Tomas, Four Days of Diarrhoea and a Flooded Road
Maria brings her 14-month-old son Tomas to a rural clinic. For four days he has had watery stools, about eight a day, and vomited twice yesterday. He is still breastfeeding. Today he is restless and thirsty, his eyes look sunken, he cries without tears, his mouth is dry, and when the nurse pinches the skin of his abdomen it goes back slowly. He weighs 9,2 kg; his card shows he weighed 10,1 kg at 12 months. His immunisation card shows BCG, the 6-, 10- and 14-week doses, and measles at 9 months - nothing since. The clinic has oral rehydration salts but the zinc stock has run out. The nearest hospital is 45 km away and the road is flooded; the ambulance comes only when called by radio. Maria has one litre of boiled, cooled water in a bottle, a cup and a spoon.
1. Classify Tomas's dehydration and decide on the plan of action, justifying each step.
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Classification. The signs are: restless and thirsty, sunken eyes, no tears, dry mouth, and a skin pinch that goes back slowly. These are the classic signs of some dehydration (formerly 'moderate'). Severe dehydration would show lethargy or unconsciousness, inability to drink or poor drinking, and a very slow skin pinch, often with weak pulse and cold hands. He is not yet in that group, but he is close to it, and his weight has fallen from 10,1 kg to 9,2 kg - nearly 9% - which is a serious sign in a 14-month-old.
Plan of action:
- Start Plan B at the clinic immediately, before any decision about travel: oral rehydration salts given by cup and spoon, roughly 75 ml per kg over four hours, which is 9,2 × 75 ≈ 690 ml. Continue breastfeeding between sips.
- Reassess after four hours. If the eyes are less sunken, tears return, the child is passing urine and drinking normally, he can go home with ORS and clear instructions.
- Refer if vomiting stops him keeping any fluid down, if he becomes lethargic, if there is blood in the stool, if he passes no urine, or if the mother cannot manage at home. The flooded road makes early referral difficult, so the decision to move must be made early rather than late - call for the ambulance while treatment is running, not after he worsens.
- Record the zinc stock-out and arrange a supply from the health centre; zinc shortens the diarrhoea and reduces recurrence.
2. Show exactly how Maria should prepare and give the oral fluid, both with a sachet and without one, and explain why the measurements matter.
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With a sachet: read the instructions on that sachet, because sachets are made for different volumes (1 litre or 200 ml). For a 1-litre sachet, dissolve the whole sachet in 1 litre of clean water - the boiled, cooled water Maria has is ideal. Stir until fully dissolved; do not add sugar, salt or anything else, and do not use half a sachet in the same amount of water. Made-up solution keeps for 24 hours at most and should be thrown away after that.
Without a sachet - home-made solution: to 1 litre of clean water add 6 level teaspoons of sugar and 1 level teaspoon of salt. Stir until dissolved. It should taste no saltier than tears. Measuring matters: too little salt does not replace the sodium the child is losing, while too much salt can cause dangerous high sodium levels, especially in a small child, and too much sugar draws more water into the bowel and makes the diarrhoea worse.
How to give it: use a cup and spoon, not a bottle. Give 5–10 ml (about one or two teaspoons) every one to two minutes, small and often, because a large volume at once makes a child vomit. If he vomits, wait about ten minutes, then resume more slowly. Keep breastfeeding throughout - breast milk is a fluid, not a food to withhold.
Monitoring: count the wet nappies and watch the eyes, tears and mouth. If he will not drink, drinks poorly, or vomits everything, that is a reason to return at once.
3. Give the feeding, follow-up and immunisation advice Maria needs before she leaves the clinic.
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Feeding. Continue breastfeeding on demand, and give extra fluids after every loose stool - about 100 ml for a child of this age after each one. Do not stop other foods; offer soft, easily eaten meals more often than usual (porridge, mashed vegetables, egg) and one extra meal a day for two weeks after the diarrhoea stops, to catch up on the weight lost. Avoid sweet drinks, undiluted juice and fizzy drinks, which pull water into the bowel and worsen diarrhoea. Ask about zinc - 20 mg a day for 10–14 days - from the health centre when stock arrives.
Follow-up. Weigh Tomas again in one week and plot the weight; a child who has not regained weight needs review. Emphasise the weight loss from 10,1 kg to 9,2 kg so the mother understands why the follow-up matters.
Danger signs - return immediately if the child: cannot drink or feed, becomes more ill or sleepy, has blood in the stool, passes no urine for six hours, has sunken eyes or a dry mouth again, or develops a high fever.
Prevention and immunisation. Handwashing with soap after the latrine and before feeding; safe storage of drinking water in a covered container; safe disposal of stools; exclusive attention to food hygiene. His card shows nothing since measles at 9 months, so he is due for the second measles dose at 18 months and should be checked against the schedule now - measles and diarrhoea together are a dangerous combination, and a missed immunisation is easy to fix today.