Acute gastroenteritis (AGE) is defined as an abrupt-onset illness characterised by diarrhoea with or without vomiting, fever, and abdominal pain, lasting less than fourteen days.¹ It continues to be one of the most common causes of illness in children and a major contributor to under-five morbidity and mortality worldwide, particularly in low- and middle-income countries.² Globally, diarrhoeal disease accounts for approximately half a million deaths annually in children younger than five years, and India contributes a substantial share of this burden.³ Dehydration resulting from excessive fluid and electrolyte loss is the most important and potentially life-threatening complication of acute gastroenteritis.⁴ The degree of dehydration determines the line of management, ranging from home-based oral rehydration to hospitalisation with intravenous fluid therapy, and its timely recognition is therefore central to reducing preventable childhood deaths.⁵ The World Health Organization (WHO) has classified dehydration into three categories — no dehydration, some dehydration, and severe dehydration — based on a combination of clinical signs such as general condition, thirst, sunken eyes, and skin pinch, which remains the most widely used bedside tool in resource-constrained settings.⁶ Several Indian studies have highlighted that clinical assessment scales, though simple, can be highly sensitive when applied systematically by trained health personnel.⁷ Bhatnagar et al. and other Indian workers have emphasised that a stepwise clinical approach combined with appropriate use of oral rehydration salts (ORS) and zinc supplementation can substantially reduce the duration of illness and the need for hospital admission.⁸ Despite the widespread availability of low-osmolarity ORS and national programmes promoting its use, a considerable proportion of children continue to present with moderate to severe dehydration, often due to delayed care-seeking, low health literacy, and inappropriate home management practices such as fluid restriction.⁹ Biochemical evaluation, including serum electrolytes, blood urea, and acid-base status, complements clinical assessment, especially in children with severe dehydration or those who fail to respond to initial therapy.¹⁰ Electrolyte disturbances such as hyponatraemia, hypernatraemia, and hypokalaemia are not infrequent and may independently influence the clinical course and outcome.¹¹ Indian hospital-based data on the correlation between clinical dehydration scoring and biochemical derangement remain relatively limited, and continued documentation from different geographic and demographic settings is valuable for strengthening local management protocols.¹² Furthermore, national child health programmes in India, including the Integrated Management of Neonatal and Childhood Illness (IMNCI) and Facility Based Management of Diarrhoea guidelines, have placed strong emphasis on training frontline healthcare workers to recognise dehydration using simple observational signs rather than relying solely on laboratory confirmation. Nevertheless, periodic hospital-based audits of clinical profile and dehydration severity remain necessary to identify local gaps in care-seeking behaviour, referral patterns, and the appropriateness of fluid therapy actually administered, so that training and counselling efforts can be suitably directed. Against this background, the present hospital-based study was undertaken to evaluate the clinical profile of children admitted with acute gastroenteritis, to grade the severity of dehydration using the WHO clinical scale, and to correlate clinical and biochemical parameters with the eventual treatment outcome, so as to reinforce evidence-based, cost-effective management practices suited to the Indian setting. Aims and Objectives To study the clinical profile of children with acute gastroenteritis, to assess the severity of dehydration using the WHO clinical dehydration scale, and to correlate clinical signs with biochemical parameters and treatment outcome.

