3) Buffers act immediately to correct an abnormal pH

a) Premature neonates have less homeostatic buffering mechanisms

b) Bicarbonate deficit (a slightly lower pH at 7.30 to 7.35) is more common because of high metabolic acid production and renal immaturity (metabolic acidosis)

d. Renal function

1) Kidneys are functionally immature

2) Inefficient in ability to maintain fluid balance, excrete metabolic products, concentrate or dilute urine, retain or excrete sodium, and acidify urine

e. Integumentary system

1) Stratum corneum is underdeveloped; skin is thin and fragile

a) Transepidermal water loss may be significant

b) Increased permeability and absorption of topically applied substances

c) Agents applied to the skin are readily absorbed and may be toxic; avoid the use of solvents and bonding agents, remove preparation agent with sterile water or saline once the procedure is complete

d) Avoid the use of isopropyl alcohol for cutaneous antisepsis; associated with chemical burns in preterm neonates

2) Dermal instability (less collagen and fewer elastic fibers) allows fluid accumulation, edema

3) Diminished cohesion between dermis and epidermis; prone to epidermal stripping with tape removal; use tape sparingly

f. Hepatic function

1) Liver immature in ability to function, secrete bile, and conjugate bilirubin

2) Affects the ability to metabolize drugs and vitamins; formation of plasma proteins and ketones; storage of glycogen; and capacity to break down amino acids

g. Thermoregulation system

1) Incapable of maintaining thermal stability

2) Decreased ability to produce heat, and limited energy and heat stores

3) Changes in temperature result in physiologic stress

4) Hyper/hypothermia may be life-threatening

5) Healthcare professionals should work to maintain a neutral thermal environment, including the use of radiant warmers, isolettes, heat lamps, chemical mattresses, and hats

h. Electrolyte balance

1) The regulation of fluid volume and solute concentration (electrolytes) are interrelated

2) Plasma sodium concentration is higher, it decreases with age

3) Potassium concentration is higher during first few months of life than at any other time, as is plasma chloride concentration

4) Low magnesium and calcium levels

a) Inability of premature neonate to regulate calcium, combined with high level of serum phosphate (6.5 to 7.5 mg/dL), may contribute to hypocalcemia-associated tetany

b) This condition may be associated with an immature parathyroid or vitamin D deficiency

2. Neonate (term infant at birth to 28 days)

a. Body water content

1) TBW estimated to be approximately 70% to 80% of BW by term

2) Largest proportion of body water (40% to 50%) contained in the ECF compartment

3) Circulating blood volume is approximately 85 to 90 mL/kg of BW

b. BSA

1) Estimated to be two times as great as that of an adult

2) Gastrointestinal membranes remain larger in proportion to those of an adult

c. Acid-base regulation: immature renal function and high metabolic acid production cause a tendency toward mild acidosis (pH 7.30 to 7.35)

d. Renal function: immature and inefficient kidneys lead to excretion of larger quantities of solute-free water than those found in older pediatric patients

e. Integumentary system: barrier function of the full-term infant is mature

f. Hepatic function: similar to that of the premature neonate

g. Thermoregulation

1) Healthy full-term neonates are capable of limited heat production to meet normal heat energy needs

2) Certain factors, such as stress, hypoxia, hypoglycemia, sepsis, and BW, may limit the ability to thermally self-regulate

3) Heat production gradually improves with age and initiation of feedings

h. Electrolyte balance: similar to that of the premature neonate

3. Infant (1 month to 1 year)

a. Body water content

1) TBW approximately 75%

2) During the first year, the percentage of ECF decreases from 45% to 27%

3) In one day, as much as one-half of ECF is exchanged through urine output, respiration, and heat loss

