October 2006: (I)457– 464

Nutrition in Clinical Care

Hydration and Cognitive Function in Children

Kristen E. D’Anci, PhD, Florence Constant, MD, PhD, and Irwin H. Rosenberg, MD

Adequate fluid intake is critical for survival. While tain fluid balance in most people. Moreover, cultural
adults are at liberty to drink fluids as wanted, children patterns of fluid intake are sufficient to override a true

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and infants are dependent upon caregivers for food physiological thirst. Risk for dehydration, therefore,
and fluid. Children are at greater risk for dehydration arises under special circumstances such as illness, injury,
than adults due to their higher surface-to-mass ratio. heat stress, or physical activity, and also according to
Additionally, children have different thirst sensitivities age. Indeed, fluid requirements relative to body weight
and body cooling mechanisms than adults. Children are greatest during the early neonatal period and through
differ from adults in total body water content, and boys childhood. As a consequence, children may be more
and girls differ in body water content with maturation. susceptible to fluid losses and are therefore at greater risk
Research in young adults shows that mild dehydration for dehydration than are adults.
corresponding to only 1% to 2% of body weight loss
can lead to significant impairment in cognitive func-
tion. Dehydration in infants is associated with confu- WATER BALANCE
sion, irritability, and lethargy; in children, it may
produce decrements in cognitive performance. The balance between loss and gain of fluids main-
© 2006 International Life Sciences Institute tains body water within relatively narrow limits.1 The
doi: 10.1301/nr.2006.oct.457– 464 routes of water loss from the body are the urinary system,
Key words: children, cognitive function, hydration the skin, the respiratory surfaces, and the gastrointestinal
tract. The primary avenues for restoration of water bal-
ance are fluid and food ingestion, with water oxidation
making a minor contribution.2 The volumes of water that
INTRODUCTION
individuals obtain from drinks and food are highly vari-
Water and fluid balance in humans is sharply regu- able, although it is generally reported that the majority
lated and complex. People drink liquids not only in normally comes from liquids.3
response to physiological thirst, but also in response to a
variety of cultural, social, and psychological factors. The Thirst and Water Intake Regulation
type and amount of fluid consumed is dependent upon
relative palatability and temperature of the fluid, meal The act of drinking may not be directly involved
type and size, and water safety and availability. Fluid with a physiological need for water intake, but can be
intakes generally are considered to be adequate to main- initiated by habit, ritual, taste, or a desire for a warm or
cooling effect.4 A number of the sensations associated
with thirst are learned, with signals such as dryness of the
Dr. D’Anci is with the Nutrition & Neurocognition mouth or throat inducing drinking, while distension of
Laboratory, Jean Mayer USDA Human Nutrition Re-
the stomach can stop ingestion before a fluid deficit has
search Center on Aging at Tufts University, Boston,
Massachusetts; Dr. Rosenberg is with the Nutrition been restored. However, the underlying regulation of
and Neurocognition Laboratory, Jean Mayer USDA thirst is controlled separately by the osmotic pressure and
Human Nutrition Research Center on Aging and the volume of the body fluids, and as such is regulated by the
Gerald J. and Dorothy R. Friedman School of Nutrition same mechanisms that affect water and solute reabsorp-
Science and Policy, Tufts University; Dr. Constant is tion in the kidneys and control central blood pressure.
with Nestlé Waters, Issy-les-Moulineaux, France. Despite large variations in salt and water intake, homeo-
Please address all correspondence to: Irwin H.
static mechanisms maintain a normal plasma osmolality
Rosenberg, MD, Nutrition and Neurocognition Labo-
ratory, Jean Mayer USDA Human Nutrition Research of 275 to 290 mOsm/kg and a normal sodium level
Center on Aging, 711 Washington Street, Boston, MA between 135 and 145 mEq/L.
02111; Phone: 617-556-3331; Fax: 617-556-3243; Water is excreted from the body through urine and
E-mail: [email protected]. by insensible losses such as respiration and evaporation

