Interpretations

Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2019-317831 on 24 July 2020. Downloaded from http://ep.bmj.com/ on January 7, 2025 by guest. Protected by
How to interpret symptoms, signs
and investigations of dehydration in
children with gastroenteritis
Antonio Prisco, Daniela Capalbo ‍ ‍, Stefano Guarino,
Emanuele Miraglia del Giudice, Pierluigi Marzuillo ‍ ‍

Department of Woman, Child ABSTRACT of dehydration. These are outlined in

and of General and Specialized
Dehydration is a significant cause of morbidity table 1 and include decreased skin turgor,
Surgery, Università degli Studi
della Campania Luigi Vanvitelli, and mortality in children worldwide. Infants and capillary refill time of >2 s, ill appear-
Napoli, Italy young children are vulnerable to dehydration, ance, absent tears, abnormal respiration
and clinical assessment plays a pivotal role in pattern, dry mucous membranes, sunken
Correspondence to their care. In addition, laboratory investigations eyes, abnormal (weak or feeble) radial
Dr Pierluigi Marzuillo,
Department of Woman, Child can, in some children, be helpful when assessing pulse, tachycardia and decreased urine
and of General and Specialized the severity of dehydration and for guiding output.4–7 The absence of these signs,
Surgery, Università degli Studi rehydration treatment. In this interpretation, among children with gastroenteritis, was
della Campania Luigi Vanvitelli,
Naples 80138, Italy; ​pierluigi.​ we review the current literature and provide an highly predictive of the child not having
marzuillo@​gmail.​com evidence-­based approach to recognising and dehydration with a negative predictive
managing dehydration in children. value (NPV) of over 90%.4–7
Accepted 10 June 2020 Unfortunately, the symptoms and signs
Published Online First
24 July 2020 listed above and in table 1 were not specific
BACKGROUND for dehydration; that is, the presence of
Worldwide, it has been estimated that one or more of the symptoms could not

copyright.
approximately one in five paediatric be used to accurately confirm dehydration
deaths can be attributed to dehydration as present. The most specific symptoms
related to gastroenteritis.1 2 The increased and signs of dehydration were reported
fluid losses from vomiting and diarrhoea as prolonged capillary refill time of >2 s
can result in rapid fluid and electrolyte (positive predictive value (PPV) 0.57–
shifts leading to dysregulation of phys- 0.65) and decreased skin turgor (PPV
iological mechanisms such as thirst. In 0.52–0.57). The remaining symptoms and
extremis, this can lead to volume depletion signs were non-­ specific for dehydration
and dangerous electrolyte imbalances.1 with a PPV of less than 0.5.4–7
An understanding of the symptoms, signs Based on these findings, it is reason-
and investigations used to assess and able to assume that, in a child with acute
manage dehydration is vital for any clini- gastroenteritis, if all of the symptoms and
cian caring for acutely unwell children. signs listed are absent, then dehydration
This interpretation therefore focuses is unlikely. The presence of any of the
entirely on the management of dehydra- features listed should alert the clinician to
tion in children with an acute gastrointes- the possibility of dehydration while also
tinal illness. Other, less common, causes being mindful that many of the features
of dehydration (eg, diabetic ketoacidosis, are non-­specific and may indicate other
renal failure, cardiac failure, liver disease illnesses.
and postoperative care) are not covered. One approach to rising awareness
Throughout this interpretation, dehy- and to standardise care in this area has
© Author(s) (or their dration will be described as mild (<5% of been the development of clinical deci-
employer(s)) 2021. No weight loss), moderate (5%–10% weight sion tools. One such tool validated for
commercial re-­use. See rights loss) or severe (>10% weight loss).3 use in children (aged 1 month–3 years) is
and permissions. Published
by BMJ. the Clinical Dehydration Scale (CDS),8
WHAT ARE THE SYMPTOMS AND summarised in table 2. Another useful
To cite: Prisco A, Capalbo D,
Guarino S, et al. Arch SIGNS OF DEHYDRATION IN A CHILD? resource is the National Institute for
Dis Child Educ Pract Ed A number of clinical features were iden- Health and Care Excellence (NICE) clin-
2021;106:114–119. tified from the literature as predictive ical guideline 84: ‘Diarrhoea and vomiting

