A 9 kg toddler with diarrhoea: calculating Plan B and resisting unnecessary drugs
A 14-month-old boy weighing 9 kg is brought to the OPD at 11 am with 3 days of watery diarrhoea (8–10 stools/day), vomiting twice this morning, and no urine for 8 hours. He is irritable but drinks eagerly when offered ORS. His eyes are sunken, the skin pinch on the abdomen goes back slowly, and his mouth is dry. Temperature 38.1°C, pulse 128/min, respiratory rate 34/min. The mother stopped breastfeeding yesterday because she thought milk was causing the diarrhoea; she has been giving plain water and one ORS packet made up correctly but only about 200 mL in total. There is no blood in the stool. The child has no neck stiffness, no convulsions, and no general danger sign. The health centre has ORS packets, zinc tablets, IV fluids and a referral link 30 minutes away.
1. Classify the dehydration and calculate the ORS volume for the first 4 hours. Show your calculation.
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This is some dehydration, not severe dehydration. He has two or more of the signs: sunken eyes, slow skin pinch, dry mouth, and he drinks eagerly. He is irritable rather than lethargic, has no convulsions, and is able to drink, so there is no severe dehydration and no immediate need for IV fluids.
Use Plan B: 75 mL/kg over 4 hours.
- 75 mL × 9 kg = 675 mL over 4 hours.
- That is about 170 mL per hour, or roughly 15–20 mL every 10–15 minutes by cup and spoon.
Give small, frequent amounts; if he vomits, wait 10 minutes and resume more slowly. Continue breastfeeding on demand throughout. Reassess at 4 hours: if dehydration signs persist, repeat Plan B; if he becomes unable to drink or worsens, start IV fluids and refer. The calculation matters because under-dosing leaves dehydration uncorrected and over-dosing by rapid IV bolus can cause harm.
2. Which common treatments should you avoid here, and why?
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Avoid antibiotics: there is no blood in the stool, no suspected cholera, and no systemic infection requiring them; unnecessary antibiotics promote resistance and do not shorten watery diarrhoea. Avoid loperamide and other antimotility drugs: in children they can cause ileus, drowsiness and death. Avoid an unnecessary IV line while the child can drink; IV fluids are for severe dehydration or failure of oral therapy. Do not stop breastfeeding; the mother's belief that milk causes diarrhoea is wrong and stopping milk removes fluid and energy. Do not give only plain water, because it does not replace sodium and glucose. Do not give a more concentrated ORS mix or a home-made solution with unknown salt content. Also avoid antipyretics purely for a low-grade fever if the child is comfortable; treat fever only if it causes distress.
3. What feeding and follow-up advice will you give, and what would make you refer immediately?
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Give zinc 20 mg daily for 14 days (he is over 6 months). Continue breastfeeding on demand and add small, frequent, energy-dense feeds such as rice, dal and mashed vegetables as soon as he accepts them; do not withhold food. Give ORS after each loose stool in addition to the Plan B volume. Teach the mother the signs that must bring her back: unable to drink or breastfeed, repeated vomiting, blood in stool, no urine for 8 hours, sunken eyes that worsen, fever that persists, convulsions, or unusual sleepiness. Refer immediately if any general danger sign appears, if he cannot drink, if the skin pinch becomes very slow, or if he deteriorates during the 4-hour observation. Document the weight, the calculated volume, the zinc start date and the return advice.