Severe dehydration in a 13-month-old in winter
A 13-month-old boy is brought to the soum health centre in February with 3 days of watery diarrhoea and repeated vomiting. He has been breastfed less often because the mother is ill. He weighs 8.0 kg; his weight 2 months ago was 9.0 kg. He is lethargic, with sunken eyes, no tears, a dry mouth and a skin pinch that returns after 3 seconds. Capillary refill is 4 seconds, pulse 160/min, respirations 42/min, temperature 37.9°C. The mother says he has passed no urine for 12 hours. He responds to voice but is drowsy. The soum has 500 mL bags of Ringer's lactate, nasogastric tubes, ORS sachets, zinc dispersible tablets 20 mg, and intravenous ceftriaxone. There is no paediatric intensive care; the aimag hospital is 2.5 hours away by ambulance. The mother is worried and asks whether he needs an injection.
1. Classify the dehydration, state whether shock is present, and write the Plan C fluid regimen with volumes and timing for this child.
Read the worked answer
Classification: severe dehydration with signs of shock - lethargy, sunken eyes, skin pinch 3 seconds, capillary refill 4 seconds, pulse 160/min, no urine for 12 hours. This is more than simple severe dehydration; he has compromised circulation and needs intravenous fluids immediately.
Plan C for a child aged 12 months or older:
- First 30 minutes: 30 mL/kg = 240 mL of Ringer's lactate as a rapid IV infusion.
- Next 2.5 hours: 70 mL/kg = 560 mL of Ringer's lactate.
- Total: 800 mL over 3 hours.
Reassess every 15–30 minutes. If the pulse slows, capillary refill improves and he becomes more alert, continue. If he is still shocked after the first bolus, repeat 20 mL/kg and reassess; do not simply run all fluid at a fixed rate without looking at the child.
If IV access fails, use the intraosseous route if trained and equipped; otherwise give ORS by nasogastric tube at 20 mL/kg/hour for 6 hours while arranging urgent transfer. Do not give oral fluids to a drowsy child who cannot swallow safely.
After rehydration, switch to ORS and continue breastfeeding. The mother's question about an injection should be answered honestly: the injection is fluid, not an antibiotic, and it is needed because he is shocked.
2. Which additional treatments will you give and which will you withhold? Justify each.
Read the worked answer
Give zinc: 20 mg dispersible tablet once daily for 10–14 days. Zinc shortens the duration and severity of diarrhoea and reduces recurrence. This child is over 6 months, so 20 mg is correct.
Give ORS: once he can drink, give 5 mL after each loose stool and continue breastfeeding. ORS is the main treatment for diarrhoea; the IV fluid is only for the shock phase.
Give ceftriaxone only if there is a specific indication, such as bloody diarrhoea, suspected cholera with severe dehydration, or another confirmed bacterial infection. Watery diarrhoea without blood does not routinely need antibiotics, and unnecessary ceftriaxone promotes resistance.
Withhold antidiarrhoeal drugs such as loperamide; they are dangerous in children and do not treat dehydration.
Withhold routine antiemetics unless vomiting prevents oral rehydration; if needed, use a single dose of ondansetron where available, but never as a substitute for fluids.
Do not give hypotonic fluids such as 5% glucose alone for resuscitation; they do not restore circulating volume and can cause hyponatraemia.
Continue feeding. Withholding food prolongs diarrhoea and worsens malnutrition.
3. What findings at reassessment would make you refer urgently, and how would you prepare the child for transfer?
Read the worked answer
Refer urgently if:
- Shock persists after 1–2 fluid boluses (pulse remains above 160/min, capillary refill over 4 seconds, cold extremities).
- Consciousness deteriorates, or he has a seizure.
- Breathing becomes fast or laboured, suggesting pneumonia or acidosis.
- He develops bilious vomiting, abdominal distension or absent bowel sounds - possible surgical abdomen or ileus.
- Urine output remains absent after rehydration.
- He cannot tolerate ORS and IV access is lost.
Preparation for transfer: keep the IV line secure, continue Ringer's lactate at the prescribed rate, and monitor pulse, respirations, temperature and urine output. Keep him warm - a wet, cold child deteriorates quickly in February. Give oxygen if SpO2 is below 90%. Send the mother with a referral note stating weight, fluid given, urine output, stool frequency and any drugs given. Arrange a nasogastric tube if he is vomiting and cannot take ORS. The ambulance should carry ORS, Ringer's lactate and a suction device. Document the time of transfer and the receiving hospital.