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Assessment Of Severity Of Dehydration

A child's hydration status should be classified as no dehydration, some dehydration or severe dehydration according to WHO criteria.

Assessment of Dehydration of Patients with diarrhoea

- Look and Feel:

Look at the child’s general condition.

Is the child:

Lethargic or unconscious?

Restless and irritable?

- Look for sunken eyes.

- Offer the child fluid, is the child:

Not able to drink or drinking poorly?

Drinking eagerly, thirsty?

- Pinch the skin of the abdomen.

Does it go back:

Very slowly (Longer than 2 seconds)? Slowly?

Two of the following signs.

- Lethargic or unconscious

Severe Dehydration

Weight the patient and use treatment plan C

- Sunken eyes

- Not able to drink or drinking poorly

Skin pinch goes back very slowly.

Two of the following sign:

- Restless, irritable

- Sunken eyes

- Drinks eagerly, thirsty

- Skin pinch goes back slowly

Some dehydration

Weight the patient if possible, and use treatment plan B

Not enough signs to classify as some or severe dehydration

No dehydration

Use treatment Plan A

  1. Being lethargic and sleepy are not the same.' A lethargic child is not simply asleep: the child's mental state is dull and the child cannot be fully awakened; the child may appear to be drifting into unconsciousness.     
  2. In same infants and children, the eyes normally appear somewhat sunken. It is helpful to ask the mother if the child's eyes are normal or more sunken than usual.
  3. Dryness of the mouth and tongue can also be palpated with a clean finger. The mouth may be dry in a, child who habitually breathes through the mouth. The mouth may be wet in a dehydrated child owing to recent vomiting or drinking.     
  4. The skin pinch is less useful in infants or children with marasmus (severe wasting) or kwashiorkor (severe malnutrition with oedema), or obese children.       

What is oral Rehydration therapy (ORT)


The term ORT include      

  1. Complete oral rehydration salts (ORS) solution with composition with in the WHO recommended range.
  2. Solutions made /Tom sugar and salt
  3. Food based solutions

What Is Ort?

 ORS is an important from of ORT, for prevention as well as treatment of dehydration

Type of ORT

Composition per litre

Appropriate use

 Home made fluids with substrate

 and salt

 Sugar and salt solution

Sugar (Sucrose) 40g

Salt (NaCl) 4g

Prevention of dehydration

 Food based solutions


 Rice water with salt


 Lassi with salt

Rice approximately 50g

(precise measurement not required) Salt 4g

 Prevention of dehydration

Home fluids without insisting on both    a glucose precursor and salt or their  presence in specified amounts

 1) Plain water, lemon water, coconut  water, soups.

 2) Thin rice kanji, dal water without  salt

Prevention of dehydration; most useful in presence of continued feeding which provides both absorbable and some salt.

What Is Not Ort?

Glucose water without salt. Fluids  without starch or sugar and salt in  children who are starved. Fluids  consumed in very small quantities ego  Tea.



* May be used for treatment of dehydration when ORS is not available and while child is being taken to a facility where ORS is available'


ORS solution

  1. Physiological basis - Glucose linked enhanced sodium absorption in the small intestine remains largely intact during acute diarrhoea of diverse aetiology.    
  2. Apart from glucose, sodium co-transport occurs with oligosaccharides {maltodextrins), disaccharides (sugar), and starch (rice) as they all release glucose after hydrolysis.       
  3. On other hand amino acid ego Glutamine, glycine, alanine, or their dipeptides are also known to independently stimulate sodium absorption. 

Composition of Who Oral Rehydration Salt Solution

Ingredients per liter of ORS

solution (gm)

Concentration of various ingredients in WHO ORS solution (mmo/L)

Sodium chloride




Trisodium citrate





Sodium bicarbonate





  Potassium chloride




  Glucose, anhydrous





Treatment plan A patients without physical signs of dehydration

They require fluid for replacement of ongoing losses .to prevent dehydration.


ORS for prevention of dehydration



  Amount of ORS to give after each   loose stool

  Amount of ORS to provide for   us at hour

  Less than 24 mon.

  50-100 ml

  500 ml/day

  2-10 yr

  100-200 ml

  1000 ml/day

  > 10 yr

  As much wanted

  2000 ml/day



Treatment plan B patients with physical signs of dehydration

The fluid therapy for dehydration has three components­

  1. Correction of the existing water and electrolyte deficit rehydration therapy   
  2. Replacement of ongoing losses due to continuing diarrhoea to prevent recurrence of dehydration maintenance therapy
  3. Provision of normal daily fluid requirement.       ­ 

Deficit Replacement: Rehydration therapy


Give 75 ml/Kg of ORS in the first 4 hours.

Maintenance fluid therapy


This begins when signs of dehydration disappear usually with in 4 hours. ORS given for replacement of ongoing stool losses to maintain hydration ORS given approximately 10-20 ml/Kg BW for each liquid stool. after plain water in between.


When is oral rehydration therapy ineffective.

  1. High stool purge rate, more than 15 ml/Kg BW/hr
  2. Persistent vomiting greater than 3 vomitings per hour
  3. Abdominal distension and ileus
  4. Glucose malabsorption
  5. Incorrect preparation or administration of ORS solution 

Treatment plan C children with severe dehydration should be given rapid IV rehydration

  1. Start IV drip immediately
  2. The best IV fluid solution is Ringer's Lactate solution An ideal preparation would be RL with 5% dextrose. However, it is not available. If plain Ringer's Lactate is also not available, normal saline solution (0.9% NaCI) can be used.
  3. Give 100 ml/Kg of the chosen solution divided as follows ­ 
First give 30 mil Kg in  Then given 70 ml/kg in
< 12 months     1 hr 5 hr
Older children   30 min 2 ½ hr

If child has also severe PEM then rapid IV rehydration done more slowly. I.e. 10-12 hr for < 12 months and 4-6 hr in older children.


Drug therapy in Acute diarrhea


The only specific clinical indication for use antimicrobial agents are­

  1. Cholera
  2. Dysentery
  3. Associated non-gastro intestinal infections 

Acute diarrhea in the severely Malnourished child


Assessment of dehydration in severely malnourished children


A) Signs that are not reliable

  1. Mental state - A severely malnourished child is usually apathetic when left alone or irritable when handled.
  2. Mouth, tongue and tears- The severely malnourished child usually has a dry mouth and absent tears because of atrophied salivary and lacrimal gland.
    Skin turgor- Lack of supporting tissues and subcutaneous fat results in thin and loose skin. It may flatten slowly or not flatten at all when pinched. Presence of edema may mask diminished turgor of the skin.

The signs that remain useful for -assessing dehydration are eagerness to drink (sign of some dehydration) weak or absent radial pulse and decreased or absent urine flow (sign of severe dehydration)


Fluid therapy in a severely malnourished children with diarrhea and dehydration.


Give WHO-ORS slowly at the rate of 70-100 ml/Kg over a period of 8-10 hrs rather than 4 hrs as given to a well nourished child during IV rehydration therapy fluid given at rate of ,15 ml/Kg once more then 10 ml/Kg/hr till pt is able to accept orally.

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