Nutrition Reviews姞, Vol. 64, No. 10 457

from skin. Increases in plasma osmolality and activation proximately 60% in boys and to approximately 50% in
of osmoreceptors (intracellular) and baroreceptors (ex- girls by puberty (Figure 2). The percentage of TBW is
tracellular) stimulate hypothalamic release of arginine decreased relative to body mass as a function of in-
vasopressin. Vasopressin acts at the kidney to decrease creased proportion of body fat, as seen in post-pubertal
urine volume and promote retention of water. Increasing girls and in overweight children. Recent data from the
levels of vasopressin are associated with greater ratings Fels Longitudinal study show that the progression of
of thirst and greater fluid intake. An increase of 1% to TBW changes with maturation.8 Longitudinal TBW data
2% plasma osmolality is sufficient to provoke the thirst from Caucasian boys and girls from 8 to 20 years of age
reflex (Figure 1). Thirst is generated at a higher plasma were collected using deuterium nuclear magnetic reso-
osmolality than vasopressin release, resulting in first a nance spectroscopy. In girls, %TBW increases until
concentration of urine and conservation of body water about age 14 (puberty) and then levels off (8 yrs: 14.8 ⫾
and then a subsequent drive to increase fluid intake. 1.9 L; 14 yrs: 27.5 ⫾ 3.7 L; 16 yrs: 28.4 ⫾ 4.1 L; 20 yrs

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Thirst is also seen in cases of blood loss and in fluid loss 29.0 ⫾ 3.4 L). In boys, %TBW increases until about age
following burn trauma. In general, the sensation of thirst 16, when it also levels off (8 yrs: 16.2 ⫾ 2.0 L; 14 yrs:
results in an intake of fluid adequate to restore water 32.6 ⫾ 6.8 L; 16 yrs: 40.6 ⫾ 7.7 L; 20 yrs 42.0 ⫾ 5.0 L).
balance. Cessation of drinking, however, occurs before In general, boys at all ages tend to have higher propor-
cellular rehydration is achieved. Rather, oropharyngeal tions of TBW than do girls.8
cues produce a decrease in vasopressin release and sub- Recommended adequate water intake in children
sequently a decrease in drinking behavior.5 It has been and adults under average conditions is 1 mL/kcal.9 Mea-
observed that most terrestrial animals are in a chronic suring water intakes and, by extrapolation, hydration
state of fluid deficit, drinking only enough to achieve status, in the general population is somewhat difficult but
homeostatic water levels. not unfeasible. Water intakes and TBW for children are
Hypernatremia, defined as plasma concentrations of described in the Dortmund (Germany) Nutritional and
Na above 145 mEq/L, can result from decreased fluid Anthropometric Longitudinally Designed Study (DONALD)9
intake and can cause restlessness, altered mental status, and in the US National Health and Nutrition Examina-
confusion, and fatigue. So-called water intoxication, or tion Survey (NHANES).3 In the DONALD study, fluid
hyponatremia, occurs when plasma concentrations of Na intakes from food and liquid ingestion, as well as meta-
drop below 135 mEq/L. Interestingly, hyponatremia in- bolic water, averaged around 1.9 L/d for 9- to 13-year-
duced by ingesting large amounts of fluids results in
old German boys and approximately 1.7 L/d in 9- to
similar somatic symptoms as dehydration: nausea, fatigue,
13-year-old German girls. In data from NHANES III,
confusion, and apathy,6 but the effects of hyponatremic
total water intake averaged around 2.5 L/d for 9- to
states on cognition have not been fully evaluated.
13-year-old US boys and 2.2 L/d for 9- to 13-year-old
US girls (see Table 1 for all reported age ranges),
Total Body Water and Risk of Dehydration in suggesting that children in the United States have a
Children higher hydration level than German children. However,
it is important to note that in all cases, US children
At birth, total body water (TBW) is approximately
consumed more calories per day compared with German
75% of total body composition. TBW decreases to ap-
children, and this is a contributing factor to the differ-
ences in fluid intakes.
Children may be at greater risk for dehydration than
adults for several reasons. Young people have a greater
surface-to-mass ratio, allowing for greater water losses
from the skin. Fever and diarrhea result not only in a
reduction in body water, but also in potentially lethal
electrolyte imbalances. In developing countries, diar-
rheal diseases are a leading cause of death in children,
resulting in approximately 1.5 to 2.5 million deaths per
year.10 Mortality in these cases can many times be
prevented with appropriate oral rehydration therapy.
Children, infants in particular, are dependent upon
caregivers for provision of fluids. In the case of infants,
Figure 1. Comparison of osmotic threshold for vasopressin caregivers may not be aware of the extent of insensible
release and stimulation of the thirst reflex. (Used with permis- water loss and adequate hydration may therefore not be
sion from Pathophysiology of the Endocrine System.4) provided.11 As an example, inadequate breast-feeding is

