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Hydration in Children

Research Institute of Child Nutrition, Dortmund, GERMANY

Address reprint requests to: Dr. Friedrich Manz, Research Institute of Child Nutrition, Heinstück 11, D-44225 Dortmund, GERMANY. E-mail: fr.manz{at}t-online.de

	ABSTRACT

TOP FOOTNOTES ABSTRACT INTRODUCTION HISTORIC MODELS OF RECOMMENDED... HYDRATION IN NEWBORNS DIETARY ADVICE CONCLUSION REFERENCES

 
Water supply is a basic public problem. In modern science, three periods with different approaches to define recommended water intake in adults can be distinguished. Pediatricians agree that hydration in children may be optimal only in breastfed infants. More data are required on the health effects of different hydration states and varying water intakes in particular age and gender groups to define optimal ranges of water intake. The fetus grows in an exceptionally well-hydrated environment. Water metabolism shows several peculiarities in preterm and term infants. Infant diarrhea remains a major topic of basic and clinical research. Water intoxication in infants, toddlers, and children is rare and can only be found in exceptional circumstances. Hydration status characterized by hyponatremia may play a role in the pathogenesis of febrile convulsions in toddlers. There is increasing indirect evidence that spontaneous drinking behavior of a population may be fixed and anchored in the age range of toddlers.

Sex differences in hydration status are common, but not obligatory. What causes theses differences? What is behind the various circadian rhythms of urine osmolality in children? At what age and in what quantities can alcohol and caffeine consumption be tolerated? How can individual susceptibility be defined? Reflecting on the modern epidemic of obesity in children and adolescents, a public consensus concerning use and misuse of sweetened drinks seems mandatory. Dietary reference intakes of water refer to 24-hour intake. In nutritional counselling, food and meal-based dietary advice is primarily given. Young parents are confronted with a flood of advice of varying quality. Recommendations on fluid consumption should be collated and revised.

Key words: hydration, dehydration, hypohydration, children

Key teaching points:

• Preterm infants show several peculiarities of water metabolism and the available techniques to measure body composition of preterm infants only allow comparisons between groups, not long-term observations of individuals.

• Individual, familial, and cultural hydration status, characterized by free water reserve, differs remarkably in children.

• While based on correct observation at the time, much of the common popular public opinion regarding health advice concerning fluid intake has been proven wrong from a modern day perspective.

	INTRODUCTION

TOP FOOTNOTES ABSTRACT INTRODUCTION HISTORIC MODELS OF RECOMMENDED... HYDRATION IN NEWBORNS DIETARY ADVICE CONCLUSION REFERENCES

 
There are now established daily reference values for most essential nutrients. These vary enormously in the precision with which they have been calculated and are constantly undergoing revision. Interestingly, water, the quantitatively most important and most essential nutrient (defining "most essential" as the one whose lack would result in death the fastest), has no generally promoted dietary reference intake values [1]. Differences such as climate, physical activity, and renal solute load and the lack of a generally accepted marker of euhydration make characterizing individual hydration status and defining an adequate total water intake difficult. Thus, the role of different states of hydration status in the pathophysiology of different morbidities is not well delineated.

In this survey, several topics of interest concerning hydration in healthy infants and children are presented. Effects of different dehydration stages on exercise performance, wellness, cognitive function, and mental performance (such as reduced alertness and ability to concentrate and tiredness and headaches) will be discussed by other authors in this supplement.

	HISTORIC MODELS OF RECOMMENDED WATER INTAKE

TOP FOOTNOTES ABSTRACT INTRODUCTION HISTORIC MODELS OF RECOMMENDED... HYDRATION IN NEWBORNS DIETARY ADVICE CONCLUSION REFERENCES

 
An adequate supply of water and/or fluids is a basic public problem and different societies use various methods to address it. Modern science started to quantify total water intake and loss in adults in the second part of the 19th century (Table 1).

After World War I, Gamble used a very strict protocol of fluid restriction in a small group of healthy young students to define mean maximum urine osmolality as 1400 mosm/kg [4]. Using this value and a mean renal solute load of 700 mosm/d, he estimated a minimum urine volume of 500 ml/d and calculated a mean minimum total water excretion of 1400 ml/d. In the following years, the amount of minimum urine volume was questioned. Adolph observed a minimum urine volume of 900ml/d in soldiers in the desert [5]. Widdowsen perhaps referred her proposal of a minimum urine volume of 300 ml/d to the special nutritional habits of New Guinean sweet potato eaters [6]. Daily total water intake was recommended at just above the minimum. The sum of water in food and metabolic water is more than 1 L in adults, so water supply in European adults seemed adequate.

