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Table 14.1 - Assessment of dehydration, adapted from WHO aCitation a.World Health Organization. Pocket book of hospital care for children: Guidelines for the management of common illnesses. 2nd ed. Geneva : World Health Organization; 2013.
Clinical features (2 or more of the following signs) | Classification | ||
A | B | C | |
| Mental status | Normal | Restless, irritability | Lethargic or unconscious |
| Eyes | Normal | Sunken (a)Citation a.Sunken eyes may be a normal feature in some children. Ask the parent/carer if the child's eyes are the same as usual or if they are more sunken than usual. | Sunken (a)Citation a.Sunken eyes may be a normal feature in some children. Ask the parent/carer if the child's eyes are the same as usual or if they are more sunken than usual. |
| Skin pinch | < 1 second | Goes back slowly | Goes back very slowly (> 2 seconds) |
| Thirst | No thirst, drinks normally | Thirsty, drinks eagerly | Unable to drink or drinks poorly |
| Urine output | Normal | Reduced | Absent for several hours |
Children with no dehydration do not require admission.
Most children with some dehydration can be managed at home after an initial period of observation (4 to 6 hours) to ensure that they are able to tolerate adequate oral rehydration treatment.
Admit:
- All children with severe dehydration.
- Children < 4 months of age and/or < 4 kg weight with some dehydration.
- Children with some dehydration if there is no possibility for short-term observation while starting rehydration treatment.
Important: always reassess the child’s hydration and clinical condition regularly – clinical improvement is the best indicator of treatment response.
Treatment Plan A (no dehydration): treat diarrhoea at home
Rule 1 - Give the child more fluids than usual, to prevent dehydration
- Encourage
- Breastfeeding
- Frequent drinking: oral rehydration salts (ORS), salted drinks (e.g. salted rice water,
soup etc.)
- Give the child as much liquid as they want until diarrhoea stops. Use the amounts shown below for ORS as a guide. Describe and show the amount to be given after each stool is passed, using a local measure.
| Weight (kg) | < 5 | 5 to < 10 | 10 to 20 | > 20 |
| ORS (mL) to be given after each loose stool | 50 | 100 | 200 | 300 |
| Quantity of ORS to provide for home treatment/day | 1 | 1 | 2 | 4 |
- Show the parent/carer how to prepare ORS and how to give it.
- Give a teaspoonful every 1-2 minutes to children under 2 years. Do not use a baby bottle.
- Give frequent sips from a cup for older children.
- If the child vomits, wait 10 minutes. Then give the solution more slowly (e.g. a spoonful every 2-3 minutes).
- If diarrhoea continues after the ORS sachets are used up, tell the parent/carer to give other fluids as described above or to return for more sachets of ORS. If symptoms persist for more than 48 hours, take the child for consultation.
Rule 2 - Continue to feed the child, to prevent malnutrition
- Breastfeeding should always be continued.
- The infantʹs usual diet should be continued during diarrhoea and increased afterwards.
- Most children with watery diarrhoea regain their appetite after dehydration is corrected.
- Milk:
- Infants of any age who are breastfed should be allowed to breast-feed as often and
as long as they want. Infants will often breastfeed more than usual, encourage this. Infants who are not breastfed, should be given their usual milk feed (formula) at least
every three hours, if possible by cup.
- Children aged 6 months and over or who are already taking soft foods should be given cereals, vegetables and other foods, in addition to milk. If the child is over 6 months and such foods are not yet being given, they should be started during the diarrhoea episode or soon after it stops.
- Foods rich in potassium, such as bananas, coconut milk and fresh fruit juice are beneficial
- Offer the child food every three or four hours (six times daily)
- Infants of any age who are breastfed should be allowed to breast-feed as often and
Rule 3 - Take the child to a health worker if there are signs of dehydration or other problems
The parent/carer should take the child to a health worker if the child:
- Starts to pass many watery stools
- Vomits repeatedly
- Becomes very thirsty
- Is eating or drinking very poorly
- Develops a fever
- Has blood in the stool; or
- Does not get better in three days
Treatment Plan B (some dehydration): oral rehydration treatment
If breastfeeding, encourage continuation if the child is keen and alert.
Prescribe ORS 75 mL/kg over 4 hours:
| Weight (kg) | < 6 | 6 to < 10 | 10 to < 12 | 12 to < 19 | 19 to < 30 |
| Total ORS (mL) over 4 hours | 200-400 | 400-700 | 700-900 | 900-1400 | 1400-2200 |
| Volume of ORS per hour (mL/hr) | 50-100 | 100-175 | 175-225 | 225-350 | 350-550 |
How to give ORS
- Show the parent/carer how to give ORS in small, frequent quantities e.g. using a teaspoon or syringe for infants and young children (5 mL every 5 minutes), or regular sips from a cup for older children.
- If child vomits ORS, wait a few minutes (5 min) and encourage child to take smaller
volumes or sips. - In addition to rehydration with treatment plan B, give extra ORS to replace fluids lost with each loose stool according to plan A (above).