458 Nutrition Reviews姞, Vol. 64, No. 10

 Decrements in physical performance in athletes have
been observed under conditions of as little as 2% dehy-
dration, measured acutely as percent body weight loss.
During exercise, children may not hydrate adequately
when allowed to drink according to thirst.20 Fluid intake
during athletic events can be enhanced by presenting
palatable carbohydrate-electrolyte fluids in lieu of plain
water.21 What is particularly troubling is that after peri-
ods of physical exertion, voluntary fluid intake may be
inadequate to offset fluid deficits.18,19 Mild to moderate
dehydration can therefore persist for some hours after the
conclusion of physical activity.

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HYDRATION AND COGNITIVE FUNCTION

Figure 2. Total body water, intracellular fluid, and extracellular Cognitive function can be clustered into several
fluid as a percentage of body weight and a function of age. main domains: memory functions, attention functions,
(Used with permission from Behrman et al., 2004.7) perceptual functions, executive functions, psychomotor
functions, and language skills. Each of the cognitive
domains can be further divided in a number of more
becoming more common as a risk factor for dehydration
specified functions. Memory functions, for example, in-
in infants.12 Nursing mothers with insufficient milk may
clude short-term and long-term memory encoding, stor-
not recognize the signs of progressive dehydration in
age and retrieval functions, and working memory. Further
their infants, and parents may not recognize signs of
differentiation is made with regard to the type of infor-
dehydration in older children. One report suggests that
mation that is processed; for example, auditory, visual,
although most parents understand what dehydration is,
verbal, spatial, abstract, or procedures. Attention can be
only about two-thirds could identify more than one sign
subdivided in selective, divided, and sustained attention
of dehydration.13
functions, whereas executive functions encompass more
complex processes such as reasoning, planning, concept
Hydration and Physical Activity in Children formation, evaluation, and strategic thinking.22
Research in our laboratory and others supports the
Children may also be at greater risk for “voluntary hypothesis that mild dehydration produces alterations in a
dehydration,” a state of water deficit where fluids have number of important aspects of cognitive function such as
been ingested to the point where thirst no longer provides concentration, alertness, and short-term memory in young
a drive to drink, but where adequate repletion of fluids adults 18 to 25 years of age23-27 and in the oldest adults 50
has not been achieved. Voluntary dehydration is seen to 82 years of age.28 Most of the cited studies were ran-
most commonly in child athletes or following climatic domized, controlled trials. The results vary with respect to
heat stress. Children may not recognize the need to magnitude of effect on cognition and in direction of effect.
replace lost fluids, so children and coaches need specific In some studies, cognitive performance was not altered by
guidelines for fluid intake.14 Additionally, children may mild dehydration.29 In others, mild dehydration produced
require longer acclimation to increases in environmental
temperature than do adults. It is recommended that child
Table 1. Total Water Intakes of US and German
athletes or children in hot climates begin athletic activ-
Children
ities in a well-hydrated state and drink fluids over and
US* German†
above the thirst threshold. One study published in 1994
found that one-third of British school-aged children had mean mL/d
nothing to drink prior to the beginning of the school day, Boys and Girls
reflecting a fluid fast of over 12 hours.15 Since then, Age 1–3 (US) 2–3 (G) 1420 1114
several programs have been instituted in the United Age 4–8 1779 1363
Kingdom to promote adequate water intake in school- Boys age 9–13 2535 1891
children.16,17 Girls age 9–13 2240 1676
Research suggests that, especially at the beginning *Fluid intake from food and beverages (data from Food and
of the season, young athletes are at particular risk for Nutrition Board, Institute of Medicine, 20043).
dehydration due to lack of acclimatization to weather †Total water from food, beverages, and metabolic water (data
conditions or suddenly increased activity levels.18,19 from Sichert-Hellert et al., 20019).

