Dehydration is a common clinical presentation in pediatrics, and it can lead to

significant morbidity and mortality. It is important to recognize the signs and

symptoms of dehydration in order to prevent complications such as hypovolemic
shock, end-organ failure and death.

Case #1
A 4-month-old boy presents with copious vomiting and diarrhea for the last 24
hours. His parents say it started shortly after he woke up yesterday. He has not
tolerated formula since the previous evening and has not urinated all day. The
parents describe the diarrhea as non-bloody and liquid brown. The emesis is non-
bloody and non-bilious. The parents mention that their son attends daycare. His
first set of vitals is temperature 37ºC, pulse 170, respiratory rate 34, blood pressure
80/42. On exam the baby is difficult to arouse, his eyes are sunken, his mucous
membranes are dry, and his anterior fontanel is depressed. On skin examination,
his capillary refill time is 4 seconds, and he has abnormal skin turgor. Upon
stimulation he begins to cry, but does not produce any tears.

Case #2

A 4-year-old girl, previously healthy, presents with fever, headache and vomiting
for two days. Her parents say she started feeling weak last night prior to calling
EMS. She refused her dinner and skipped breakfast today. She has vomited three
times and is complaining of a headache and neck pain. Her vitals on presentation
are temperature 39.4ºC, pulse 110, respiratory rate 16, blood pressure 100/60. She
appears ill and mildly lethargic, and has tacky mucous membranes, normal
capillary refill and normal skin turgor. On pulmonary exam, her lungs are clear to
auscultation, and she has no accessory muscle use.

Epidemiology & Pathophysiology

Dehydration is a frequent reason for emergency room visits and affects at least 2
million children annually.1 Frequently caused by gastroenteritis, dehydration may
result in serious morbidity and mortality. Gastroenteritis and dehydration account
for 30% of all infant and toddler deaths worldwide, and approximately 300 deaths
annually in the U.S.2 Gastroenteritis alone results in 1.9 million pediatric deaths
annually, or 19% of all deaths under the age of 5. 3
Clinically significant dehydration, as used in this review, refers to extracellular
fluid volume depletion. The body contains two major volume compartments, the
extracellular fluid (ECF) and intracellular fluid (ICF). The ICF represents two-
thirds of the body’s fluid, while the ECF accounts for the remaining third. The
ECF can further be divided into the interstitial fluid (75%) and plasma (25%).
When symptoms of dehydration occur, the intravascular volume, the plasma
component of the ECF, is depleted.

In infants (children under 1 year), the ECF and ICF comprise 70% of their total
weight, while in adults they account for only 60%. 4 An average 70-kg adult
excretes 40 ml/kg of water per day, while a 5-kg infant excretes 100 ml/kg, and is
therefore more susceptible to dehydration.  4 Infants and young children require
greater volumes of water than adults to maintain a homeostatic fluid environment.

Clinical dehydration can be classified as mild (less than 3% change in body

weight), moderate (3%–9% change in body weight) or severe (greater than 9%
change in body weight).5 These are rough percentages and do not always correlate
with clinical presentation.

Although the majority of children presenting with dehydration have associated

acute gastroenteritis, it is important to consider the multiple other etiologies. Most
pediatric dehydration is secondary to fluid losses from vomiting and diarrhea, but it
can also be from severe bacterial infection such as pneumonia, meningitis or
urinary tract problems. Other etiologies of dehydration include diabetic
ketoacidosis, pyloric stenosis or anything causing increased intracranial pressure.
Volume depletion can also occur secondary to trauma with associated hemorrhage.

Presentation
The presentation of dehydration may vary but can include the symptoms of
vomiting, diarrhea, headache, abdominal pain and myalgias. Signs may include
pallor, depressed anterior fontanel in newborns and infants, delayed capillary refill,
abnormal skin turgor, abnormal respiratory pattern, absent tear production and
tachycardia.