4) At approximately 3 months, blood volume is 75 to 80 mL/kg BW

b. BSA

1) Remains proportionately larger than that of an adult

2) More vulnerable to fluid balance disturbances

c. Acid-base regulation: pH within the normal range (7.35 to 7.45)

d. Renal function

1) Remains immature and inefficient

2) Vulnerable to any change in fluid status because of limited ability to respond and regulate fluid and solutes

e. Hepatic function: remains immature

f. Electrolyte balance

1) Serum phosphate slightly greater than that of the adult

2) Other electrolyte concentrations are within the normal adult ranges

4. Toddler (1 to 3 years)

a. Body water content

1) After first year, TBW content is approximately 64%

a) 34% in the ICF compartment

b) 30% in the ECF compartment

2) By the end of the second year, TBW approaches the adult percentage of approximately 60%

a) 36% in the ICF compartment

b) 24% in the ECF compartment

3) Blood volume of 70 to 75 mL/kg (approximately equal to that of an adult)

b. BSA: by the end of the third year, approaches proportions similar to those of an adult

c. Acid-base regulation: pH within the normal range

d. Renal function: reaches full maturity at the end of the second year

e. Electrolyte balance

1) Serum phosphate level remains slightly above that of the adult

2) Other electrolyte concentrations are within the normal adult ranges

5. Preschool (3 to 6 years)

a. Body water content

1) TBW is 60%, equal to that of an adult

a) 36% in the ICF compartment

b) 24% in the ECF compartment

2) Blood volume is approximately equal to that of an adult

b. BSA: proportionally equal to that of an adult

c. Acid-base regulation: pH within the normal range

d. Renal function: mature kidney function

e. Electrolyte balance

1) Serum phosphate level remains slightly above that of the adult until approximately age 5 years

2) Other electrolyte concentrations within normal adult ranges

6. School age (6 to 12 years)

a. Body water content

1) TBW is 60% and equal between males and females until puberty

2) Blood volume is approximately equal to that of an adult

b. BSA: proportionally equal to that of an adult

c. Acid-base regulation: pH within the normal range

d. Renal function: mature kidney function

e. Electrolyte balance: serum levels within normal adult ranges

7. Adolescent (12 to 18 years)

a. Body water content

1) From puberty to maturity, percentage of TBW is somewhat higher in the male (60%) than in the female (52%)

2) Probably the result of differences in body composition, particularly fat and muscle content

3) Like adults, the ICF comprises 40% to 50% of the total BW, and the ECF comprises 20% to 30% of the total BW

4) Blood volume is 65 to 70 mL/kg (equal to that of an adult)

b. BSA: equal to that of an adult

c. Acid-base regulation: pH within the normal range

d. Renal function: mature kidney function

e. Electrolyte balance: serum levels within normal adult ranges

1. Premature neonate/neonate

a. Response to stress

1) Increased oxygen consumption

2) Apnea or bradycardia

3) Hyper/hypoglycemia

4) Vasoconstriction

5) Changes in heart rate, blood pressure (BP), and cerebral blood flow

b. Preparation for procedures

1) Use developmentally supportive measures to minimize stress, such as a pacifier, talking softly, swaddling, or avoiding sudden moves

2) Enlist additional help for procedure (positioning and holding)

3) Employ measures to maintain thermal stability

4) Assess and manage pain

5) Time procedures before feedings or sufficiently after feedings to minimize the risk of vomiting and aspiration

2. Infant

a. Social and emotional needs

1) A sense of trust (or mistrust) develops

2) Major fears are separation and stranger anxiety

3) Pleasure is desired and unpleasant situations are avoided, if possible

4) Communicates by crying

5) Response to pain is similar to that of a neonate

a) At approximately 3 to 6 months, able to localize pain and purposefully withdraw the extremity

b) At approximately 6 months, a response to pain is influenced by the recall of past painful experiences associated with objects or persons

b. Preparation for procedures

1) Implement same approaches as those used for neonate

2) Response to procedures is related to separation from the primary caregiver; allow parent/caregiver to remain during procedure, if possible

3) Perform invasive or painful procedures in a separate “safe” room, not in a crib (or bed)

4) Keep harmful objects out of reach

5) Comfort and cuddle infants after procedures

3. Toddler

a. Social and emotional needs

1) Major fears are separation anxiety (from parents or primary caregivers viewed as their protectors) and loss of control

2) May calm with security items such as pacifier, blanket, and stuffed animal

3) Egocentric (inability to recognize views of others), use magical thinking, and have little concept of time or body integrity

4) Has little concept of cause and effect

5) Increasingly mobile and striving for independence

b. Preparation for procedures

1) Understand that toddlers can be very strong and resistant to procedures

2) Just before procedures, briefly and simply explain what they will see, hear, taste, smell, and feel using a positive, firm, and direct approach

