Severe dehydration in an oedematous 14-month-old: why the standard Plan C arithmetic is wrong here
Master A, 14 months old, weighs 8.6 kg, and is brought to the PHC on a Monday morning with watery stools 10 to 12 times a day for three days, vomiting after feeds, and no urine for 10 hours. He is lethargic, with sunken eyes, a skin pinch that takes 3 seconds to retract, and capillary refill of 4 seconds. His mother says he has been drinking poorly. Temperature 38.1 °C, pulse 150/min, respiratory rate 46/min. Mid-upper arm circumference is 11.9 cm and there is bilateral pitting pedal oedema. The medical officer is away at a district meeting; an ANM and one staff nurse are on duty. The PHC stocks Ringer's lactate, 5% dextrose, normal saline, ORS packets, zinc tablets and injectable ceftriaxone, but has no paediatric intensive care, and arranging the ambulance to the district hospital takes 90 minutes. The mother is frightened and wants to take the child home after 'one bottle of glucose'.
1. Classify his hydration status and nutritional status, justifying each conclusion from the findings.
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Hydration: severe dehydration. WHO uses four signs - lethargy or unconsciousness, sunken eyes, inability to drink or poor drinking, and a skin pinch returning very slowly (2 seconds or more). Two or more of these indicate severe dehydration. He has all four, plus capillary refill of 4 seconds, pulse 150/min and no urine for 10 hours, which together amount to compensated-to-decompensating shock. He needs intravenous fluid now, not oral trial.
Nutrition: severe acute malnutrition, on the strength of the oedema. This is the trap in the question. A MUAC of 11.9 cm is below the 12.5 cm cut-off used for community screening but is not below the 11.5 cm SAM threshold. If you stopped there you would call him moderate malnutrition. However, bilateral pitting pedal oedema of nutritional origin classifies a child as SAM with kwashiorkor-type oedematous malnutrition irrespective of MUAC or weight-for-height. The oedema also means his true lean mass is lower than 8.6 kg suggests.
That single conclusion changes everything that follows: fluid volumes, fluid composition, feeding and even how the fluids are monitored.
2. Calculate the first-hour fluid plan with your working. Explain why the usual WHO Plan C regimen is unsafe in this child, and what you would monitor during the infusion.
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Working: the standard Plan C for severe dehydration is 100 mL/kg over 3 hours, giving 30 mL/kg in the first hour (8.6 × 30 = 258 mL) and 70 mL/kg over the next two hours (about 602 mL), total 860 mL. In SAM with oedema, that volume and rate are hazardous: these children have reduced myocardial reserve, low albumin with altered oncotic pressure, and impaired sodium handling, so rapid rehydration precipitates fluid overload and heart failure.
Therefore: give 15 mL/kg over the first hour - 8.6 × 15 = 129 mL - of Ringer's lactate with 5% dextrose (half-strength Darrow's with 5% dextrose is an alternative). Reassess every 10 to 15 minutes.
- If he improves (pulse and respiratory rate fall, capillary refill shortens, he becomes more alert, urine appears): repeat 15 mL/kg over the second hour, then move to oral ReSoMal in small frequent amounts.
- If he does not improve: treat as septic shock - oxygen, blood culture, ceftriaxone, and whole blood 10 mL/kg over 3 hours if available, and transfer.
Stop or slow the infusion for: rising pulse or respiratory rate, enlarging liver, new periorbital puffiness, basal crepitations, or a gallop rhythm.
3. The mother wants to leave after 'one bottle of glucose'. How do you handle this, and what is the feeding, zinc and follow-up plan?
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Handling the mother: her fear is reasonable and her request is not. A bottle of glucose is water and sugar, not treatment: it will not reverse shock and it may worsen hyponatraemia. Do not argue abstractly. Let her stay beside the child, involve her in counting drips and holding the cup, and explain in her own language what each sign (urine, alertness) means. Be explicit that leaving now could kill him, and state that the staff will not let him go unattended. Document the counselling. Do not physically restrain her; escalate to the ANM or medical officer if she insists.
Plan:
- Ceftriaxone as prescribed - children with SAM and severe dehydration are treated for presumed systemic infection.
- Zinc 20 mg daily for 14 days (the dose for a child over 6 months).
- Oral rehydration with ReSoMal once intravenous fluids are stopped, 5 to 10 mL/kg per loose stool, and continue breastfeeding if he is breastfed.
- F-75 at 100 mL/kg/day because oedema is present - 860 mL/day in 8 feeds of about 108 mL every 3 hours; start as soon as he can swallow, nasogastric if not. No iron and no high-protein formula during stabilisation.
- Discharge only after oedema is resolving and feeds are tolerated, with a follow-up date within 3 days, weekly growth monitoring, and clear return-danger signs: not feeding, convulsions, lethargy, fast breathing, blood in stool, repeated vomiting.