DOI: 10.1542/peds.2007-3141 2008;122;545-549 Pediatrics

Ran D. Goldman, Jeremy N. Friedman and Patricia C. Parkin Gastroenteritis

Validation of the Clinical Dehydration Scale for Children With Acute

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ARTICLE

Validation of the Clinical Dehydration Scale forChildren With Acute GastroenteritisRan D. Goldman, MDa,b, Jeremy N. Friedman, MB, ChB, FRCPCc,d, Patricia C. Parkin, MD, FRCPCc,d

aPediatric Research in Emergency Therapeutics Program, Division of Pediatric Emergency Medicine, BC Children’s Hospital, Vancouver, Canada; bDepartment ofPediatrics, Child and Family Research Institute, University of British Columbia, Vancouver, Canada; cPediatric Outcomes Research Team, Division of Pediatric Medicine,Hospital for Sick Children, Toronto, Canada; dDepartment of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada

The authors have indicated they have no financial relationships relevant to this article to disclose.

What’s Known on This Subject

Acute gastroenteritis is one of the most common reasons for hospitalization of youngchildren. We previously created a clinical dehydration scale but had not yet validated it.

What This Study Adds

The clinical dehydration scale and the 3 severity categorieswere valid for a prospectivelyenrolled cohort of patients assessed in a tertiary emergency department.

ABSTRACT

OBJECTIVE.We previously created a clinical dehydration scale. Our objective was tovalidate the clinical dehydration scale with a new cohort of patients with acutegastroenteritis who were assessed in a tertiary emergency department in a developedcountry.

METHODS.A prospective observational study was performed in an emergency depart-ment at a large pediatric tertiary center in Canada. Children 1 month to 5 years of agewith symptoms of acute gastroenteritis who were assessed in the emergency depart-ment were enrolled consecutively during a 4-month period. The main outcomemeasures were length of stay, proportion of children receiving intravenous fluidrehydration, and proportions of children with abnormal serum pH values or bicar-bonate levels.

RESULTS.A total of 205 children were enrolled, with a mean age of 22.4 � 14.9 months;103 (50%) were male. The distribution of severity categories was as follows: nodehydration (score of 0), n � 117 (57%); some dehydration (score of 1–4), n � 83(41%); moderate/severe dehydration (score of 5–8), n � 5 (2%). The 3 dehydrationcategories were significantly different with respect to the validation hypotheses(length of stay, mean � SD: none, 245 � 181 minutes; some, 397 � 302 minutes;moderate/severe, 501 � 389 minutes; treatment with intravenous fluids: none,n �17, 15%; some, n � 41, 49%; moderate/severe, n � 4, 80%; number of vomitingepisodes in the 7 days before the emergency department visit: none, 8.4 � 7.7 episodes; some, 13 � 10.7 episodes;moderate/severe, 30.2 � 14.8 episodes).

CONCLUSION. The clinical dehydration scale and the 3 severity categories were valid for a prospectively enrolled cohortof patients who were assessed in our tertiary emergency department. The scoring system was valuable in predictinga longer length of stay and the need for intravenous fluid rehydration for children with symptoms of acutegastroenteritis. Pediatrics 2008;122:545–549

ACUTE GASTROENTERITIS (AGE) is one of the most common reasons for hospitalization of young children. AmongUS children �5 years of age, gastroenteritis causes an estimated 220 000 admissions per year, with a total

hospital length of stay (LOS) of 925 000 days,1 and results in direct costs for outpatient and hospital visits of morethan $2 billion per year.2

It was suggested previously that the clinical ability of physicians to estimate degrees of dehydration is lacking andlaboratory studies are needed to enhance accurate assessment.3 Until recently, the level of dehydration wasfrequently determined without using a unified validated scale.4–6 Several authors have attempted to determine areliable measure of dehydration by using combinations of clinical findings.3,4,6–8 A systematic review found that thebest individual examination signs for assessment of dehydration were prolonged capillary refill time, abnormal skinturgor, and abnormal respiratory pattern.9 Grouping signs can improve diagnostic accuracy.