3) Allow the toddler to play with equipment or role play with a doll

4) Explain the aspects of the procedure that will require cooperation, use distraction or diversion techniques during the procedure

5) Encourage the presence of a parent/caregiver during the procedure, if possible

6) Support child during the procedure with verbal and touch stimulation; give permission to cry, yell, or use other means to verbally express discomfort

7) Always be honest and never tell a child the procedure will not hurt when it will

8) Contain or use a comfort hold as necessary and use more than one assistant

9) Provide a reward or surprise after the procedure to end the experience on a positive note

4. Preschooler

a. Social and emotional needs

1) Major fears are bodily injury and mutilation, loss of control, fear of the unknown, the dark, or being left alone

2) Developing a sense of initiative and desire to please people

3) Difficulty differentiating a “good” hurt (beneficial treatment) from a “bad” hurt (illness or injury)

4) Beginning to view themselves separately from their parents

b. Preparation for procedures

1) Implement same approaches as for toddler

2) Involve in care and give choices when possible, but avoid excessive delays

3) Explain why procedures are performed

4) Reassure child that he or she has not done anything wrong and that the procedure is not a form of punishment

5) Prepare with conversations about infusion procedures in advance

6) Allow parent/caregiver(s) to remain during the procedure, if possible

7) Provide a great deal of reassurance and clear explanations

5. School age

a. Social and emotional needs

1) Major fears are bodily injury and mutilation, loss of control, not being able to live up to expectations of important others, and death

2) Developing a sense of self-esteem and are interested in helping and pleasing

3) Capable of following directions and can be involved in their treatment

4) Becoming increasingly independent and may seek more privacy

b. Preparation for procedures

1) Remember that this child can comprehend more detailed explanations

2) Explain the procedure ahead of time using correct scientific/medical terminology, simple diagrams of anatomy and physiology, and demonstrating equipment

3) Allow time before, during, and after the procedure for questions and discussion

4) Remember this child can view himself separately from his parents and may prefer privacy (from parents and peers) during the procedures

5) Encourage cooperation through praise and flattery

6) Include in decision making, such as time of day to perform procedures or the preferred intravenous site

7) If appropriate, discuss with child and parent/caregiver who will be present during the procedure for support

6. Adolescent

a. Social and emotional needs

1) Increasingly capable of abstract thought and reasoning

2) Very conscious of body image and appearance and fearful of something happening that will make him/her different from peers

3) Taking more responsibility for decisions regarding personal healthcare needs

4) May experience mood swings and regression in coping mechanisms

5) While striving for independence, may have difficulty in accepting new authority figures and may resist complying with procedures

6) May prefer solitary activities

b. Preparation for procedures

1) Prepare for procedure ahead of time

2) Provide and guard privacy

3) Include and encourage adolescent to participate in discussions regarding his/her condition and care

4) Expect occasional noncompliance or lack of interest

5) Answer questions honestly (do not talk down to patient) and explain the consequences of decisions or procedures

1. Health perception/health management

a. Studies have reported that 60% of medical conditions in children can be diagnosed by history alone

b. Immunization status and exposure to communicable diseases

c. Medical history: the presence of chronic illnesses, congenital defects, hospitalizations, surgeries

d. Reason for seeking medical treatment

e. Onset and frequency of symptoms

f. Methods of treatment for current illness (include prescribed fluid mixtures and medications, over-the-counter drugs, and home remedies)

g. Information to obtain for children younger than 2 years (and when appropriate because of related developmental disabilities or complications of prematurity)

1) Prenatal history: medications, complications, treatments

2) History of labor and delivery, Apgar scores, complications

3) Gestational age at delivery, birth weight, and length

4) Congenital defects or neonatal illnesses

2. Nutritional metabolic pattern

a. Typical and current appetite

1) Frequency of feedings

2) Amount

b. Infant feeding patterns

1) Method (e.g., breast, bottle, cup, feeding tube)

2) Formula type

3) Solid foods

4) Fluids

c. Any difficulties perceived with diet or feeding behavior

1) Choking or difficulty breathing with feeding; consider tracheoesophageal fistula

2) Cyanosis with feeding; consider possible congenital heart defect

d. Vomiting in relationship to feedings

1) Frequency

2) Amount and characteristics of emesis

3) Projectile (possibly indicative of pyloric stenosis or bowel obstruction)

