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Dehydration

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Presentation

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
Method of mixing infant formula; volume of water to powder being used
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; measure of recent weight versus weight on presentation
Travel
Recent antibiotic use
Possible ingestions

Physical Examination

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. 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.^[9]

A prospective pilot cohort study of 242 Italian children at two emergency departments found that capillary refilling time was a useful and quick triage parameter for identifying pediatric dehydration requiring prompt rehydration.^[10]

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

Symptom/Sign	Mild Dehydration	Moderate Dehydration	Severe Dehydration
Level of consciousness	Alert	Lethargic	Obtunded
Capillary refill*	2 s	2-4 s	>4 s, cool limbs
Mucous membranes	Normal	Dry	Parched, cracked
Tears	Normal	Decreased	Absent
Heart rate	Slightly increased	Increased	Very increased
Respiratory rate/pattern*	Normal	Increased	Increased and hyperpnea
Blood pressure	Normal	Normal, but orthostasis	Decreased
Pulse	Normal	Thready	Faint or impalpable
Skin turgor*	Normal	Slow	Tenting
Fontanel	Normal	Depressed	Sunken
Eyes	Normal	Sunken	Very sunken
Urine output	Decreased	Oliguria	Oliguria/anuria
* Best indicators of hydration status^[11]

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

Severity	Infants (weight < 10 kg)	Children (weight >10 kg)
Mild dehydration	5% or 50 mL/kg	3% or 30 mL/kg
Moderate dehydration	10% or 100 mL/kg	6% or 60 mL/kg
Severe dehydration	15% or 150 mL/kg	9% or 90 mL/kg

