## Clinical Assessment This child has **mild-to-moderate dehydration** (slightly sunken eyes, skin turgor 1–2 seconds, slightly dry mucous membranes, alert and playful, normal vital signs, normal urine output). According to WHO and IAP guidelines, mild–moderate dehydration without shock is managed with **oral rehydration therapy (ORT)** on an outpatient or short-stay basis. ## Dehydration Severity and Management Pathway ```mermaid flowchart TD A[Acute diarrhea + dehydration]:::outcome --> B{Assess severity}:::decision B -->|Mild-moderate<br/>Alert, normal BP<br/>Skin turgor <2 sec| C[Oral Rehydration<br/>Therapy]:::action B -->|Severe<br/>Lethargic, hypotensive<br/>Skin turgor >2 sec| D[IV Rehydration<br/>Bolus]:::action C --> E[WHO-ORS<br/>75 mmol/L Na<br/>65 mmol/L glucose]:::action E --> F[Continue breastfeeding<br/>& age-appropriate diet]:::action F --> G[Reassess at 4 hours]:::decision G -->|Improved| H[Discharge with<br/>counseling]:::outcome G -->|Worsened| I[Escalate to IV]:::action D --> J[0.9% saline bolus<br/>100 mL/kg over 30 min]:::action J --> K[Maintenance + replacement]:::action ``` ## Key Points on ORT Management **High-Yield:** WHO-recommended low-osmolarity ORS (75 mmol/L sodium, 65 mmol/L glucose) is the **gold standard** for mild–moderate dehydration. It reduces stool output by ~30% compared to standard ORS (90 mmol/L sodium) and has lower incidence of hypernatremia. **Key Point:** Breastfeeding should **continue** during diarrhea—it provides immune factors, maintains nutrition, and does not worsen diarrhea. **Clinical Pearl:** A child who is alert, playful, with normal vital signs and normal urine output is not in shock and does not require hospitalization or IV fluids. ORT is safe, effective, and cost-effective. ## ORT Administration Protocol | Aspect | Detail | |--------|--------| | **ORS composition** | Sodium 75 mmol/L, glucose 65 mmol/L, chloride 65 mmol/L, potassium 20 mmol/L | | **Volume** | 50–100 mL/kg over 4 hours (mild–moderate dehydration) | | **Method** | Frequent small sips (5–10 mL every 5 minutes) to reduce vomiting | | **Ongoing losses** | 10 mL/kg per stool + 2 mL/kg per vomit | | **Breastfeeding** | Continue throughout | | **Diet** | Resume age-appropriate diet (not rice water alone; include protein, fat, carbohydrate) | | **Reassessment** | At 4 hours; if improved, continue ORT; if worsened, escalate to IV | **Warning:** Plain water alone is **inadequate**—it lacks sodium and glucose, risking hyponatremia and poor absorption. Rice-based diet alone (without ORS) is also insufficient for rehydration. **Mnemonic: BRAT Diet is OUTDATED** — Bananas, Rice, Applesauce, Toast is no longer recommended. Use **age-appropriate, nutrient-dense foods** (eggs, yogurt, vegetables, meat) alongside ORS. [cite:WHO Pocket Book of Hospital Care for Children 2nd ed.; IAP Guidelines on Acute Diarrhea in Children 2017]
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