4) Timing of emesis in relation to feeding; assess for reflux

e. Food restrictions, allergies, or special diet intolerance

f. Other health problems or religious practices

g. Vitamins or supplements

h. Information for the child younger than 1 year: pattern of introduction of new foods

3. Medication history: dosages and frequency of medications taken in the last 2 months

4. Allergies

a. Food or medication

b. Potential allergic reactions associated with, but not limited to, intravenous medications, topical antimicrobial solutions or ointments, tape, and latex

c. Maternal allergies, especially for the newborn

5. Bowel elimination

a. Frequency, color, amount, odor, and consistency

b. Diarrhea (dehydration occurs rapidly in an infant experiencing diarrhea)

c. Toilet training and age when achieved

d. Presence of colostomy/ileostomy

e. Need for laxatives, enemas, or suppositories

6. Bladder elimination

a. Frequency, color, and odor of the urine

b. Problems associated with urination

1) Bed-wetting

2) Burning or other dysuria

3) Dribbling

4) Oliguria

5) Polyuria

6) Urinary retention

7) Need for catheterization or presence of a stoma

c. Toilet training (during daytime or nighttime) and any accidents

d. If not toilet trained, the number and frequency of wet diapers in the last 24 hours (normally an infant will have at least six to seven wet diapers per day)

7. Skin integrity: complaints, abnormalities, chronic conditions, and presence of a rash

8. Activity-exercise pattern

a. Gross and fine motor skills

b. Self-care activity information appropriate to the child’s age and developmental abilities

c. Normal affect

d. Effect of symptoms or complaints on activity patterns

9. Cognitive-perceptual pattern: any sensory perception deficits (hearing, smell, sight, touch)

10. Self-perception pattern: impact of illness on how the child feels about himself or herself

11. Role-relationship pattern

a. Questions appropriate for child’s age and developmental abilities

b. Primary language spoken

c. Language development or characteristics of speech

d. Any concerns related to communication

12. Coping/stress management

a. Reactions to and coping methods for stress

b. Any losses or changes in the child’s life in the past year

c. Support person

13. Family history

a. Significant medical histories of immediate family members to identify the genetic traits or diseases with familial tendencies

b. Diseases or conditions possibly influencing child’s health

1) Heart disease

2) Diabetes

3) Hypertension

4) Cancer

5) Obesity

6) Congenital anomalies (e.g. heart defects)

7) Growth or developmental abnormalities

8) Allergies

9) Asthma

10) Coagulation disorders

11) Sickle cell disease

12) Convulsions

13) Genetic conditions (e.g., cystic fibrosis)

14) Mental or other emotional problems

15) Syphilis

16) Rheumatic fever

17) History of maternal drug or alcohol abuse

1. Growth measurements: record on chart for BSA calculations

a. Crown-to-heel recumbent length (children younger than 24 months)

b. Standing height/stature (children older than 24 months)

c. Weight (mass): record all measurements in grams/kilograms on growth chart

1) Weigh unclothed infant on platform-type scale, measuring to the nearest 10 g or half ounce

a) Attempt to weigh each time under similar circumstances, such as before or after feedings, same time of day, same scale

b) Obtain a daily weight if the child is receiving infusion therapy or medications based on kilogram weight

2) Weigh toddlers and older children on a standing scale, measuring to the nearest one-fourth pound; remove heavy clothing and shoes

3) Compare prior weight to current weight as an indicator of fluid volume deficit (FVD) or excess

4) Changes in weight should be monitored closely and reported to the licensed independent practitioner (LIP) if significant

5) Assess for FVD by determining the percent of loss from normal BW

a) Percentage of weight loss equals level of dehydration

b) Weigh an ill infant daily to determine the percentage of fluid loss

c) Weight loss caused by FVD occurs more rapidly than that caused by catabolism

2. Temperature

a. Assess baseline body temperature

b. Temperature measurement devices

1) Mercury thermometers (mercury is a toxic substance) rarely used in clinical settings

2) Electronic thermometer: axillary, oral, and rectal

3) Tympanic membrane sensor is accurate only if probe fits well in ear canal (usually in children older than 1 year)

