II. Epidemiology
- Pediatric Dehydration is responsible for 200,000 hospitalizations and 300 deaths in the U.S. per year
III. History: Triage
- History from parents can help rule-out Dehydration
- Findings correlated with adequate hydration
- No decreased oral intake
- No decrease in Urine Output
- No history of Vomiting
- Normal tear production
- References
IV. Precautions
- Markers of Dehydration have low accuracy as single measures, but useful in combination
V. Efficacy: Best markers of pediatric hydration status
- Increased Respiratory Rate (rapid deep breathing)
- May be a sign of Metabolic Acidosis
- Abnormal skin turgur
- Pinch skin at umbilical level of lateral abdominal wall
- Skin Tenting with a >2 second delay in return to normal suggests Dehydration
-
Capillary Refill
- Perform in a warm room
- Press on Sternum or pad of foot in infants
- Press on finger tuft in children (held at heart level)
- Capillary Refill Time over 2 seconds suggests Dehydration
- Serum bicarbonate
- Serum bicarbonate >15-17 mEq/L decreases the likelihood of Clinically SignificantDehydration
- Serum bicarbonate <13 mEq/L increases the likelihood that Oral Rehydration Solution will fail
- Teach (1997) Clin Pediatr 36(7): 395-400 [PubMed]
VI. Efficacy: Poor markers of pediatric hydration status (low sensitivity and Specificity)
VII. Findings: Minimal or subclinical Dehydration
- Deficit: 1-2% (10-20 ml/kg)
- Symptoms and signs
- Increased Thirst
- Mild Oliguria
VIII. Findings: Mild Dehydration
- Deficit <5% loss
- Child: 3% deficit (30 ml/kg)
- Infant: 5% deficit (50 ml/kg)
- Signs and Symptoms
- Dry lips
- Thick Saliva
- Decreased Tears
- Anterior Fontanelle flat
- Decreased Urine Output
IX. Findings: Moderate Dehydration
- Deficit 5-9% loss
- Child: 6% deficit (60 ml/kg)
- Infant: 9% deficit (90 ml/kg)
- Signs and symptoms
- Eyes sunken
- Tears absent
- Dry mucus membranes
- Sunken Fontanelle
- Pulse weak and rapid (Tachycardia)
- Tachypnea
- Compensatory Tachypnea for Metabolic Acidosis without respiratory distress
- Skin turgur is prolonged (Skin slowly retracts or tents for 2 sec)
- Delayed Capillary Refill (2-4 seconds)
- Listless and Irritable
- Urine characteristics
- Dark color
- Oliguria (Urine Output <1-2 cc/kg/hour)
- Urine Specific Gravity = 1.030 (low Test Sensitivity and Specificity)
- Blood Urea Nitrogen (BUN) increased (low Test Sensitivity and Specificity)
- Metabolic Acidosis
- Arterial pH <7.30
- Serum bicarbonate <17 meq/L (failure to respond to ORS is associated with serum bicarbonate <13 meq/L)
X. Findings: Severe Dehydration
- Deficit >10% loss
- Child: >10% deficit (100 ml/kg)
- Infant: 15% deficit (150 ml/kg)
- Signs and symptoms
- Limp and cold
- Lethargy or coma
- Toxic appearance
- Sunken eyes
- Very dry mucous membranes
- Acrocyanosis
- Thready and rapid pulse (severe Tachycardia)
- Grunting
- Deep and rapid Respiratory Rate
- Compensatory Tachypnea for Metabolic Acidosis without respiratory distress
- Decreased Blood Pressure
- Children compensate and maintain Blood Pressure with Sinus Tachycardia and vascular constriction
- Hypotension is an ominous late marker of severe Dehydration in Children and heralds cardiovascular collapse
- Skin turgur is very prolonged (Skin slowly retracts or tents for >4 sec)
- Skin retracts >2 sec
- Oliguria or Anuria
- Specific Gravity >1.035
- Capillary Refill >4 seconds
- Blood Urea Nitrogen (BUN) markedly increased
- Severe Metabolic Acidosis
- Arterial pH <7.10
XI. Management
XII. References
- Walton (2020) Crit Dec Emerg Med 34(6): 3-9
- Canavan (2009) Am Fam Physician 80(7):692-6 [PubMed]