Subcutaneous Pediatric Rehydration Therapy — A New Option When Oral Rehydration Fails

Although oral rehydration therapy is great for pediatric patients with gastroenteritis*, it doesn’t work for everyone. And now we have a new option for patients with mild to moderate dehydration [but if the patient has compensated or uncompensated shock (severe dehydration) don’t waste time — put in the intraosseous now!].

* Make sure that the patient doesn’t have something other than  gastroenteritis causing the vomitting and/or diarrhea: eg., diabetic ketoacidosis, increased intracranial pressure, a surgical abdomen, etc. For a good differential diagnosis of pediatric gastroenteritis, see Reference (1).

The following is the complete post from Reference (2) [To learn how to perform subcutaneous pediatric rehydration, see detailed References (3) and (4)]:

Options to Intravenous Fluids

The Morsels have focused a lot on pediatric dehydration topics in the past. We have covered the utility of Probiotics and the need to be vigilant against Hypoglycemia [A great pediatric mnemonic from Emergency Medicine Cases: A-B-C-D-E-F-G (A-B-C — Don’t Ever Forget Glucose)]. We have discussed specific infections, like Salmonella, and whether antibiotics are necessary. Naturally, we have also covered Oral Rehydration Therapy and the burden of Diarrhea. Despite what we know, we still occasionally run into “problems” when managing the pediatric patient with dehydration.

Unfortunately, regardless of the general public’s belief that getting an IV is easy, obtaining an IV in a dehydrated child is quite difficult, even when they are only moderately dehydrated. This is one great reason to really advocate for ORT in anyone who is not severely dehydrated. Unfortunately, on occasion, ORT will not be successful at adequately rehydrating the patient. What are our options then?

Interosseous, Nasogastric and Subcutaneous Fluids!

Interosseous Needle

  • Is the child in SHOCK? Put in the IO!
  • Is the child severely dehydrated (which is also known as SHOCK)? Put in the IO!
    • Should be done without hesitation in a child who lacks easily obtainable IV access and signs of poor perfusion.
    • IO is known to be faster than IV placement.
    • Fluids can be delivered as effectively as IV.
    • Can be used in any age (IO shown to be faster than UVC in newborns).
    • For those patients who are not obtunded, the worse part of the IO seems to be associated with the infusion of the fluids not the IO placement.
    • Infusing lidocaine into the IO can assist in relieving discomfort.

Subcutaneous Fluids (Hypodermoclysis)

  • Hyaluronidase aided hypodermoclysis is method by which the hyaluronic acid in the intercellular matrix is hydrolysized.
  • This makes the intercellular matrix less viscous and allows for diffusion of injected subcutaneous fluids.
  • At 48 hours after the administration of the hyaluronidase, the matrix is completely restored.
  • Initial pilot study in 2009 (Allen Pediatrics 2009) demonstrated the method is effective at rehydrating mild or moderately dehydrated children (2mo – 10 yrs) and that it was safe and was well tolerated.
  • It is also noted that the SubQ catheter can typically be placed within 2 minutes.
  • Recent randomized study of hyaluronidase-facilitated subcutaneous fluid vs IV showed similar mean fluid volume administration in the ED along with higher successfully placed catheters and physician and parental satisfaction. (INFUSE-II Clinic Therap 2012).

Moral of the Story:

It is easy to order an IV… but it is not always easy to obtain an IV, particularly in the child who is dehydrated. It is useful to consider your other options before you request that IV is attempted for the 7th time. The 7th attempt is usually not that lucky.


(1) Pediatric Gastroenteritis Differential Diagnoses, Updated: May 27, 2016, from

(2) Options to Intravenous Fluids from Pediatric EM Morsels

(3) Subcutaneous (SQ) Hydration Augmented with Hyaluronidase Emergency Department Clinical Practice Guideline [Full Text PDF]

  This clinical practice guideline, including a copy of Gorlick’s dehydration scale and a link to a video demonstrating how Hylenex is administered, is available on the Cardinal Glennon Web site.

(4) Nursing Procedure for Initiating Subcutaneous Fluid Administration. [Link to the PDF Download]

(5) Recombinant human hyaluronidase-enabled subcutaneous pediatric rehydration. Pediatrics [PubMed Abstract] . 2009 Nov;124(5):e858-67. doi: 10.1542/peds.2008-3588. Epub 2009 Oct 5.

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