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• The sensitivity of non-invasive clinical examination to detect dehydration has been questioned without any evidence
  Malcolm G Coulthard
  Published on: 22 March 2016

• Published on: 22 March 2016

  The sensitivity of non-invasive clinical examination to detect dehydration has been questioned without any evidence

  • Malcolm G Coulthard, Consultant paediatric nephrologist

  The ADC Archivist recently reported that Freedman et al had revealed that "old-fashioned clinical examination" missed about 20% of cases of significant dehydration in children.[1] Their assessment of this work was not surprising because the meta-analysis in the Journal of Pediatrics carries the headline message that even the "most accurate, noninvasive" methods could only "identify dehydration suboptimally", and it was a...

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  The ADC Archivist recently reported that Freedman et al had revealed that "old-fashioned clinical examination" missed about 20% of cases of significant dehydration in children.[1] Their assessment of this work was not surprising because the meta-analysis in the Journal of Pediatrics carries the headline message that even the "most accurate, noninvasive" methods could only "identify dehydration suboptimally", and it was a high quality analysis which only included studies that had accurately quantified the degree of dehydration by serial weighings.[2] However, Freedman et al's conclusions are misleading because they only selected papers for analysis that had evaluated a rapid triaging tool, and none which had undertaken standard full clinical examinations.

  The four papers that qualified for Freedman et al's statistical reanalysis had used the 'Clinical Dehydration' and 'Gorelick' scores to detect dehydration secondary to gastroenteritis. The individual components of these tests were not mentioned in their meta-analysis paper, but either can be performed quickly on a fully-clothed infant in less than a minute. They rely on scoring (a) the child's general appearance (seeking signs of thirst, restlessness, lethargy and irritability, drowsiness, limpness, cold, sweatiness, or coma), (b) whether the eyes look sunken, (c) if the tongue feel moist, and (d) if tears are reduced or absent, all on simple scales. They do not include any of the following components of routine clinical examinations: capillary refill time, pulse rate and volume, respiratory pattern, peripheral coolness, or skin turgor. As such, these authors are not entitled to list their triage-type scoring as being the "most accurate, noninvasive" clinical tests for dehydration. By presenting their data as they did, Freedman et al may have produced a false- impression among paediatricians about the sensitivity of full, careful clinical examinations for evaluating fluid-balance status, and by reviewing it as they did the ADC Archivist may have inadvertantly perpetuated this confusion.

  References

  1. Archivist. Assessing dehydration. Archives of Diesease in Childhood 2015;100:999. 2. Freedman SB, Vandermeer B, Milne A, Hartling L. Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis. Journal of Pediatrics 2015;166:908- 16.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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