Clinical detection of dehydration
A range of symptoms and signs have traditionally been considered useful in the detection of dehydration. The GDG found that many of these did not have evidence with regard to their reliability, particularly in those children with less severe degrees of dehydration.
The GDG considered that the identification of symptoms useful for the detection of dehydration would be important, particularly because they could be employed as part of the remote assessment process. However, the only symptom of possible value identified from the evidence was a report of ‘normal urine output’ and the evidence between studies was inconsistent. The GDG considered that enquiry should be made about this matter, and that some reassurance could be taken if the urine output was said to be normal. The GDG also agreed that carers were acutely aware of any change in the child’s behaviour (irritability, lethargy) and appearance (for example ‘sunken eyes’), and so it seemed appropriate to specifically enquire about these.
With regard to the role of physical signs in the detection of dehydration, the GDG examined the evidence from the systematic review and identified two limitations to the included studies. First, the review appeared to report on children with 5% dehydration or worse and, given the symptoms and signs identified, the GDG strongly suspected that many of the patients might have been considerably more than 5% dehydrated. Therefore, the stronger associations reported for CRT, abnormal skin turgor and abnormal breathing pattern did not mean that these signs would be useful for the detection of less severe dehydration. On the contrary, the GDG considered that those signs suggested the presence of relatively severe dehydration. Second, neither the prevalence of dehydration nor the post-test probabilities of dehydration were presented. One or other of these parameters was needed to interpret the likelihood ratios presented.
Therefore, this study did not provide reliable evidence on the value of symptoms and signs for the detection of lesser degrees of dehydration. However, the GDG agreed that the presence of one or more symptoms or signs evaluated in those studies and conventionally employed in assessment for dehydration would suggest clinically significant dehydration.
The study of CRT using a digital technique (DCRT) showed a relationship between abnormal DCRT and dehydration. However, this remains an experimental technique that is not yet established as a method for routine clinical use.
Clinical assessment of dehydration severity
The GDG recognised that there was a lack of compelling evidence to support efforts to accurately distinguish varying degrees of dehydration on the basis of symptoms and signs. In the absence of such evidence, any system of classification was inevitably arbitrary and subjective and based on the clinician’s judgement and a ‘global assessment’ of the child’s condition.
In the past, it was common to describe three levels of dehydration, referred to as mild (3–5%), moderate (6–9%) and severe (≥10%), with an implication that it was possible to make such distinctions based on the clinical assessment (see ). A number of recent guidelines ( and ) had adopted simpler schemes in which just two degrees of dehydration were to be distinguished – ‘some dehydration’ (or ‘mild to moderate dehydration’), variably defined as 3–8% or 5–10% dehydration, and ‘severe dehydration’, variably defined as ≥9% or >10% dehydration. Even these simpler classifications could be difficult to implement in clinical practice. The GDG considered that it was not possible to accurately distinguish ‘sunken’ and ‘very sunken’ or ‘deeply sunken’ eyes, or between skin pinch retracting ‘slowly’ and ‘very slowly’, or between ‘dry’ and ‘very dry’ mucous membranes. There was also no evidence on the reliability of these various signs either individually or in combination in distinguishing varying degrees of dehydration. In addition, there was no evidence to justify arbitrary categorisation on the basis of specific numbers of clinical symptoms or signs as had been suggested ().
Classification of dehydration severity by the American Subcommittee on Acute Gastroenteritis.
The GDG decided to adopt a new and even simpler clinical assessment scheme () Patients would merely be classified as follows: ‘no clinically detectable dehydration’, ‘clinical dehydration’ and ‘clinical shock’. With this assessment scheme the clinician would have to recognise the presence of clinical dehydration. This simplified scheme does not imply that the degree of dehydration is uniform, but rather acknowledges the difficulties in accurately assessing dehydration severity. The GDG recognised that experienced clinicians could distinguish marked differences in the severity of dehydration. They also considered that clinical signs were likely to be more pronounced and numerous in those with severe dehydration. However, firm recommendations linking clinical symptoms and signs with specific varying levels of dehydration were impossible. The crucial point however, is that the scheme is all that is required to guide fluid management (Chapter 5). In this guideline a standard fluid regimen is recommended for all (non-shocked) children with dehydration, with adjustments being made to the fluid regimen over time based on regular reassessment during the rehydration process.
Symptoms and signs of clinical dehydration and shock. Interpret symptoms and signs taking risk factors for dehydration into account. Within the category of ‘clinical dehydration’ there is a spectrum of severity indicated by increasingly (more...)
