Factors Related to Dehydration in Children Admitted to the Emergency Department: A Cross-Sectional Study

The World Health Organization (WHO) defines dehydration as a condition resulting from excessive loss of body water (1). Dehydration is a common disorder of body fluids encountered in the nursing care of infants and young children. It occurs when the total output of body fluids is greater than the total intake (2). Dehydration is a leading cause of death among children under 5 years of age worldwide. Approximately 760,000 children around the world contract diarrheal diseases annually. A study by Omoke et al. reported a 15.9% prevalence of dehydration in children (3), while Vorlasane et al. observed a higher rate of 48.4% (4). Maleki et al. studied 118 Iranian children under 3 years old with acute gastroenteritis and found mild dehydration in 46.4%, moderate in 35.7%, and severe in 17.9% (5). According to Mosav et al.'s study, among children with gastroenteritis referred to medical centers, 4.4% of patients had mild dehydration, 78.7% had moderate dehydration, and 20.8% had severe dehydration, of which 41.6% of these patients had disorders in sodium levels and 17.2% had disorders in potassium levels (6).

Dehydration in children is mostly caused by acute gastroenteritis, primarily due to infectious agents. In the United States, 75% to 90% of infectious diarrhea is caused by viral infections, while bacterial pathogens and parasites contribute to less than 20% and 5% of cases, respectively (1). The degree of dehydration varies according to age, with infants having a total body water content of 70% to 80% of body weight and older children having 60%. Dehydration is classified as mild (3% to 5% loss of body weight), moderate (6% to 10%), and severe (over 10%) (7). Children experiencing persistent diarrhea who consume excessive water may develop hyponatremic dehydration due to simultaneous loss of sodium and bicarbonate (8). Colleti et al. identified prolonged skin turgor, capillary refill time, abnormal breathing, and decreased serum bicarbonate as signs of dehydration (9). In the study by Maleki et al., rotavirus gastroenteritis was associated with fever (65.5%), vomiting (65.5%), and rhinorrhea (24.1%) (5). Prisco et al. described symptoms of moderate dehydration, including thirst, restlessness, slightly sunken eyes, reduced tears, and mucous membrane adhesion (10). Hoxha et al. listed decreased skin turgor, sunken eyes, weak pulse, tachycardia, impaired breathing, decreased tears, dry mucous membranes, prolonged capillary refill time, and decreased urinary output as dehydration symptoms (11).

Considering the high prevalence of dehydration (3) and the risks caused by it, including the risk of death and the costs imposed on the health and treatment system and families due to the increase in the duration of hospitalization and the return visits of patients, it is necessary to investigate its causes and formulate preventive strategies (6, 12). Amirkola Children's Hospital in Babol, Iran, experiences a high number of dehydration-related emergency visits. Limited studies have been conducted on dehydration factors in Iranian children, emphasizing the need for further research in this area. Additionally, factors contributing to dehydration in children may vary across countries and regions due to differences in cultural, economic conditions, and healthcare facilities.

The aim of this study was to identify the factors related to dehydration in children admitted to the Emergency Department of Amirkola Children's Hospital, with the goal of providing suitable solutions to prevent dehydration among children in this region and ultimately reduce its prevalence.

In this study, 141 children with moderate to severe dehydration were included, with a mean age of 30.60 ± 2.98 months. Of the participants, 41.1% resided in rural areas, and 15.7% had a recent travel history (Table 1).

In this study, 61% of patients visited the emergency department 48 hours after symptom onset. Notably, 44% of participants did not receive zinc supplements, and 59.6% of families were unaware of the significance of ORS administration. Additionally, 19.9% of mothers did not wash their hands before preparing food (Table 2).

In this study, 79.9% of the referred children had fever, 69.5% had nausea, 30.5% had abdominal distention, and 61.7% had abnormal skin turgor. Other symptoms associated with dehydration are listed in Table 3.

The likelihood of dyspnea in patients with a history of drug use was 4.86 times higher than in those without such a history [odds ratio (OR), 4.86; 95% confidence interval (CI), 1.29 - 18.23]. Rural patients demonstrated a threefold increased likelihood of abnormal skin turgor compared to urban patients. Additionally, children who did not receive zinc supplements (OR, 1.33), resided in rural areas (OR, 1.35), or had mothers who did not wash their hands before food preparation (OR, 1.48) were more likely to experience diarrhea (Table 4).

This study explored the factors associated with dehydration in children admitted to the emergency department of Amirkola Children's Hospital, Babol. We found that 61% of children arrived at the emergency department 48 hours after the onset of diarrhea symptoms. This delay in seeking care could be a significant contributing factor to the severity of dehydration observed in these children. Rapid oral rehydration therapy administered over 3 to 4 hours is crucial for treating acute gastroenteritis with dehydration (16). Timely and appropriate referral of children with diarrhea can potentially reduce up to 20% of childhood deaths and prevent its long-term complications (17). Fikire et al. identified several key factors contributing to the delayed referral of children with diarrhea, including the child's gender (female), age (less than 24 months), caregivers without formal education, poor economic status, dissatisfaction with healthcare workers' performance in the past six months, and lack of respect from healthcare providers (18).

In our study, 71% of patients initially attempted home remedies, suggesting that reliance on such methods could be a reason for delayed emergency department visits. Furthermore, over 60% of parents were unaware of ORS treatment for dehydration, highlighting a knowledge gap regarding effective home remedies. Inappropriate home remedies, such as administering opiates, self-administering drugs, temporary serum therapy, and providing oral solutions with high carbohydrate concentrations (e.g., hot plant extracts), not only fail to effectively treat dehydration but can sometimes exacerbate the condition.

