Page 65 - 15Diarrhoeaandvomiting

Diarrhoea and vomiting caused by gastroenteritis in children under 5 years

admission, receiving drugs at home before admission and ‘wasted child’. All the significant factors
were then analysed in a step-wise regression model and the results showed two clinical factors
to be independently associated with the development of dehydration: vomiting during episode
and received ORT at home before admission. Since the information was collected by a pre-tested
questionnaire, information on the preparation and method of giving oral fluids could not be
collected and the authors attributed the increased risk in children receiving ORT to ineffective
preparation and administration of oral fluids. [EL = 2+]

Evidence summary
There were four relevant case–control studies of good quality [all EL = 2+] conducted in countries
with similar healthcare settings but different from that of the UK. Despite the different location of
research and culture-specific risk factors investigated, these studies showed consistent results for
widely applicable risk factors for the development of dehydration in children with gastroenteritis.
In terms of demographic factors, younger children (younger than 12 months, with even higher
risk for those very young) and those with malnutrition were at a greater risk of dehydration.
The studies showed a consistent and strong association of severity of symptoms, i.e. increased
frequency of vomiting (>2 episodes per day) and stool production (>5 episodes per day), with a
greater risk of dehydration. In terms of management, withdrawal of breastfeeding and other fluids
including ORS solution during diarrhoea were strongly associated with risk of dehydration.

GDG translation from evidence to recommendations
The GDG recognised that the clinical studies available were conducted in resource-poor
developing countries. In those settings, there would probably be differences from the UK such as
a high prevalence of malnutrition. Nevertheless, the GDG considered that the consistency with
which these studies identified specific risk factors was likely to be important. Moreover, some of
the findings were both intuitively to be expected and consistent with clinical experience in the
UK. Thus, frequent or persistent diarrhoea and vomiting were almost certainly important. The risks
identified in relation to age and birthweight were consistent with physiological principles and with
clinical experience and were also important. The finding in clinical studies that prior administration
of ORT reduced the risk seemed intuitively credible. The consistent finding in the studies that
continued breastfeeding was associated with a reduced risk was also potentially important.

Recommendations on risk factors for dehydration

Recognise that the following are at increased risk of dehydration:
• children younger than 1 year, particularly those younger than 6 months
• infants who were of low birthweight
• children who have passed more than five diarrhoeal stools in the previous 24 hours
• children who have vomited more than twice in the previous 24 hours
• children who have not been offered or have not been able to tolerate supplementary fluids
before presentation
• infants who have stopped breastfeeding during the illness
• children with signs of malnutrition.

4.1.2 Clinical detection of dehydration and assessment of severity

Clinical questions
What symptoms or signs (individually or in combination) can detect the presence of dehydration?
If dehydration is detected, what symptoms or signs (individually or in combination) can indicate
its severity?

It is a common practice in textbooks and guidelines to suggest various clinical manifestations as
being indicative of dehydration. It has also been suggested in various published guidelines that the
severity of dehydration may be estimated on the basis of symptoms and signs. The GDG explored
the published literature to examine the available evidence on these important considerations.

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