A 200 ml Glass of ORS: Dehydration Plan and a Wrong Dilution
A 20-month-old boy weighing 8.5 kg is brought to an Anganwadi centre with watery diarrhoea for three days, about 8–10 stools a day, and two episodes of vomiting. He is restless and thirsty, drinks eagerly from a glass, has sunken eyes and no tears when crying; his mouth is dry, and the skin pinch on the abdomen goes back slowly. He has passed urine three times in the last 24 hours. His mid-upper-arm circumference is 12.5 cm. The mother has brought one ORS packet, which the health worker sees is meant for 1 litre, but she has already dissolved the whole packet in a 200 ml glass of water and is offering it to the child. She also has a bottle of orange soft drink and a loperamide tablet bought from the village shop. The tube well is 300 m away, and the family stores water in a covered pitcher at home.
1. Assess the dehydration, name the plan, and calculate how much ORS he needs over the next 4 hours. Show your working.
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Assessment: he has some dehydration. He shows two or more of the signs: restlessness and thirst with eager drinking, sunken eyes, no tears, dry mouth, and a slow skin pinch. He is not in severe dehydration - he is conscious, able to drink, and has passed urine three times, though less than usual.
Plan: Plan B - oral rehydration with ORS under supervision for 4 hours, then reassess.
Calculation: Plan B uses 75 mL per kg over 4 hours.
- 8.5 kg × 75 mL = 637.5 mL, i.e. about 640 mL in 4 hours.
- That is roughly 160 mL each hour, given by cup and spoon in small frequent sips - about a teaspoon every 1–2 minutes.
Practical points:
- If he vomits, stop for 10 minutes and then resume more slowly; vomiting is not a reason to stop ORS.
- Continue breastfeeding between ORS sips.
- Reassess at 4 hours: if the eyes are still sunken, the skin pinch still slow, or he cannot drink, refer for intravenous fluids.
- Show the mother how to count the sips, and keep a written tally of what goes in and what comes out.
2. What is wrong with the 200 ml solution and with the other items the mother has, and how would you correct them in front of her?
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The 200 ml glass: the packet is made for 1 litre, so dissolving it in 200 mL makes the solution about five times too concentrated. Strong ORS draws water out of the body instead of putting it in, and can cause hypernatraemia, irritability, seizures and worse diarrhoea. It must be thrown away, not diluted "roughly" afterwards.
The soft drink: it has too much sugar and too little sodium, so it does not replace the salts lost in stool and can worsen the osmotic diarrhoea. The loperamide tablet is dangerous in a small child - it slows the gut, traps fluid and toxin, and can cause drowsiness and ileus.
Teaching in front of the mother:
- Wash hands with soap; take 1 litre of clean water (boiled and cooled if possible).
- Empty the whole packet into it and stir until dissolved - no sugar or salt added.
- Cover it and use within 24 hours; make a fresh batch after that, and discard if it looks cloudy.
- Give by cup and spoon, not by bottle.
Also give zinc - 20 mg daily for 14 days for a child over 6 months - and continue feeding. Antibiotics and antidiarrhoeals are not routine for watery diarrhoea. Explaining why the strong solution harms him is what stops her repeating it at home.
3. The MUAC is 12.5 cm. Interpret it and state the follow-up you would arrange, including the danger signs to teach the family.
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Interpretation: mid-upper-arm circumference is measured on the left arm, midway between shoulder and elbow, with the tape snug but not pinching. A MUAC below 11.5 cm indicates severe acute malnutrition; 11.5 to 12.5 cm suggests moderate acute malnutrition. At 12.5 cm he sits right on the boundary, so he is not severely wasted but is at risk, especially with three days of diarrhoea and poor intake.
Follow-up:
- Re-measure MUAC and weight after rehydration, when the child is not dehydrated; dehydration flatters the measurement.
- Refer to the Anganwadi worker for growth monitoring and supplementary nutrition; advise energy-dense home food and continued breastfeeding.
- Review in 3–5 days, and again at 14 days after the diarrhoea episode.
- Check immunisation and give vitamin A if due.
Danger signs to teach the family - return at once if any appear:
- Passing no urine for many hours, or very dark urine.
- Sunken eyes that do not improve, or the child becoming drowsy and difficult to wake.
- Unable to drink or breastfeed, or vomiting everything.
- Blood in the stool, high fever, or fast breathing.
Reasoning: MUAC is a screening tool, not a diagnosis, so borderline values must be confirmed with weight-for-height and a repeat measurement rather than labelled on one reading.