Children are at a far great risk of dehydration than adults for a variety of reason and consequently all paramedics should be vigilent in their assessment of dehydration in children. Not only are children more likely to become severely dehydrated than adults, but they are less likely to be effectively treated early. Children have a higher metabolic rate, are more prone to gastroenteritis leading to fluid loss through diarrhoea and vomiting, and insensible fluid loss through fevers.
As a paramedic this is how I assess dehydration in a child:
1. Because children generally are uncomfortable with strangers, leave the normal routine tool based assessments until a little later when you have some trust. Assess the patient to see if they appear globally well or unwell. Are they awake? Are they interacting normally? Are they crying, but consolable? Are they looking at you and tracking your movements? Are Ask the parents or carers if they look normal, and if not, in what way?
2. Look at overall urine output. Ask the parents/carer if their nappies have been wet or dry? A normal infant will have wet nappies at least every 4 hours. If the nappies are dry after 4 hours there is something wrong and most likely the child is dehydrated or has a renal problem.
3. Assess the mucuous membranes (such as the mouth and bucal mucossa) for signs of dryness or moisture.
4. In neonates, the undeveloped cranium provides a soft fontonelle (the top part of the cranium where majority of the joins eventually come together). If this is sunken it is a sign that the neonate or infant is severely dehydrated.
5. Assess skin turgor. Normal skin is soft and easily returns to its normal position is moved. Dehydrated skin remains where you squeeze it and only slowly returns to its normal position.
6. Look at the eyes – sunken eyes, like a sunken fontanelle is a bad sign indicating dehydration.
7. Look for changes in overall perfusion, such as skin colour, level of consciousness, pule rate, blood pressure and respiratory pattern. A decreased BP is a late sign of severe dehydration.
8. Look for the injury/illness that you can’t see, such as diabetes mellitus, which will cause osmotic diuresis. Ask questions about recent injuries or illness. Has the child had any fall recently?
Always be weary when assessing children for dehydration. Children compensate tremendously well, but only provide a very minimal amount of decompensation.
Children at a High Risk of Dehydration
The following is a list of children who have been identified as being at a higher risk of dehydration:
1.Children younger than 1 year, especially those younger than 6 months!
2. Infants who were of low birth weight.
3. Children who have passed six or more diarrhoeal stools in the past 24 hours.
4. Children who have vomited three times or more in the past 24 hours.
5. Children who have not been offered or have not been able to tolerate supplementary fluids before presentation (don’t forget many parents through good intentions have stop giving fluids to their children in an attempt to reduce the vomiting and diarrhoea).
6. Infants who have stopped breastfeeding during the illness.
7. Children with signs of malnutrition.
Signs of Hyponatremic Dehydration
Dehydration with concurrent hyponatremia is clinically much more dangerous than dehydration on its own. The following are signs associated with dehydration with concurrent hyponatremia:
– Jittery movements
– Increased muscle tone
– Drowsiness or coma.
These patients need urgent medical intervention. As a paramedic you must recognise the child with hyponatremic dehydration and act fast.