We reported previously on the development of a clinical dehydration scale (CDS) for children 1 to 36 months ofage with AGE in the emergency department (ED).10 With the use of formal measurement methods (item selectionand reduction, reliability, discriminatory power, validity, and responsiveness), the CDS consists of 4 clinical items,which may be summed for a total score ranging from 0 to 8 (Table 1). We assessed the measurement properties

www.pediatrics.org/cgi/doi/10.1542/peds.2007-3141

doi:10.1542/peds.2007-3141

KeyWordsscale, validation, dehydration,gastroenteritis

AbbreviationsCDS—clinical dehydration scaleED—emergency departmentAGE—acute gastroenteritisLOS—length of stay

Accepted for publication Dec 18, 2007

Address correspondence to Ran D. Goldman,MD, Division of Pediatric Emergency Medicine,BC Children’s Hospital, 4480 Oak St,Vancouver, BC V6H 3V4, Canada. E-mail:rgoldman@cw.bc.ca

PEDIATRICS (ISSN Numbers: Print, 0031-4005;Online, 1098-4275). Copyright © 2008 by theAmerican Academy of Pediatrics

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(sensitivity, specificity, and likelihood ratios) of the CDSto predict 3 dehydration categories. The final 3 catego-ries were no dehydration (CDS score of 0), some dehy-dration (CDS score of 1–4), and moderate/severe dehy-dration (CDS score of 5–8). The aim of the current studywas to validate prospectively the CDS dehydration cat-egories with a new cohort of children.

METHODSThis was a prospective observational study of children 1month to 5 years of age with suspected AGE in the ED.For the purpose of the study, we defined AGE accordingto the American Academy of Pediatrics practice param-eter, that is, “diarrheal disease of rapid onset, with orwithout accompanying symptoms and signs such as nau-sea, vomiting, fever, or abdominal pain.”2

Our tertiary care pediatric ED has �50 000 visits an-nually and provides specialized pediatric emergency carefor a population of 3 to 4 million children in southernOntario. Between January 1, 2005, and May 6, 2005,parents of children with vomiting or diarrhea during the24 hours before arrival at the ED were approached by aresearch assistant and asked to sign an informed consentform for participation in the study. We excluded chil-dren with diarrhea for �10 days (which suggested achronic diarrheal disease), any suspected cause of dehy-dration other than presumed gastroenteritis, or a chronicdisease (renal disease, gastrointestinal disease, cystic fi-brosis, including coexisting malnutrition, or a failure tothrive). We also excluded children who had receivedtreatment with intravenous fluids within the previous24 hours or had visited our ED for the same illness in the7 days before arrival (because this might have altered thetreatment of the child during the second visit).

The triage nurse in the ED completed the CDS assess-ment (Table 1) after the history was recorded and aphysical examination was performed. The patient thencontinued to be treated by the attending ED physicianwithout any active study-related intervention.

We collected information on age, gender, length ofillness, and numbers of episodes of vomiting and diar-rhea, as reported by the parents. In addition, we col-lected information on the chief complaint, final diagno-sis at discharge or admission, whether a trial of oralrehydration was implemented, whether intravenous flu-ids were administered, and serum pH and bicarbonateresults if plasma samples were obtained. The normalvalue for serum pH was considered �7.32 and that forserum bicarbonate levels �18 mEq/L, according to the

reference ranges for the laboratory at the Hospital forSick Children (P.C.P., C. Macarthur, MD, A. Khambalia,PhD, R.D.G., and J.N.F., unpublished data, 2007). Wethen calculated the LOS in the ED, defined as the time ofarrival in triage to the time of discharge or the time ofthe decision to admit the patient to the observation unit(in the ED) or the general pediatrics inpatient unit.