Differential Diagnoses

Bettari L, Fiuzat M, Shaw LK, et al. Hyponatremia and long-term outcomes in chronic heart failure--an observational study from the Duke Databank for Cardiovascular Diseases. J Card Fail. 2012 Jan. 18(1):74-81. [QxMD MEDLINE Link].
Guarner J, Hochman J, Kurbatova E, Mullins R. Study of outcomes associated with hyponatremia and hypernatremia in children. Pediatr Dev Pathol. 2011 Mar-Apr. 14(2):117-23. [QxMD MEDLINE Link].
Zaki SA, Mondkar J, Shanbag P, Verma R. Hypernatremic dehydration due to lactation failure in an exclusively breastfed neonate. Saudi J Kidney Dis Transpl. 2012 Jan. 23(1):125-8. [QxMD MEDLINE Link].
Arora SK. Hypernatremic disorders in the intensive care unit. J Intensive Care Med. 2013 Jan-Feb. 28(1):37-45. [QxMD MEDLINE Link].
Colletti JE, Brown KM, Sharieff GQ, Barata IA, Ishimine P, ACEP Pediatric Emergency Medicine Committee. The management of children with gastroenteritis and dehydration in the emergency department. J Emerg Med. 2010 Jun. 38(5):686-98. [QxMD MEDLINE Link].
Parkin PC, Macarthur C, Khambalia A, Goldman RD, Friedman JN. Clinical and laboratory assessment of dehydration severity in children with acute gastroenteritis. Clin Pediatr (Phila). 2010 Mar. 49(3):235-9. [QxMD MEDLINE Link].
Koster C, Klingelhofer D, Groneberg DA, Schwarzer M. Rotavirus - Global research density equalizing mapping and gender analysis. Vaccine. 2016 Jan 2. 34(1):90-100. [QxMD MEDLINE Link].
Cheuvront SN, Kenefick RW, Montain SJ, Sawka MN. Mechanisms of aerobic performance impairment with heat stress and dehydration. J Appl Physiol. 2010 Dec. 109(6):1989-95. [QxMD MEDLINE Link].
[Guideline] Goldman RD, Friedman JN, Parkin PC. Validation of the clinical dehydration scale for children with acute gastroenteritis. Pediatrics. 2008 Sep. 122(3):545-9. [QxMD MEDLINE Link].
Caruggi S, Rossi M, De Giacomo C, et al. Pediatric dehydration assessment at triage: prospective study on refilling time. Pediatr Gastroenterol Hepatol Nutr. 2018 Oct. 21 (4):278-88. [QxMD MEDLINE Link].
Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?. JAMA. 2004 Jun 9. 291(22):2746-54. [QxMD MEDLINE Link].
Steiner MJ, Nager AL, Wang VJ. Urine specific gravity and other urinary indices: inaccurate tests for dehydration. Pediatr Emerg Care. 2007 May. 23(5):298-303. [QxMD MEDLINE Link].
Brandt KG, de Castro Antunes MM, da Silva GA. Acute diarrhea: evidence-based management. J Pediatr (Rio J). 2015 Nov-Dec. 91 (6 Suppl 1):S36-43. [QxMD MEDLINE Link].
[Guideline] Carson RA, Mudd SS, Madati PJ. Clinical practice guideline for the treatment of pediatric acute gastroenteritis in the outpatient setting. J Pediatr Health Care. 2016 Nov - Dec. 30(6):610-6. [QxMD MEDLINE Link].
Lee GO, Richard SA, Kang G, et al, for the MAL-ED Network Investigators. A comparison of diarrheal severity scores in the MAL-ED multisite community-based cohort study. J Pediatr Gastroenterol Nutr. 2016 Nov. 63(5):466-73. [QxMD MEDLINE Link].
World Health Organization. WHO Drug Information Vol. 16, No. 2, 2002: new formula oral rehydration salts. Available at http://apps.who.int/medicinedocs/en/d/Js4950e/2.4.html. May 10, 2002; Accessed: November 29, 2018.
UNICEF. New formulation of oral rehydration salts (ORS) with reduced osmolarity - Report from a meeting of experts jointly organized by UNICEF and WHO. WHO/CAH/01.22. Technical bulletin no 9. May 10, 2002. Available at https://www.unicef.org/supply/files/Oral_Rehydration_Salts(ORS)_.pdf.
Kumar R, Kumar P, Aneja S, Kumar V, Rehan HS. Safety and efficacy of low-osmolarity ORS vs. modified rehydration solution for malnourished children for treatment of children with severe acute malnutrition and diarrhea: a randomized controlled trial. J Trop Pediatr. 2015 Dec. 61(6):435-41. [QxMD MEDLINE Link].
Atherly-John YC, Cunningham SJ, Crain EF. A randomized trial of oral vs intravenous rehydration in a pediatric emergency department. Arch Pediatr Adolesc Med. 2002 Dec. 156(12):1240-3. [QxMD MEDLINE Link].
Hartling L, Bellemare S, Wiebe N, Russell K, Klassen TP, Craig W. Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. Cochrane Database Syst Rev. 2006 Jul 19. 3:CD004390. [QxMD MEDLINE Link].
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].
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].
Marchetti F, Bonati M, Maestro A, et al, for the SONDO (Study ONdansetron vs DOmperidone) Investigators. Oral ondansetron versus domperidone for acute gastroenteritis in pediatric emergency departments: multicenter double blind randomized controlled trial. PLoS One. 2016 Nov 23. 11(11):e0165441. [QxMD MEDLINE Link].
Uhlig U, Pfeil N, Gelbrich G, et al. Dimenhydrinate in children with infectious gastroenteritis: a prospective, RCT. Pediatrics. 2009 Oct. 124(4):e622-32. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention. Rotavirus vaccine information statement (VIS). Updated: October 18, 2016. Available at http://www.cdc.gov/vaccines/hcp/vis/vis-statements/rotavirus.html. Updated: October 18, 2016; Accessed: November 27, 2016.