4) Disposable strip

5) Digital thermometer: axillary, oral, and rectal

6) Temporal artery thermometer

c. Sites for measurement

1) Rectal

a) Risk of rectal wall perforation; avoid with thrombocytopenia, neutropenia, or recent rectal surgery

b) Up to age 2 years

c) Normal range: 36.2°C to 37.8°C

2) Axillary

a) Up to 4 to 6 years or older if condition indicates

b) Normal range: 36.5°C to 37°C

3) Oral

a) Children older than 2 years who are cognitively able

b) Normal: 37°C

4) Tympanic

a) May not be as accurate in children <3 years of age

b) Normal range: 35.8°C to 38°C

5) Temporal

a) Normal ranges have not been established

b) Not recommended as a replacement for other devices as skin temperature may not be as reflective as a core temperature

d. Deviations from normal

1) Subnormal temperature may be a sign of sepsis in the neonate and infant

2) Elevated temperatures are seen in children early in dehydration, and as the condition worsens, the temperature may become subnormal

3) Children younger than 3 years tend toward rapid temperature elevation and the resulting vulnerability to febrile seizures (>39°C/102°F)

4) Each degree of rise or fall in temperature causes the basal metabolic rate (BMR) to increase

5) Increase in BMR results in additional fluid and caloric requirements of 10% to 20% above maintenance requirements

3. Pulse

a. Assessment of rate and rhythm

1) Apical pulse is the best site for auscultation; in children younger than 2 years, the apical pulse is more reliable than the peripheral pulse and should be assessed for rate and rhythm for 1 full minute

2) In children older than 2 years, the radial pulse is satisfactory

b. Normal range

1) Neonates/infants: 120 to 160 beats per minute (bpm)

2) Toddlers: 90 to 140 bpm

3) Preschoolers: 80 to 125 bpm

4) School age children: 70 to 100 bpm

5) Adolescents: 55 to 90 bpm

c. Deviations from normal

1) Changes in rate and rhythm may indicate changes in circulating blood volume or electrolyte imbalances

2) Tachycardia may be an early sign of fluid depletion; as the condition worsens, the pulse becomes more rapid, weak, and thready

d. Assessment of peripheral pulses

1) Pulses palpable in adults are palpable in healthy children

2) Evaluate presence and quality

a) During early childhood, a comparison between radial and femoral pulses should be done at least once to detect the presence of circulatory impairment, such as coarctation of the aorta (a congenital heart condition in which the lower extremity pressure is less than the upper extremity pressure)

b) Discrepancy between central and peripheral pulses may result from vasoconstriction

c) Pulse volume directly related to BP

d) Narrow pulse pressure, weak thready pulse may indicate shock

e) Widened pulse pressure, bounding pulse may indicate septic shock, fluid overload, or the presence of a patent ductus arteriosus

4. Respirations

a. Rate, rhythm, and depth should be noted in the same manner as for the adult

b. Normal range (rate/minute)

1) Infants: 30 to 60

2) Toddlers: 24 to 60

3) Preschoolers: 20 to 30

4) School age children: 16 to 22

5) Adolescents: 15 to 20

c. Deviations from normal

1) Apnea: defined as 15- to 20-second or longer period without respiration

2) Alterations in rate may represent inadequate oxygenation or attempt to compensate for metabolic acid-base imbalances

5. BP

a. Assessment

1) Use appropriate size cuff

2) Child should be quiet and stabilized

3) Measure in either upper arm or thigh in infants

4) Measurements of the lower extremities should be done on any child with elevated pressures in the upper extremities and at least once during childhood to detect abnormalities such as coarctation of the aorta

5) Not always a reliable sign of FVD in a young child because vessel elasticity may (initially) keep the BP stable, despite diminished blood volume

b. Normal range

1) Infants

a) Systolic: 74 to 100 mmHg

b) Diastolic: 50 to 70 mmHg

2) Toddlers

a) Systolic: 80 to 112 mmHg

b) Diastolic: 50 to 80 mmHg

3) Preschoolers

a) Systolic: 82 to 110 mmHg

b) Diastolic: 50 to 78 mmHg

4) School age children

a) Systolic: 84 to 120 mmHg

b) Diastolic: 54 to 80 mmHg

5) Adolescents

a) Systolic: 94 to 140 mmHg

b) Diastolic: 62 to 88 mmHg

c. Deviations from normal

1) May indicate a change in circulating blood volume

2) FVD may decrease

3) Fluid volume overload may increase

4) In infants and children, may not be an accurate indicator of shock because the circulatory system may compensate