In this study, most children exhibited symptoms such as fever (71%), vomiting (69.5%), abnormal skin turgor (61.7%), lack of tears (95.7%), oliguria (35.7%), paleness (48.2%), and abdominal distension (30.5%). The high prevalence of vomiting and fever in our study can be attributed to the inclusion of samples with moderate and severe dehydration. This finding is consistent with Vorlasane et al.'s study, which reported vomiting (66.6%) and fever (60.6%) as the most common symptoms associated with diarrhea in dehydrated hospitalized children (4). Another study revealed that 3% of children referred with diarrhea presented with prolonged capillary refill time, 71% had a thread-like pulse, 97% had dry mucous membranes, 54% had abnormal skin turgor, and 10.5% had oliguria (19). Vorlasane et al. found fever (60%) and vomiting (66%) as the most common symptoms associated with diarrhea (4). In Sharma et al.'s study, abdominal distension (29%), vomiting (71%), fever (87%), and respiratory disorder (27%) were symptoms linked to severe dehydration (20).

History of travel, underlying illness of the child, and the mother's failure to wash hands before preparing food were the most significant factors related to dehydration in our study. Non-observance of public hygiene during travel, such as dining at restaurants, consuming prepared food, and the lack of proper sanitary facilities, may contribute to these findings. Soriano-Arandes et al. also reported travel history as a risk factor for gastroenteritis syndrome (21). Additionally, another study found that 84% of children with diarrhea and dehydration had at least one additional diagnosis, such as malaria, pneumonia, HIV, tuberculosis, anemia, meningitis, rickets, or asthma (22). Furthermore, hand washing has been demonstrated to reduce diarrhea incidence by approximately 30% in high-income countries and low- to middle-income communities (23). Other studies have also highlighted the importance of hand washing, toilet cleanliness, access to safe drinking water, and timely initiation of complementary feeding in reducing gastroenteritis (24, 25). Sharma et al. further identified factors such as living in crowded environments (lack of hygiene), not being exclusively breastfed in the first six months, not receiving ORS solution before referral, and no history of oral zinc supplementation as elements associated with severe dehydration (20).

In this study, the likelihood of dyspnea was higher in children who had a history of underlying disease. This problem may be due to the presence of accompanying diseases that have affected the respiratory system. On the other hand, the imbalance of fluids and electrolytes caused by dehydration (metabolic acidosis) can be associated with disturbances in the breathing pattern (26). The findings of our study showed that rural children had more skin turgor disorder. Considering that the disturbance in the intensity of skin turgor depends on the severity of dehydration, rural children probably had more severe dehydration than urban children. Late referral (due to the greater distance of the villagers from the medical centers) or the lower health level of the villagers can justify this issue. In Özdil and Vardar's study, complications of dehydration were more common in rural and suburban children than in urban children (27).

Children who did not take zinc supplements had more oliguria in this study. Since oliguria is seen in people who are more severely dehydrated, oliguria is more common in children who have not taken zinc supplements (28). Zinc supplementation in children who are dehydrated due to diarrhea helps to control diarrhea and the severity of dehydration by accelerating the recovery of intestinal epithelium (29). The results of this study showed that abdominal distension was more common in children who had a history of underlying disease. This is probably because diarrhea (one of the most important causes of dehydration in children) is more severe in children with underlying diseases. Severe diarrhea can cause significant abdominal distension due to the formation of gas, liquids, or excrement in the intestine (30). Travel history and the mother's failure to wash hands before preparing food were related to abdominal distension in the studied children. In Dawson et al.'s study, the symptoms of dehydration were more severe in children who had a history of traveling and did not observe hygiene tips such as hand washing (31). In fact, not washing hands is likely to lead to more severe diarrhea and, as a result, abdominal distension.

Seizures were significantly higher in children who had a history of underlying disease in this study. It is possible that the underlying disease that led to the use of medication played a role in the occurrence of seizures in the present study. Additionally, in the study by Kariuki et al., infectious diseases in childhood and neonatal and perinatal complications are mentioned as seizure risk factors (32). The results of our study showed that the frequency of diarrhea had a significant relationship with not taking zinc supplements. A study in Nigeria found that only about 30% of children with diarrhea received zinc supplements (33). The WHO recommends treating childhood diarrhea with ORS and zinc supplementation (34). Oral rehydration solution and zinc supplementation are easy and effective interventions, and it is estimated that ORS reduces the risk of mortality from diarrhea by 93%, and zinc supplementation reduces the duration of diarrhea, stool output, and the risk of persistent diarrhea (35).

Our study showed that children living in villages and children whose mothers did not wash their hands before preparing food had more diarrhea. In the study by Chatterjee et al. in west Bengal, India, similar results were obtained (36). Of course, one of the possible reasons for this is the lower level of health in the village environment compared to the city and the lower level of knowledge among mothers. One of the strengths of this study is the comprehensive investigation of factors related to dehydration in children. Our study also had some limitations. The majority of children suffering from dehydration had gastroenteritis, and the factors related to other causes of dehydration may have been hidden from the researcher. In this study, only children with moderate and severe dehydration were examined, and the results may not be generalizable to children with mild dehydration. Due to the cross-sectional nature of this study, it is not possible to establish causality, and the long-term effects of the identified risk factors on dehydration cannot be assessed over time.