114    Prisco A, et al. Arch Dis Child Educ Pract Ed 2021;106:114–119. doi:10.1136/archdischild-2019-317831
 Table 1 Summary of studies quantifying the diagnostic performance of clinical signs of dehydration and/or investigating their predictivity of dehydration severity
Author Study setting Inclusion criteria Exclusion criteria Sample size Key results
Caruggi et al 2 children’s EDs Children aged 9 months–17 Newborn babies 242 Significant correlation between
(Italy) years with acute (correct age <1 month), ►► CRT and dehydration.
gastroenteritis children on tube feeding or ►► CDS correlated with percentage dehydration and length of stay.
with chronic poor health
(listed)
Falszewska et al 1 children’s ED Children aged Other causes of dehydration 128 children CDS unable to rule out dehydration but was able to predict severity
(Poland) 1 month–5 years with acute (listed)
gastroenteritis
Gorelick et al 1 urban ED Children aged 1 month Symptoms longer than 5 186 children All these parameters were significantly associated with the presence of dehydration:
(USA) to 5 years with acute day-­duration, history of ►► Decreased skin elasticity: PPV 0.57, NPV 0.93, sensitivity 0.35, specificity 0.97.
gastroenteritis chronic disease (listed) ►► CRT>2 s: PPV 0.57, NPV 0.94, sensitivity 0.48, specificity 0.96.
12 hours at another health ►► Ill general appearance: PPV 0.42, NPV 0.95, sensitivity 0.59, specificity 0.91.
►► Absent tears: PPV 0.40, NPV 0.96, sensitivity 0.67, specificity 0.89.
facility and hyponatremia or
►► Abnormal respiration pattern: PPV 0.37, NPV 0.94, sensitivity 0.43, specificity 0.86.
hypernatremia.
►► Dry mucous membranes: PPV 0.29, NPV 0.99, sensitivity 0.80, specificity 0.78.
►► Sunken eyes PPV 0.29, NPV 0.95, sensitivity 0.60, specificity 0.84.
►► Abnormal radial pulse: PPV 0.25, NPV 0.93, sensitivity 0.43, specificity 0.86.
►► Tachycardia PPV 0.20, NPV 0.93, sensitivity 0.46, specificity 0.79.
►► Decreased urine output: PPV 0.17, NPV 0.97, sensitivity 0.85, specificity 0.53.
Mackenzie et al 1 children’s Children under 4 years Less than 5% dehydration 102 children Signs of dehydration of >4%
hospital (Australia) admitted with gastroenteritis ►► Deep breathing (PPV 0.58, p=0.023).

Prisco A, et al. Arch Dis Child Educ Pract Ed 2021;106:114–119. doi:10.1136/archdischild-2019-317831

►► Decreased peripheral perfusion (PPV 0.65, p=0.024).
►► Decreased skin turgor (PPV 0.52, p=0.056).
Hoxha et al 1 urban hospital Children aged 200 children The number of episodes of diarrhoea correlate with the degree of dehydration (p=0.004).
(Kosovo) 1 month–5 years admitted
with gastroenteritis
Friedman et al 1 tertiary Children between 1 and Any cause of dehydration 141 children General ill appearance, sunken eyes, dry mucous membranes and absent tears were
children’s ED 36 months of age with chronic disease significantly associated with the degree of dehydration: Pearson’s correlation coefficients
(Canada) gastroenteritis were 0.66, 0.62, 0.74 and 0.74, respectively.
Steiner et al Meta-­analysis 26 studies in young children 13 excluded due to the lack 1246 children Three signs had a clinically helpful pooled LR in detecting 5% dehydration:
aged 1 month–5 years of an accepted diagnostic ►► Prolonged CRT: LR 4.1 (95% CI 1.7 to 9.8).
standard or other limitation in ►► Abnormal skin turgor had a pooled LR of 2.5 (95% CI 1.5 to 4.2).
study design ►► Abnormal respiratory pattern: LR of 2.0 (95% CI 1.5 to 2.7).
Low urine output did not increase the likelihood of 5% dehydration (LR, 1.3; 95% CI, 0.9 to
1.9).
CDS summarised in table 2.
CDS, Clinical Dehydration Score; CRT, capillary refill time; ED, emergency department; LR, likelihood ratio; NPV, negative predictive value; PPV, positive predictive value.
Interpretations