Following World War II, three other models were proposed. Since energy and water turnover are closely related, in 1968, the US National Research Council proposed an intake of 1 ml water per kcal for practical reasons [7]. A second model defined adequate intake according to physiologic and epidemiologic criteria. Euhydration is ensured if 97% of the subjects in a particular group show a total water intake resulting in a urine osmolality below the third percentile of maximum urine osmolality [8,9]. Finally, water intake in patients with gout should produce a diuresis of more than 2 ml/min or 2880 ml/d to guarantee maximum urine uric acid excretion [10]. According to these models, water supply is inadequate in many countries.

Infants
Pediatricians agree that hydration in children may be optimal only in breastfed infants. However, their hydration status is very peculiar. Total water intake per unit of body weight is four times higher in infants compared to German adults (Table 2) [9,11–13]. Breast milk has higher water content per energy unit than the diet of adults. Nevertheless, urine volume per unit energy is almost identical. Infants retain water for growth and have higher non-renal water losses due to a higher body surface area related to body mass. However, osmolar load per unit of energy is four times lower which corresponds to a very low urine osmolality of 130 mosm/kg and leaves only a small renal dilution capacity to excrete an extra water load. In the past, the design of an infant formula with a low osmolar load was a major challenge. A 10% loss of body water is equally life threatening in infants and adults. However, the time required for this situation to occur is much shorter in infants due to the low total body water pool related to water turnover. In infants, the only chance to save lives in critical situations, such as a bout of acute gastroenteritis, is through target-oriented curative and preventive therapy.

Hydration in Fetuses and Preterm Infants
Cell volume is a key factor of cellular metabolism and growth [15]. Acute hyperhydration favors anabolism. In pregnant women, the extracellular volume is expanded [16], the set point of vasopressin secretion is shifted by 10 mosm/kg to lower plasma osmolality levels [17], and the metabolic clearance rate of vasopressin is four times higher [18]. Plasma osmolality of the fetus is even lower and amnion fluid even more hypotonic. Thus, the fetus grows up in an exceptionally well-hydrated environment. Dehydration of the mother or oligohydramnion due to other reasons may favor intrauterine growth retardation. Lambs exposed in utero to maternal hypertonicity demonstrated plasma hypertonicity and arterial hypertension after birth, which indicates in utero programming of altered set points for systemic osmolality and blood pressure regulation [19]. Does maternal hydration status in pregnancy clinically affect fetal growth and postnatal development of blood pressure?

Preterm infants show several peculiarities of water metabolism. The step from an intra- to extrauterine milieu is accompanied by fundamental changes in body composition [20]. Furthermore, many metabolic and hormonal systems are rearranged [21]. Water losses by the thin skin are very high, the kidneys are immature, and glomerular filtration rate (GFR) is low. There is a basal renal sodium loss and restrained diluting and concentrating capacity. The halftime of water and sodium excretion are relatively long. In enteral feeding, tolerance to higher volumes and osmolalities is protracted and there is a disposition to edema. An increase in body weight may be tissue growth, glycogen deposition, or expansion of extracellular volume. The available techniques to measure body composition of preterm infants only allow comparisons between groups, but not long-term observations of individuals [20]. Many questions are still not answered. Which model for extrauterine growth may replace the model of intrauterine growth? Which levels and changes of plasma osmolality and extracellular volume affect growth?

Thus, disturbances in water homeostasis are a major problem in caring for very-low-birth-weight infants. For clinicians, it is still very difficult to counteract all the fluid and electrolyte challenges. Hyperhydration may result in cerebral hemorrhaging, persistent ductus arteriosus, bronchopulmonary dysplasia, dehydration in necrotizing enterocolitis, or secondary surfactant deficiency. Appropriate fluid management has been demonstrated to greatly affect outcomes. Above all, non-invasive parameters for diagnosis and continuous control and intelligent documentation systems with easy handling should be established.

	HYDRATION IN NEWBORNS

TOP FOOTNOTES ABSTRACT INTRODUCTION HISTORIC MODELS OF RECOMMENDED... HYDRATION IN NEWBORNS DIETARY ADVICE CONCLUSION REFERENCES

 
Water transporters and water pools undergo profound changes in the postnatal period [22] Postnatal weight loss and its effect on the different water pools is still not fully understood. Furthermore, indications and therapeutic measures to counterbalance weight losses and markers to control them seem rather unspecific. In term neonates presenting with severe hyperbilirubinemia, fluid supplementation decreases the exchange transfusion rate and phototherapy duration [23]. A high protein and sodium content of formulas and weaning food may result in a submaximal urine osmolality. If water intake is reduced, and/or water output increased, such as in gastroenteritis, there is an increased risk of hypertonic dehydration [24]. Infants have a high water turnover with a three times higher water intake per kg body weight than adults. Therefore, infants are the most vulnerable population regarding toxicity of xenobiotics in water.

