Dehydration Clinical Presentation

  • Author: Lennox H Huang, MD, FAAP; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Mar 12, 2012
 

History

The following should be considered in patients with dehydration:

  • Intake of fluids, including the volume, type (hypertonic or hypotonic), and frequency
  • Urine output, including the frequency of voiding (last wet diaper), presence of concentrated or dilute urine, hematuria
  • Stool output, frequency of stools, stool consistency, presence of blood or mucus in stools
  • Emesis, including frequency and volume and whether bilious or nonbilious, hematemesis
  • Contact with ill people, especially others with gastroenteritis, use of daycare
  • Underlying illnesses, especially cystic fibrosis, diabetes mellitus, hyperthyroidism, renal disease
  • Fever
  • Appetite patterns
  • Weight loss
  • Travel
  • Recent antibiotic use
  • Possible ingestions
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Physical

A complete physical examination may assist in determining the underlying cause of the patient's dehydration and in defining the severity of dehydration. The clinical assessment of severity of dehydration determines the approach to management. In general, physical signs of dehydration have poor precision and accuracy. Rather than attempting to assign an exact percentage of dehydration, one should attempt to place the child in one of 3 broad categories.

The determination of dehydration severity should be based on the overall constellation of symptoms. Patients in a given category need not exhibit all the signs and symptoms listed below. Literature reviews have suggested that delayed capillary refill, delayed skin turgor, and abnormal respiratory pattern are the most reliable clinical signs of dehydration in children. Validated clinical dehydration scales may be a useful adjunct to predict need for intravenous fluid and longer stays in the emergency department.[5]

Table 1. Clinical Findings of Dehydration (Open Table in a new window)

Symptom/SignMild DehydrationModerate DehydrationSevere Dehydration
level of consciousnessAlertLethargicObtunded
Capillary refill*2 s2-4 s>4 s, cool limbs
Mucous membranesNormalDryParched, cracked
TearsNormalDecreasedAbsent
Heart rateSlightly increasedIncreasedVery increased
Respiratory rate/pattern*NormalIncreasedIncreased and hyperpnea
Blood pressureNormalNormal, but orthostasisDecreased
PulseNormalThreadyFaint or impalpable
Skin turgor*NormalSlowTenting
FontanelNormalDepressedSunken
EyesNormalSunkenVery sunken
Urine outputDecreasedOliguriaOliguria/anuria
* Best indicators of hydration status[6]

Table 2. Estimated Fluid Deficit (Open Table in a new window)

SeverityInfants (weight < 10 kg)Children (weight >10 kg)
Mild dehydration5% or 50 mL/kg3% or 30 mL/kg
Moderate dehydration10% or 100 mL/kg6% or 60 mL/kg
Severe dehydration15% or 150 mL/kg9% or 90 mL/kg
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Causes

Determination of the cause of dehydration is essential. Poor fluid intake, excessive fluid output, increased insensible fluid losses, or a combination of the above may cause intravascular volume depletion. Successful treatment requires identification of the underlying disease state.

  • Common causes
    • Gastroenteritis: This is the most common cause of dehydration. If both vomiting and diarrhea are present, dehydration may rapidly progress.[7, 8]
    • Stomatitis: Pain may severely limit oral intake.
    • Diabetic ketoacidosis (DKA): Dehydration is caused by osmotic diuresis. Weight loss is caused by both excessive fluid losses and tissue catabolism. Rapid rehydration, especially rapid initial volume resuscitation, may be associated with a poor neurologic outcome. DKA requires very specific and controlled treatment (see Diabetic Ketoacidosis).
    • Febrile illness: Fever causes increased insensible fluid losses and may affect appetite.
    • Pharyngitis: This may decrease oral intake.
  • Life-threatening causes
    • Gastroenteritis
    • DKA
    • Burns: Fluid losses may be extreme. Very aggressive fluid management is required (see Burns, Thermal).
    • Congenital adrenal hyperplasia: This may have associated hypoglycemia, hypotension, hyperkalemia, and hyponatremia.
    • GI obstruction: This is often associated with poor intake and emesis. Bowel ischemia can result in extensive capillary leak and shock.
    • Heat stroke: Hyperpyrexia, dry skin, and mental status changes may occur.[9]
    • Cystic fibrosis: This results in excessive sodium and chloride losses in sweat, placing patients at risk for severe hyponatremic hypochloremic dehydration.
    • Diabetes insipidus: Excessive output of very dilute urine can result in large free water losses and severe hypernatremic dehydration.
    • Thyrotoxicosis: Weight loss is observed, despite increased appetite. Diarrhea occurs.
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Contributor Information and Disclosures
Author

