Proper hydration is central to the health and well-being of children

Abstract

Introduction On an average, 50-70% of the body consists of water distributed in the intracellular and extracellular compartments 1. Water is essential for thermo-regulation, as well as for all metabolic functions of the body 2. It is continuously lost from the body via urine, faeces, breath and skin. This water loss should be replaced continuously by water, fluids and diet in order to maintain water balance 1. Though adults can maintain water balance efficiently, young infants and children are at a higher risk of dehydration 3. Even mild dehydration can produce multiple negative impacts on the health and well-being of infants and young children 3. This review discusses the central role of water in the body, water recommendations, effects of dehydration in children, assessment of hydration status in children and summarises the findings of available research studies conducted on the hydration status of children and their impact.

Full text

Proper hydration is central to the health and … Sri Lanka Journal of Child Health, 2023; 52(3): 336-341
336
Review Article
Proper hydration is central to the health and well-being of children
*Thushari Bandara
1
, G H S Fernando
2
Sri Lanka Journal of Child Health, 2023; 52(3): 336-341
DOI: http://doi.org/10.4038/sljch.v52i3.10399
(Key words: Water, Children, Hydration, Health, Dehydration)
Introduction
On an average, 50-70% of the body consists of water
distributed in the intracellular and extracellular
compartments
1
. Water is essential for thermo-
regulation, as well as for all metabolic functions of
the body
2
. It is continuously lost from the body via
urine, faeces, breath and skin. This water loss should
be replaced continuously by water, fluids and diet in
order to maintain water balance
1
. Though adults can
maintain water balance efficiently, young infants
and children are at a higher risk of dehydration
3
.
Even mild dehydration can produce multiple
negative impacts on the health and well-being of
infants and young children
3
. This review discusses
the central role of water in the body, water
recommendations, effects of dehydration in
children, assessment of hydration status in children
and summarises the findings of available research
studies conducted on the hydration status of children
and their impact.
Method
A literature search was conducted using Google
Scholar, PubMed, Medline, and Cochrane library
databases. ‘Hydration’, ‘dehydration’, ‘hydration of
children’, ‘water requirement’, ‘impacts of
hydration’, were the search terms used. The
literature search was limited to articles published in
English.
Results
Water and life
Earth is known as the ‘Water Planet’ as about 75%
of the earth comprises water
4
. Approximately 70%
_________________________________________
1
Department of Medical Laboratory Sciences,
Faculty of Allied Health Sciences, University of
Ruhuna, Galle, Sri Lanka,
2
Base Hospital,
Udugama, Sri Lanka
*Correspondence: wvthush@yahoo.com
https://orcid.org/0000-0002-2556-1192
(Received on 06 November 2022: Accepted after
revision on 15 November 2022)
The authors declare that there are no conflicts of
interest
Personal funding was used for the project.
Open Access Article published under the Creative
Commons Attribution CC-BY License
of the human body consists of water
4
. Water is the
fundamental solvent which is essential for nearly all
biochemical reactions that take place in the body,
including cellular respiration
5
. Water aids in the
proper electrolyte balance in the body and thereby
helps to maintain optimal functioning of vital organs
such as the brain
5
. Being the main part of blood,
water plays a key role in maintaining a healthy
cardiovascular system
5
. Without water there is no
existence or life.
Water recommendations
Gender and age-specific daily water intake
recommendations have been published by the
Institute of Medicine (IOM), USA
6
. According to
IOM recommendations, adequate total water intake
is 0.7 L/day for infants aged 0-6 months and 0.8
L/day for infants aged 7-12 months. Recommended
water intake for 1–3-year-old children and 4–8-year-
old children are 1.3 L/day and 1.7 L/day,
respectively. Boys and girls aged 9-13 years should
ingest 2.4 L/day and 2.1 L/day respectively. Boys
and girls above 14 years old should ingest 3.3 L/day
and 2.3 L/day respectively. Good hydration plays a
pivotal role in good health and well-being of
individuals of all ages
7
.
Dehydration
Dehydration is defined as a rapid loss of over 3% of
body weight in relation to water and electrolyte
disturbance due to water or sodium depletion
8
.
Dehydration is classified as isotonic, hypertonic or
hypotonic
8
. Isotonic dehydration is a balanced
depletion of water and sodium which results in
extracellular fluid (ECF) loss
8
. Hypertonic
dehydration is depletion of total body water content
due to reduced water intake, pathologic fluid losses
or both. Here, due to the resulting hypernatraemia in
the ECF, water is drawn from the intracellular fluid
(ICF)
8
. Hypotonic dehydration occurs due to
depletion of sodium and water where sodium loss
predominates, creating an ECF loss
8
. Dehydration is
associated with morbidity and mortality in
individuals of all ages
9
.
Symptoms of dehydration vary, based on the amount
of water loss. When water loss is about 1% of body
weight, increased thirst and impairment of
thermoregulation occur
10
. Thirst is increased at 2%
of water loss; at 3% water loss, symptoms such as