RESULTS Study Design and Setting: This was a hospital-based, cross-sectional, observational study conducted in the Department of Paediatrics of a tertiary care teaching hospital. Study Duration: The study was carried out over a period of twelve months. Sample Size: A total of 200 children fulfilling the inclusion criteria were enrolled by consecutive sampling during the study period. Inclusion Criteria: ● Children aged 1 month to 5 years admitted with acute onset diarrhoea (≥3 loose stools in 24 hours) of less than 14 days' duration, with or without vomiting. ● Parents/guardians who provided written informed consent for participation. Exclusion Criteria: ● Chronic or persistent diarrhoea (duration ≥14 days). ● Children with known chronic renal, cardiac, hepatic disease, severe acute malnutrition, or congenital gastrointestinal anomalies. ● Children on treatment for surgical abdominal conditions. Methodology: After obtaining institutional ethics committee approval and written informed parental consent, a detailed history (duration and frequency of stools and vomiting, presence of blood/mucus, fever, urine output, feeding history, and prior treatment) was recorded on a pre-tested, structured proforma. A thorough clinical examination was performed, including assessment of general condition, level of consciousness, thirst, eyes (sunken/normal), tears, mucous membranes, skin pinch (skin turgor), capillary refill time, pulse rate, blood pressure, and weight. Severity of dehydration was graded using the WHO clinical dehydration classification (no dehydration, some dehydration, severe dehydration) and cross-validated using the Clinical Dehydration Scale (CDS) and Vesikari severity scoring system. Relevant investigations, including serum electrolytes (sodium, potassium), blood urea, serum creatinine, capillary blood glucose, and stool examination, were performed as clinically indicated. Children were managed as per WHO/IAP (Indian Academy of Paediatrics) guidelines for management of acute diarrhoea, using oral rehydration salts, intravenous fluids, zinc supplementation, and continued feeding, and outcome parameters including duration of hospital stay, need for intravenous therapy, and final outcome were recorded. Statistical Analysis: Data were entered in Microsoft Excel and analysed using SPSS software version 25.0. Categorical variables were expressed as frequencies and percentages, and continuous variables as mean ± standard deviation. The Chi-square test was used to determine association between clinical signs and severity of dehydration, and Spearman's correlation was used to compare the Vesikari severity score with WHO dehydration grade. A p-value of less than 0.05 was considered statistically significant. WHO Clinical Dehydration Classification: Children were graded as having no dehydration when there were insufficient signs to classify as some or severe dehydration; some dehydration when two or more of the following were present — restlessness/irritability, sunken eyes, drinking eagerly/thirsty, and skin pinch going back slowly; and severe dehydration when two or more of the following were present — lethargy or unconsciousness, sunken eyes, inability to drink or drinking poorly, and skin pinch going back very slowly (≥2 seconds). Vesikari Severity Scoring System: The Vesikari score is a 20-point composite scale that grades the severity of an episode of acute gastroenteritis based on duration and frequency of diarrhoea and vomiting, maximum recorded temperature, degree of dehydration, and treatment received. A score of ≤6 was considered mild, 7–10 moderate, and ≥11 severe disease. This score was used in the present study as an independent measure to cross-validate the WHO clinical dehydratio

A total of 200 children with acute gastroenteritis were enrolled and analysed during the study period. The demographic, clinical, biochemical, and outcome-related findings are summarised below. Table 1: Age and Sex Distribution of Study Population (n=200) Age Group Male n (%) Female n (%) Total n (%) 1–6 months 22 (11.0) 15 (7.5) 37 (18.5) 6–12 months 54 (27.0) 39 (19.5) 93 (46.5) 1–2 years 24 (12.0) 18 (9.0) 42 (21.0) 2–5 years 17 (8.5) 11 (5.5) 28 (14.0) Total 117 (58.5) 83 (41.5) 200 (100.0) Table 2: Clinical Presenting Features (n=200) Clinical Feature Number of Children Percentage (%) Loose watery stools 200 100.0 Vomiting 152 76.0 Fever 118 59.0 Abdominal pain/irritability 96 48.0 Blood/mucus in stool 18 9.0 Decreased urine output 84 42.0 Refusal of feeds 71 35.5 Table 3: Severity of Dehydration as per WHO Classification (n=200) Dehydration Status Number of Children Percentage (%) No dehydration 53 26.5 Some dehydration 108 54.0 Severe dehydration 39 19.5 Total 200 100.0 Table 4: Association of Clinical Signs with Severity of Dehydration Clinical Sign No Dehydration (n=53) Some Dehydration (n=108) Severe Dehydration (n=39) χ² value p-value Sunken eyes 6 (11.3%) 58 (53.7%) 36 (92.3%) 68.42 <0.001* Delayed skin pinch 3 (5.7%) 49 (45.4%) 37 (94.9%) 84.15 <0.001* Increased thirst/drinks eagerly 10 (18.9%) 76 (70.4%) 18 (46.2%) 39.27 <0.001* Unable to drink/lethargic 0 (0.0%) 8 (7.4%) 31 (79.5%) 112.6 <0.001* Dry mucous membrane 9 (17.0%) 64 (59.3%) 35 (89.7%) 58.91 <0.001* *Statistically significant (p<0.05) Table 5: Serum Electrolyte Abnormalities according to Severity of Dehydration Electrolyte Abnormality No Dehydration (n=53) Some Dehydration (n=108) Severe Dehydration (n=39) Total n (%) Hyponatraemia (Na⁺<135 mEq/L) 4 (7.5%) 31 (28.7%) 22 (56.4%) 57 (28.5) Hypernatraemia (Na⁺>145 mEq/L) 1 (1.9%) 9 (8.3%) 8 (20.5%) 18 (9.0) Hypokalaemia (K⁺<3.5 mEq/L) 3 (5.7%) 19 (17.6%) 13 (33.3%) 35 (17.5) Raised blood urea (>20 mg/dL) 2 (3.8%) 24 (22.2%) 27 (69.2%) 53 (26.5) Normal electrolytes 45 (84.9%) 58 (53.7%) 6 (15.4%) 109 (54.5) Table 6: Correlation of Vesikari Severity Score with WHO Dehydration Grade Vesikari Score Category No Dehydration Some Dehydration Severe Dehydration Total Mild (≤6) 44 21 0 65 Moderate (7–10) 9 71 9 89 Severe (≥11) 0 16 30 46 Total 53 108 39 200 Spearman's correlation coefficient between Vesikari score and WHO dehydration grade was r = 0.78 (p<0.001), indicating strong positive correlation. Table 7: Treatment Modality and Outcome (n=200) Parameter Number of Children Percentage (%) ORS alone 124 62.0 Intravenous fluids required 76 38.0 Zinc supplementation given 196 98.0 Antibiotics required (dysentery/sepsis) 22 11.0 Hospital stay ≤3 days 141 70.5 Hospital stay >3 days 59 29.5 Recovered and discharged 199 99.5 Referred to higher centre 1 0.5 Mortality 0 0.0 The mean duration of hospital stay was 3.4 ± 1.2 days. Children with severe dehydration required a significantly longer hospital stay (mean 5.1 ± 1.4 days) as compared to those with some dehydration (mean 3.0 ± 0.9 days) (p<0.001). No mortality was recorded during the study period, and only one child with severe dehydration complicated by acute kidney injury was referred to a higher centre for further management.

Acute gastroenteritis continues to be a leading cause of paediatric hospitalisation in India, and dehydration remains its most clinically relevant complication.¹³ In the present study, the majority of affected children (46.5%) belonged to the 6–12 month age group, which corresponds with the period of weaning and increased exposure to contaminated food and water, a finding consistent with earlier Indian studies by Kumar et al. and Elliott, who similarly reported peak incidence of AGE in infants between six months and two years of age.¹⁴ The male preponderance observed in this study (58.5%) is comparable to that reported in several Indian hospital-based series, possibly reflecting greater care-seeking behaviour for male children in certain community settings rather than a true difference in disease susceptibility.¹⁵ In the present study, some dehydration was the most common category (54.0%), followed by no dehydration (26.5%) and severe dehydration (19.5%). These findings are in agreement with data reported from other Indian tertiary care centres, where 'some dehydration' was consistently the predominant category among hospitalised children, underscoring the continued need for early triage and appropriate ORS-based management before progression to severe dehydration occurs.¹⁶ The proportion of severe dehydration in the present cohort, though lower than in some rural community-based studies, still represents a substantial at-risk group requiring intravenous rehydration and close monitoring.¹⁷ Clinical signs such as sunken eyes, delayed skin pinch, and inability to drink showed a strong and statistically significant correlation with the severity of dehydration (p<0.001), validating the continued utility of the WHO clinical dehydration scale as a rapid, low-cost bedside assessment tool, particularly in settings where laboratory facilities may not be immediately available.¹⁸ This is consistent with the original validation studies of the WHO and Clinical Dehydration Scale by Gorelick et al. and later Indian validation work, which similarly demonstrated that a combination of a small number of clinical signs can reliably predict the degree of fluid deficit.