Lennox H Huang, MD, FAAP  Associate Professor and Chair, Department of Pediatrics, McMaster University School of Medicine; Chief of Pediatrics, McMaster Children's Hospital

Lennox H Huang, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Physician Executives, Canadian Medical Association, Ontario Medical Association, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Krishnapriya R Anchala, MD, MS, FAAP  Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, McMaster University

Krishnapriya R Anchala, MD, MS, FAAP is a member of the following medical societies: American Academy of Pediatrics, Canadian Medical Association, and Ontario Medical Association

Disclosure: Nothing to disclose.

Dan L Ellsbury, MD  Consulting Staff, Pediatrix Medical Group of Iowa; Consulting Staff, Department of Pediatrics, Neonatology Intensive Care Unit, Mercy Medical Center of Des Moines

Dan L Ellsbury, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Caroline S George, MD  Associate Professor, Consulting Staff, Department of Pediatrics, Division of Critical Care Medicine, University of Minnesota Medical School

Caroline S George, MD is a member of the following medical societies: American Academy of Pediatrics and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

G Patricia Cantwell, MD, FCCM  Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team, Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids – Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society

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.

Barry J Evans, MD  Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Mary E Cataletto, MD  Director of Children's Sleep Services, Winthrop Sleep Disorders Center, Mineola, NY; Professor of Clinical Pediatrics, State University of New York at Stony Brook, Stony Brook, NY

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians

Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

References

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Table 1. Clinical Findings of Dehydration
Symptom/SignMild DehydrationModerate DehydrationSevere Dehydration
level of consciousnessAlertLethargicObtunded
Capillary refill*2 s2-4 s>4 s, cool limbs
Mucous membranesNormalDryParched, cracked
TearsNormalDecreasedAbsent
Heart rateSlightly increasedIncreasedVery increased
Respiratory rate/pattern*NormalIncreasedIncreased and hyperpnea
Blood pressureNormalNormal, but orthostasisDecreased
PulseNormalThreadyFaint or impalpable
Skin turgor*NormalSlowTenting
FontanelNormalDepressedSunken
EyesNormalSunkenVery sunken
Urine outputDecreasedOliguriaOliguria/anuria
* Best indicators of hydration status[6]
Table 2. Estimated Fluid Deficit
SeverityInfants (weight < 10 kg)Children (weight >10 kg)
Mild dehydration5% or 50 mL/kg3% or 30 mL/kg
Moderate dehydration10% or 100 mL/kg6% or 60 mL/kg
Severe dehydration15% or 150 mL/kg9% or 90 mL/kg
Table 3. Composition of Appropriate Oral Rehydration Solutions
SolutionCarbohydrate (g/dL)Sodium (mEq/L)Potassium (mEq/L)Base (mEq/L)Osmolality
Pedialyte2.5452030250
Infalyte3502530200
Rehydralyte2.5752030310
WHO/UNICEF*2902030310
* World Health Organization/United Nations Children's Fund
Table 4. Composition of Inappropriate Oral Rehydration Solutions
SolutionCarbohydrate (g/dL)Sodium (mEq/L)Potassium (mEq/L)Base (mEq/L)Osmolality
Apple juice120.4260700
Ginger ale93.50.13.6565
Milk4.9223630260
Chicken broth0233330
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