Diarrhoea and Dehydration in NYI (Chapter 18)

Learning Objectives

After completion of this chapter the participant should be able to:

Assess the severity of dehydration.
Describe the management of no, moderate and severe dehydration.

Assessment of Severe Dehydration

In triage the letter D stands for Dehydration. In this chapter, we will look at the assessment of the degree of dehydration in the infant with diarrhoea, vomiting, or due to poor feeding.

The normally frequent yellowish or slightly greenish loose seedy stools (like a pea soup) a few times (this is subjective) per day of breastfed babies are not diarrhoea. These are normal breast feeding 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:

Ask:

Duration: for how long has the child had diarrhoea or vomiting?
Is there blood in the stool?

Examine the infant and assess the severity of dehydration.

To assess if the child is severly dehydrated you need to know:

Is the child lethargic?
Does the child have sunken eyes?

Does a skin pinch take longer than 2 seconds to go back?

Can the child suck or drink?

Assessment of the Degree of Dehydration

Degree of Dehydration	Examine the Child	Manage the Child
Severe Dehydration	Is the child lethargic or unconscious PLUS have at least 2 of the following signs: Unable to drink or drinking poorly Sunken eyes? Skin pinch goes back very slowly, > 2 seconds	Manage severe dehydration: Plan C If signs of sepsis or low weight: Start antibiotics Admit or refer
Some Dehydration	Does the child have at least 2 of the following signs: Restless, irritable Thirsty, drinking eagerly Sunken eyes Skin pinch goes back very slowly, > 2 seconds	Manage some dehydration: Plan B If signs of sepsis or low weight: Start antibiotics Admit or refer
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

The important difference between severe and moderate dehydration is that in severe dehydration the infant cannot or will not drink; in some dehydration the infant can drink. 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 hypovolaemic shock due to the diarrhoea. The diagnosis of severely impaired circulation due to diarrhoea (hypovolaemic shock) is made if:

P or U score on AVPU scale
Weak or absent peripheral pulse
Cold peripheries
Temperature gradient
Capillary refill > 3 secs

Treatment of Severe Dehydration – Plan C

Use syringe pump if available.

Management of severe dehydration needs IV fluids, but if the child is alert and 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 as follows; do not use dextrose 5% solution):

Age	First give 30 ml/kg	Then give 70 ml/kg
0-2 months	1 hour	5 hours

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 (120 ml/kg) by NG tube.

Reassess the infant every hour

Provide supportive care – keep the infant warm, ensure O₂ saturations >90%; check blood sugar and treat if <2.5 mmol/l or 45 mg/dl; if jaundiced, treat.

Treatment of Some Dehydration – Plan B

Determine the amount of ORS to give during the first four 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.

Volume of ORS – Plan B for the NYI

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

Teach the mother how to give ORS solution.

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 the child needs to be reassessed immediately.

After 4 hours: reassess the child and classify the degree of dehydration.

Select the appropriate plan to continue treatment, for example if the infant is no longer dehydrated but if s/he still has diarrhoea or is vomiting, then s/he needs ORS after each loss to prevent dehydration; therefore, move to Plan A

Teach mother how to prepare ORS solution at home and give her enough packets to complete rehydration. Advise her to give 5ml/kg after each loose stool and show her, using her own cup, how much this is.

Instruct the mother to give zinc (10 mg per day) for 10 to 14 days if age <6months.

Zinc reduces the risk of recurrence.
Zinc speeds resolution of symptoms.

Treatment of No Dehydration –
Plan A

Explain the Rules of Home Treatment

Give extra fluid – as much as the child will take.
Continue breastfeeding frequently and for longer at each feed.
When to return to hospital.

Role of Antibiotics

Watery diarrhoea is likely to be viral therefore should not be treated with antibiotics
Only visibly bloody diarrhoea is treated with antibiotic (careful there may be a surgical cause).

If antibiotics are needed prescribe:

Ciprofloxacin for 3 days, 7.5mg/kg or
Ceftriaxone 50mg/kg iv for 5 days

Key Facts for Providers:
Diarrhoea and Dehydration in NYI

Be familiar with normal stools patterns for different age groups.
Take a history.
Assess the patient for dehydration and classify it.
Manage the patient according to the level of dehydration according to:

Plan A – no dehydration
Plan B – Some dehydration
Plan C – Severe dehydration

Most children will not require antibiotics so should not be given routinely but assess each child to see if eligable.