Page 68 - 15Diarrhoeaandvomiting

Assessing dehydration and shock

Table 4.1 Summary characteristics of clinical signs used to detect 5% dehydration

Finding (no. of studies) Total no. Summary likelihood ratios Sensitivity Specificity
of children (with 95% CI) (95% CI) (95% CI)
Positive (+LR) Negative (−LR)
Prolonged capillary refill (4 ) 478 4.1 (1.7 to 9.8) 0.57 (0.39 to 0.82) 0.60 (0.29 to 0.91) 0.85 (0.72 to 0.98)
Abnormal skin turgor (5) 602 2.5 (1.5 to 4.2) 0.66 (0.57 to 0.75) 0.58 (0.40 to 0.75) 0.76 (0.59 to 0.93)
Abnormal respiratory pattern (4) 581 2.0 (1.5 to 2.7) 0.76 (0.62 to 0.88) 0.43 (0.31 to 0.55) 0.79 (0.72 to 0.86)
Sunken eyes (4) 533 1.7 (1.1 to 2.5) 0.49 (0.38 to 0.63) 0.75 (0.62 to 0.88) 0.52 (0.22 to 0.81)
Dry mucous membranes (4) 533 1.7 (1.1 to 2.6) 0.41 (0.21 to 0.79) 0.86 (0.80 to 0.92) 0.44 (0.13 to 0.74)
Cool extremity (2) a 206 1.5, 18.8 0.89, 0.97 0.10, 0.11 0.93, 1.00
Weak pulse (2) a 360 3.1, 7.2 0.66, 0.96 0.04, 0.25 0.86, 1.00
Absent tears (3) 398 2.3 (0.9 to 5.8) 0.54 (0.26 to 1.13) 0.63 (0.42 to 0.84) 0.68 (0.43 to 0.94)
Increased heart rate (3) 462 1.3 (0.8 to 2.0) 0.82 (0.64 to 1.05) 0.52 (0.44 to 0.60) 0.58 (0.33 to 0.82)
Sunken fontanelle (3) 308 0.9 (0.6 to 1.3) 1.12 (0.82 to 1.54) 0.49 (0.37 to 0.60) 0.54 (0.22 to 0.87)
Poor overall appearance (3) 398 1.9 (0.97 to 3.8) 0.46 (0.34 to 0.61) 0.80 (0.57 to 1.00) 0.45 (−0.1 to 1.00)
a Point estimate from individual studies.

Table 4.2 Classification of dehydration severity by Armon et al. 17

No dehydration Mild–moderate dehydration Severe dehydration
Less than 3% weight loss 3–8% weight loss ≥9% weight loss
No signs Ordered by increasing severity: Increasingly marked signs from the
• dry mucous membranes (be wary in mild–moderate group plus:
the mouth breather) • decreased peripheral perfusion
• sunken eyes (and minimal or no tears) (cool/mottled/pale peripheries;
• diminished skin turgor (pinch test capillary refill time > 2 seconds)
1–2 seconds) • circulatory collapse
• altered neurological status
(drowsiness, irritability)
• deep (acidotic) breathing

Table 4.3 Classification of dehydration severity by WHO 76
No dehydration Some dehydration Severe dehydration
Not enough signs to Two or more of the following signs: Two or more of the following signs:
classify as some or severe • restlessness, irritability • lethargy/unconsciousness
dehydration • sunken eyes • sunken eyes
• drinks eagerly, thirsty • unable to drink or drinks poorly
• skin pinch goes back slowly • skin pinch goes back very slowly
(≥2 seconds)

Table 4.4 Classification of dehydration severity by ESPGHAN 77
Variable No signs of dehydration Some dehydration Severe dehydration
General condition Well, alert, restless, Restless, irritable Lethargic or unconscious, floppy
irritable
Eyes Normal Sunken Very sunken and dry
Tears Present Absent Absent
Mouth/tongue Moist Dry Very dry
Thirst Drinks normally, not thirsty Thirsty, drinks eagerly Drinks poorly or not able to drink
Skin Pinch retracts immediately Pinch retracts slowly Pinch retracts very slowly
% body weight loss <5% 5–10% >10%

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