History

The goal of the history and physical examination is to determine the severity and etiology 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
Fluid loss (eg, vomiting, diarrhea)
Number of wet diapers compared with normal, suggesting oliguria or anuria
Activity level
Possible ingestions that may cause vomiting
Heat and sunlight exposures for insensible losses
Current illness pattern, fever, ill contacts
Recent weight prior to current illness (infants typically have regular well child appointments with weight recorded)

Physical Examination

The severity of dehydration is typically measured as the acute weight loss (presumably fluid) as a percentage of preillness weight. However, the pre-illness weight is often not available in the ED setting and clinicians have to rely on the patient’s history and physical examination findings to assess the severity of dehydration.

On the basis of a systematic review, Steiner et al found that the most useful signs (ie, highest likelihood ratios) for recognizing 5% dehydration are the following^[6]:

Abnormal capillary refill time
Abnormal skin turgor
Abnormal respiratory pattern

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 status	Normal, alert	Restless or fatigued, irritable		Apathetic, lethargic, unconscious
Heart rate	Normal	Normal to increased		Tachycardia or bradycardia
Quality of pulse	Normal	Normal to decreased		Weak, thready, impalpable
Breathing	Normal	Normal to increased		Tachypnea and hyperpnea
Eyes	Normal	Slightly sunken		Deeply sunken
Fontanelles	Normal	Slightly sunken		Deeply sunken
Tears	Normal	Normal to decreased		Absent
Mucous membranes	Moist	Dry		Parched
Skin turgor	Instant recoil	Recoil < 2 seconds		Recoil >2 seconds
Capillary refill	< 2 seconds	Prolonged		Minimal
Extremities	Warm	Cool		Mottled, 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.^[5]

Differential Diagnoses

Mange K, Matsuura D, Cizman B, et al. Language guiding therapy: the case of dehydration versus volume depletion. Ann Intern Med. 1997 Nov 1. 127(9):848-53. [QxMD MEDLINE Link].
Sterns RH, Cappuccio JD, Silver SM, Cohen EP. Neurologic sequelae after treatment of severe hyponatremia: a multicenter perspective. J Am Soc Nephrol. 1994 Feb. 4 (8):1522-30. [QxMD MEDLINE Link].
Singhi SC, Shah R, Bansal A, Jayashree M. Management of a child with vomiting. Indian J Pediatr. 2013 Apr. 80(4):318-25. [QxMD MEDLINE Link].
Glaser NS, Ghetti S, Casper TC, Dean JM, Kuppermann N. Pediatric diabetic ketoacidosis, fluid therapy, and cerebral injury: the design of a factorial randomized controlled trial. Pediatr Diabetes. 2013 Mar 13. [QxMD MEDLINE Link]. [Full Text].
King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21. 52:1-16. [QxMD MEDLINE Link].
Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?. JAMA. 2004 Jun 9. 291(22):2746-54. [QxMD MEDLINE Link].
Wathen JE, MacKenzie T, Bothner JP. Usefulness of the serum electrolyte panel in the management of pediatric dehydration treated with intravenously administered fluids. Pediatrics. 2004 Nov. 114(5):1227-34. [QxMD MEDLINE Link].
Lozon MM. Pediatric vascular access and blood sampling techniques. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia: WB Saunders; 2004. 357-8.
Jauregui J, Nelson D, Choo E, Stearns B, Levine AC, Liebmann O, et al. The BUDDY (Bedside Ultrasound to Detect Dehydration in Youth) study. Crit Ultrasound J. 2014. 6 (1):15. [QxMD MEDLINE Link].
Jauregui J, Nelson D, Choo E, Stearns B, Levine AC, Liebmann O, et al. The BUDDY (Bedside Ultrasound to Detect Dehydration in Youth) study. Crit Ultrasound J. 2014. 6(1):15. [QxMD MEDLINE Link]. [Full Text].
Spandorfer PR, Alessandrini EA, Joffe MD, Localio R, Shaw KN. Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial. Pediatrics. 2005 Feb. 115(2):295-301. [QxMD MEDLINE Link].
Freedman SB, Adler M, Seshadri R, Powell EC. Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med. 2006 Apr 20. 354(16):1698-705. [QxMD MEDLINE Link].
Heyman MB, Abrams SA, SECTION ON GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION., COMMITTEE ON NUTRITION. Fruit Juice in Infants, Children, and Adolescents: Current Recommendations. Pediatrics. 2017 Jun. 139 (6):[QxMD MEDLINE Link].
Freedman SB, Willan AR, Boutis K, Schuh S. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. JAMA. 2016 May 10. 315 (18):1966-74. [QxMD MEDLINE Link].
Kersten H. Oral ondansetron decreases the need for intravenous fluids in children with gastroenteritis. J Pediatr. 2006 Nov. 149(5):726. [QxMD MEDLINE Link].
Alhashimi D, Alhashimi H, Fedorowicz Z. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev. 2006 Oct 18. CD005506. [QxMD MEDLINE Link].
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. 1996 Mar. 97(3):424-35. [QxMD MEDLINE Link].
Barkin RM, Ward DG. Infectious diarrheal disease and dehydration. Marx JA. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia, Pa: Mosby/Elsevier; 2006. Vol 3: 2623-34.
Danewa AS, Shah D, Batra P, Bhattacharya SK, Gupta P. Oral Ondansetron in Management of Dehydrating Diarrhea with Vomiting in Children Aged 3 Months to 5 Years: A Randomized Controlled Trial. J Pediatr. 2016 Feb. 169:105-9.e3. [QxMD MEDLINE Link].
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. 2009 Jul. 54(1):117-9. [QxMD MEDLINE Link].
Santillanes G, Rose E. Evaluation and Management of Dehydration in Children. Emerg Med Clin North Am. 2018 May. 36 (2):259-273. [QxMD MEDLINE Link].

