DEHYDRATION IN CHILDREN UNDER FIVE YEARS

Assess degree of dehydration following the table below.

Clinical features of dehydration in children

SIGNS DEGREE OF DEHYDRATION
NONE SOME SEVERE
General
condition
Well, alert Restless,
irritable
Lethargic,
drowsy or
unconscious
Eyes Not sunken Sunken Sunken
Fontanel Not sunken Sunken Sunken
Ability
to drink
Drinks
normally
Drinks
eagerly,
thirsty
Drinks poorly
or not able to
drink
Skin pinch Goes back
immediately
Goes back
slowly;
<2 seconds
Goes back
very slowly;
>2 seconds
Treatment Plan A Plan B Plan C

Management

Plan A (No dehydration and for prevention)

  • Counsel the mother on the 4 rules of home treatment: extra fluids (ORS), continue feeding, zinc supplementation, when to return
  • Give extra fluids: as much as the child will take
    • If child exclusively breastfed, give ORS or safe clean water in addition to breast milk
    • If child not exclusively breastfed, give one or more of: ORS, soup, rice-water, yoghurt, clean water
    • In addition to the usual fluid intake, give ORS after each loose stool or episode of vomiting
      Child <2 years: 50-100 ml
      Child 2-5 years: 100-200 ml
    • Give the mother 2 packets to use at home
    • Giving ORS is especially important if the child has been treated with Plan B or Plan C during current visit
    • Give frequent small sips from a cup
  • Advice the mother to continue or increase breastfeeding
    If child vomits, wait 10 minutes, then give more slowly
  • In a child with high fever or respiratory distress, give plenty of fluids to counter the increased fluid losses in these conditions
  • Continue giving extra fluid as well as ORS until the diarrhoea or other cause of dehydration stops
  • If diarrhoea, give Zinc supplementation
    Child <6 months: 10 mg once a day for 10 days
    Child >6 months: 20 mg once a day for 10 days

Plan B (Some dehydration)

  • Give ORS in the following approximate amounts during the first 4 hours
    AGE
    (MONTHS)
    <4 4–12 13–24 25–60
    Weight (kg) <6 6–9.9 10–11.9 12–19
    ORS (ml) 200–
    400
    400–
    700
    700–
    900
    900–
    1400
    • Only use child’s age if weight is not known
    • You can also calculate the approximate amount of
      ORS to give a child in the first 4 hours as weight
      (kg) x 75 ml
  • Show the mother how to give the ORS
    • Give frequent small sips from a cup
    • If the child wants more than is shown in the table, give more as required
    • If the child vomits, wait 10 minutes, then continue more slowly
  • For infants <6 months who are not breastfed, also give 100-200 ml of clean water during the first 4 hours
  • Reassess patient frequently (every 30-60 minutes) for classification of dehydration and selection of Treatment PlanAfter 4 hours
  • Reassess the patient
  • Reclassify the degree of dehydration
  • Select the appropriate Treatment Plan A, B or C
  • Begin feeding the child in the clinicIf mother must leave before completing the child’s
    treatment
  • Show her how to prepare ORS at home and how much ORS to give to finish the 4-hour treatment
    • Give her enough packets to complete this and 2 more to complete Plan A at home
  • Counsel mother on the 4 rules of home treatment: extra fluids, continue feeding, zinc, when to return

Plan C (Severe dehydration)


If you are unable to give IV fluids and this therapy is not available nearby (within 30 minutes) but a nasogastric tube (NGT) is available or the child can drink

  • Start rehydration with ORS by NGT or by mouth:
    Give 20 ml/kg/hour for 6 hours (total = 120 ml/
    kg)
  • Reassess the child every 1-2 hours
    • If there is repeated vomiting or increasing
      abdominal distension, give more slowly
    • If hydration status is not improving within 3
      hours, refer the child urgently for IV therapy
  • After 6 hours, reassess the child
  • Classify the degree of dehydration
  • Select appropriate Plan A, B, or C to continue
    treatment.If you are unable to give IV fluids but IV treatment is
    available nearby (i.e. within 30 minutes)
  • Refer urgently for IV treatmentIf the child can drink:
    • Provide mother with ORS and show her how to give frequent sips during the trip to the referral facilityIf you are able to give IV fluids
    • Set up an IV line immediately
      • If child can drink, give ORS while the drip is set up
    • Give 100 ml/kg of Ringer’s Lactate
      • Or half-strength Darrow’s solution in glucose 2.5% or sodium chloride 0.9%
      • Divide the IV fluid as follows:
    AGE FIRST GIVE
    30 ML/KG IN:
    THEN GIVE
    70 ML/KG IN:
    Infants <1 years 1 hour* 5 hours*
    Child 1-5 years 30 minutes* 2½ hours*
    * Repeat once if radial pulse still very weak/
    undetectable
  • Reassess patient frequently (every 30-60 minutes) to re-classify dehydration and treatment plan
  • If the patient is not improving
    • Give the IV fluids more rapidly

    As soon as patient can drink, usually after 3-4 hours in infants or 1-2 hours in children

    • Also give ORS 5 ml/kg/hour
    • Continue to reassess patient frequently; classify degree of dehydration; and select appropriate Plan A, B, or C to continue treatment

Note

  • If possible, observe child for at least 6 hours after rehydration to ensure that the mother can correctly use ORS to maintain hydration