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337
dry mouth, vague discomfort and loss of appetite are
reported. Impairment of 20-30% work capacity is
seen at 4% water loss and at 5% water loss,
headache, difficulty in concentration and sleepiness
are reported. At 6% tingling and numbness of
extremities are reported and at 7% of water loss
collapse occurs and death is reported at 10%
dehydration
10
.
Dehydration consequences in children
Infants and young children possess higher metabolic
needs and higher metabolic rates
3
. Their insensible
water loss is also higher due to higher body surface
area to volume ratio
3
. Therefore, they are more
susceptible to dehydration. Dehydration is reported
as a major cause of morbidity and mortality in
infants and young children worldwide
11
.
Maintenance of optimal hydration is crucial for
infants and children due to many physiological and
behavioural motives
2
.
Assessment of hydration status
Change of body weight, bioelectrical impedance,
urine colour, urine osmolality, urine specific gravity,
plasma osmolality and saliva osmolality are among
the techniques used to assess the hydration status
12
.
Measurement of body weight change is the simplest
method to assess acute changes in body water. This
can be performed quickly, easily, and does not
require technical expertise. However, changes of
body composition not related to hydration status
makes this method unreliable for long duration
studies. As body weight is affected by fluid intake,
food ingestion, faecal losses and urine production
etc., body weight change does not reflect hydration
status over hours. Therefore, measurement of body
weight change is not appropriate for assessing
hydration status in free-living conditions
12
.
Isotope dilution is an accurate method to measure
total body water. Here, a precise trace amount of an
isotope (commonly deuterium) is administered
orally or intravenously. The tracer is distributed all
over the body fluid compartments. After reaching
equilibrium, tracer concentration is measured in
plasma, urine or saliva. However, isotope dilution
methods are very costly and need high technical
expertise. Bioelectrical Impedance Analysis (BIA)
is a technique to measure body water based on the
electrical properties of tissues. Depending on water
and electrolyte content, different tissues conduct
electrical current differently and considering this
property, sex and age specific equations are
developed to link body resistance to the electrical
current of total body water, extra cellular water and
intracellular water
14
. BIA techniques provide rapid
feedback, are non-invasive, inexpensive and easy to
perform. However, their sensitivities and
reproducibility have been questioned as many
factors affect BIA measurements.
Historically, plasma osmolality has been considered
a standard marker for assessing the hydration
status
14
. Osmolality could be determined using a
freezing-point depression osmometer or a vapour
pressure-depression osmometer. Though this
technique is inexpensive, it is invasive and not
suitable for children. Further, relevance of plasma
osmolality is a matter of context. For example, in
acute dehydration such as during physical exercise,
plasma osmolality is changed, yet in chronic
dehydration, plasma osmolality could be preserved
through brain regulation and kidney adaptation
15
.
Urinary indices are widely used for assessing the
hydration status. There are three main urinary
markers, namely, urine colour, urine osmolality and
urine specific gravity. Concentration of osmotic
solutes in urine denotes urine osmolality and it is
measured by using freezing-point or vapour
pressure-depression osmometers. Urine osmolality
is governed by the amounts of solutes and the
volume of water. Most abundant solutes in water are
sodium, potassium and urea and their concentrations
depend on the diet. Dehydration produces highly
concentrated small volumes of urine with a higher
osmolality. Under proper hydration conditions,
large volumes of urine are produced with low
osmolality. Urine osmolality reflects the capacity of
the kidneys to respond to variations in body water
balance and ranges from 50 to 1400 mOsm/kg. In
some pathological conditions like diabetes insipidus
and chronic kidney disease, renal functions and
capacities are compromised, and in such situations,
urinary indices should not be used
8
. Urine
osmolality is adequately sensitive to catch minor
changes in hydration status. Urine osmolality is
reported to represent dehydration more accurately
than blood indices
16
. It is non-invasive and
inexpensive.
Urine specific gravity is the weight of urine divided
by the weight of an equal volume of distilled water.
Specific gravity of plain water is 1·000. In normal
urine specific gravity usually ranges from 1·013 to
1·029. Dehydration has been defined by a urine
specific gravity above 1·020-1·025. Urine specific
gravity test strips are available but the refractometer
is the ‘gold standard’ for measuring urine specific
gravity. Studies have reported that urine osmolality
and urine specific gravity are powerfully correlated
and consistent
16
.
The third common urinary marker used for assessing
hydration status is urine colour. A urine colour chart
has been developed to measure urine concentration
of healthy humans
17
. This chart contains a
standardized colour scale ranging from 1 (pale
yellow, corresponding to dilute urine) to 8 (dark
brown, corresponding to concentrated urine). Cut-
off value between euhydration and dehydration has