Three primary validation hypotheses were con-structed a priori. The first hypothesis was that the 3dehydration categories (none, some, or moderate/se-vere) would be positively associated with the LOS. Thesecond hypothesis was that the 3 dehydration categorieswould be positively associated with the proportion ofchildren receiving intravenous fluid rehydration. Thethird hypothesis was that the 3 dehydration categorieswould be positively associated with the proportion ofchildren with abnormal serum pH values or bicarbonatelevels. A secondary validation hypothesis was that the 3dehydration categories (none, some, or moderate/se-vere) would be positively associated with the number ofvomiting and diarrhea episodes before presentation tothe ED. The study was approved by the Hospital for SickChildren Research Ethics Board, and informed parentalconsent was obtained.

As recommended previously by the World HealthOrganization, using the CDS we classified dehydration asnone, some, or moderate/severe.11,12 In accordance withthe definitions we used previously (P.C.P., C. Macarthur,MD, A. Khambalia, PhD, R.D.G., and J.N.F., unpub-lished data, 2007) and for the purpose of the analysis, wecategorized the CDS results into no dehydration (definedas a CDS score of 0), some dehydration (defined as a CDSscore of 1–4), and moderate/severe dehydration (de-fined as a CDS score of 5–8).

Data were entered into Microsoft Excel (Microsoft,Redmond, Washington) with a double-data entry tech-nique. Statistical analyses were conducted with SPSS forWindows 13 (SPSS, Chicago, IL). Baseline characteristicswere reported by using descriptive statistics. The 3 vali-dation hypotheses were analyzed by using analysis ofvariance (for continuous data) and the �2 test (for pro-portional data). A P value of �.05 was considered sig-nificant.

RESULTS

Baseline CharacteristicsDuring the study period, we recruited a total of 211patients. We excluded 2 patients because scores were notdetermined by the triage nurse and 3 patients becausethey had incomplete data. Of the 206 completed records,103 (50%) were for boys; the mean age was 22.4 � 14.9months.

The dehydration scores were 0 for 117 children(57%), 1 to 4 for 84 children (41%), and �5 for 5children (2%). A total of 196 children (95%) were dis-charged from the hospital, and 10 (5%) were admittedto the hospital.

Children with increased severity of dehydrationtended to be older (P � .06). Fifty-nine children (29%)had venous blood samples obtained. Seventeen children

TABLE 1 CDS10

Characteristic Scoreof 0

Score of 1 Score of 2

General appearance Normal Thirsty, restless, or lethargicbut irritable whentouched

Drowsy, limp, cold, orsweaty; comatoseor not

Eyes Normal Slightly sunken Very sunkenMucous membranes

(tongue)Moist Sticky Dry

Tears Tears Decreased tears Absent tears

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(29%) had pH values of �7.31 (range: 7.14–7.31), andthe rest had values of �7.32 (range: 7.32–7.43). Twenty-three children (39%) had bicarbonate levels of �17mEq/L (range: 11–17 mEq/L), and the rest had levels of�18 mEq/L (range: 18–25 mEq/L). Fifty-five (93%) ofthe children who had blood samples taken were treatedat least in part with intravenous fluid rehydration.

The median LOS for the cohort was 231 minutes(mean � SD: 313 � 252 minutes). Twenty-one children(10%) were discharged with no rehydration attempted inthe ED. One hundred seventy-seven children (86%) weretreated with oral rehydration, and 54 (31%) of the 177needed intravenous fluid administration, as determined bythe ED staff physician. Eight children (4%) were givenintravenous fluids without an oral rehydration trial.

Validation HypothesesThe results for the validation hypotheses are presentedin Table 2. The 3 dehydration categories (none, some, ormoderate/severe) were positively associated with theLOS (none, 245 � 181 minutes; some, 397 � 302 min-utes; moderate/severe, 501 � 389 minutes; P � .001).The 3 dehydration categories were positively associatedwith the proportions of children who received intrave-nous fluid rehydration (none, 15%; some, 49%; mod-erate/severe, 80%; P � .001). The 3 dehydration cate-gories demonstrated a trend toward positive associationswith the proportions of children with abnormal serumpH values or bicarbonate levels, but this was not statis-tically significant. A box plot comparing the LOS in theED for children in the 3 groups is presented in Fig 1.

