A 2-year-old boy from rural Maharashtra presents with acute watery diarrhea for 3 days and signs of moderate dehydration (sunken eyes, skin turgor >2 seconds, lethargy). Which of the following is NOT an appropriate management step in WHO-recommended rehydration protocol?

Explanation

## WHO Classification and Management of Dehydration in Acute Diarrhea ### Dehydration Severity Assessment Moderate dehydration is defined by the presence of two or more of: increased thirst, restlessness, sunken eyes, drinks eagerly, skin pinch goes back slowly (>2 seconds). ### Appropriate Management of Moderate Dehydration **Key Point:** WHO recommends **oral rehydration therapy (ORT)** as first-line for moderate dehydration in children with acute diarrhea, provided there is no shock, persistent vomiting, or altered consciousness. | Management Component | Details | |---|---| | **ORS regimen** | 75 mL/kg over 4 hours (approximately 10 mL/kg/hour) | | **Reassessment** | Every 1–2 hours to classify hydration and guide further therapy | | **Feeding** | Continue breastfeeding and age-appropriate foods during rehydration | | **IV fluids** | Reserved for severe dehydration, shock, or failed ORT (persistent vomiting, inability to drink) | ### Why IV Bolus Is NOT Indicated Here **High-Yield:** Intravenous fluid bolus (20 mL/kg over 15–30 minutes) is the **emergency management for hypovolemic shock** (severe dehydration with signs of circulatory compromise: weak pulse, cold extremities, altered mental status). This child has **moderate dehydration without shock**—ORT is sufficient and preferred. **Clinical Pearl:** IV rehydration is reserved for: - Severe dehydration (>10% fluid loss) - Hypovolemic shock - Persistent vomiting preventing ORT - Altered consciousness - Cholera with rapid fluid losses ### Continuation of Feeding **Key Point:** WHO and UNICEF guidelines emphasize that **continued feeding during rehydration does NOT worsen diarrhea** and reduces malnutrition risk. Breastfeeding should continue; solid foods should be reintroduced as soon as the child can tolerate them. ### Summary Table: Dehydration Management Algorithm | Dehydration Grade | Clinical Signs | First-Line Therapy | IV Fluids? | |---|---|---|---| | **Mild** | Normal mental status, normal skin turgor, normal eyes | ORS 50 mL/kg over 4 hours | No | | **Moderate** | Lethargy/restlessness, sunken eyes, skin turgor >2 sec | ORS 75 mL/kg over 4 hours | No (unless failed ORT) | | **Severe** | Shock, weak pulse, cold extremities, altered consciousness | IV bolus 20 mL/kg 0.9% saline over 15–30 min, then reassess | **Yes** | [cite:Park 26e Ch 8]