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been set as 4. Urine colour is a cheap non-invasive
tool which does not require technical expertise.
Further, it provides immediate results. This method
is reported to have the best specificity (97%) among
all urinary markers
17
. However, the urine colour
chart lacks sensitivity and could be disturbed by
dietary factors, illness and medications. A linear
relationship has been established between urine
colour, osmolality and specific gravity suggesting
that all of them are suitable for assessing the
hydration status.
Research related to hydration of children
Suh H, et al
18
published a review of the water intake
practices and hydration status of children. There
were 32 observational studies in this review
representing a total of 36,813 children. The review
compared the total water/fluid intake and water
intake recommendations with the underhydration
cut-off of urine osmolality >800mOsm/kg, of
children living in 25 countries. Of 32 studies, only
11 reported both the water intake and hydration
status of children. Twelve studies reported average
water/fluid intake below the guidelines, and 4
studies reported underhydration based on urine
osmolality (>800mOsm/kg). Nineteen countries
compared water/fluid intake with the guidelines, and
reported that 60 ± 24% children (10-98%) failed to
meet the guideline. This suggests that children are
not ingesting enough water/fluid and are not
adequately hydrated.
Zaghloul G, et al
19
evaluated the morning hydration
status of 519 school children 9-11 years old in
Egypt. The study collected information about the
children’s breakfast and their urine osmolality was
analysed. The average urine osmolality of children
was 814mOsm/kg; in 57% children, it was
>800mOsm/kg and in 24.7% it was >1000
mOsm/kg. A total water intake below 400mL was
associated with a greater risk of dehydration. This
study concluded that most Egyptian school children
arrived at school with a hydration deficit.
Barker M, et al
20
evaluated the morning hydration
status of 452 British primary school children, aged
9-11 years, in South Yorkshire, related to breakfast
water intake. Children’s urinary osmolality was
measured and data on dietary intake and fluid
consumption were collected. There was a mild
hydration deficit in 60% children with urinary
osmolality above 800mOsm/kg. There was a high
prevalence of elevated urinary osmolality in boys
compared to girls (68.4% vs 53.5%). In 18.6%
children urinary osmolality was over
1000mOsm/kg.
Bonnet F, et al
21
assessed the morning hydration
status in 529 French schoolchildren aged 9-11 years.
Urine samples of the children were collected in the
morning to measure urine osmolality and their food
and fluid intake data were collected to calculate the
nutritional composition. More than one third of
children had urine osmolalities ranging from 801-
1,000mOsm/kg. About 22.7% children had urine
osmolality over 1,000mOsm/kg. It was more
significant in boys than girls. Majority (73.5%) of
children had consumed less than 400 mL at
breakfast. Total water intake at breakfast was
significantly and inversely related to high urine
osmolality. Over two thirds of children in the sample
had a hydration deficit.
Iglesia-Altaba I, et al
22
studied the patterns of fluid
consumption in 146 children and adolescents by a
cross-sectional study in Spain, and compared them
with adequate water intake recommendations by the
European Food Safety Agency (EFSA). This study
assessed total fluid intake from all sources by means
of a validated liquid intake 7-day record. Results
indicated that 73% children and 72% adolescents
had not met EFSA recommendations for fluid
intake. Furthermore, 40% children and 50%
adolescents were consuming sugar-sweetened
beverages (SSB) at least once a day. Study
concluded that the drinking habits of Spanish young
populations were far removed from current
recommendations and that their SSB consumption
was higher.
Laksmi PW, et al
23
reported the daily total fluid
intake (TFI) with the types of fluids in Indonesia and
compared TFI with the fluid intake
recommendations established by the Ministry of
Health, Republic of Indonesia. They collected data
in 32 cities over nine Indonesian regions. Their
sample comprised 388 children 4-9 years old, 478
adolescents 10-17 years old and adults. They used a
validated fluid intake 7-day record for data
collection. According to their results, 67%
participants met adequate intake (AI) of water from
fluids; 78% children and 80%
adolescents met AI.
Though drinking water was the chief contributor to
TFI in every age group, sugar-sweetened drinks
were consumed by 62% children and 72%
adolescents. Furthermore, an SSB intake ≥1
serving/day was observed in 24% children and 41%
adolescents.
The relationship between hydration and cognitive
performance is an emerging area of research. A
study conducted in USA investigated the association
between total water intake and cognitive control
among pre-pubertal children. In this study, to assess
cognitive control and ability to battle distractions
and maintain focus, children aged 8-9-years
completed a modified flanker task. Results of the
study indicated an association between water intake
and cognitive control by means of a task that
modulates inhibition. Excessive intake of water

