TABLE 1123 Clinical Assessment of Severity of Dehydration

Temperature, pulse, and blood pressure all provide information concerning the degree of illness. The rest of the physical examination should focus on signs of concurrent viral illness, such as upper respiratory tract infections, that may be associated with gastroenteritis, as well as abdominal findings. A rectal examination is often useful in obtaining a stool sample for detection of occult blood, culture, examination for leukocytes, measurement of pH, and detection of reducing substances. It can also rule out anal fissures as the cause of bloody stools.

Serum electrolyte levels, particularly sodium and bicarbonate levels, should be assessed in any child considered significantly dehydrated. A markedly elevated blood urea nitrogen concentration with a relatively normal creatinine value may indicate recent or rapid dehydration. Serum creatinine values tend to be low in infants and young children, and a creatinine value of 1 mg/dL in this age group may represent a doubling in the normal value. The rest of the diagnostic workup should include a stool sample for the abovementioned tests and a urine sample for culture and analysis.

The decision to rehydrate the child as an inpatient or outpatient or orally or intravenously is dependent upon several factors. Children with greater than 10 percent dehydration, hypernatremic (Na > 150 meq/dL) dehydration, or symptomatic hyponatremia (Na < 130 meq/dL) should be admitted to the hospital. Oral hydration for these children may be attempted in the hospital, depending on the circumstances and cardiovascular stability of the patient. However, if there are any indications of significant peripheral vascular compromise or pending shock, intravenous hydration is mandatory. For a child who is isotonically 5 to 10 percent dehydrated, the choice of inpatient versus outpatient management is dependent on the ability of the person caring for the child to administer oral fluids. Children with this degree of dehydration tend to do well with oral hydration, and this approach may be attempted initially.

Contraindications to oral rehydration are severe vomiting or a required regimen of oral feedings. For the child with less than 5 percent dehydration, oral rehydration should be attempted. If the infant has been breast-fed, feeding should be continued and oral electrolyte-glucose solution given in addition until diarrhea subsides. If the infant has been fed a cow's-milk-based diet, feedings should be resumed slowly after initial feedings with oral rehydration solutions as tolerated, preferably with a lactose-free formula. Increased stool output may occur as feedings are increased, but a gradual increase of caloric intake over 4 or 5 days should avoid exacerbation of diarrhea. The total fluid intake of oral electrolyte solution and regular diet should be approximately 150 mL/kg/day. 2 2,22,23,24 and25

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