115
copyright.
Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2019-317831 on 24 July 2020. Downloaded from http://ep.bmj.com/ on January 7, 2025 by guest. Protected by
Interpretations

Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2019-317831 on 24 July 2020. Downloaded from http://ep.bmj.com/ on January 7, 2025 by guest. Protected by
Measuring serum urea and creatinine levels is helpful
Table 2 Clinical Dehydration Scale
when assessing severe dehydration only with very
Items 0 1 2 high serum urea values (greater than 16.7 mmol/L)
General Normal Thirsty, restless, or Disoriented, and creatinine values (greater than 80 μmol/L) reli-
appearance lethargic but irritable hypotonic, cold ably predicting severe dehydration.10 13 Unfortunately,
when touched or sweaty skin,
urea and creatinine levels are unhelpful in mild and
unconscious
moderate dehydrations.
Eyes Normal Slightly sunken Very sunken
Of the tests advised by NICE,9 the blood gas (specif-
Mucous Moist ‘Sticky’ Dry
ically bicarbonate levels) correlates the best with
membranes
severity, as shown in table 4.12 13 16 17 As a general
Tears Tears Decreased tears Absent tears
trend, the lower the venous bicarbonate levels, the
A score of 0 represents no dehydration (<3%); a score of 1–4,
greater the severity of dehydration.10
some dehydration (≥3%–6%); and a score of 5–8, moderate/severe
dehydration (≥6%).
WHAT ABOUT OTHER TESTS?
There are a number of other tests that have been
caused by gastroenteritis in under 5 s: diagnosis and
suggested as helpful in the assessment of dehydration
management’.9
in children. These include urinary testing (sodium and
specific gravity) and blood tests (blood urea nitrogen
WHICH SYMPTOMS AND SIGNS ARE BEST FOR
(‘BUN’), BUN to creatinine ratio and uric acid).12–14 17 18
PREDICTING THE SEVERITY OF DEHYDRATION?
Urinary testing for specific gravity is of almost no
Predicting the severity of dehydration is challenging
value when assessing for dehydration and should not
and requires the clinician to interpret and combine
be routinely used.18 Urinary sodium levels may be
a mixture of symptoms and signs. When taking the
helpful with a urine sodium of less than 90 mmol/L
history, it is important to ask about the number of
being shown to be highly sensitive and specific for
episodes of diarrhoea and/or vomiting, as well as asking
dehydration.17 A urinary sodium may therefore be
about intake, duration of illness and estimated urine
useful in children where the traditional clinical assess-
output. Of the reported symptoms, it is the number of
ment of hydration may be difficult, for example, dehy-
episodes of diarrhoea and/or vomiting that correlates
dration in conditions such as nephrotic syndrome.