¹⁹ The strong positive correlation (r = 0.78) observed between the Vesikari severity score and WHO dehydration grade in the present study further supports the complementary use of standardised scoring systems alongside clinical judgement for objective severity grading and research comparability.²⁰ Biochemical evaluation revealed hyponatraemia as the most common electrolyte disturbance (28.5%), followed by raised blood urea (26.5%) and hypokalaemia (17.5%), with the frequency of abnormalities increasing significantly with worsening dehydration severity. Similar patterns of electrolyte derangement have been documented by Indian workers such as Bhatnagar et al. and Toledo et al., who reported that hyponatraemic dehydration was relatively common in children managed with home fluids of inappropriate composition prior to hospital presentation.²¹ This reinforces the importance of counselling caregivers regarding correct preparation and administration of low-osmolarity ORS at the community level.²² With regard to management, ORS alone was sufficient in 62% of children in the present study, closely reflecting the WHO recommendation that the overwhelming majority of dehydration episodes can be managed without intravenous therapy when initiated early and correctly.²³ The need for intravenous fluids in the remaining 38% of children, most of whom had some or severe dehydration, highlights the residual burden of delayed presentation despite ongoing national programmes promoting ORS and zinc use.²⁴ Importantly, no mortality was recorded in the present cohort, and the mean hospital stay was short (3.4 ± 1.2 days), an outcome comparable to other Indian hospital-based studies and attributable to prompt clinical assessment, adherence to standard treatment protocols, and early institution of appropriate rehydration therapy.²⁵ The present study reaffirms that a structured, protocol-based clinical approach to the assessment of dehydration, supported selectively by biochemical evaluation in moderate-to-severe cases, remains both feasible and effective in a resource-limited Indian tertiary care setting, and continues to be applicable across primary, secondary, and tertiary levels of care. The predominance of infants in the 6–12 month age group also carries practical implications for immunisation and nutrition counselling, since this period coincides with the introduction of complementary feeds and the waning of protective maternal antibodies. Health education directed specifically at mothers of infants in this age group, focusing on safe complementary feeding practices, hand hygiene, and safe drinking water, may therefore yield a disproportionately large reduction in disease burden.²⁵ Similarly, the relatively high proportion of children presenting with fever (59.0%) and blood or mucus in stools (9.0%) in the present series suggests that a subset of AGE episodes may have a bacterial or invasive component, warranting judicious and rational use of antimicrobials strictly as per standard treatment guidelines rather than empirical prescription, which remains a recognised concern in Indian outpatient and inpatient settings alike. Limitations of the Study This was a single-centre, hospital-based study with a relatively modest sample size, which may limit generalisability of the findings to the wider community. Stool culture and viral aetiological workup were not performed for all children, and follow-up beyond hospital discharge was not undertaken to assess longer-term nutritional outcome. Being a hospital-based rather than community-based study, the findings may also carry an inherent referral bias towards relatively sicker children, and true community-level severity distribution may differ from that observed in the present cohort.

Acute gastroenteritis with dehydration continues to be a significant cause of hospitalisation among young children, particularly infants between six months and one year of age. The WHO clinical dehydration scale, based on simple, reproducible bedside signs such as sunken eyes, skin pinch, and ability to drink, correlates strongly with objective severity scoring systems and biochemical derangement, and remains a dependable tool for triaging children in resource-limited settings. The majority of children can be successfully managed with oral rehydration therapy and zinc supplementation alone, reserving intravenous fluids for those with severe dehydration or complications. Strengthening community awareness regarding early and correct use of low-osmolarity ORS, along with training of primary healthcare workers in systematic clinical assessment of dehydration, is likely to further reduce morbidity, hospitalisation, and the residual burden of diarrhoeal disease among Indian children.