DISCUSSIONWe described previously the development of the CDS foruse in young children with AGE in the ED.10 The 4-itemscale (which includes general appearance, eyes, mucous

membranes, and tears) takes a triage nurse �2 minutesto complete and is simple to use. Furthermore, by usingthe 8-point CDS, we assessed the diagnostic test proper-ties of 3 dehydration severity categories, that is, no de-hydration (CDS score of 0), some dehydration (CDSscore of 1–4), and moderate/severe dehydration (CDSscore of 5–8) (P.C.P., C. Macarthur, MD, A. Khambalia,MD, R.D.G., and J.N.F., unpublished data, 2007). Wenow demonstrate, with this new, prospectively enrolledcohort of patients, that the dehydration categories cor-relate well with LOS and treatment with intravenousfluid rehydration.

The validation in this study supports the use of the

FIGURE 1Box plot comparing the LOS in the ED for children with no dehydration (score of 0; n �115), somedehydration (score of 1–4;n� 77), ormoderate/severe dehydration (score of�5; n� 5). Solid horizontal lines indicatemedian, boxes are interquartile range,whiskersare 1.5 times the range between 15th and 75th percentile, circles and stars are outliers.

TABLE 2 Associations for Dehydration Severity Categories

Variable No Dehydration(n � 117)

Some Dehydration(n � 84)

Moderate/SevereDehydration

(n � 5)

P

Child informationAge, mean � SD, mo 20.7� 13.6 24.1� 15.9 34.2� 21.2 .06Male, n (%) 58 (50) 43 (51) 2 (40) .88

Primary validation hypothesesLOS, mean � SD, min 245� 181 397� 302 501� 389 �.001Oral rehydration, n (%) 100 (85) 73 (87) 3 (60) .22Intravenous rehydration, n (%) 17 (15) 41 (49) 4 (80) .001pH of �7.32 (N � 59), n (%) 2 (14) 14 (34) 1 (25) .36Bicarbonate level of �18 mEq/L(N � 59), n (%)

4 (29) 16 (39) 3 (75) .22

Secondary validation hypothesesNo. of vomiting episodes in past 7 d,median (interquartile range)

7 (9) 11 (9) 32 (27.5) Mann-Whitney test, �.00(none to some), .01(some to moderate/severe)

No. of diarrhea episodes in past 7 d,median (interquartile range)

7 (17.5) 6 (13) 28 (23.5) Mann-Whitney test, .41(none to some), .02(some to moderate/severe)

Single P values for primary validation hypotheses are from a single analysis of variance test.

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CDS and the 3 dehydration severity categories for diag-nostic and therapeutic purposes in children 1 month to 5years of age with AGE presenting to an urban tertiarycare ED in a developed country. The CDS can be used tohelp guide clinicians in treatment decisions (oral or in-travenous fluid rehydration) and disposition (discharge,observation unit, or hospital admission). Although it istrue that most definitions of dehydration are based onchanges (losses) in weight,13 baseline weights rarely areavailable to clinicians, especially for children �1 year ofage, who do not visit their primary care providers fre-quently. A validated scale such as the one we havedeveloped can assist in treatment decisions in the ab-sence of a recent accurate weight.

Several previous efforts to devise a simple dehydra-tion scale have been reported. Gorelick et al4 and Dug-gan et al6 reported clinical predictors of dehydrationsimilar to the 4 items in our scale. Mackenzie et al5 founddecreased peripheral perfusion, deep breathing, and de-creased skin turgor to be associated with �4% dehydra-tion. However, some of those studies had limitations,because they had different outcome measures6 regardingthe level of dehydration, included physicians in train-ing,5 or incorporated older children6 or only admittedpatients.5 More recently, Steiner et al9 systematicallyreviewed 11 clinical signs and results of 7 laboratory testsfrom a total of 7 studies, before the publication of ourdehydration scale. They found that, although the mostuseful individual signs for predicting 5% dehydration inchildren were abnormal capillary refill time (likelihoodratio: 4.1; 95% confidence interval: 1.7–9.8), abnormalskin turgor (likelihood ratio: 2.5; 95% confidence inter-val: 1.5–4.2), and abnormal respiratory pattern (likeli-hood ratio: 2.0; 95% confidence interval: 1.5–2.7), com-binations of examination signs were better than anyindividual sign in predicting dehydration.

