4. Dehydration

4.2. Dehydration Degrees

The most accurate way to assess the degree of dehydration is by calculating the percentage of weight loss. However, a child’s weight prior to the episode is rarely known, and it is usually necessary to rely on clinical signs. Table 7 describes the clinical signs according to different degrees of dehydration.

According to IMCI guidelines the signs suggesting severe dehydration include the following 4 signs: lethargy or unconscious, sunken eyes, skin pinch that goes back very slowly, and not able to drink or drinking poorly. A child with at least 2 of these signs is classified as severe (pink). The 4 signs that indicate some dehydration (yellow) include restless or irritable, sunken eyes, thirsty and drinks eagerly, sunken eyes, and the skin pinch goes back slowly (not very slowly). Again the child must have at least 2 of these signs. Children 2 months to 5 years that do not have at least 2 signs are considered green and do not have some or severe dehydration.

Even if an accurate assessment of the degree of dehydration might not be possible, a diagnosis of mild (fluid loss <5% of body weight) or severe (fluid loss >10% and usually accompanied by significant hemodynamic disturbance) dehydration can be made through the clinical signs that become visible in each condition.

Severe dehydration (fluid loss 10% of body weight) is usually accompanied with significant hemodynamic disturbance.

Remember that decreased skin turgor (skin pinch) may be misleading, since it can be present in malnourished children without dehydration. The Integrated Management of Childhood Illness (IMCI) strategy classifies dehydration and determines its treatment according to clinical findings (Table 7).

The IMCI strategy classifies dehydration and determines its treatment according to clinical findings.

Table 7. Classification of Dehydration

PINK
Two of the following signs:
  • Lethargy/unconsciousness
  • Sunken eyes
  • Drinks poorly or unable to drink
  • Skin turgor: skin pinch goes back very slowly
YELLOW
Two of the following signs:
  • Restless, irritable
  • Sunken eyes
  • Drinks eagerly, thirsty
  • Skin turgor: skin pinch goes back slowly
GREEN
Not enough signs to classify as dehydration
PINK
Severe dehydration
YELLOW
Some dehydration
GREEN
No dehydration
PINK
  • If no other severe classification: give fluids for severe dehydration (Plan C)
  • If another severe classification: urgently refer with ORS during transport
  • Continue breastfeeding if possible
  • If cholera suspected: give antibiotic
YELLOW
  • Give fluids and food (Plan B)
  • If severe condition: refer urgently with ORS
  • Continue breastfeeding
  • Explain danger signs
  • Follow-up in 24–48 hours if needed
GREEN
  • Give adequate food and fluids (Plan A)
  • Explain danger signs
  • Follow-up in 5 days if symptoms persist

Hypertonic Dehydration

Hypertonic dehydration usually presents with specific features associated with the underlying physiologic process that causes it. Risk factors include previous exposure to very hot weather or to heated rooms while wearing too much clothing, resulting in significant sweating with low sodium loss; fever; or the administration of fluids containing too much salt. Typical clinical signs (sunken eyes, decreased skin turgor, hypotension) are less evident than in isotonic or hypotonic dehydration of the same severity. The tendency to develop shock is delayed because the intravascular volume is relatively protected by the water shift from the intracellular space. The patient is usually very irritable, even with very severe degrees of dehydration, and drinks avidly. Seizures and intracranial hemorrhage may occur. For treatment, if ORT has failed or is contraindicated, intravenous (IV) rehydration therapy should correct the electrolytic disorder within 36 to 48 hours. This situation is different in hypotonic dehydration, where IV correction can be attained within a few hours using polyelectrolytic solutions.