There are three clinical scales designed to asses the degree of dehydration in
children (see Figure 1): a World Health Organization scale (used for children 1
month–5 years); the Gorelick scale (1 month–5 years); and the Clinical
Dehydration Scale, or CDS (1 month–3 years).3 The WHO scale is composed of
four clinical signs that are assessed based on severity. Demonstrating fewer than
two signs from columns B and C correlates to less than 5% (or zero to mild)
dehydration; demonstrating two signs from column B corresponds to 5%–10%
dehydration; and showing two from column C corresponds to greater than 10% (or
severe) dehydration. The Gorelick scale consists of multiple signs, each assigned
one point. A total of 3 points or more corresponds to 5% change in body weight,
and 7 points corresponds to a 10% change.3 The CDS is also composed of four
clinical signs that are each scored from 0–2. A total score of 0 represents no
dehydration, 1–4 is some dehydration, and 5–8 is moderate/severe dehydration. 3

A group led by Dr. Kimberly Pringle of Brown University performed a study in

Rwanda of children presenting with diarrhea and/or emesis and compared all three
clinical scales against the gold standard for determining dehydration, body weight
percentage change. All scales showed poor sensitivities and specificities and were
found to be ineffective at predicting the actual degree of dehydration. 3 Another
study, led by Canadian pediatrician Benoit Bailey, MD, found the CDS scale was a
good predictor of length of hospital stay (p<0.001). 6

Although there is overlap among the three scales and they do not effectively
predict true degree of dehydration, they all illustrate clinical signs that can be
assessed within a matter of seconds, which can guide clinical decision making. A
review of 26 dehydration studies found the most useful (i.e., highest likelihood
ratios) signs for recognizing 5% dehydration are abnormal capillary refill,
abnormal skin turgor and abnormal respiratory pattern. 2 These three clinical
parameters can be used effectively while assessing pediatric patients.

Management
After clinically evaluating the severity of dehydration, a practitioner can decide
whether IV therapy is necessary. The WHO, CDC, American Academy of
Pediatrics and European Society for Paediatric Gastroenterology and Nutrition all
support the use of oral rehydration therapy (ORT) for mild or moderate
dehydration.3,7 IV therapy is usually reserved for severe dehydration. In terms of
prehospital management, ORT is typically not found on ambulances. Ideally, a
patient should be transported to a hospital for a more thorough evaluation. If in the
hospital it is determined that ORT is appropriate, 50 ml/kg should be given over
four hours. For moderate dehydration, 100 ml/kg can be given over that period. 7

In terms of IV therapy, the clinical standard is to administer an initial 20 ml/kg

bolus of isotonic crystalloid fluid, such as 0.9% normal saline or lactated
Ringer’s.7 If the patient does not respond to one bolus, it is appropriate to try a total
of 3–4 20 ml/kg boluses before considering other etiologies of hypovolemia and
prior to using pressors.5 Isotonic crystalloid is used to effectively restore
intravascular volume without causing free water retention. Administering
hypotonic fluid, such as 0.45% or 0.22% saline, can lead to hyponatremia. 8

This is because dehydration causes a state of antidiuretic hormone (ADH) excess

due to volume depletion. Administering hypotonic fluid with an elevated ADH
would cause excess amounts of free water to be retained, leading to
hyponatremia.9 One retrospective review of children found that 18.5% of those
admitted with gastroenteritis who had normal blood sodium levels and were treated
with hypotonic fluid developed mild hyponatremia. 10 Hyponatremia can lead to
serious neurologic sequelae, and thus hypotonic fluids should initially be avoided.
Hyponatremia also frequently occurs when parents or other caregivers attempt to
rehydrate children with fluids with inadequate amounts of sodium, such as water,
juice, soda and Gatorade.7 Caretakers should be advised against giving
inappropriate oral rehydration solutions on scene or en route to the hospital.

A Cochrane Library database review found no significant clinical differences

between ORT and IV therapy for treating dehydration secondary to gastroenteritis
in children. ORT did have a higher rate of paralytic ileus; however, the IV group
has all the risks related to IV placement and therapy. For every 25 children who
received ORT, one failed and needed IV hydration. 11

Other rehydration methods include nasogastric, intraperitoneal, subcutaneous,

intraosseous and rectal rehydration. Unfortunately, there are few clinical trials that
evaluate the efficacy and long-term safety of some of these techniques. Nasogastric
rehydration has been adequately studied. It is a safe technique with minimal
adverse effects and has been found in four different clinical trials to have efficacy
similar to IV therapy.1 NG rehydration can be performed using nonsterile oral
rehydration solution.
Intraosseous rehydration is also as effective as IV therapy. 1 Furthermore, IO access
is sometimes faster and more reliable than IV access; however, it should only be
reserved for crisis situations.

