Paediatric Dehydration and Malnutrition
A 14-month-old boy is brought to a primary health care clinic in the mountains of Lesotho with a 3-day history of watery diarrhoea (8–10 times per day) and vomiting. He is lethargic, has sunken eyes, and a skin pinch goes back very slowly. His weight is 8.2 kg (below the 3rd percentile for age). He is not able to drink or breastfeed. The clinic has oral rehydration salts (ORS) and intravenous fluids (Ringer's lactate and normal saline), but no nasogastric tubes. The nearest hospital is 2 hours away by road, and transport is not immediately available. The nurse is the only health worker present.
1. Classify the child's dehydration according to WHO guidelines and outline the immediate management plan.
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The child has severe dehydration based on: lethargy, sunken eyes, very slow skin pinch, inability to drink or breastfeed, and vomiting. According to WHO, severe dehydration requires Plan C: intravenous rehydration. The nurse should:
- Start IV Ringer's lactate (or normal saline) immediately: 100 mL/kg over 3 hours (for infants under 12 months) or 30 mL/kg in the first hour, then 70 mL/kg over 5 hours (for children over 12 months). This child is 14 months, so give 30 mL/kg (246 mL) in the first hour, then 70 mL/kg (574 mL) over the next 5 hours.
- Reassess every 15–30 minutes for signs of overhydration or improvement.
- Give ORS by mouth as soon as the child can drink, to replace ongoing losses (5–10 mL/kg after each loose stool).
- Give zinc supplementation (20 mg daily for 14 days) as soon as possible.
- Continue breastfeeding if the child is able.
- Monitor for hypoglycemia – check blood glucose if possible and treat with 10% dextrose if low.
- Arrange urgent referral to the hospital for further management of severe malnutrition and dehydration, as the child may need nasogastric feeding and monitoring for complications.
Rationale: Severe dehydration is a life-threatening emergency. IV fluids are the fastest way to restore circulation. Zinc reduces duration and severity of diarrhoea. Malnutrition increases the risk of complications and mortality, so referral is essential.
2. The child's mother asks why he cannot just be given ORS by mouth. How should the nurse respond, and what are the dangers of oral rehydration in this case?
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The nurse should explain that the child is too weak to drink and is vomiting, so oral fluids alone would not be absorbed quickly enough to reverse severe dehydration. ORS is lifesaving for mild to moderate dehydration, but in severe dehydration the gut may not absorb fluids effectively, and vomiting prevents adequate intake. Intravenous fluids are needed to quickly restore blood volume and prevent shock.
The dangers of attempting oral rehydration in this child include:
- Aspiration due to lethargy and inability to swallow.
- Continued fluid loss and progression to shock.
- Electrolyte imbalance if fluids are not adequately replaced.
However, once the child's condition improves and he can drink, ORS should be given to replace ongoing losses. The nurse should also teach the mother how to prepare and give ORS at home to prevent future episodes.