Prasetyo D, Sabaroedin IM, Ermaya YS, Soenarto Y. Association between severe dehydration in rotavirus diarrhea and exclusive breastfeeding among infants at Dr. Hasan Sadikin General Hospital, Bandung, Indonesia. J Trop Med. 2015. 2015:862578. [QxMD MEDLINE Link].
Shanley L, Mittal V, Flores G. Preventing dehydration-related hospitalizations: a mixed-methods study of parents, inpatient attendings, and primary care physicians. Hosp Pediatr. 2013 Jul. 3(3):204-11. [QxMD MEDLINE Link].
Adrogue HJ, Madias NE. Hypernatremia. N Engl J Med. 2000 May 18. 342(20):1493-9. [QxMD MEDLINE Link].
Bellemare S, Hartling L, Wiebe N, et al. Oral rehydration versus intravenous therapy for treating dehydration due to gastroenteritis in children: a meta-analysis of randomised controlled trials. BMC Med. 2004 Apr 15. 2:11. [QxMD MEDLINE Link]. [Full Text].
Bender BJ, Ozuah PO, Crain EF. Oral rehydration therapy: is anyone drinking?. Pediatr Emerg Care. 2007 Sep. 23(9):624-6. [QxMD MEDLINE Link].
Bhatnagar S, Bahl R, Sharma PK, et al. Zinc with oral rehydration therapy reduces stool output and duration of diarrhea in hospitalized children: a randomized controlled trial. J Pediatr Gastroenterol Nutr. 2004 Jan. 38(1):34-40. [QxMD MEDLINE Link].
Choice Study Group. Multicenter, randomized, double-blind clinical trial to evaluate the efficacy and safety of a reduced osmolarity oral rehydration salts solution in children with acute watery diarrhea. Pediatrics. 2001 Apr. 107(4):613-8. [QxMD MEDLINE Link].
Dale J. Oral rehydration solutions in the management of acute gastroenteritis among children. J Pediatr Health Care. 2004 Jul-Aug. 18(4):211-2. [QxMD MEDLINE Link].
Duggan C, Fontaine O, Pierce NF, et al. Scientific rationale for a change in the composition of oral rehydration solution. JAMA. 2004 Jun 2. 291(21):2628-31. [QxMD MEDLINE Link].
Duggan C, Refat M, Hashem M, et al. How valid are clinical signs of dehydration in infants?. J Pediatr Gastroenterol Nutr. 1996 Jan. 22(1):56-61. [QxMD MEDLINE Link].
Duke T, Molyneux EM. Intravenous fluids for seriously ill children: time to reconsider. Lancet. 2003 Oct 18. 362(9392):1320-3. [QxMD MEDLINE Link].
Fonseca BK, Holdgate A, Craig JC. Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch Pediatr Adolesc Med. 2004 May. 158(5):483-90. [QxMD MEDLINE Link].
Gorelick MH, Shaw, KN, Murphy, KO. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997. May;(5):99:E6. [QxMD MEDLINE Link].
Holliday M. The evolution of therapy for dehydration: should deficit therapy still be taught?. Pediatrics. 1996 Aug. 98(2 Pt 1):171-7. [QxMD MEDLINE Link].
Holliday MA, Friedman AL, Segar WE, et al. Acute hospital-induced hyponatremia in children: a physiologic approach. J Pediatr. 2004 Nov. 145(5):584-7. [QxMD MEDLINE Link].
Holliday MA, Friedman AL, Wassner SJ. Extracellular fluid restoration in dehydration: a critique of rapid versus slow. Pediatr Nephrol. 1999 May. (4):292-7. [QxMD MEDLINE Link].
Hoorn EJ, Geary D, Robb M, et al. Acute hyponatremia related to intravenous fluid administration in hospitalized children: an observational study. Pediatrics. 2004 May. 113(5):1279-84. [QxMD MEDLINE Link].
King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21. 52(RR-16):1-16. [QxMD MEDLINE Link].
Miyasaka K, Shimizu N, Kojima J. Recent trends in pediatric fluid therapy. Methods Find Exp Clin Pharmacol. 2004 May. 26(4):287-94. [QxMD MEDLINE Link].
Moritz ML, Ayus JC. Preventing neurological complications from dysnatremias in children. Pediatr Nephrol. 2005 Dec. 20(12):1687-700. [QxMD MEDLINE Link].
Moritz ML, Ayus JC. Prevention of hospital-acquired hyponatremia: a case for using isotonic saline. Pediatrics. 2003 Feb. 111(2):227-30. [QxMD MEDLINE Link].
Moritz ML, Manole MD, Bogen DL, Ayus JC. Breastfeeding-associated hypernatremia: are we missing the diagnosis?. Pediatrics. 2005 Sep. 116(3):e343-7. [QxMD MEDLINE Link].
Murphy C, Hahn S, Volmink J. Reduced osmolarity oral rehydration solution for treating cholera. Cochrane Database Syst Rev. 2004. CD003754. [QxMD MEDLINE Link].
Nager AL, Wang VJ. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Pediatrics. 2002 Apr. 109(4):566-72. [QxMD MEDLINE Link].
Nalin DR, Hirschhorn N, Greenough W, et al. Clinical concerns about reduced-osmolarity oral rehydration solution. JAMA. 2004 Jun 2. 291(21):2632-5. [QxMD MEDLINE Link].
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Phin SJ, McCaskill ME, Browne GJ, Lam LT. Clinical pathway using rapid rehydration for children with gastroenteritis. J Paediatr Child Health. 2003 Jul. 39(5):343-8. [QxMD MEDLINE Link].
Playfor SD. Hypotonic intravenous solutions in children. Expert Opin Drug Saf. 2004 Jan. 3(1):67-73. [QxMD MEDLINE Link].
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Santosham M, Keenan EM, Tulloch J, et al. Oral rehydration therapy for diarrhea: an example of reverse transfer of technology. Pediatrics. 1997 Nov. 100(5):E10. [QxMD MEDLINE Link].
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Table 1. Clinical Findings of Dehydration

