Appendix 2. Assessment and treatment of diarrhoea

a - Evaluation of dehydration (adapted from the WHO)

Mental status

Normal, awake

Agitated, irritable

Lethargic or unconscious

Radial pulse

Easily palpable

Palpable (possibly rapid)

Difficult to palpate (weak) or absent

Eyes

Normal

Sunken

Sunken

Skin pinch

Disappears rapidly

Disappears slowly (< 2 seconds)

Disappears very slowly (> 2 seconds)

Thirst

Drinks normally

Thirsty, drinks avidly

Incapable or drinks very little


DIAGNOSIS

 ↓
NO DEHYDRATION

 ↓
SOME DEHYDRATION

 ↓
SEVERE DEHYDRATION

Notes:
– Sunken eyes are a sign of dehydration (loss of soft tissue volume causing eyes to sink into their orbits) but may be a normal feature in some children.
Ask the mother if the child’s eyes are the same as usual or are more sunken than usual.
– Skin pinch: this test evaluates the loss of skin elasticity due to a decrease in water content. The slower the skin pinch disappears, the greater the degree of dehydration.
Skin pinch is assessed by pinching the skin of the abdomen between the thumb and forefinger, without twisting. In the elderly, this sign is not as reliable, as normal aging diminishes skin elasticity. In these patients, checking skin pinch can be done on the chest below the clavicle.
– Thirst is not always a good indicator of dehydration. Severely dehydrated patients and the elderly may not feel thirsty, even in the presence of clear signs of dehydration. The objective is to determine if the patient is able to drink, rather than the level of thirst. If the patient drinks normally or avidly, then oral rehydration is indicated and is likely to succeed. Those who have difficulty drinking will require close surveillance as they risk failing oral therapy, necessitating a change in protocol (e.g. switching to IV rehydration).

b - Prevention of dehydration in children and adults (ORS, Plan A)

Administer oral rehydration solution (ORS) after each loose stool, until diarrhoea ceases, as below: 

Age

Amount of ORS

Under 2 years

50-100 ml (10 to 20 teaspoons) after each loose stool

2 to 10 years

100-200 ml (½ to 1 glass) after each loose stool

Over 10 years

at least 200-250 ml (at least 1 glass) after each loose stool

c - Treatment of some dehydration in children and adults (ORS, Plan B) 

Weight

Age

Total volume of ORS

Volume of ORS per hour

3 to < 4 kg

0 to < 1 month

230 ml

60 ml per hour for 4 hours

4 to < 5 kg

1 to < 2 months

300 ml

75 ml per hour for 4 hours

5 to < 6 kg

2 to < 3 months

400 ml

100 ml per hour for 4 hours

6 to < 7 kg

3 to < 4 months

480 ml

120 ml per hour for 4 hours

7 to < 8 kg

4 to < 7 months

550 ml

140 ml per hour for 4 hours

8 to < 9 kg

7 to < 10 months

600 ml

150 ml per hour for 4 hours

9 to < 10 kg

10 to < 12 months

700 ml

180 ml per hour for 4 hours

10 to < 13 kg

1 to < 2 years

800 ml

200 ml per hour for 4 hours

13 to < 15 kg

2 to < 3 years

1000 ml

250 ml per hour for 4 hours

15 to < 17 kg

3 to < 4 years

1200 ml

300 ml per hour for 4 hours

17 to < 19 kg

4 to < 5 years

1400 ml

350 ml per hour for 4 hours

19 to < 21 kg

5 to < 6 years

1600 ml

400 ml per hour for 4 hours

21 to < 24 kg

6 to < 7 years

1600 ml

400 ml per hour for 4 hours

24 to < 27 kg

7 to < 8 years

1800 ml

450 ml per hour for 4 hours

27 to < 30 kg

8 to < 9 years

2000 ml

500 ml per hour for 4 hours

30 to < 32 kg

9 to < 10 years

2200 ml

550 ml per hour for 4 hours

32 to < 35 kg

10 to < 11 years

2400 ml

600 ml per hour for 4 hours

35 to < 39 kg

11 to < 12 years

2800 ml

700 ml per hour for 4 hours

39 to < 44 kg

12 to < 13 years

3200 ml

800 ml per hour for 4 hours

44 to < 50 kg

13 to < 14 years

3600 ml

900 ml per hour for 4 hours

≥ 50 kg

≥ 14 years

4000 ml

1000 ml per hour for 4 hours

≥ 75 kg


6000 ml

1500 ml per hour for 4 hours

 If the patient wants to drink more than prescribed, give more ORS.