copyright.
best with severity.10
Blood testing for BUN and BUN/creatinine levels
During the examination, it is important to make
may also be helpful in some. An elevated BUN greater
a global assessment of the child’s health while also
than 45 mg/dL (16 mmol/L) is indicative of at least
specifically examining for skin turgor, capillary refill
moderate dehydration,12 whereas a BUN to creati-
time, dryness of mucous membranes, appearance of
nine ratio of less than 20 is indicative of an absence of
eyes (sunken or not) and the presence of tears. The
dehydration.14
individual predictive value of these signs has been
discussed already (table 1), and the presence of any
one feature should alert the clinician to possibility EXPERIMENTAL TESTING
of dehydration.4–7 10–12 The greater the number of The digitally measured capillary refill time (DCRT)
features, the greater the likely degree of dehydration.6 is an innovative approach for predicting dehydration
The CDS provides a pragmatic approach to assessing severity. The test requires use of specific software
severity (table 2) and can be used to aide decision to analyse ‘frame-­by-­frame’ the video of one of the
making.4 8 Similarly, NICE CG84 provides guidance on child’s fingertips both before and after a light pressure
assessing severity with features of dehydration listed, is applied for 5 s. Studies have demonstrated that a
including five ‘red flag’ signs of ‘reduced responsive- DCRT of >0.4 s was 100% sensitive (95% CI 75% to
ness, reduced skin turgor, tachycardia, tachypnoea and 100%) and had a specificity of 91% (95% CI 82% to
sunken eyes’.9 97%) for predicting the presence of at least moderate
dehydration.19
CAN LABORATORY INVESTIGATIONS BE USED TO Ultrasound (US) scanning has been proposed as a
ASSESS THE SEVERITY OF DEHYDRATION? quick method to determine the severity of dehydration
NICE does not recommend routine blood testing in the in children. Two different US measures (aorta to infe-
assessment of dehydration in children. Blood testing is rior vena cava (IVC) ratio and IVC inspiratory collapse)
only recommended for children who require intrave- have been studied as methods of estimating dehydra-
nous therapy, have signs of shock or where hypona- tion in children. The aorta to IVC ratio demonstrated
traemia/hypernatraemia is suspected.9 When testing a sensitivity of 93% and specificity of 59% compared
is required, NICE only recommends measuring blood with 93% and 35% for IVC inspiratory collapse.20 The
sugar, electrolytes, urea, creatinine and a blood gas. use of US remains experimental but could become of
This approach is supported by the available evidence greater clinical relevance as point-­of-­care US becomes
summarised in table 3.7 10 12–18 more widely available.20

116 Prisco A, et al. Arch Dis Child Educ Pract Ed 2021;106:114–119. doi:10.1136/archdischild-2019-317831
 Table 3 Summary of studies investigating predictivity of dehydration severity of laboratory investigations
Level of
evidence
(Oxford
Centre for
Evidence
Sample Based
Author Study setting Study design Inclusion criteria Exclusion criteria size Medicine) Key results
Hoxha et al 1 urban hospital Prospective cohort Children aged 1 month–5 years 200 2 In severe dehydration, creatinine levels (mmol/L) were significantly higher
(Kosovo) study admitted with diarrhoea and/ children compared with other dehydration degrees (61.65±34.97 vs 41.16±7.49 in mild
or vomiting during the 2-­year dehydration, 41.27±10.16 in moderate dehydration)
study period The venous bicarbonate levels (mmol/L) in non-­dehydrated patients were
21.1±2.78, in mild dehydration 19.09±2.88, whereas in moderate and severe
(>10% wt loss) dehydration, 16.31±3.16 and 12.18±3.78, respectively (p<0.001).
The base excess (BE) in severe dehydration (−18.96) compared with none
(−5.9), mild (−8.57) and moderate dehydration (−12.26) decreased significantly
(p<0.001).
Tam et al 1 tertiary children’s Case comparison Children aged <18 years with 73 cases 2 The following parameters were statistically significant (p<0.05) between the
ED trial diarrhoea and vomiting who and 143 control group and the dehydrated group:
(Canada) clinically required intravenous controls ►► Urine sodium/potassium ratio (2.3 (0–56) vs 0.69 (0–4.4)).
fluids for rehydration compared ►► Urine sodium, fractional sodium excretion (%) (0.52 (0–10.4) vs 0.19
with minor trauma patients who (0–0.89)).
required intravenous needling ►► Serum bicarbonate (mmol/L) (24 (18–30) vs 20 (10–27)).
for conscious sedation The best markers for dehydration were urine Na<90 mmol/L and serum
bicarbonate<21 mmol/L (area under receiver operating characteristic