The GDG was aware of the crucial importance of identifying those children with hypovolaemic shock. They would require specific emergency management with administration of IV fluid boluses (Section 5.4) and so it was essential that signs of shock should be recognised without delay. Many patients with hypovolaemic shock were likely to have obvious and pronounced signs of dehydration in addition to the specific clinical manifestations of shock. However, this might not always be the case. For example, a small infant with gastroenteritis might experience sudden severe fluid loss at the onset of gastroenteritis sufficient to cause hypovolaemic shock before any signs of dehydration (for example, dry mucous membranes or reduced skin turgor) were present. Hence it was appropriate to distinguish the symptoms and signs of shock from those of dehydration. Inevitably, there was some overlap, in that both dehydration and shock might be associated with a change in conscious state. In dehydration, lethargy or irritability might commonly occur, while in shock there might be a more profound depression of consciousness. Likewise, dehydration would often cause an increased heart rate but in shock this might be much more pronounced. The diagnosis of shock would be based on the clinician’s global assessment, taking account of each of the relevant symptoms and signs. With severe shock the manifestations would be unequivocal. In lesser degrees of shock, for example as the symptoms and signs first appeared, there might be some difficulty in distinguishing it from severe dehydration. The GDG concluded that when there was uncertainty the safe approach would be to treat as though shock was present (Section 5.4).
The GDG identified several ‘red flag’ signs in dehydration whose presence should alert the clinician to a risk of progression to shock (see ). These were altered responsiveness (for example, irritable, lethargic), sunken eyes, tachycardia, tachypnoea, and reduced skin turgor. Children with such red flag signs require especially careful consideration and close monitoring. The GDG considered that monitoring to follow the ‘illness trajectory’ was critically important particularly in these ill children. Thus tachycardia (a red flag sign) would be of even greater concern if it worsened over time, pointing to a serious risk of clinical deterioration and shock.
The GDG recognised that this recommended clinical assessment scheme was novel and would be unfamiliar to clinicians. However, it had the great advantage of simplicity, would be easy to implement, and would provide the clinical information necessary for appropriate fluid management. As discussed later in Chapter 5, those with dehydration will usually be treated with oral fluid rehydration, those with red flag symptoms and/or evidence of deterioration will require careful management, probably in a hospital setting, while those with suspected or definite shock will require emergency IVT in hospital. In the community setting, it will be necessary for the healthcare professional to decide whether monitoring the response to rehydration therapy can be carried out safely in the home setting and if so under what level of supervision (general practitioner, community children’s nurse, etc.). Where there are concerns about a parent’s ability to monitor their child’s condition and to provide appropriate care, referral to hospital might be required.
The GDG considered that recognition of the symptoms and signs of dehydration and shock needs considerable expertise. Clinicians therefore require training and experience in order to ensure competence in assessing children with gastroenteritis. This should be at an appropriate level to allow the individual to work safely and effectively in their specific clinical role.
Recommendation on clinical detection of dehydration and assessment of severity
During remote or face-to-face assessment ask whether the child:
Use to detect clinical dehydration and shock.
Research recommendation
In children with gastroenteritis, what is the predictive value of clinical symptoms and signs in assessing the severity of dehydration, using post-rehydration weight gain as the reference standard, in primary and secondary care settings?
Why this is important
Evidence from a systematic review* suggests that some symptoms and signs (for example, prolonged capillary refill time, abnormal skin turgor and abnormal respiratory pattern) are associated with dehydration, measured using the accepted ‘gold standard’ of the difference between pre-hydration and post-hydration weight. However, 10 of the 13 included studies were not blinded and had ill-defined selection criteria. Moreover, all these studies were conducted in secondary care where children with more severe dehydration are managed.
Most children with gastroenteritis can and should be managed in the community* but there is a lack of evidence to help primary care healthcare professionals correctly identify children with more severe dehydration. Symptoms and signs that researchers may wish to investigate include overall appearance, irritability/lethargy, urine output, sunken eyes, absence of tears, changes in skin colour or warmth of extremities, dry mucous membranes, depressed fontanelle, heart rate, respiratory rate and effort, character of peripheral pulses, capillary refill time, skin turgor and blood pressure.
-
*
-
Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA: the Journal of the American Medical Association 2004;291(22):2746–54.
-
*
-
Hay AD, Heron J, Ness A; the ALSPAC study team. The prevalence of symptoms and consultations in pre-school children in the Avon Longitudinal Study of Parents and Children (ALSPAC): a prospective cohort study. Family Practice 2005;22(4):367–74.
Clinical question
What symptoms and/or signs suggest the presence of hypernatraemic dehydration?
Hypernatraemic dehydration may be defined as dehydration associated with a plasma sodium concentration greater than 150 mmol/l. Some textbooks suggest that the presenting symptoms and signs associated with this condition differ from those in dehydration without hypernatraemia. It is said that these patients may have ‘doughy’ skin, and tachypnoea, and that many of the signs normally associated with dehydration (reduced skin turgor, dryness of the mucous membranes, skin mottling, sunken eyes, altered vital signs) may not occur. The evidence for these reported differences was sought.