A nine-month-old child is brought to your ED with a history of severe diarrhoea and vomiting over several days. On presentation the child is clearly dehydrated.
a) Describe your approach to initial management in this situation
b) How would you calculate the degree of dehydration in a child based on clinical assessment?
a) Initial management
Investigations- blood gas essential mentioned essential for full marks; others may be mentioned as delayed (arterial, venous or capillary all reasonable; venous quick and useful)
Investigations: blood culture, FBC, ELFT, formal BSL as early keys, stool culture and viral screen, urine culture, nasopharyngeal aspirate for respiratory viruses, CXR
b) Assessment of dehydration
Loss of body weight:
Clinical features of mild-to-moderate dehydration; 2 or more of:
Clinical features of severe dehydration; 2 or more of:
1) Initial management of the non-specifically shocked child can consist of the following generic steps, copied and pasted from the chapter on paediatric shock:
2) Assessment of dehydration offered by the college is based on Gorelick et al (1997). Here it is, interpreted as a table:
(5-6% loss of body weight)
(7-10% loss of body weight)
(over 10% loss of body weight)
2 or more of:
2 or more of:
That whole "two or more" thing also comes from Gorelick (1997). "A subset of four factors—capillary refill >2 seconds, absent tears, dry mucous membranes, and ill general appearance—predicted dehydration as well as the entire set, with the presence of any two or more of these signs indicating a deficit of at least 5%". In general, when it comes to assessing dehydration, Gorelick et al recommend using a combination of three signs (this is also mentioned in the college answer) - a combination of three signs had a sensitivity of 87% and specificity of 82% for detecting a water deficit of 5% or more.
The FEAST trial earns a mention because mortality was found to be increased in the group of severely ill febrile African children who received fluid boluses. It was published in the previous year, and caused something of a moral panic ("What? No fluids for our sick children?"). It seems cardiovascular collapse rather than fluid overload is the cause of death among these children. It has brought into question the administration of early 20-40ml/kg boluses to these kids.
However, the college still seems to support this practice, though they acknowledge it as "controversial". In fact, even the WHO has persisted with its recommendations to give fluid boluses in septic children, which has prompted some authors to question the degree of its attachment to evidence.
Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, Nyeko R, Mtove G, Reyburn H, Lang T, Brent B, Evans JA, Tibenderana JK, Crawley J, Russell EC, Levin M, Babiker AG, Gibb DM: Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011, 364:2483-2495
Kiguli, Sarah, et al. "WHO guidelines on fluid resuscitation in children: missing the FEAST data." BMJ: British Medical Journal 348 (2014).
Steiner, Michael J., Darren A. DeWalt, and Julie S. Byerley. "Is this child dehydrated?." Jama 291.22 (2004): 2746-2754.
Levine, Adam C., et al. "Empirically Derived Dehydration Scoring and Decision Tree Models for Children With Diarrhea: Assessment and Internal Validation in a Prospective Cohort Study in Dhaka, Bangladesh." Global Health: Science and Practice 3.3 (2015): 405-418.
Freedman, Stephen B., et al. "Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis." The Journal of pediatrics 166.4 (2015): 908-916.
Friedman, Jeremy N., et al. "Development of a clinical dehydration scale for use in children between 1 and 36 months of age." The Journal of pediatrics 145.2 (2004): 201-207.
Gorelick, Marc H., Kathy N. Shaw, and Kathleen O. Murphy. "Validity and reliability of clinical signs in the diagnosis of dehydration in children." Pediatrics 99.5 (1997): e6-e6.