Nutrition Reviews姞, Vol. 64, No. 10 459

modest decrements in cognitive performance23-26 or even dration include dizziness, lethargy, agitation, irritability,
mild enhancement.23 In young adults, significantly higher restlessness, and confusion7,30-32 (Table 2). Children
mood scores for anger, confusion, and fatigue were seen with moderate hypernatremic dehydration may be lethar-
under conditions of mild dehydration.23 gic, but then show irritability when touched.7 Other
Mild dehydration (as small as 2% loss of body neurological complications of dehydration include hy-
weight as water) can impair performance on tasks such pertonicity, hyperreflexia, seizures, myelinolysis, and
as short-term memory, perceptual discrimination, arith- brain herniation. Decreased voluntary fluid intake leads
metic ability, visuomotor tracking, and psychomotor to decreased volume and increased sodium levels. In
skills.23-26 For example, Cian et al.24,25 examined the acute hypernatremia, fluid leaves the intracellular space
effects of heat stress and dehydration on cognitive func- and flows to the extracellular space. In brain, cell volume
tioning in a series of studies. In these studies, participants can decrease up to 10% to 15%, but then rapidly
(healthy young adults) were dehydrated (approximately adapts.32 In children, acute hypernatremia may have a

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2.7%) either through heat exposure or treadmill exercise. mortality rate of up to 20%, and up to 66% of survivors
In both studies, they found significantly decreased alert- experience consequent neurological symptoms.33
ness, concentration, and tracking performance and in- A recent examination of voluntary dehydration in
creased tiredness and headaches; increased reaction time 10- to 12-year-old children indicates that dehydration
was also observed (the test asked the subjects to identify throughout the day may negatively impact cognitive
the color of an object), but the number of correct answers function.34 Israeli schoolchildren were divided into nor-
was unchanged. Gopinathan et al.26 induced moderate mally hydrated or dehydrated groups based on urine
levels of dehydration (2%– 4%) through a combination osmolality. Cognitive testing took place at the beginning
of water restriction and exercise in a heated room, and of the school day and again at noon. Five tests were
demonstrated hydration-level-dependent decreases in administered: 1) hidden figures (identifying a given fig-
short-term memory, arithmetic efficiency, attention ure in patterns that contain an additional line); 2) audi-
tasks, and visuomotor tracking. tory number span (immediate memory of a sequence of
These studies demonstrate that low to moderate dictated digits); 3) making groups (constructing concep-
levels of dehydration may significantly alter cognitive tual categories); 4) verbal analogies; and 5) number
performance in young adults, in whom significantly addition. At the beginning of the day there were no
higher mood scores for anger, confusion, and fatigue significant differences in cognitive performance between
were seen under conditions of mild dehydration.23 Szin- the groups, although there was a trend for short-term
nai et al.29 did not find an alteration of cognitive perfor- memory scores, as measured by an auditory number span
mance in healthy young adults as a result of mild dehy- task, to be higher in hydrated students. At noon, how-
dration. However, the authors argue that increased ever, students initially classified as hydrated tended to
subjective task-related effort could suggest that healthy perform better on several cognitive tasks than dehydrated
volunteers exhibit cognitive compensating mechanisms students. Short-term memory scores were significantly
for increased tiredness and reduced alertness during higher in hydrated children than in dehydrated children.
slowly progressive moderate dehydration. There was a trend for hydrated students to perform better
on the verbal analogy task (measuring semantic fluency)
Hydration and Cognitive Function in Children and on the making groups task (measuring semantic
flexibility) relative to dehydrated children. Although
Dehydration ranges from mild to severe. Clinical there were a number of limitations with this study,
signs of mild dehydration (as low as 3% body weight including “self-selection” into hydration conditions, spe-
loss) are subtle, and include restlessness and increased cific climatic conditions, and no condition for provision
alertness. Clinical signs of moderate (5%–9% body of fluids to dehydrated students, the data might suggest a
weight loss) to severe (⬎10% body weight loss) dehy- negative influence of dehydration on children’s cogni-

Table 2. Affective Signs of Dehydration

Degree of Dehydration
Age Group None or Mild Moderate Severe
Infants Thirsty, alert, restless Lethargic or drowsy Limp, cold, cyanotic
extremities, may be comatose
Older children Thirsty, alert, restless Alert, postural dizziness Apprehensive, cold, cyanotic
extremities, muscle cramps
Adapted from Gorelick et al., 1997.30

