A 14-month-old with acute watery diarrhoea at a primary health centre
A 14-month-old girl weighing 9 kg is brought to a primary health centre in Haryana with three days of watery diarrhoea, 8–10 stools a day, and vomiting after feeds. The mother stopped breastfeeding two days ago because of the vomiting and has been giving diluted mango drink instead. On examination the child is irritable and restless, drinks eagerly from a cup, has sunken eyes, a dry mouth, and a skin pinch on the abdomen that goes back slowly, in under two seconds. She has not passed urine for eight hours. There is no blood in the stool and no fever. Her weight at a recent immunisation visit was 9.0 kg and today it is 8.6 kg. The health centre has oral rehydration salt packets, zinc dispersible tablets, intravenous Ringer's lactate and 5% dextrose, but no paediatric nasogastric tubes of the smallest size.
1. Classify the dehydration and justify your classification using the findings. What treatment plan follows, with the actual volumes and doses for this child?
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Classification: some dehydration (moderate), Plan B. Two or more of the following signs are required:
- Sunken eyes - present.
- Restless, irritable behaviour - present.
- Drinks eagerly, thirsty - present.
- Skin pinch goes back slowly, under 2 seconds - present.
Severe dehydration is excluded because there is no lethargy or unconsciousness, no inability to drink, and the skin pinch is not very slow (over 2 seconds). The weight loss of 0.4 kg on 9.0 kg is about 4.5%, consistent with moderate rather than severe loss (10% or more).
Plan B
- Oral rehydration salt solution, low osmolarity, 75 mL/kg over 4 hours: 75 × 9 = 675 mL, roughly 170 mL per hour, given by cup and spoon in small frequent sips; if she vomits, wait 10 minutes and resume more slowly.
- Zinc 20 mg daily for 14 days (children above 6 months), started now - it shortens the episode and reduces recurrence.
- Continue breastfeeding on demand between oral rehydration salt feeds; the mother must be told that stopping was the wrong advice.
- Continue feeding with age-appropriate food after the 4-hour rehydration period.
- Reassess at 4 hours and record the number of stools, urine passed and weight.
The 5% dextrose is not a rehydration fluid and should not be used for this purpose.
2. The mother asks for an antibiotic and an anti-vomiting medicine so the child will stop passing stool. What is your response, with reasons?
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Antibiotics Acute watery diarrhoea without blood in the stool, without fever and without cholera-like profuse rice-water stools is almost always viral or toxin-mediated and self-limiting. Antibiotics would add no benefit, would not stop the fluid loss, and would promote resistance and side effects. Antibiotics are indicated for dysentery (blood in stool, usually shigellosis), suspected cholera with severe dehydration, and specific infections such as giardiasis. Explain that the real treatment is fluid replacement and zinc.
Antimotility and antiemetic drugs Loperamide and similar agents are contraindicated in young children: they slow transit while fluid continues to be secreted into the gut, causing deceptive improvement, abdominal distension, ileus and, in some infections, prolonged carriage or toxic dilatation. They have caused deaths in infants. Routine antiemetics are also not recommended in this age group; ondansetron is reserved for persistent vomiting that prevents oral rehydration, and even then only a single weight-based dose under medical orders with continued oral rehydration.
What to say instead
- The stool will not stop immediately; the aim is to replace what is lost so the child does not dehydrate.
- Continue feeding and breastfeeding - withholding food prolongs diarrhoea.
- Avoid diluted soft drinks, fruit drinks and sweetened fluids: their high sugar and low sodium content worsens osmotic diarrhoea, which is exactly what the mango drink has been doing.
- Return immediately if there is blood in the stool, repeated vomiting, inability to drink, or no urine.
3. What findings at the 4-hour review would tell you the child has deteriorated, and how would you manage that?
Read the worked answer
Reassess the same four signs plus general condition
Improved (move to Plan A, home care) - eyes normal, drinks normally, skin pinch returns quickly, passing urine, mother confident and able to give oral rehydration salt at home after each loose stool (about 50–100 mL for this age), with zinc continued for 14 days.
Still some dehydration - repeat Plan B for another 4 hours and look for a reason: wrong mixing of the solution, too little offered, or continuing losses exceeding intake.
Severe dehydration, i.e. deterioration - any of: lethargy or unconsciousness, inability to drink or drinking poorly, a skin pinch returning very slowly (over 2 seconds), sunken eyes becoming more marked, weak or absent pulse, cold mottled extremities, deep acidotic breathing, or no urine. Persistent vomiting preventing oral intake is also an indication to change plan.
Management of severe dehydration (Plan C)
- Start intravenous Ringer's lactate immediately, 100 mL/kg total: for this child 270 mL in the first 30 minutes (30 mL/kg; the 1-hour rate applies to infants under 12 months) and 630 mL over the next 2.5 hours (70 mL/kg), reassessing every 15–30 minutes.
- Give oral rehydration salt as soon as the child can drink, alongside the drip.
- Monitor pulse, respirations, level of consciousness, urine output and weight; watch for over-hydration once urine is passed.
- Because the smallest nasogastric tubes are unavailable, do not attempt unskilled nasogastric rehydration - use the intravenous route and refer if intravenous access cannot be secured.
- Refer to the next level if there is no improvement within the first hour, or if there is altered consciousness, convulsions or suspected sepsis.