- If the child’s eyelids become puffy: stop ORS, reduce liquid intake and continue breastfeeding. Weigh the child and monitor urine output.
How to monitor the progress of oral rehydration treatment
- Check the child frequently during rehydration.
- Ensure that ORS solution is being taken correctly and the signs of dehydration are not worsening.
- After four hours, reassess the child following the guidelines in Table 1 and decide appropriate treatment plan.
- If there are no signs of dehydration, consider the child completed rehydrated. Show the parent/carer how to treat the child at home with ORS and food following treatment plan A. Give them enough sachets of ORS for 2 days.
- Also explain to the parent/carer how to reassess for signs of dehydration and when to take the child to see a health worker (see Plan A).
Giving food
- Except for breast milk, food should not be given during the initial four-hour rehydration period.
- Children on Treatment Plan B longer than four hours should be given some food every 3-4 hours as described in Treatment Plan A.
- All children over 6 months should be given some food before being sent home. This helps to emphasize to parents/carers the importance of continued feeding during diarrhoea.
Treatment Plan C: severe dehydration, rehydration by IV route
- Obtain IV or IO access.
- Mark liver border with pen.
- Administer IV Ringer lactate (RL) (or alternatively sodium chloride 0.9% if RL not available) according to the following table:
| Age | First administer 30 mL/kg (b)Citation b.Repeat this volume if radial pulse remains weak or absent. over: | Then administer 70 mL/kg over: |
| < 12 months | 1 hour | 5 hours |
| ≥ 12 months | 30 minutes | 2½ hours |
- Monitor urine output.
- Test blood glucose levels and treat hypoglycaemia if present.
- Check Hb and blood electrolytes (where available) and treat anaemia if present.
- Monitor and record signs of dehydration and vital signs every 15 to 30 minutes until they are stable for at least an hour.
- Monitor continuously for signs of fluid overload:
- Increased RR by ≥ 10 breaths/min from initial RR, or
- Increased HR by ≥ 20 beats/min from initial HR.
Plus any one of the following:
New or worsening hypoxia (decrease in SpO2 by > 5%)
New onset of rales and/or pulmonary oedema (fine crackles in lung fields)
New galloping heart rhythm
Increased liver size (liver size must have been marked with pen on arrival)
New peripheral oedema and/or puffy eyelids
Management if signs of fluid overload present:
- Stop IV fluids.
- Administer furosemide IV: 0.5 mg/kg (repeat once if necessary).
- Place child into semi-sitting position and ensure high-flow oxygen via non-rebreathing mask
- If the child’s condition is not improving, re-evaluate, consider other differential diagnoses (e.g. diabetic ketoacidosis, shock, sepsis), assess fluid losses and increase the rate of IV fluids accordingly.
- As soon as the child is awake, alert, and can tolerate a nasogastric tube (NGT) or take
oral fluids:- Start ORS at 5 mL/kg/hour in addition to the ongoing IV fluid resuscitation and encourage breastfeeding (if relevant). In addition, if tolerated, give extra ORS to replace fluids lost with each loose stool according to plan A.
- Assess the degree of dehydration at the end of the fluid resuscitation (3 hours for children, 6 hours for infants). Continue further rehydration according to degree of dehydration following the appropriate treatment plan (A, B or C).
- If hypokalaemia or, where potassium monitoring not available, if child develops signs of hypokalaemia including general fatigue, muscle cramps and weakness, abdominal distension and polyuria, treat for moderate hypokalaemia with 7.5% potassium chloride syrup (1 mmol of K+/mL) for 2 days:
- < 45 kg : 2 mmol/kg (2 mL/kg) daily
- ≥ 45 kg : 30 mmol (30 mL) 3 times daily
Note: children with severe acute malnutrition (SAM)
Dehydration is difficult to assess clinically in severely malnourished children because malnutrition may mask signs of dehydration or cause over-diagnosis of severe dehydration:
- Signs of hypovolaemia or circulatory impairment can be masked by oedema.
- Skin pinch assessment has no value if the subcutaneous tissue has completely disappeared
because the persistent and doughy character applies to this subcutaneous tissue (deep
pinch). - Sunken eyes can be present without dehydration.
Therefore, to diagnose dehydration and assess for severity in children with SAM, the following criteria are more reliable.
Clinical features (Two or more of the | Classification | ||
No dehydratation | Dehydratation | Severe dehydratation | |
Mental status | Normal | Restless, irritability | Lethargic or unconscious |
Thirst | No thirst, drinks normally | Thirsty, drinks eagerly | Unable to drink |
Urine output | Normal | Reduced | Absent for several hours |
Recent frequent watery diarrhoea and/or vomiting | Yes | Yes | Yes |
Recent obvious rapid weight loss | No | Yes | Yes |
In the case of SAM, the specific rehydration treatment is based on ReSoMal® PO.
- (a)
World Health Organization. Pocket book of hospital care for children: Guidelines for the management of common illnesses. 2nd ed. Geneva : World Health Organization; 2013.