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Table. Physical Examination Findings in Pediatric Dehydration

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 status	Normal, alert	Restless or fatigued, irritable		Apathetic, lethargic, unconscious
Heart rate	Normal	Normal to increased		Tachycardia or bradycardia
Quality of pulse	Normal	Normal to decreased		Weak, thready, impalpable
Breathing	Normal	Normal to increased		Tachypnea and hyperpnea
Eyes	Normal	Slightly sunken		Deeply sunken
Fontanelles	Normal	Slightly sunken		Deeply sunken
Tears	Normal	Normal to decreased		Absent
Mucous membranes	Moist	Dry		Parched
Skin turgor	Instant recoil	Recoil < 2 seconds		Recoil >2 seconds
Capillary refill	< 2 seconds	Prolonged		Minimal
Extremities	Warm	Cool		Mottled, 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.^[5]

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Author

Alex Koyfman, MD Assistant Professor, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Parkland Memorial Hospital

Alex Koyfman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Carrie Ng, MD Resident Physician, Department of Pediatrics, Bellevue Hospital Center, New York University School of Medicine

Carrie Ng, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Institute of Ultrasound in Medicine

Disclosure: Nothing to disclose.

Mark P Foran, MD, MPH Assistant Professor of Emergency Medicine, New York University School of Medicine; Attending Emergency Physician, Bellevue Hospital Center and NYU Langone Medical Center

Mark P Foran, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA Professor of Emergency Medicine and Clinical Pediatrics, Weill Cornell Medical College; Attending Physician, Departments of Emergency Medicine and Pediatrics, Lincoln Medical and Mental Health Center; Adjunct Professor of Emergency Medicine, Adjunct Professor of Pediatrics, St George's University School of Medicine, Grenada

Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA is a member of the following medical societies: American Academy of Pediatrics, American Academy of Urgent Care Medicine, American College of Emergency Physicians, American Heart Association, American Medical Association, Association of Clinical Research Professionals, Public Responsibility in Medicine and Research, Society for Academic Emergency Medicine, Society for Simulation in Healthcare

Disclosure: Nothing to disclose.

Additional Contributors

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, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

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