Prisco A, et al. Arch Dis Child Educ Pract Ed 2021;106:114–119. doi:10.1136/archdischild-2019-317831

curve=0.798 and 0.821, respectively; sensitivity=75% and 90%, respectively;
specificity=74% and 62%, respectively)
Narchi et al 1 urban hospital Prospective cohort Children aged 1 month–5 years, Extraintestinal infection; renal, 116 2 Reduced serum bicarbonate (<22 mmol/L) occurred in 72 patients (68%), with a
(Saudi Arabia) study diarrhoea (three or more watery respiratory, cardiac, neurological, children significant difference between the three groups (39 in mild, 23 in moderate and
stools) or vomiting for less than or endocrine anomalies; chronic 10 in severe dehydration group; p=0.009).
72 hours at presentation and diarrhoea; malnutrition; failure to When the concentration of bicarbonate was studied by age group, it was found to
dehydration thrive; and administration of diuretics be overall significantly lower in the younger (age <1 year) group (p=0.01).
or intravenous fluids within 1 week of
presentation
Steiner et al ►► 5 EDs Meta-­analysis Twenty-­six reviewed studies Eliminated 13 of the 1246 1 ►► Blood urea nitrogen (BUN)>45 mg/dL=LR of dehydration (for at least 5%
►► 6 hospitals contained original data on the 26 studies because of the lack of children dehydration) 46.1 (95% CI 2.9 to 733).
►► 2 gastroenteritis precision or accuracy of findings an accepted diagnostic standard or ►► Serum bicarbonate>15 mEq/L=LR of 0.18 (95% CI 0.08 to 0.37).
clinics for the diagnosis of dehydration other limitation in study design. ►► Serum bicarbonate<17 mEq/L=LR of 3.5 (95% CI 2.1 to 5.8).
in young children aged 1 month ►► pH<7.35=LR 2.2 (95% CI 1.2 to 4.1).
to 5 years. ►► Anion gap>20 mmol/L=LR 1.8 (95% CI 0.8 to 4.2).
►► Uric acid>600 mmol/L=LR 1.0 (95% CI 0.3 to 3.5).
Continued
Interpretations

117
copyright.
Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2019-317831 on 24 July 2020. Downloaded from http://ep.bmj.com/ on January 7, 2025 by guest. Protected by
118
Table 3 Continued
Level of
evidence
(Oxford
Centre for
Interpretations