5) Hypotension: sudden late onset is a sign of cardiac decompensation, which should be treated immediately because cardiopulmonary arrest may follow

6. Skin

a. Skin color

1) Observed in natural daylight or neutral artificial light

2) Color is the most reliably assessed in sclera, nail beds, ear lobes, lips, oral membranes, palms, and soles

3) Factors affecting skin color include ethnic group (genetics), melanin production, edema, hygiene, hemoglobin level, and environmental temperature

a) Erythema (flushed or red skin) may result from increased environmental temperature, local inflammation, infection, or an increase in red blood cells (RBCs) as a compensatory response to chronic hypoxia (plethora)

b) Pallor, or paleness, may be a sign of anemia, chronic disease, hypothermia, edema, or shock

c) Jaundice is seen with an increase in bilirubin from hemolytic or liver disease

4) Cyanosis

a) Central cyanosis, bluish discoloration of the skin

b) Occurs when there is <5 g/100 mL of desaturated hemoglobin in the circulating blood volume

c) May indicate hypoxia but is dependent on the hemoglobin concentration

5) Acrocyanosis

a) Peripheral cyanosis, bluish discoloration of the extremities

b) Frequently seen in newborns because of reduced blood flow through small capillaries

c) Normal phenomena in newborns

d) Differentiation from central cyanosis is essential

b. Skin temperature

1) Evaluated symmetrically by feeling each body part, comparing upper with lower extremities

2) A child with FVD may feel cool to the touch even while febrile because of decreased peripheral blood flow

c. Turgor

1) Refers to the amount of elasticity in the skin, one of the best indicators of adequate hydration and nutrition

2) Best determined by grasping skin on the abdomen (or medial aspect of the thigh) between thumb and index finger, pulling taut, and quickly releasing

3) Normal tissue will not tent when gently lifted

a) Brief tenting (suspension) of the skin and wrinkling are generally seen after a 3% to 5% body fluid loss

b) An infant with hypernatremia will often have firm, thick-feeling skin

d. Capillary refill; slow refill of more than 2 seconds indicates low cardiac output

e. Edema

1) Swelling or puffiness of the extremities or sacral area may be a sign of fluid excess or of several systemic disorders, such as heart failure, kidney disease, sepsis, or a protein deficiency

2) Periorbital edema; may normally be present in children who have been crying, sleeping, or have allergies

7. Mucous membranes

a. Dry mouth may be caused by FVD or mouth breathing

b. Dryness along the area between the cheek and gum will be a more accurate measurement of fluid status

c. Salivation or drooling in an infant may be a significant source of fluid loss or indicative of adequate hydration; may also be a sign of tracheoesophageal fistula, esophageal atresia, or epiglottitis

d. The tongue of a child with FVD will appear smaller than the normal

e. Absence of tearing is seen with a fluid deficit of 5% or greater

8. Fontanel

a. Assessment

1) Anterior fontanel is easily palpated in infants, generally closes by 24 months of age

2) Assess when infant is quiet

3) Assess for size, pulsation, and tenseness

b. Depressed or sunken fontanel is a sign of dehydration

c. Bulging fontanel when the infant is at rest may indicate increased intracranial pressure, hydrocephalus, or fluid overload

9. Urine

a. An adequate urine output for the newborn should be 0.5 to 1.0 mL/kg/hour and 1.0 to 2.0 mL/kg/hour for the infant

1) Most accurate method of measuring output for a child not toilet trained is to weigh the diaper before putting it on and weigh it again after infant has voided

2) One milliliter of urine will weigh 1 g

3) Urine output should be measured hourly in dehydrated children

b. A urine specific gravity value between 1.002 and 1.030 is usually an indication of fluid balance

1) High specific gravity occurs when there is protein or glucose in the urine or the urine is concentrated from FVD

2) Because the renal system of infants and young children is immature, the specific gravity is a less reliable indicator of fluid status

10. Neurologic

a. Behavior

1) Early signs of hypernatremia in infants and young children may include lethargy and somnolence

