Severe Dehydration in a 2-Year-Old With Acute Watery Diarrhoea
A 2-year-old girl weighing 10 kg is brought to the subcenter by her mother with a three-day history of acute watery diarrhoea, about eight stools per day, and vomiting after feeds. She weighed 11 kg three days ago. The child is lethargic, her eyes are sunken, she does not take the ORS cup when offered, and her mucous membranes are dry. A skin pinch on the abdomen goes back slowly, taking about 3 seconds. Her pulse is 130/min, respiratory rate 34/min, temperature 37.8°C, and capillary refill is 4 seconds. Her mother says there is no blood in the stool and the child has passed urine once since morning. Home ORS was prepared but the child refused it. The subcenter has IV Ringer lactate, ORS packets, zinc tablets, and a referral link to the district hospital 18 km away.
1. Classify the dehydration using WHO criteria and justify your classification with the specific findings in this child.
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Using WHO criteria, she has severe dehydration. Severe dehydration requires two or more of: lethargy or unconsciousness, sunken eyes, inability to drink or poor drinking, and a skin pinch returning very slowly (more than 2 seconds). She meets all four: she is lethargic, her eyes are sunken, she refuses the ORS cup, and the skin pinch takes about 3 seconds. The 1 kg weight loss, about 9% of body weight, supports a significant fluid deficit, and urine output is reduced. There is no blood in the stool, so dysentery is not the current picture. Capillary refill of 4 seconds and a pulse of 130/min indicate poor peripheral perfusion. She needs urgent IV rehydration, not home ORS alone.
2. Calculate and describe the fluid plan for this child, including the type, volume, and rate of fluid.
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For a child aged 2 years with severe dehydration, WHO Plan C is indicated. Give Ringer lactate 100 mL/kg total: 30 mL/kg (300 mL) in the first 30 minutes, then 70 mL/kg (700 mL) over the next 2.5 hours. That is approximately 300 mL in the first 30 minutes and about 280 mL/hr for the remaining 2.5 hours, using a burette or infusion pump if available. Reassess every 15–30 minutes: pulse, respiratory rate, capillary refill, skin pinch, eyes, mental status, and urine output. If IV access fails, use the intraosseous route or arrange urgent referral. Start zinc 20 mg daily for 14 days once vomiting settles, continue breastfeeding, and restart ORS between IV fluids as tolerated.
3. What nursing monitoring and referral decision would you make for this child?
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Monitor for overhydration-rising respiratory rate, basal crackles, puffy eyelids, and a full neck vein-especially when the child begins drinking. Watch for hypoglycaemia and hypokalaemia; check blood glucose at the start. If she develops convulsions, stop the infusion, check glucose and sodium, and manage according to protocol. Refer to the district hospital if she remains lethargic after the first hour, cannot drink after 3–4 hours, has persistent vomiting, or develops abdominal distension. Because the facility is 18 km away, arrange referral before evening if there is no clear improvement rather than waiting overnight. Document intake, output, and the time of each reassessment.