Evidence
Sample Based
Author Study setting Study design Inclusion criteria Exclusion criteria size Medicine) Key results
Teach et al 1 tertiary children’s Cohort study Children aged 2 weeks–12 years Diabetes mellitus, diabetes insipidus, 57 children 2 The following laboratory parameters were significantly correlated in simple linear
ED with acute (<1 week) known renal insufficiency of any regression models to fluid deficit:
(USA) dehydration aetiology ►► BUN/creatinine ratio (BUN/Cr)=r 0.52 p=0.0005.
►► Uric acid=r 0.35 p=0.03.
Serum BUN/Cr>20: sensitivity 92.3%, specificity 33.3%, PPV 40%, NPV 90%
Serum BUN/Cr>30: sensitivity 61.5%, specificity 70.4%, PPV 50%, NPV 79.2%
Serum BUN/Cr>40: sensitivity 23.1%, specificity 88.8%, PPV 50%, NPV 70.1%
Serum uric acid >300µmol/L sensitivity 84.6%, specificity 40.7%, PPV 40.7%, NPV
84.6%
Serum uric acid>450µmol/L: sensitivity 30.1%, specificity 59.2%, PPV 26.7%, NPV
64%
Serum uric acid >600µmol/L: sensitivity 46.1%, specificity 77.8%, PPV 33.3%, NPV
67.7%
Yilmaz et al 1 tertiary paediatric Retrospective Children aged 1–21 months Patients younger than 1 month or 168 3 At multiple linear regression analysis, dehydration severity correlated strongly to
department and 1 study with acute gastroenteritis and older than 24 months and those with urea (p<0.001) and bicarbonate (p=0.01), but no to sodium (p=0.28).
tertiary children’s ED dehydration, and treated with additional health problems, such as Serum bicarbonate concentrations of 15 mmol/L or more exclude a severe
(Turkey) intravenous fluid therapy malnutrition, urinary tract infections dehydration (PPV=89.6%, NPV=28%).
and septicaemia
Vega et al 1 tertiary children’s Prospective Children aged 2 weeks–15 years 97 2 Serum bicarbonate level of <17 mEq/L was 77% sensitive for moderate
ED who have required intravenous dehydration and 94% sensitive for severe dehydration. When clinical impression
(USA) fluid for acute dehydration was combined with a bicarbonate concentration of <17 mEq/L, sensitivity for
prediction of severe dehydration increased to 100%.
Mackenzie 1 children’s hospital Prospective cohort Children under 4 years admitted 102 2 The laboratory findings that pointed to dehydration of 4% or more, in a
et al (Australia) study with gastroenteritis children statistically significant way, were
►► Serum urea>6 mmol/L=PPV 0.63, p<0.001.
►► pH<7.35=VPP 0.62, p=0.024.
►► Base deficit≥7= PPV 0.5, p=0.103.
Increasing urea levels were associated with a higher level of dehydration
(p=0.505, p<0.001). Reduced blood pH was associated with a higher level of
dehydration (p=−0.453, p<0.001). Increasing base deficit was associated with a
higher level of dehydration (p=−0.378, p<0.001).
Steinert et al 1 children’s ED Prospective cohort Children aged 3–36 months 79 children 2 Urine-­specific gravity (r=−0.06, p=0.64), urine ketones (r=0.08, p=0.52) and
(USA) study with gastroenteritis, clinically urine output during rehydration (r=0.01, p=0.96) did not correlate with the initial
suspected moderate degree of dehydration.
dehydration, need for
intravenous rehydration
ED, emergency department; LR, likelihood ratio; NPV, negative predictive value; PPV, positive predictive value.

Prisco A, et al. Arch Dis Child Educ Pract Ed 2021;106:114–119. doi:10.1136/archdischild-2019-317831

copyright.
Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2019-317831 on 24 July 2020. Downloaded from http://ep.bmj.com/ on January 7, 2025 by guest. Protected by
 Interpretations

Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2019-317831 on 24 July 2020. Downloaded from http://ep.bmj.com/ on January 7, 2025 by guest. Protected by
Table 4 Mean±SD of venous bicarbonate and base excess levels in relation to dehydration levels
Non-­dehydrated Moderate Severe
patients Mild dehydration dehydration dehydration P value
Venous bicarbonate levels (mmol/L) 21.1±2.78 19.09±2.88 16.31±3.16 12.18±3.78 0.001
Base excess −5.9±3.29 −8.57±3.91 −12.26±4.31 −18.96±4.92 0.001

