A 18-month-old boy from rural Maharashtra presents to the emergency department with a 3-day history of watery diarrhea (8–10 stools/day) and vomiting. On examination: sunken eyes, skin turgor returns slowly (>2 seconds), mucous membranes dry, urine output reduced. Vital signs: HR 140/min, BP 90/60 mmHg, RR 28/min. Weight 10 kg. The child is alert and able to drink. What is the most appropriate next step in management?

Explanation

## Clinical Assessment This child has **some/moderate dehydration** (sunken eyes, slow skin turgor >2 seconds, dry mucous membranes, reduced urine output, tachycardia) but is **alert and able to drink** — a critical distinction in WHO/IAP dehydration management. ## WHO Dehydration Classification | Feature | No Dehydration | Some Dehydration | Severe Dehydration | |---|---|---|---| | General condition | Well, alert | Restless/irritable | Lethargic/unconscious | | Eyes | Normal | Sunken | Very sunken | | Thirst | Normal | Drinks eagerly | Unable to drink | | Skin turgor | Returns quickly | Returns slowly (>2s) | Returns very slowly (>3s) | This child fits **"some dehydration"** (WHO Plan B): alert, able to drink, slow skin turgor — **NOT severe dehydration**. There are no signs of shock (pulses are present, BP 90/60 mmHg is acceptable for age, sensorium is intact). ## Why ORT is the Correct Answer (Option C) **Key Point:** According to WHO and IAP guidelines (IMNCI/IMCI), a child with **some (moderate) dehydration who is alert and able to drink** should receive **oral rehydration therapy (ORT) with low-osmolarity ORS** (WHO Plan B: 75 mL/kg over 4 hours). This is the standard of care regardless of tachycardia, which is expected in moderate dehydration. - Low-osmolarity ORS (245 mOsm/L): Na 75 mEq/L, Glucose 75 mmol/L - Reduces stool output, vomiting, and need for IV therapy compared to standard ORS - Safe, effective, and guideline-recommended for moderate dehydration with preserved oral intake **Clinical Pearl:** The ability to drink is the single most important factor distinguishing WHO Plan B (ORT) from Plan C (IV fluids). Tachycardia alone does not mandate IV therapy in a child who is alert and drinking. ## Why Not IV 0.9% Saline 50 mL/kg over 4 Hours (Option A)? IV rehydration at 50 mL/kg over 4 hours is used when the child **cannot tolerate oral intake** (persistent vomiting, altered consciousness, or failed ORT). Since this child is alert and able to drink, ORT is the preferred first-line approach per WHO/IAP guidelines. IV therapy is a backup if ORT fails. ## Why Not Nasogastric ORT (Option B)? NG tube delivery is an alternative when a child cannot drink but IV access is unavailable. It is not first-line when the child can drink orally. ## Why Not IV Bolus 100 mL/kg over 1 Hour (Option D)? The 100 mL/kg rapid bolus is reserved for **severe dehydration with shock** — weak/absent pulses, altered sensorium, very sunken eyes, inability to drink. This child is alert with BP 90/60 mmHg (acceptable for age), no altered sensorium, and no signs of circulatory collapse. ## Ongoing Management - Reassess after 4 hours of ORT - Add 10 mL/kg ORS for each stool (ongoing losses) - If child deteriorates or cannot tolerate ORT → escalate to IV therapy **High-Yield:** WHO Plan B = ORT 75 mL/kg over 4 hours for "some dehydration" in a child who is alert and able to drink. IV fluids are reserved for Plan C (severe dehydration/shock) or failed ORT. [cite: WHO/UNICEF ORS Guidelines 2006; IAP Textbook of Pediatrics 6e; Park's Textbook of Preventive and Social Medicine 26e Ch 7]