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Is skin turgor reliable as a means of assessing hydration status in children?
  1. O Fayomi, Specialist Registrar Accident & Emergency Medicine, Wycombe General Hospital,
  2. I Maconochie, Consultant Paediatric Accident & Emergency Medicine,
  3. R Body, Clinical Research Fellow
  1. St Mary’s Hospital, London

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    Report by O Fayomi, Specialist Registrar Accident & Emergency Medicine, Wycombe General HospitalSearch checked by I Maconochie, R Body, Consultant Paediatric Accident & Emergency Medicine; Clinical Research FellowSt Mary’s Hospital, London

    A short cut review was carried out to establish whether skin turgor is a reliable indicator of hydration status in children. 478 papers were found in Medline and 107 in Embase using the reported searches, of which 4 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of three of these papers are tabulated (the fourth is a partial review). It is concluded that skin turgor is only moderately reliable at indicating hydration status in children.

    Clinical scenario

    A 3-year-old girl is brought to the emergency department with a 2 day history of vomiting and diarrhoea. You wish to estimate her hydration status to determine whether rehydration therapy is needed and remember being taught that increased skin turgor is associated with dehydration. You wonder how reliable this clinical sign actually is.

    Three part question

    In [children attending the emergency department with suspected dehydration] [what is the degree of variation between observers] when [ performing assessment of skin turgor]

    Search strategy

    Medline 1966–2006 November Week 3 and Embase 1980–07/04. Medline: (turgor.af. OR (clinical sign$ OR examination).mp. OR exp Physical Examination/) AND (exp Dehydration/OR dehydrat$.mp. OR exp Hypovolemia/OR (hypovolaem$ OR hypovolaem$).mp.) AND (Best BETs Paediatric filter (maximally sensitive))

    Embase: (turgor.af. OR (clinical sign$ OR examination).mp. OR exp Physical Examination/) AND (exp Dehydration/OR dehydrat$.mp. OR exp Hypovolemia/OR (hypovolaem$ OR hypovolaem$).mp.) limit to Child, Unspecified Age

    Search outcome

    478 papers were found using Medline and 107 using Embase, three of which were relevant to the topic of interest. One relevant systematic review summarised two of these papers but included no additional papers (Steiner et al, 2004).

    Comment(s)

    Dehydration is an important cause of childhood morbidity and mortality worldwide. Skin turgor is generally accepted as part of the clinical assessment of hydration status in children being a quick, non-invasive test that can be performed at the bedside. Unrecognised fluid deficit can lead to electrolyte and acid-base disturbances as well as end organ damage. Conversely over estimation of fluid deficit can result in inappropriate rehydration therapy. The value of any clinical test is a function of its ability to detect a particular condition and its reliability. The limited number of studies which have various sources of bias show only moderate agreement for inter-observer reproducibility when skin turgor is used to clinically assess hydration status in children.

    CLINICAL BOTTOM LINE

    Skin turgor measurement, whilst part of the initial assessment of children with suspected dehydration, is only moderately reliable and other clinical signs should be sought to confirm this diagnosis.

    Table 2

    Report by O Fayomi, Specialist Registrar Accident & Emergency Medicine, Wycombe General HospitalSearch checked by I Maconochie, R Body, Consultant Paediatric Accident & Emergency Medicine; Clinical Research FellowSt Mary’s Hospital, London

    References

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