Page 71 - 15Diarrhoeaandvomiting

Diarrhoea and vomiting caused by gastroenteritis in children under 5 years

Recommendation on clinical detection of dehydration and assessment of severity

During remote or face-to-face assessment ask whether the child:
• appears unwell
• has altered responsiveness, for example is irritable or lethargic
• has decreased urine output
• has pale or mottled skin
• has cold extremities.
Use Table 4.6 to detect clinical dehydration and shock.

Table 4.6 Symptoms and signs of clinical dehydration and shock
Interpret symptoms and signs taking risk factors for dehydration into account. Within the
category of ‘clinical dehydration’ there is a spectrum of severity indicated by increasingly
numerous and more pronounced symptoms and signs. For clinical shock, one or more of the
symptoms and/or signs listed would be expected to be present. Dashes (–) indicate that these
clinical features do not specifically indicate shock. Symptoms and sig-ns with red flags ( ) may
help to identify children at increased risk of progression to shock. If in doubt, manage as if
there are symptoms and/or signs with red flags.
Increasing severity of dehydration

No clinically detectable Clinical dehydration Clinical shock
dehydration
Appears well deteriorating –
Appears to be unwell or
Symptoms (remote and face-to- face assessments) Alert and responsive example, irritable, lethargic) Decreased level of
Altered responsiveness (for
consciousness
Normal urine output
–
Decreased urine output
Skin colour unchanged
Pale or mottled skin
Skin colour unchanged
Warm extremities
Altered responsiveness (for
Decreased level of
Alert and responsive Warm extremities Cold extremities
example, irritable, lethargic) consciousness
Skin colour unchanged Skin colour unchanged Pale or mottled skin
Warm extremities
Cold extremities
Warm extremities
–
Eyes not sunken
Sunken eyes
(except after a drink)
(except for ‘mouth breather’)
Signs (face-to-face assessments) Moist mucous membranes Dry mucous membranes –
Normal heart rate
Tachycardia
Tachycardia
Tachypnoea
Normal breathing pattern
Tachypnoea
Normal peripheral pulses
Prolonged capillary refill time
Normal capillary refill time
Normal capillary refill time
–
Normal skin turgor Normal peripheral pulses Weak peripheral pulses
Reduced skin turgor
Normal blood pressure Normal blood pressure Hypotension (decompensated
shock)
Research recommendation
In children with gastroenteritis, what is the predictive value of clinical symptoms and signs
in assessing the severity of dehydration, using post-rehydration weight gain as the reference
standard, in primary and secondary care settings?
Why this is important
Evidence from a systematic review* suggests that some symptoms and signs (for example,
prolonged capillary refill time, abnormal skin turgor and abnormal respiratory pattern) are

* Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA: the Journal of the American Medical Association 2004;291(22):2746–54.

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