Symptom/Sign	Mild Dehydration	Moderate Dehydration	Severe Dehydration
Level of consciousness	Alert	Lethargic	Obtunded
Capillary refill*	2 s	2-4 s	>4 s, cool limbs
Mucous membranes	Normal	Dry	Parched, cracked
Tears	Normal	Decreased	Absent
Heart rate	Slightly increased	Increased	Very increased
Respiratory rate/pattern*	Normal	Increased	Increased and hyperpnea
Blood pressure	Normal	Normal, but orthostasis	Decreased
Pulse	Normal	Thready	Faint or impalpable
Skin turgor*	Normal	Slow	Tenting
Fontanel	Normal	Depressed	Sunken
Eyes	Normal	Sunken	Very sunken
Urine output	Decreased	Oliguria	Oliguria/anuria
* Best indicators of hydration status^[11]

Table 2. Estimated Fluid Deficit

Severity	Infants (weight < 10 kg)	Children (weight >10 kg)
Mild dehydration	5% or 50 mL/kg	3% or 30 mL/kg
Moderate dehydration	10% or 100 mL/kg	6% or 60 mL/kg
Severe dehydration	15% or 150 mL/kg	9% or 90 mL/kg

Table 3. Composition of Appropriate Oral Rehydration Solutions

Solution	Carbohydrate (g/dL)	Sodium (mEq/L)	Potassium (mEq/L)	Base (mEq/L)	Osmolality
Pedialyte	2.5	45	20	30	250
Infalyte	3	50	25	30	200
Rehydralyte	2.5	75	20	30	310

Table 4. WHO-UNICEF Oral Rehydration Solutions

Solution	Sodium (mEq/L)	Chloride (mEq/L)	Glucose, Anhydrous (mEq/L)	Potassium (mEq/L)	Citrate (mEq/L)	Osmolality
Standard	90	80	111	20	10	311
Reduced osmolarity	75	65	75	20	10	245
UNICEF = United Nations International Children's Emergency Fund, WHO = World Health Organization.^{[16, 17]}

Table 5. Composition of Inappropriate Oral Rehydration Solutions

Solution	Carbohydrate (g/dL)	Sodium (mEq/L)	Potassium (mEq/L)	Base (mEq/L)	Osmolality
Apple juice	12	0.4	26	0	700
Ginger ale	9	3.5	0.1	3.6	565
Milk	4.9	22	36	30	260
Chicken broth	0	2	3	3	330

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Author

Lennox H Huang, MD, FAAP Chief Medical Officer, The Hospital for Sick Children; Associate Professor of Pediatrics, University of Toronto Faculty of Medicine; Associate Clinical Professor of Pediatrics, McMaster University School of Medicine, Canada

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

Disclosure: Nothing to disclose.

Coauthor(s)

Krishnapriya R Anchala, MD, MS, FAAP Associate Professor of Paediatrics, Co-Coordinator, Paediatric Undergraduate Clerkship Program, Emergency Medicine Rotation, University of Toronto Faculty of Medicine; Staff Physician in Paediatric Emergency Medicine, The Hospital for Sick Children, Canada

Krishnapriya R Anchala, MD, MS, FAAP is a member of the following medical societies: American Academy of Pediatrics, 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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

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, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

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/ Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Director, Palliative Care Team, Holtz Children's Hospital; Medical Manager, FEMA, South Florida Urban Search and Rescue, Task Force 2

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, Wilderness Medical Society

Disclosure: Nothing to disclose.

Sections Dehydration
Overview
Presentation
DDx
Workup
Treatment
- Medical Care
- Diet
- Prevention
- Show All
Medication
Questions & Answers
Tables
References

Dehydration Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

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