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correlated with higher ability to maintain task
performance once inhibitory demands were
increased
24
. Though the mechanism by which fluid
intake arbitrates cognition and brain health is
unclear in humans, animal studies have provided
evidence for dehydration-induced curtailment in
neuronal cell proliferation and neuronal cell
shrinkage due to water depletion from cells
25
.
Further, dehydration is known to elevate circulatory
stress hormone levels i.e., cortisol which are related
to decrements in cognitive function
26
.
Bar-David Y, et al
27
conducted a study to assess the
relationship between cognitive test scores and the
state of hydration in 58 elementary school students
in grade 6, aged 10.1-12.4 years. Urine samples of
the children were collected in the morning and noon
to measure urine osmolality and five cognitive tests
(number addition, hidden figures, auditory number
span, making groups and verbal analogies) were
performed in the morning and at noon-time. Of the
sample, 32 students were dehydrated (urine
osmolality >800mOsm/kg) in the morning. Results
indicated an overall significant positive trend in four
of the five tests in the hydrated group suggesting that
dehydration is a common issue in school-aged
children which adversely affects their cognitive
functions.
Amaerjiang N, et al
28
conducted a longitudinal study
in China to assess the variations in hydration status
and renal impairment, among 1885 children (mean
age 7.7 years). They used urine specific gravity to
assess the dehydration status, and the levels of β2-
microglobulin (β2-MG) and microalbumin (MA) to
evaluate the impairment of renal functions. Study
reported that prevalence of dehydration among
children was 61.9%, and that it was significantly
higher in boys (64.3%). Study documented
tendencies for the change of renal indicators over
time alone with different hydration statuses. A new
indicator ratio, β2-MG/MA, has validated the
consistent trends of renal function impairment
(especially related to tubular stress/damage), in
dehydrated children. Renal impairment trends have
been shown to worsen as a function of school days
of the week. Further, dehydration status was shown
to intensify the renal impairment in childhood
during the school weekdays.
Summary and conclusions
Water is the basis of life. It is essential for
metabolism, transport of substances across the body,
thermoregulation, cellular homeostasis and proper
circulatory as well as cognitive functions. Optimal
water intake and appropriate hydration status
positively affect multiple cardinal aspects of human
physiology. Though water is cheap, the value added
by water to life and good health is expensive.
However, this aspect has not been addressed well up
to date. Though there is growing interest in the area
of hydration over the last couple of years, research
has not focused adequately on the hydration status
and its impacts, especially in children. Children are
at a great risk of dehydration. Available limited
literature provides concrete evidence that the
majority of children are poorly hydrated. It is of
paramount importance to better understand the
barriers in children for drinking water, and pay
attention to encourage and promote their water
intake through multi-component interventions,
combining educational, behavioural and
environmental approaches, in order to ensure
adequate hydration, optimal cognition, as well as
proper cardiovascular and renal functions in
children.
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