There are several potential limitations to our study.First, the study was conducted in only 1 center, a tertiarypediatric center. Future studies should be multicentered,including developing countries and small centers, to in-crease the generalizability of our findings. Second, wehad a relatively small number of children in the moder-ate/severe dehydration category, which limited our abil-ity to analyze data separately for that group. However,this is similar to other studies conducted in North Amer-ica, where children present early during the course oftheir illness. Third, our validation efforts used LOS, andit is important to note that this indicator is influenced bymultiple factors, such as staffing and the busyness of theED. Practice variations among staff physicians may ac-count for some of the differences in children’s LOS andthe decision to administer fluids intravenously, but wesuggest that such practice variations were minimized bythe fact that all faculty members in this ED were trainedin pediatric emergency medicine. Furthermore, mini-mizing practice variations is not a requirement for de-veloping and testing a validation hypothesis. If practicevariations were eliminated through implementation of aset of criteria (such as clinical practice guidelines), thenit would not be possible to assess validation of the scale;for example, assessment of the relationship between

CDS scores and intravenous fluid use would be con-founded by the established criteria for intravenous fluiduse. Fourth, it is possible that, while we were conductingthis validation study, some staff members started usingthe scale and changed their practices because of thestudy (Hawthorne effect). However, we suggest that therelatively short period of the study and the novel use ofthe CDS in our department accounted for a negligibleHawthorne effect. Triage nurses were not sharing theresults of the scoring with physicians, and the formscontaining the scores were not part of the patients’medical records. Furthermore, the CDS was not part ofthe recommended guidelines, and its use was notpresented to the staff as a recommended guideline.Fifth, because of the relatively small number of chil-dren for whom blood tests were performed, we wereunable to determine the validity of our third hypoth-esis, that is, that the 3 dehydration categories wouldbe positively associated with the proportions of chil-dren with abnormal serum pH values or bicarbonatelevels. Future research is needed to provide informa-tion on this hypothesis.

CONCLUSIONSThe CDS and the 3 dehydration severity categories werevalid for a prospectively enrolled cohort of patients as-sessed in our tertiary ED. The CDS was valuable inpredicting a longer LOS and the need for intravenousfluid rehydration for children with symptoms of AGE.The CDS may be added to a decision-making algorithmto guide the treatment of children with AGE.

ACKNOWLEDGMENTSDr Goldman is supported by the Child and Family Re-search Institute (Vancouver, Canada). The Pediatric Out-comes Research Team is supported by a grant from theHospital for Sick Children Foundation (Toronto, Can-ada).

REFERENCES1. Cicerello HG, Glass RI. Current concepts of the epidemiology of

diarrheal diseases. Semin Pediatr Infect Dis. 1994;5(3):163–1672. American Academy of Pediatrics, Provisional Committee on

Quality Improvement, Subcommittee on Acute Gastroenteritis.Practice parameter: the management of acute gastroenteritis inyoung children. Pediatrics. 1996;97(3):424–435

3. Vega RM, Avner JR. A prospective study of the usefulness ofclinical and laboratory parameters for predicting percentage ofdehydration in children. Pediatr Emerg Care. 1997;13(3):179–182

4. Gorelick MH, Shaw KN, Murphy KO. Validity and reliability ofclinical signs in the diagnosis of dehydration. Pediatrics. 1997;99(5). Available at: www.pediatrics.org/cgi/content/full/99/5/e6

5. Mackenzie A, Barnes G, Shann F. Clinical signs of dehydrationin children. Lancet. 1989;2(8663):605–607

6. Duggan C, Refat M, Hashem M, Wolff M, Fayad I, SantoshamM. How valid are clinical signs of dehydration in infants?J Pediatr Gastroenterol Nutr. 1996;22(1):56–61