Diarrhea in Infants and Toddlers
According to the World Health Organization (WHO), there were 10,800,000 deaths in children below five years old worldwide in 2000 [25]. Most children died in East and West Africa, India, Bangladesh and China. Ninety percent of deaths occurred in 42 countries. Diarrhea was the most common diagnosis (22%). WHO estimated that 88% died due to lack of care or inadequate treatment. Clean water, sanitation, and hygiene were available in only 47% of the countries. Only 39% of the victims were exclusively breastfed for six months. Thirty percent received antibiotics and only 20% received oral rehydration solutions.

Prevention and therapy of infant mortality due to diarrhea has a long tradition. People have known for a long time that exclusive breastfeeding reduces mortality. In 1900, breastfed German infants had a seven times lower mortality rate than non-breastfed infants [26]. In the early 1900s, introduction of sanitary water supply, increased hygiene in formula preparation, and a scientifically based change of alimentation decreased infant mortality dramatically [27]. Parenteral fluid, glucose, and electrolyte therapy was introduced in 1935 [28] and oral rehydration solutions in the 1960s [29]. Recently, vaccination against rotavirus, the most common cause of infant diarrhea in industrialized countries, proved to be highly effective [30]. Nevertheless, infant diarrhea remains a major topic of basic and clinical research. Today, we have several highly efficient means at our disposal to prevent and treat infant diarrhea. The high mortality of infant diarrhea is no longer the result of lack of knowledge or therapeutic means. The great challenge is national and international solidarity for implementing and evaluating culture-adapted basic health systems and education for all of young women.

Water Intoxication
Water intoxication in infants and children is rare. The accident is usually due to a combination of high water intake, low nutritional osmolar load, increased minimum urine osmolality, lack of knowledge and empathy, and iatrogenic errors. Compulsive water drinking is a modern epidemic [31]. As long as formulas yielded a high renal solute load, dilution of formulas was mandatory in patients with diarrhea. Nowadays, the renal solute load is so low that dilution may result in water intoxication.

Drowning is a leading cause of injury-related death in children, especially in the US [32]. Water intoxication has been observed in anorexia nervosa [33] and water babies [34]. Iatrogenic water intoxication has been published in many scenarios including: renal concentration tests with the vasopressin analogue DDAVP [35]; in tap water enema [36]; gastric lavage [37]; routine use of parenteral hypotonic solutions in patients with a high risk for inadequate ADH release [38]; and in medical treatment with drugs with ADH stimulation or ADH-like effect [39]. Febrile convulsions in infants and toddlers are common, and hyponatremia, as a marker of hydration status, may play a role in the pathogenesis [40].

Development of Spontaneous Drinking Behavior
Hydration status in breastfed infants seems to be very similar all over the world. However, individual, familial, and cultural hydration status characterized by free water reserve differs remarkably in children and adults [11]. Nephrologists know how difficult it is to get school children, adolescents, and adults with urolithiasis or pyelonephritis to permanently increase their fluid intake. Thus, there is increasing indirect evidence that secondary, spontaneous, non-homeostatic, non-regulatory, or freely emitted drinking behavior may develop and be anchored in the toddler age group [41]. If this hypothesis proves correct, implications of this observation for health education and public health would be very important.

Hydration and Sex
Men are known to be at greater risk of urolithiasis and cardiovascular and renal diseases than women. A higher urine concentration seems to be associated with an accelerated progression of chronic kidney disease and delayed renal sodium excretion [42]. In most countries, men show a higher mean urinary osmolality than women do. However, there are exceptions to this in Poland, Italy, and Israel for example [11]. Compared to boys, German girls show a lower mean 24-h urine osmolality of 83 mosm/kg [43]. Considering differences of energy intake and setting water input of boys as 100%, German girls younger than seven years old showed a corrected higher water input of 3.2% and a corresponding higher corrected free water reserve of 3.5% of water input (Table 3). Girls ages seven to 10.9 years old have a higher corrected free water reserve of 6.2%, despite a corrected lower water input of 1.9% due to lower corrected non-renal water losses of 6.7% and a lower corrected obligatory urine volume of 1.4%. To our knowledge, there are no comparable data characterizing sex difference of hydration status with regard to water input and its three output parameters: non-renal water losses, obligatory urine volume (taking into account both renal solute load and maximum renal concentration capacity), and free water reserve. It would be very interesting to know if these sex differences in hydration status can also be found in other populations. Previous studies suggest that small boys and old men have a sweat rate much the same as small girls and old women [44,45]. Therefore, are the higher sweat losses in sexually active men really the main reason for their poorer hydration status in many countries?

Caffeine, Alcohol, and Sweetened Drinks
Caffeine is a psychoactive substance. Higher caffeine intake among seventh to ninth grade students was associated with shorter nocturnal sleep duration, increased wake time after sleep onset, and increased daytime sleep [47]. What are the scientific arguments concerning the right time to offer caffeinated beverages to students and in what quantities? How does one define individual susceptibility to caffeine?

