An 8.4 kg Infant with Severe Dehydration, a Glucose of 2.6 and One Other Nurse
Amina is an 11-month-old girl, weight 8.4 kg, brought to the district hospital by her mother with three days of watery diarrhoea and vomiting and one day of poor feeding. She is lethargic, with sunken eyes, a skin pinch that returns very slowly, and she drinks poorly when offered oral rehydration solution. Vital signs: axillary temperature 38.3 °C, heart rate 176/min, respiratory rate 46/min, capillary refill 4 seconds, BP 70/40 mmHg. She has not passed urine for eight hours. Bedside glucose is 2.6 mmol/L. Sodium 133 mmol/L, potassium 3.0 mmol/L. The mother stopped breastfeeding yesterday because a relative told her the child 'needs a rest'. The ward stocks oral rehydration salts, Ringer's lactate 500 mL bags, 10% dextrose 100 mL, and a working infusion pump. There is one other nurse on the ward and eight inpatients. The doctor is in the outpatient department.
1. Classify Amina's dehydration and set out the fluid plan with actual volumes for her, explaining the reasoning behind each step.
Read the worked answer
Classification. She has severe dehydration. The signs stack up: lethargy, sunken eyes, a very slow skin pinch, inability to drink properly, capillary refill of 4 seconds, tachycardia, hypotension and eight hours without urine. Under WHO/IMCI this is Plan C - severe dehydration - and oral rehydration alone is not appropriate, although she should still be offered ORS while the drip is set up.
Fluid plan for a child under 12 months (Plan C):
- First hour: 30 mL/kg = 30 × 8.4 = 252 mL of Ringer's lactate over 1 hour.
- Following 5 hours: 70 mL/kg = 70 × 8.4 = 588 mL over 5 hours (about 118 mL/h).
- Total: 840 mL over 6 hours. This is the under-12-month schedule; children aged 12 months to 5 years receive the same volumes but over 3 hours (30 mL/kg in 30 minutes, then 70 mL/kg in 2.5 hours).
Reasoning and safeguards.
- Use a 500 mL bag, a burette or infusion pump so the hourly volume is exact, because an infant given a free-flowing adult drip can be overloaded.
- Reassess every 15–30 minutes for the first hour, then hourly: pulse, capillary refill, respiratory rate, skin pinch, level of consciousness, urine output. If she is not improving, increase the rate and inform the doctor; if she develops puffy eyelids, a rising respiratory rate or a gallop, reconsider the rate.
- If intravenous access fails after a few attempts, give ORS by nasogastric tube at 20 mL/kg/h for 6 hours rather than spending 30 minutes on needles.
- Reassess and move to Plan B (ORS 75 mL/kg over 4 hours) once she can drink and is no longer severely dehydrated.
2. What will you do about the glucose of 2.6 mmol/L and the potassium of 3.0 mmol/L, and why does the order of those actions matter?
Read the worked answer
Hypoglycaemia comes first. A glucose of 2.6 mmol/L in a lethargic infant is a treatable cause of the lethargy and can worsen brain injury if left while the drip is being argued over.
- Give an intravenous bolus of 10% dextrose, 2 mL/kg = about 17 mL, following the unit protocol (some protocols use 5 mL/kg; check which one is signed locally). Do not use 50% dextrose undiluted in an infant.
- Recheck the glucose after 30 minutes. If still low, repeat the bolus and start a maintenance dextrose-containing infusion.
- Once conscious and able to swallow, restart breastfeeding and continue feeding throughout rehydration - the mother's decision to stop was based on poor advice, not on the child's needs.
Potassium comes after urine output. A potassium of 3.0 mmol/L needs correction, but never as a bolus. Give it orally (ORS contains potassium) or as part of the maintenance fluid once urine output is established, at the prescribed concentration, and never by rapid IV push. Repeat the electrolytes as ordered.
The order matters because both hypoglycaemia and hypokalaemia can cause arrhythmia and neurological harm, but an undiluted potassium bolus kills faster than the deficiency does, and dextrose given before a sample is taken can obscure the diagnostic picture. Draw the confirmatory samples when the line is inserted, then treat the glucose.
Also give zinc 20 mg daily for 10–14 days (she is over 6 months) - it shortens the diarrhoea and reduces recurrence - and continue breastfeeding alongside ORS.
3. The mother is preparing for discharge on the second day. What teaching and follow-up plan will you give her, and which return signs are non-negotiable?
Read the worked answer
Feeding and fluids.
- Breastfeed more often, including during and after the diarrhoea. Stopping breastfeeding was the one thing that most increased Amina's risk.
- Give ORS after every loose stool: roughly 50–100 mL for a child under 2 years, using a cup and spoon, slowly. Show the mother how to mix a sachet in exactly one litre of clean water and discard it after 24 hours.
- Continue zinc 20 mg daily for 10–14 days even after the stools settle.
- Offer small, frequent, energy-dense meals as appetite returns; do not withhold food.
What not to do. No antidiarrhoeal medicines, no home-made sugar-salt mixtures with wrong proportions, and no antibiotics unless the doctor prescribes them - most acute watery diarrhoea is viral.
Return immediately if: she cannot drink or feed, she is repeatedly vomiting everything, she becomes more sleepy or floppy, her eyes sink or she stops passing urine, there is blood in the stool, she has a high fever that does not settle, or her breathing becomes fast or deep (a sign of acidosis).
Follow-up. Review in the clinic in 2–3 days, weigh her and plot the weight, and check the mother's understanding by asking her to demonstrate mixing the ORS and to repeat the danger signs back. Ask about the relative who advised stopping breastfeeding and, if appropriate, include that person in the teaching - the household belief, not the mother alone, is what determines whether this recurs.