7. Ozuah PO, Avner JR, Stein RE. Oral rehydration, emergencyphysicians, and practice parameters: a national survey. Pediat-rics. 2002;109(2):259–261

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8. Plata Rueda E, Diaz Cruz G. Clinical and biochemical evalu-ation of the degree of dehydration in children with acutediarrhea [in Spanish]. Bol Med Hosp Infant Mex. 1974;31(3):561–576

9. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?JAMA. 2004;291(22):2746–2754

10. Friedman JN, Goldman RD, Srivastava R, Parkin PC. Develop-ment of a clinical dehydration scale for use in children between1 and 36 months of age. J Pediatr. 2004;145(2):201–207

11. World Health Organization, Program for Control of DiarrhoealDiseases. A Manual for the Treatment of Diarrhoea. Geneva,Switzerland: World Health Organization; 1990

12. King CK, Glass R, Bresee JS, Duggan C. Managing acute gastro-enteritis among children: oral rehydration, maintenance, andnutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1–16

13. Liebelt EL. Clinical and laboratory evaluation and manage-ment of children with vomiting, diarrhea and dehydration.Curr Opin Pediatr. 1998;10(5):461–469

EVIDENCE-BASED PAEDIATRIC AND ADOLESCENT DIABETES*

Editors: Allgrove, Jeremy, Swift, Peter G.F., Greene, Stephen,Publisher: Blackwell Publishing; Imprint: BMJ BooksList Price: $105.95Reviewer: Christine Yu, MD (University of Chicago Medical Center)DESCRIPTION: This book summarizes the etiology, complications, andmanagement of pediatric diabetes, focusing on aspects of diabetic care that areunique to the pediatric and adolescent population. It describes the evidence,when available, underlying knowledge of diabetes and its therapy, as well asa graded assessment of the quality of the evidence.PURPOSE: The purpose is to describe the strength of the evidence under-lying many aspects of pediatric diabetes. In addition, it aims to point out areasof management in which strong evidence does not exist, but for whichexperts have provided a consensus opinion. This worthwhile book providesuseful evidence-based information to busy practitioners.AUDIENCE: Written for a broad spectrum of medical professionals involvedin treating patients with pediatric diabetes, the book is easy reading, providinguseful information for practitioners of all levels, from medical students topediatric endocrinologists. The authors have published a number of peer-reviewed papers on childhood diabetes.FEATURES: The book covers multiple aspects of pediatric and adolescentdiabetes care, including the more commonly discussed topics such as etiology,natural progression, and management of type 1 diabetes. However, it alsoreviews rare forms of diabetes and the increasingly important subject of type2 diabetes. The chapters on diabetes in specific populations (very youngchildren and adolescents), are helpful since recommendations targeted forthese subgroups of patients are not readily available elsewhere. The chapteron etiology of type 1 diabetes nicely summarizes the current evidence with-out overwhelming the reader and the categorization of information by thestrength of the evidence is particularly valuable. However, the book acknowl-edges that there are many areas in which there is no strong evidence and inthose cases, substitutes the recommendations of clinical practice guidelines orexpert opinion. Chapter four on the management of type 1 diabetes includesa table summarizing comparative studies of insulin regimens in children,which is an effective way of outlining the evidence. Although the authorsindicate that some topics are omitted because they have limited application tochildren to date, a short chapter on some of the newer therapies available toadults would have been welcome (i.e. exenatide, pramlintide, DPP-IV inhib-itors), as some of these therapies may be used in adolescents in the nearfuture.ASSESSMENT: This is an accessible and enjoyable review of the evidenceunderlying the main aspects of pediatric diabetes care.

*Review provided by ©Doody’s Review Service™. www.medinfonow.com

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DOI: 10.1542/peds.2007-3141 2008;122;545-549 Pediatrics

Ran D. Goldman, Jeremy N. Friedman and Patricia C. Parkin Gastroenteritis

Validation of the Clinical Dehydration Scale for Children With Acute

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