After completion of this session the participant should be able to:
In triage the letter D stands for Dehydration. In this session we will look at the assessment of the degree of dehydration in the infant with diarrhoea or vomiting or due to poor feeding. The normally frequent yellowish or slightly greenish loose seedy stools (like a pea soup) of about 6- 8 times per day of breastfed babies are not diarrhoea. These are normal BF stools. If the stools have changed from the usual pattern and are many and watery, it is diarrhoea. When a young infant presents with diarrhoea or vomiting:
To assess if the child is severely dehydrated you need to know:
| Degree of dehydration | Examine the child | Manage the child |
|---|---|---|
| Severe dehydration | Does the child have at least 2 of the following signs:
|
Manage severe dehydration: Plan C Admit or refer |
| Some dehydration | Does the child have at least 2 of the following signs:
|
Manage some dehydration: Plan B
If signs of sepsis or low weight: |
| No dehydration | Not enough signs to classify as severe or some dehydration Skin pinch goes back immediately |
Manage with Plan A Home care Advise mother when to return immediately Follow up in 3 days Advise mum to return earlier if not improving |
After examining the child decide on the degree of dehydration and choose the appropriate WHO management for diarrhoea, plan A, B or C
It is important also to note if the young infant has hypovolemic shock due to the diarrhoea. The diagnosis of severely impaired circulation due to diarrhoea (hypovolemic shock) is made:
Management of severe dehydration needs IV fluids, but if the child can drink give ORS by mouth or via NG tube if the child is unable to drink, while the drip is set up.
Plan C: give 100 ml/kg Ringer’s lactate solution IV, (or, if not available use normal saline; do not use dextrose 5% solution) as follows:
| Age | First give 30 ml/kg | Then give 70 ml/kg |
|---|---|---|
| 0-2 months | 1 hour | 5 hour |
Also give ORS (5 ml/kg/hour) as soon as the child can drink, usually after 3 - 4 hours. If IV treatment is not possible, give ORS 20 ml/kg/hour for 6 hours (120ml/kg) by NG tube. Reassess the infant every hour.
Provide supportive care - keep the infant warm, ensure O2 saturations >90%; if jaundiced treat, check clood sugar and treat if <2.5 mmol/l or 45 mg/dl.
Determine the amount of ORS to give during the first 4 hours. The approximate amount of ORS required (in ml) can be calculated by multiplying the child’s weight (in kg) by 75. If the child wants more ORS than shown, give more.
| Weight | Amount of ORS |
|---|---|
| 1 - 2 kg | 30 mls every hour for 4 hours |
| 2 - 4 kg | 60 mls every hour for 4 hours |
| 4 - 6 kg | 90 mls every hour for 4 hours |
Give frequent small sips from a cup or spoon or small amounts via NG tube. If the child vomits, wait 10 minutes, then continue, but more slowly. Continue breastfeeding. Teach mother danger signs and tell her to call if the condition of the infant worsens, for example if diarrhoea worsens or child has persisting vomiting. Then child needs to be reassessed immediately.
Select the appropriate plan to continue treatment, for example if the infant is no longer dehydrated but if he still has diarrhoea or is vomiting then s/he needs ORS after each loss to prevent dehydration, therefore move to Plan APlan A.
Teach mother how to prepare ORS solution at home and give her enough packets to complete rehydration. Advise her to give at least 50ml after each loose stool and show her using her own cup how much this is.
Instruct the mother to give Zinc (half tablet, 10 mg) per day for 10 days