Dehydration according to WHO
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WHO dehydration classification assessment treatment guidelines
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WHO dehydration classification signs symptoms treatment plan
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WHO dehydration three classifications signs symptoms ORS treatment plan A B C
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Dehydration According to WHO
Definition
Dehydration is a deficit of total body water caused by either excess water loss (hyperosmolality) or salt loss (hypo-osmolality). Common causes include diarrhea, vomiting, sweating, inadequate intake, and excessive urinary losses (e.g., from hyperglycemia or diuretics). - Tintinalli's Emergency Medicine, p. 124
WHO Classification of Dehydration
The WHO uses a 3-tier classification based on clinical signs and symptoms, primarily developed in the context of diarrheal illness.
Assessment Signs (4 Key Clinical Findings)
| Clinical Sign | No Dehydration | Some Dehydration | Severe Dehydration |
|---|---|---|---|
| General condition | Well, alert | Restless, irritable | Lethargic or unconscious |
| Eyes | Normal | Sunken | Very sunken |
| Thirst / Drinking | Drinks normally, not thirsty | Drinks eagerly, thirsty | Not able to drink or drinking poorly |
| Skin pinch | Goes back immediately | Goes back slowly | Goes back very slowly (>2 seconds) |
Classification rule: 2 or more signs from a row = that level of dehydration.
- Park's Textbook of Preventive and Social Medicine; WHO Diarrhoea Treatment Guidelines
1. No Dehydration (Green)
- Not enough signs to classify as "some" or "severe"
- Fluid losses are present but clinically compensated
Treatment - Plan A (Home treatment):
- Give extra fluids (ORS or recommended home fluids) after every loose stool
- Children <2 years: 50-100 mL ORS per stool
- Children 2-10 years: 100-200 mL ORS per stool
- Older children/adults: as much as wanted
- Continue feeding; increase breastfeeding frequency
- Give zinc supplementation (10 mg/day for infants <6 months; 20 mg/day for children >6 months, for 10-14 days)
- Return immediately if: child cannot drink, condition worsens, develops sunken eyes, passes many watery stools, or has fever
2. Some Dehydration (Yellow)
- 2 or more of: restless/irritable, sunken eyes, drinks eagerly/thirsty, skin pinch returns slowly
- Estimated fluid deficit: ~5-10% body weight
- If also has a severe classification - refer urgently to hospital with ORS sips en route
Treatment - Plan B (ORS in clinic over 4 hours):
| Age | Weight | ORS Volume over 4 hours |
|---|---|---|
| Up to 4 months | <6 kg | 200-400 mL |
| 4-11 months | 6-<10 kg | 400-700 mL |
| 12-23 months | 10-<12 kg | 700-900 mL |
| 2-4 years | 12-<19 kg | 900-1400 mL |
- Approximate calculation: weight (kg) × 75 mL
- If child wants more ORS, give more
- For infants <6 months not breastfed: also give 100-200 mL clean water
- Give frequent small sips; if vomiting occurs, wait 10 min then continue more slowly
- Reassess after 4 hours and reclassify
3. Severe Dehydration (Pink)
- 2 or more of: lethargic/unconscious, sunken eyes, unable to drink/drinking poorly, skin pinch returns very slowly (>2 seconds)
- Estimated deficit: >10% body weight (approximately 100 mL/kg)
- Medical emergency
Treatment - Plan C (IV fluid resuscitation):
| Step | Action |
|---|---|
| Can give IV fluids immediately | Give Ringer's Lactate (preferred) or normal saline: 100 mL/kg - Infants (<12 mo): 30 mL/kg over 1 hour, then 70 mL/kg over 5 hours - Children (>12 mo): 30 mL/kg over 30 min, then 70 mL/kg over 2.5 hours |
| Reassess every 15-30 min | If radial pulse is weak/not improving, repeat the first bolus |
| IV unavailable; can drink | Give ORS via nasogastric tube: 20 mL/kg/hour for 6 hours (total 120 mL/kg) |
| IV unavailable; cannot drink | Refer URGENTLY to hospital; give ORS sips if possible en route |
- Once improving, switch to oral ORS as soon as the child can drink
- Give ORS (5 mL/kg/hr) alongside IV fluids while drip is running
- Reassess at 3 and 6 hours to reclassify and select next treatment plan
- If cholera is suspected in a child ≥2 years: add appropriate antibiotic
Fluid Composition - WHO ORS
The WHO/UNICEF low-osmolarity ORS formula (recommended since 2004):
| Component | Amount per liter of water |
|---|---|
| Sodium chloride | 2.6 g |
| Trisodium citrate | 2.9 g |
| Potassium chloride | 1.5 g |
| Glucose (anhydrous) | 13.5 g |
| Total osmolarity | 245 mOsm/L |
This reduced-osmolarity formula (245 mOsm/L vs. the older 311 mOsm/L) decreases stool output and vomiting, and reduces the need for IV therapy.
WHO "Red Flag" Signs (Risk of Shock)
The following signs indicate risk of deterioration to shock and demand close monitoring:
- Altered responsiveness (irritable or lethargic)
- Sunken eyes
- Tachycardia
- Tachypnoea
- Reduced skin turgor
Additional WHO Principles
- Zinc supplementation reduces duration and severity of diarrheal illness and is mandatory alongside ORS
- Continue feeding - early refeeding improves mucosal recovery and prevents malnutrition
- No anti-diarrheal or anti-emetic drugs in children - WHO does not recommend these
- Breastfeeding should never be stopped during dehydration treatment
- Antibiotics only for specific causes: cholera, dysentery (Shigella), certain bacterial enteritis
WHO Classification in Context
No single clinical sign is sufficient in isolation. The WHO system classifies using combinations of signs. - Tintinalli's Emergency Medicine, p. 886
Recent evidence notes that even the two-tier distinction ("some" vs. "severe") can be difficult to apply reliably in clinical practice, as the accuracy of individual signs such as skin turgor and eye sunkenness varies between examiners. Weight-based fluid deficit calculation remains the gold standard but requires a known premorbid weight. - NCBI Bookshelf - Clinical dehydration assessment
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