Background
Though often considered a benign disease, acute gastroenteritis remains a major cause of morbidity and mortality in children around the world, accounting for 1.87 million deaths annually in children younger than 5 years, or roughly 19% of all child deaths.[1] Because the disease severity depends on the degree of fluid loss, accurately assessing dehydration status remains a crucial step in preventing mortality. Luckily, most cases of dehydration in children can be accurately diagnosed by a careful clinical examination and treated with simple, cost-effective measures.
See the video below depicting a child with acute gastroenteritis.
Child with slow skin pinch (reduced skin turgor).Pathophysiology
Adequate fluid balance in humans depends on the secretion and reabsorption of fluid and electrolytes in the intestinal tract; diarrhea occurs when intestinal fluid output overwhelms the absorptive capacity of the gastrointestinal tract. The 2 primary mechanisms responsible for acute gastroenteritis are (1) damage to the villous brush border of the intestine, causing malabsorption of intestinal contents and leading to an osmotic diarrhea, and (2) the release of toxins that bind to specific enterocyte receptors and cause the release of chloride ions into the intestinal lumen, leading to secretory diarrhea.[2]
However, even in severe diarrhea, various sodium-coupled solute co-transport mechanisms remain intact, allowing for the efficient reabsorption of salt and water. By providing a 1:1 proportion of sodium to glucose, classic oral rehydration solution (ORS) takes advantage of a specific sodium-glucose transporter (SGLT-1) to increase the reabsorption of sodium, which leads to the passive reabsorption of water. Rice- and cereal-based ORS may also take advantage of sodium-amino acid transporters to increase reabsorption of fluid and electrolytes.[2]
Epidemiology
Frequency
United States
Children in the United States experience, on average, 1.3-2.3 episodes of diarrhea each year. Overall, acute gastroenteritis accounts for than 1.5 million outpatient visits, 220,000 hospitalizations, and direct costs of more than $2 billion each year in the United States alone.[3]
International
Worldwide, children younger than 5 years experience an estimated 1.4 billion episodes of diarrhea each year, leading to 123 million clinic visits, 9 million hospitalizations, and 1.87 million deaths, with more than 98% of these deaths occurring in the developing world.[4, 1]
Though the prevalence of acute gastroenteritis in children has changed little over the past 4 decades, the mortality has declined sharply, from 4.6 million in the 1970s to 3 million in the 1980s to 2.5 million in the 1990s.[4] One of the most important reasons for this decline has been the increasing international support for the use of ORS as the treatment of choice for acute diarrhea, with the proportion of diarrheal episodes treated with ORS rising from 15% in 1984 to 40% in 1993.[4]
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| Symptom or Sign | No or Minimal Dehydration | Mild to Moderate Dehydration | Severe Dehydration |
| Mental status | Alert | Restless, irritable | Lethargic, unconscious |
| Thirst | Drinks normally | Drinks eagerly | Drinks poorly |
| Heart rate | Normal | Normal to increased | Tachycardia |
| Quality of pulses | Normal | Normal to decreased | Weak or unpalpable |
| Breathing | Normal | Normal or fast | Deep |
| Eyes | Normal | Slightly sunken | Deeply sunken |
| Tears | Present | Decreased | Absent |
| Mouth and tongue | Moist | Dry | Parched |
| Skin fold | Instant recoil | Recoil < 2 seconds | Recoil >2 seconds |
| Capillary refill | Normal | Prolonged | Prolonged or minimal |
| Extremities | Warm | Cool | Cold, mottled, cyanotic |
| Urine output | Normal | Decreased | Minimal |
| *Adapted from King et al. MMWR Recomm Rep. 2003;52(RR-16):1-16.[2] | |||
| Severe Dehydration | Two of the following signs: -Lethargic or unconscious -Sunken eyes -Not able to drink or drinking poorly -Skin pinch goes back very slowly |
| Some Dehydration | Two of the following signs: -Restless, irritable -Sunken eyes -Thirsty, drinks eagerly -Skin pinch goes back slowly |
| No Dehydration | Not enough of the above signs to classify as some or severe dehydration |
| *Adapted from World Health Organization.[9] | |
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