460 Nutrition Reviews姞, Vol. 64, No. 10

tion. Moreover, the authors observe that in hot climates, lead to underperfusion of the brain. In older persons,
chronic voluntary dehydration may play a significant role urge incontinence is associated with a greater urine loss
in cognitive performance. To date, this study is the only relative to other forms of incontinence. In this popula-
one investigating the interaction between dehydration tion, urge incontinence is positively correlated with a
and cognitive performance in children. decrease in cognitive performance and with underperfu-
Preliminary observations by schoolteachers in the sion of the frontal lobes of the cerebral cortex.38,39
United Kingdom indicate that programs encouraging However, it should be noted that dehydration was not
water intake in students might improve student atten- measured directly in these studies. Cerebral underperfu-
tion and concentration,54 but at the time of this review sion is also associated with confusion, dementia, and
no scientific data on these observations had been lethargy, suggesting that changes in brain hydration lev-
published. els may be partially responsible for the effects of dehy-
dration on cognitive performance.

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Hydration and Brain Injury Dehydration is known to increase circulating levels
of stress hormones such as cortisol,40 and in humans,
As described above, cellular dehydration occurs in increased levels of cortisol have been associated with
hypernatremia as water leaves the cell across the decrements in cognitive function.41-44 It is theorized that
concentration gradient. Such cellular shrinkage is as- some of the effects of dehydration are therefore related to
sociated with neuronal lesions and brain edema.35 the activation of the hypothalamic-pituitary-adrenocorti-
Brain imaging of infants and children with hypernatre- cal axis and the release of stress hormones. This hypoth-
mia suggests that increased plasma osmolality is as- esis may be supported by observations in animals that
sociated with cerebral lesions in thalamic, cortical, hypothalamic-pituitary-adrenocortical axis activation in-
hippocampal, and other regions. Furthermore, exces- duced by stress and/or pharmacological administration of
sively fast rehydration can cause rapid influx of water glucocortocoids (stress hormones) can produce dendritic
into brain cells, resulting in cerebral edema, and these atrophy in hippocampal neurons, and that this atrophy is
insults to the brain may be long-lasting or even per- associated with cognitive decrements.45
manent. Children develop hyponatremic encephalopa- Arginine vasopressin is released in response to fluid
thy at higher sodium concentrations than do adults. decrements. As described above, vasopressin released in the
Also, children have a higher brain-to-skull ratio than hypothalamus activates the thirst response and thus pro-
adults, leaving less room for brain expansion. Evi- vokes drinking. Vasopressin may act as a neuromodulator
dence suggests that many of the neurological sequelae to produce excitatory effects in neural tissue. Elevated
of dysnatremias are due to damage resulting from levels of vasopressin may enhance cognitive functioning on
rapid changes in fluid balance across cellular concen- certain tasks.44 Specifically, elevated plasma vasopressin is
tration gradients, rather than hypo- or hypernatremic associated with increased attention and arousal, and this
states per se. There are few studies examining either excitatory effect may explain some of the contradictory
the short- or long-term influence of dehydration on findings on the effects of dehydration on cognition.
cognitive functioning in these children. In animal studies, chronic dehydration increases gluta-
Some research36,37 suggests that repeated bouts and mate and GABA release and augments norepinephrine-
prolonged episodes of diarrhea in early childhood could induced release of glutamate and norepinephrine-induced
produce long-term cognitive decrements. These decre- inhibition of GABA release.46 Chronic dehydration may
ments are independent of maternal education, parasitic therefore produce an increase in neuronal activity and
infection, and many other variables. Although it is dif- enhance the actions of both excitatory (glutamate) and
ficult to parse the effects of malnutrition and dehydration inhibitory (GABA) neurotransmitters. The exact pro-
on the cognitive performance of these children, it is cesses that these differing neurotransmitters affect are
possible that dehydration-mediated changes in brain complex and well beyond the scope of this review. In
physiology could contribute to persistent cognitive im- brief, inhibitory and excitatory neurotransmitters may
pairments in children with early childhood diarrhea. have opposing effects on behavior and cognition. How-
ever, inhibitory and excitatory neurotransmitters may
Potential Mechanisms Relating Hydration to also have similar effects depending on receptor subtype
Cognitive Function and localization. For example, pharmacological blockade
(antagonism) of GABA-B receptors (inhibiting inhibi-
Fluid is lost through the urine and feces and through tion) augments long-term hippocampal-dependent mem-
respiration, sweat, and other insensible losses. Whatever ory.47 In contrast, activation of GABA-A receptors (ac-
the cause of loss, if fluids are not replaced, then there is tivating inhibition) enhances memory and spatial
shrinkage of plasma and extracellular volume that can learning in rats.48