Hospital Management
Depending on the etiology and severity of the dehydration, further studies may be
performed in the hospital. If the dehydration is so severe that the patient has an
altered mental status, an appropriate laboratory workup may be conducted. A basic
metabolic panel will typically be drawn which analyzes certain electrolyte levels in
the blood, such as sodium, potassium and bicarbonate. Disturbances in these
electrolytes are associated with dehydration.

Case Reviews
1) According to all scales for the evaluation of dehydration, this baby classifies as
severely dehydrated. His mental status is poor, and he has multiple signs on exam
indicating the severity of his dehydration. Additionally, his vital signs show mild
tachycardia, corresponding with low intravascular volume. His respiratory rate and
blood pressure are appropriate for his age. This baby should receive a 20 ml/kg
bolus of isotonic crystalloid fluid either IV or IO (if IV access fails) and be
transported to the hospital immediately. As for the etiology of his dehydration, he
likely suffered from acute viral gastroenteritis. He may have been infected with a
virus at daycare and subsequently developed symptoms. The organism is unlikely
bacterial given the baby’s lack of fever, lack of blood in the stool and relatively
short duration of symptoms.

2) This child is dehydrated, though clinically less dehydrated than the infant in
case #1. She is mildly lethargic and has dry and sticky mucous membranes;
however, her capillary refill and skin turgor are normal. Additionally, she has a
normal respiratory pattern. With the exception of a fever, the rest of her vital signs
are appropriate for her age. According to the WHO and Gorelick scales (the
appropriate scales for the age of 4 years), she can be categorized as mildly
dehydrated given her mental status and dry mucous membranes. She does not
require IV therapy unless she does not tolerate ORT. As for the etiology of her
mild dehydration, her presentation is suspicious for meningitis. Transport her
promptly to the hospital for further evaluation.
Conclusion
Dehydration occurs frequently, and young children are at increased risk. Recognize
key clinical signs such as abnormal capillary refill, abnormal skin turgor and
irregular respiratory pattern. If in doubt about the severity of dehydration, give a 20
ml/kg bolus of normal saline and transport the child to the hospital.
References
1. Rouhani S, Meloney L, Ahn R, Nelson BD, Burke TF. Alternative
rehydration methods: a systemic review and lessons for resource-limited
care. Pediatrics 2011; 127: e748.
2. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA 2004;
291: 2,746–54.
3. Pringle K, Shah SP, Umulisa I, et al. Comparing the accuracy of the three
popular clinical dehydration scales in children with diarrhea. Int J Emerg
Med 2011; 4: 58.

4. Reid SR, Losek JS. Rehydration role for early use of intravenous
dextrose. Pedi Emerg Care 2009; 25: 49–55.

5. Takayesu JK, Bachur RG. Pediatric dehydration.

Medscape, http://emedicine.medscape.com/article/801012-overview.
6. Bailey B, Gravel J, Goldman RD, Friedman JN, Parkin PC. External
validation of the clinical dehydration scale for children with acute
gastroenteritis. Acad Emerg Med 2010; 17(6): 583–8.

7. Canavan A, Arant BS. Diagnosis and management of dehydration in

children. Am Fam Phys 2009; 80(7): 692–96.
8. Holliday MA, Ray PE, Friedman AL. Fluid therapy for children: facts,
fashions, and questions. Arch Dis Child 2007; 92: 546–50. 

9. Moritz ML, Ayus JC. Improving intravenous fluid therapy in children with
gastroenteritis. Pediatr Nephrol 2010; 25: 1,383–4.

10. Hanna M, Saberi MS. Incidence of hyponatremia in children with

gastroenteritis treated with hypotonic intravenous fluid. Pediatr Nephrol 2010; 25:
1,471–75.
11. 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; 19(3): CD004390.
 Jonathan Ludmir, MD, is a resident in Internal Medicine and Pediatrics at the Hospital of
the University of Pennsylvania, Children’s Hospital of Philadelphia.

 
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