Two epidemics in adolescents, alcoholism and obesity, are linked to fluid intake. Alcohol's subversive influence on health and socio-economic status is well-documented. How can one help adolescents develop a responsible attitude toward consumption of alcoholic beverages?

Obesity is the result of complex interactions between many factors. There is increasing evidence that the rapidly increasing consumption of sweetened drinks by children and adolescents over the last two decades is a major factor in the worldwide obesity epidemic [48,49]. Furthermore, a high consumption of sweetened drinks may favor dental caries [50], lower bone density [51], urolithiasis [52], and severe presentation of ketoacidosis in diabetes mellitus [53]. Steps to increase public awareness concerning use and misuse of soft drinks and fruit juice have been taken [54,55].

One aspect, which has been known for a long time, has been neglected in this discussion. The postabsorption water status may vary after the consumption of the same amount of different beverages [14]. The ingestion of 100g water results in a functional water volume of 100 ml. Ten grams of glucose, transiently stored as glycogen in the liver, fix about 30 ml water. Thus, functional water volume is only 60 ml after the intake of 100 g of a 10% glucose solution. One hundred grams of a mineral water with 25 mmol/L sodium chloride results in a functional water volume of about 82 ml. Beverages with a high carbohydrate or sodium chloride content quench thirst much less than tap water. Therefore, it seems logical that the lower the postabsorptive functional water volume, the higher the intake volume.

	DIETARY ADVICE

TOP FOOTNOTES ABSTRACT INTRODUCTION HISTORIC MODELS OF RECOMMENDED... HYDRATION IN NEWBORNS DIETARY ADVICE CONCLUSION REFERENCES

 
Dietary reference intake values for water refer to 24-h water intake. They are usually based on physiologic and climatic data. In nutritional counselling, food and meal-based dietary advice is primarily used. This advice normally includes local food supply and local food demand and cultural habits. Young parents are confronted with a flood of advice of varying quality. Recently the actual policy statements of the American Academy of Pediatrics were examined [56]. Out of 192 verbal health directives, 29 were linked to water metabolism mostly and were directed towards preventing drowning and alcohol abuse. These are the official actual directives that pediatricians should give. Other professional or non-professional groups give further advice and last, but not least, many pieces of past advice persist in the minds of the population.

In Germany, verbal health advice concerning fluid intake recommended by different German physicians over the last 150 years can still be found in common popular public opinion. Almost all the advice was based on a correct observation at the time. From a modern day perspective, however, the interpretations and conclusions have mostly been proven to be wrong. Some examples are: drinks and soups make one corpulent [57]; drinking before meals reduces appetite [58]; too much water overburdens the kidney and the bladder [59]; regular breastfeeding meals at fixed times are not only a healthy measure but also a first step in education [60]; fresh food contains enough water, there is no need for fluids [61]; thirsty runners are faster as they have less body weight to transport [62]; and for each cup of coffee, an additional cup of water should be consumed [63]. Thus, scientific committees should take into account the feasibility and the evidence of scientific studies on health, and the cultural background with its common popular opinions when generating future policy statements.

	CONCLUSION

TOP FOOTNOTES ABSTRACT INTRODUCTION HISTORIC MODELS OF RECOMMENDED... HYDRATION IN NEWBORNS DIETARY ADVICE CONCLUSION REFERENCES

 
In most countries, men show a higher mean urinary osmolality than women do, and compared to boys, German girls show a lower mean 24-h urine osmolality. Considering differences of energy intake and setting water input of boys as 100%, German girls younger than seven years old, showed a corrected higher water intake of 3.2% and a corresponding higher corrected free water reserve of 3.5%. Girls ages seven to 10.9 years old have a higher corrected free water reserve of 6.2%, despite a corrected lower water input of 1.9% due to lower corrected non-renal water losses of 6.7% and a lower corrected obligatory urine volume of 1.4%. There appears to be no comparable data characterizing sex difference of hydration status with regard to water input and its three output parameters: non-renal water losses, obligatory urine volume, and free water reserve. Additional research is needed to determine if these sex differences in hydration status can also be found in other populations.

	FOOTNOTES

TOP FOOTNOTES ABSTRACT INTRODUCTION HISTORIC MODELS OF RECOMMENDED... HYDRATION IN NEWBORNS DIETARY ADVICE CONCLUSION REFERENCES

 
Conflict of Interest Disclosure: There are no conflicts of interest to declare in connection with this work.

Received July 16, 2007.

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TOP FOOTNOTES ABSTRACT INTRODUCTION HISTORIC MODELS OF RECOMMENDED... HYDRATION IN NEWBORNS DIETARY ADVICE CONCLUSION REFERENCES

 

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