Nutrition Reviews姞, Vol. 64, No. 10 461

Table 3. Hydration and Cognitive Function in Children and Young Adults
Age Effects of Hydration Status on
(yrs) N Design Cognition Study
10–12 20 boys; Comparison dehydrated vs. No effect of initial hydration levels on Bar-David et al.,
31 girls euhydrated* cognitive performance at first test in 200634
the morning; at lunchtime, short-term
memory was impaired in dehydrated
children (P ⫽ 0.024)
18–21 16 men; Repeat testing in fluid • 1.65% (women) and 2% (men) Taylor et al.,
15 women restriction vs. ad libitum dehydration increased reaction time in the 200523
water intake continuous performance task (P ⬍ 0.05)
• 1.65% dehydration in women

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increased errors on the choice-reaction
time task (P ⬍ 0.05)
• 2% dehydration in men decreased
errors on the choice-reaction time task
(P ⬍ 0.05)
• Dehydration improved short-term
memory (P ⬍ 0.05) and intensified
mood scores (P ⬍ 0.05)
20–25 11 men Repeat testing in fluid 1% dehydration had no effect on Gopinithan et al.,
restriction vs. ad libitum cognitive performance; 2%, 3%, and 198826
water intake 4% dehydration impaired short-term
memory, arithmetic performance, and
visuomotor tracking (P ⬍ 0.001 for
all measures)
21–24 8 men Repeat testing in fluid 2% and 3% dehydration impaired Sharma et al.,
restriction vs. ad libitum concentration and psychomotor 198655
water intake performance (P ⬍ 0.001)
*Dehydrated meant that the urine had greater than 800 mosm/kg H2O; 11/20 boys and 21/31 girls were classified as dehydrated.

Glutamate receptor antagonists are associated with by Bar-David et al.34 seem to indicate negative effects on
memory impairments,49 but excitotoxicity produced by cognition induced by mild dehydration in children. How-
chronically high levels of glutamate agonists can also in- ever, much remains unknown about the short- and long-
duce hippocampal damage and produce cognitive decre- term effects of dehydration on cognitive function in chil-
ments.50 Dehydration is associated with a decrease in neu- dren, so these results need to be confirmed by future
ronal cell proliferation that is reversed by rehydration.51 research. Several countries, including the United States and
Using a model of lead exposure, Al Shuaib et al.52 found the United Kingdom, are already encouraging water intake
that dehydration in combination with lead exposure signif- in school-age children to promote good health and improve
icantly impairs synaptic transmission at the neuromuscular academic performance.16,17,53
junction. Neuromuscular impairments can be reflected in
decrements in psychomotor performance. Although any
links between these animal studies and human cognitive ACKNOWLEDGEMENTS
performance would be speculative, the existing research
suggests that dehydration produces many different physio- This project was supported in part by RO1-
logical effects that can individually or in combination affect DK065114 and with funds from the US Department of
cognitive and psychomotor performance. Agriculture, Agricultural Research Service, under con-
tract number 53000-063-01A (IHR) and T32 DK007651
CONCLUSIONS (KED). The contents of this publication do not necessar-
ily reflect the views or policies of the US Department of
Although the effects of dehydration on cognitive func- Agriculture, nor does mention of trade names, commer-
tion are now well documented in adults, there are few cial products, or organizations imply endorsement by the
studies examining the relationship between hydration status US Government. This review was partly supported by an
and cognitive function in children (Table 3). Data reported educational grant from Nestlé Waters.

462 Nutrition Reviews姞, Vol. 64, No. 10

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