8 Guarino A, Albano F, Ashkenazi S, et al. European Society

Clinical bottom line for paediatric gastroenterology, hepatology, and Nutrition/
European Society for paediatric infectious diseases evidence-­
►► The assessment of dehydration in children is challenging based guidelines for the management of acute gastroenteritis in
and requires a detailed history and examination. children in Europe: Executive summary. J Pediatr Gastroenterol
►► Blood tests should not be performed routinely. Nutr 2008;46:619–21.
►► The greater the number of symptoms and signs, the 9 National Collaborating Centre for Women’s and Children’s
greater the likelihood of severe dehydration. Health (UK). Diarrhoea and vomiting caused by gastroenteritis:
►► The Clinical Dehydration Scale and National Institute for diagnosis, assessment and management in children younger
Health and Care Excellence CG84 are useful tools to help than 5 years. London: RCOG Press, 2009.
clinicians identify children with dehydration. 10 Hoxha TF, Azemi M, Avdiu M, et al. The usefulness of
clinical and laboratory parameters for predicting severity of
dehydration in children with acute gastroenteritis. Med Arch
Contributors AP, DC, SG, EMdG and PM equally contributed to the literature
revision, manuscript draft and manuscript critical revision. 2014;68:304–5.
11 Friedman JN, Goldman RD, Srivastava R, et al. Development
Funding The authors have not declared a specific grant for this research from
any funding agency in the public, commercial or not-­for-­profit sectors. of a clinical dehydration scale for use in children between 1
and 36 months of age. J Pediatr 2004;145:201–7.
Competing interests None declared.
12 Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?
Patient consent for publication Not required.
JAMA 2004;291:2746–54.
Provenance and peer review Commissioned; externally peer reviewed. 13 Yilmaz K, Karaböcüoglu M, Çitak A, et al. Evaluation
Data availability statement There are no data in this work of laboratory tests in dehydrated children with acute
gastroenteritis. J Paediatr Child Health 2002;38:226–8.
ORCID iDs
14 Teach SJ, Yates EW, Feld LG. Laboratory predictors of

copyright.
Daniela Capalbo http://​orcid.​org/0​ 000-​0002-​3612-​7383
Pierluigi Marzuillo http://​orcid.​org/​0000-​0003-4​ 682-​0170 fluid deficit in acutely dehydrated children. Clin Pediatr
1997;36:395–400.
REFERENCES 15 Narchi H. Serum bicarbonate and dehydration severity in
1 Powers KS. Dehydration: Isonatremic, Hyponatremic, and gastroenteritis. Arch Dis Child 1998;78:70–1.
hypernatremic recognition and management. Pediatr Rev 16 Vega RM, Avner JR. A prospective study of the usefulness of
2015;36:274–85. clinical and laboratory parameters for predicting percentage
2 Black RE, Morris SS, Bryce J. Where and why are 10 million of dehydration in children. Pediatr Emerg Care 1997;13:179–
children dying every year? Lancet 2003;361:2226–34. 82.
3 World Health Organization. The treatment of diarrhoea: a 17 Tam RK, Wong H, Plint A, et al. Comparison of clinical
manual for physicians and other senior health workers. 4th edn. and biochemical markers of dehydration with the clinical
World Health Organization, 2005. dehydration scale in children: a case comparison trial. BMC
4 Falszewska A, Dziechciarz P, Szajewska H. Diagnostic accuracy Pediatr 2014;14:149.
of clinical dehydration scales in children. Eur J Pediatr 18 Steiner MJ, Nager AL, Wang VJ. Urine specific gravity and
2017;176:1021–6. other urinary indices: inaccurate tests for dehydration. Pediatr
5 Caruggi S, Rossi M, De Giacomo C, et al. Pediatric Emerg Care 2007;23:298–303.
dehydration assessment at triage: prospective study on refilling 19 Shavit I, Brant R, Nijssen-­Jordan C, et al. A novel imaging
time. Pediatr Gastroenterol Hepatol Nutr 2018;21:278–88. technique to measure capillary-­refill time: improving
6 Gorelick MH, Shaw KN, Murphy KO. Validity and reliability diagnostic accuracy for dehydration in young children with
of clinical signs in the diagnosis of dehydration in children. gastroenteritis. Pediatrics 2006;118:2402–8.
Pediatrics 1997;99:E6. 20 Levine AC, Shah SP, Umulisa I, et al. Ultrasound assessment
7 Mackenzie A, Barnes G, Shann F. Clinical signs of dehydration of severe dehydration in children with diarrhea and vomiting.
in children. Lancet 1989;2:605–7. Acad Emerg Med 2010;17:1035–41.

Prisco A, et al. Arch Dis Child Educ Pract Ed 2021;106:114–119. doi:10.1136/archdischild-2019-317831 119