2) Fluid retention and cerebral edema may cause restlessness and irritability

b. Changes in sensorium associated with fluid status may produce hypersensitivity to light and sound

c. Convulsions may be seen with fluid excess and fluid deficit

1. Serum electrolytes

a. Sodium

1) Preterm neonate: 132 to 140 mmol/L

2) Infant: 139 to 146 mmol/L

3) Child: 138 to 149 mmol/L

4) Adolescent: 136 to 146 mmol/L

b. Potassium

1) Infant: 4.1 to 5.3 mmol/L

2) Child: 3.4 to 4.7 mmol/L

3) Adolescent: 3.5 to 5.1 mmol/L

c. Calcium

1) Preterm neonate: <1 week of age: 6 to 10 mg/dL

2) Infant: 7.5 to 11 mg/dL

3) Child: 8.8 to 10.8 mg/dL

4) Adolescent: 8.4 to 10.2 mg/dL

d. Chloride: 98 to106 mmol/L

e. Magnesium

1) Infant: 1.4 to 2.9 mEq/L

2) Child: 1.6 to 2.6 mEq/L

f. Phosphorus/phosphate

1) Preterm neonate: 4.6 to 8 mg/dL

2) Infant: 5 to 7.8 mg/dL

3) Children 28 days to 15 years: 3.2 to 6.3 mg/dL

4) Children older than 15 years: equal to the adult value of 2.5 to 4.5 mg/dL

g. Bicarbonate

1) Preterm neonate: 18 to 26 mEq/L

2) Children younger than 2 years: 20 to 25 mEq/L

3) Children older than 2 years: 22 to 26 mEq/L

2. Hemoglobin

a. Preterm infant: 13.4 to 15 g/dL

b. Infant: (0 to 2 weeks): 14.5 to 22.5 g/dL

c. Infant (2 weeks to 6 months): 9 to 14 g/dL

1) Newborn hemoglobin level drops to its lowest point at approximately 3 to 6 months of age as a result of expansion of blood volume that accompanies rapid body growth

2) Creates a condition referred to as physiologic anemia

d. Infant to child (6 months to 12 years): 11.5 to 15.5 g/dL

e. Adolescent (12 to 18 years, males): 13.0 to 16.0 g/dL

f. Adolescent (12 to 18 years, females): 12.0 to 16.0 g/dL

3. Hematocrit

a. Neonate: 44% to 75%

b. Infant: 28% to 42%

c. Children 6 months to 2 years old: 36%

d. Children 2 to 6 years old: 37%

e. Children 6 to 12 years old: 35% to 45%

f. Adolescents (equal to adult values)

1) Males: 37% to 51%

2) Females: 35% to 47%

g. Elevated hematocrit is seen with dehydration

4. Serum osmolality: equal to adult value of 280 to 300 mOsm/kg

5. Blood urea nitrogen (BUN)

a. Preterm neonate: 3 to 25 mg/dL

b. Neonate: 8 to 18 mg/dL

c. Infant or child: 5 to 18 mg/dL

d. Adolescent: 8 to 17 mg/dL

e. BUN possibly elevated in the presence of FVD

6. Serum glucose

a. Preterm neonate: 45 to 100 mg/dL

b. Neonate: 45 to 120 mg/dL

c. Children to 16 years: 60 to 105 mg/dL

d. Children older than 16 years: 70 to 115 mg/dL

7. Urine glucose

a. May be an early sign of sepsis

b. Children may have a low renal threshold for glucose and may experience glycosuria from high concentrations of glucose

8. Arterial blood gases (best method for assessing acid-base balance and quality of blood oxygenation)

a. pH: indicates the acid-base level of the blood

1) Preterm neonate: 7.35 to 7.50

2) Neonate: 7.27 to 7.47

3) Infant and child: 7.35 to 7.45

b. PaO₂: values indicate how much oxygen the lungs are delivering to the blood

1) 75 to 100 mmHg

c. PaCO₂: value indicates how efficiently the lungs eliminate carbon dioxide

1) Infants: 27 to 40 mmHg

2) All other ages: 35 to 45 mmHg

d. Base excess: +2 mEq/L

e. Oxygen saturation: 95% to 100%

9. Bilirubin: product of hemoglobin metabolism

a. Two forms

1) Conjugated (direct)

a) Infant to adult: 0.1 to 0.4 mg/dL

2) Unconjugated (indirect)

a) Infant to adult: 0.3 to 1.1 mg/dL