Pediatric Dehydration Clinical Presentation

  • Author: James Kimo Takayesu, MD, MSc; more...
 
Updated: Nov 4, 2011
 

History

The goal of the history and physical examination is to determine the severity of the child's condition. Accurate classification of the degree of dehydration as mild, moderate, or severe allows for appropriate therapy and disposition of the patient in a timely fashion.

Obtaining a complete history from the parent or caregiver is important because it provides clues to the type of dehydration present. The emergency physician should be diligent in obtaining the following information:

  • Feeding pattern and fluids given
  • Number of wet diapers compared with normal
  • Fluid loss (eg, vomiting, oliguria or anuria, diarrhea)
  • Possible ingestions
  • Activity
  • Medications
  • Heat and sunlight exposures
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Physical Examination

On the basis of a systematic review, Steiner et al advised that the initial assessment of dehydration in young children focus on the following[3] :

  • Capillary refill time
  • Skin turgor
  • Respiratory pattern
  • Combinations of other signs

Of the findings on physical examination, the least accurate are mental status, heart rate, and fontanelle appearance.

The Table highlights the physical findings seen with different levels of pediatric dehydration.

Table. Physical Examination Findings in Pediatric Dehydration (Open Table in a new window)

Symptom Degree of Dehydration
Mild (< 3% body weight lost) Moderate (3-9% body weight lost) Severe (>9% body weight lost)
Mental statusNormal, alertRestless or fatigued, irritableApathetic, lethargic, unconscious
Heart rateNormalNormal to increasedTachycardia or bradycardia
Quality of pulseNormalNormal to decreasedWeak, thready, impalpable
BreathingNormalNormal to increasedTachypnea and hyperpnea
EyesNormalSlightly sunkenDeeply sunken
FontanellesNormalSlightly sunkenDeeply sunken
TearsNormalNormal to decreasedAbsent
Mucous membranesMoistDryParched
Skin turgorInstant recoilRecoil < 2 secondsRecoil >2 seconds
Capillary refill< 2 secondsProlongedMinimal
ExtremitiesWarmCoolMottled, cyanotic
Adapted from King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. Nov 21 2003;52(RR-16):1-16.[2]
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Contributor Information and Disclosures
Author

James Kimo Takayesu, MD, MSc  Assistant Professor in Surgery, Director of Undergraduate Medical Education, Consulting Staff, Massachusetts General Hospital; Associate Residency Director, Harvard Affiliated Emergency Medicine Residency Partners

James Kimo Takayesu, MD, MSc is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Sigma Xi, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Richard G Bachur, MD Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston

Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Ann G Egland, MD Consulting Staff, Department of Operational and Emergency Medicine, Walter Reed Army Medical Center

Ann G Egland, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Association of Military Surgeons of the US, Medical Society of Virginia, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Terrance K Egland, MD Director, Business Planning and Development, Bureau of Medicine and Surgery

Terrance K Egland, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

James Li, MD Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine

Disclosure: Nothing to disclose.

Alison Wiley Lozner, MD Resident Physician, Harvard Affiliated Emergency Medicine Residency, Brigham and Women's Hospital; Clinical Fellow in Emergency Medicine, Harvard Medical School

Alison Wiley Lozner, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Mange K, Matsuura D, Cizman B, et al. Language guiding therapy: the case of dehydration versus volume depletion. Ann Intern Med. Nov 1 1997;127(9):848-53. [Medline].

  2. King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. Nov 21 2003;52(RR-16):1-16. [Medline].

  3. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?. JAMA. Jun 9 2004;291(22):2746-54. [Medline].

  4. Wathen JE, MacKenzie T, Bothner JP. Usefulness of the serum electrolyte panel in the management of pediatric dehydration treated with intravenously administered fluids. Pediatrics. Nov 2004;114(5):1227-34. [Medline].

  5. Hom J, Sinert R. Evidence-based emergency medicine/systematic review abstract. Comparison between oral versus intravenous rehydration to treat dehydration in pediatric gastroenteritis. Ann Emerg Med. Jul 2009;54(1):117-9. [Medline].

  6. Lozon MM. Pediatric vascular access and blood sampling techniques. In: Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia: WB Saunders; 2004:357-8.

  7. [Best Evidence] Spandorfer PR, Alessandrini EA, Joffe MD, Localio R, Shaw KN. Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial. Pediatrics. Feb 2005;115(2):295-301. [Medline].

  8. [Best Evidence] Freedman SB, Adler M, Seshadri R, Powell EC. Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med. Apr 20 2006;354(16):1698-705. [Medline].

  9. Kersten H. Oral ondansetron decreases the need for intravenous fluids in children with gastroenteritis. J Pediatr. Nov 2006;149(5):726. [Medline].

  10. [Best Evidence] Alhashimi D, Alhashimi H, Fedorowicz Z. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev. Oct 18 2006;CD005506. [Medline].

  11. American Academy of Pediatrics. Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics. Mar 1996;97(3):424-35. [Medline].

  12. Barkin RM, Ward DG. Infectious diarrheal disease and dehydration. In: Marx JA. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 3. 6th ed. Philadelphia, Pa: Mosby/Elsevier; 2006:2623-34.

 
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Table. Physical Examination Findings in Pediatric Dehydration
Symptom Degree of Dehydration
Mild (< 3% body weight lost) Moderate (3-9% body weight lost) Severe (>9% body weight lost)
Mental statusNormal, alertRestless or fatigued, irritableApathetic, lethargic, unconscious
Heart rateNormalNormal to increasedTachycardia or bradycardia
Quality of pulseNormalNormal to decreasedWeak, thready, impalpable
BreathingNormalNormal to increasedTachypnea and hyperpnea
EyesNormalSlightly sunkenDeeply sunken
FontanellesNormalSlightly sunkenDeeply sunken
TearsNormalNormal to decreasedAbsent
Mucous membranesMoistDryParched
Skin turgorInstant recoilRecoil < 2 secondsRecoil >2 seconds
Capillary refill< 2 secondsProlongedMinimal
ExtremitiesWarmCoolMottled, cyanotic
Adapted from King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. Nov 21 2003;52(RR-16):1-16.[2]
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