A malnourished child with diarrhoea and vomiting at an anganwadi-cum-health centre
A 15-month-old girl is brought to an anganwadi-cum-health centre in Haryana by her mother with loose stools for five days and poor feeding. The child weighs 7.0 kg and has a mid-upper arm circumference of 11.2 cm. Her birth weight was 2.6 kg. She has no swelling of the feet. Her eyes are sunken, she is lethargic, and a skin pinch on the abdomen goes back slowly (about 2 seconds). She takes a few sips of water when offered but vomits immediately. The mother says she stopped breastfeeding at 6 months and gives diluted buffalo milk (one part milk to one part water) and tea, with no dal, egg or mashed food. The family is poor and the mother works as a daily wage labourer. There is no dehydration corner with IV fluids at this centre; ORS packets are available. The nearest CHC with paediatric admission is 12 km away and the ambulance takes about 20 minutes. The child's immunization is up to date.
1. Classify the child's nutritional status and hydration using the findings, and justify your classification with at least two criteria.
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The MUAC of 11.2 cm is below 11.5 cm, so she has severe acute malnutrition (SAM) in the 6–59 month age group. Her weight of 7.0 kg at 15 months is far below the expected weight and supports this. No foot oedema means marasmus rather than kwashiorkor.
For hydration, sunken eyes plus lethargy are enough to classify severe dehydration, and the slow skin pinch and repeated vomiting support it. This is more than 'some dehydration'. The combination of SAM, severe dehydration and vomiting makes her a complicated case needing facility care.
The reasoning is that each sign alone is a clue; together they change the level of care required, from home advice to urgent referral.
2. What will you do at this centre while arranging referral, and why is oral rehydration alone not enough here?
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Give ORS in small, frequent sips by cup and spoon while arranging transfer, but do not force fluids if she is vomiting persistently or becoming less responsive. She needs intravenous fluids (Plan C) at the CHC. Keep her warm, continue breastfeeding if she will take it, and check for hypoglycaemia: if she is conscious and able to swallow, give a little sugar water or expressed breast milk. Do not give antibiotics without a prescriber.
Call 108, write a referral slip with weight, MUAC, hydration signs and treatments given, and send the mother with the child. Oral rehydration alone is not enough because persistent vomiting and lethargy make oral intake unreliable and she is already severely dehydrated. The judgement is not to keep her at the centre for oral rehydration when she needs intravenous therapy.
3. List the counselling points for the mother, including why diluted milk and tea are harmful.
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Explain that diluted buffalo milk and tea do not provide enough energy or protein and displace breast milk and complementary foods. After rehydration, the child needs frequent, energy-dense feeds: mashed dal, rice, egg, khichri with oil, and continued breastfeeding up to 2 years.
Show the mother how to prepare ORS correctly and when to return: poor feeding, repeated vomiting, blood in stool, or drowsiness. Link her to the anganwadi for growth monitoring and take-home ration. Counselling must be practical and respectful of the family's work constraints, or it will not be followed.
The reasoning is that correcting the diet prevents relapse; treating only the diarrhoea would leave the underlying cause unchanged.