1. World Health Organization. The treatment of diarrhoea: a manual for physicians and other senior health workers. 4th revision. Geneva: WHO; 2005. 2. Walker CL, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, et al. Global burden of childhood pneumonia and diarrhoea. Lancet. 2013;381(9875):1405-16. 3. Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, et al. Global, regional, and national causes of under-5 mortality in 2000–15. Lancet. 2016;388(10063):3027-35. 4. Bhutta ZA. Acute gastroenteritis in children. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, editors. Nelson Textbook of Pediatrics. 20th ed. Philadelphia: Elsevier; 2016. p. 1854-72. 5. King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1-16. 6. World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. Geneva: WHO; 2014. 7. Bhatnagar S, Lodha R, Choudhury P, Sachdev HP, Shah N, Narayan S, et al. IAP guidelines 2006 on management of acute diarrhoea. Indian Pediatr. 2007;44(5):380-9. 8. Bhatnagar S, Bahl R, Sharma PK, Kumar GT, Saxena SK, Bhan MK. Zinc with oral rehydration therapy reduces stool output and duration of diarrhea in hospitalized children. J Pediatr Gastroenterol Nutr. 2004;38(1):34-40. 9. Ghosh S, Sengupta PG, Mandal SK, Ghosh S, Chowdhury SR, Chattopadhyay B. Diarrhoea and its home management: a study in a periurban area of Calcutta. J Indian Med Assoc. 2000;98(6):325-8. 10. Duggan C, Santosham M, Glass RI. The management of acute diarrhea in children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 1992;41(RR-16):1-20. 11. Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997;99(5):e6. 12. Pawar SK, Kumar A, Rathi SK. Correlation of clinical dehydration scale with biochemical parameters in children with acute diarrhoea. Indian J Pediatr. 2015;82(9):793-7. 13. Ahmed S, Al-Mamun MA, Nahar B, Ahmed T, Faruque AS, Sarker SA. Clinico-epidemiological profile of children hospitalized with acute diarrhoea. J Health Popul Nutr. 2011;29(4):357-64. 14. Kumar R, Agarwal SS, Deorari AK. Diarrhoeal disease in children: an overview. Indian J Pediatr. 1993;60(4):483-92. 15. Elliott EJ. Acute gastroenteritis in children. BMJ. 2007;334(7583):35-40. 16. Chandra RK, Sarkar SA, Ghosh AK. Clinical profile of acute diarrheal disease in hospitalized children below five years. Indian J Community Med. 2005;30(3):85-7. 17. Faruque AS, Malek MA, Khan AI, Huq S, Salam MA, Sack DA. Diarrhoea and severe dehydration in children under five: a hospital-based study. J Health Popul Nutr. 2004;22(1):39-45. 18. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA. 2004;291(22):2746-54. 19. Friedman JN, Goldman RD, Srivastava R, Parkin PC. Development of a clinical dehydration scale for use in children between 1 and 36 months of age. J Pediatr. 2004;145(2):201-7. 20. Ruuska T, Vesikari T. Rotavirus disease in Finnish children: use of numerical scores for clinical severity of diarrhoeal episodes. Scand J Infect Dis. 1990;22(3):259-67. 21. Bhatnagar S, Alam S, Sharma PK. Electrolyte disturbances in children with acute diarrhoea: a hospital-based study. Indian J Pediatr. 2009;76(9):925-8. 22. Toledo I, Sepulveda C, Elgueta A. Hyponatraemic dehydration in infants with acute gastroenteritis. J Trop Pediatr. 2001;47(5):289-92. 23. World Health Organization, UNICEF. Clinical management of acute diarrhoea: WHO/UNICEF joint statement. Geneva: WHO; 2004. 24. National Rural Health Mission. Facility Based Management of Diarrhoea, Pneumonia and other Common Childhood Illnesses: Participant's manual. New Delhi: Ministry of Health and Family Welfare, Government of India; 2013. 25. Singh J, Sundaram KR, Bhandari N, Kumar R. Diarrhoeal morbidity and its determinants among children in a rural community. Indian Pediatr. 1995;32(6):679-86.