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Referral and warning signs
When to refer
Patients with Severe Dehydration (Plan C) require immediate IV therapy - refer urgently to HC3/HC4 or Hospital if IV cannot be initiated locally. Refer patients with Some Dehydration (Plan B) if they fail to improve, develop danger signs (e.g., lethargy, unable to drink), or have persistent vomiting. Refer any child whose hydration status worsens despite treatment.
Red flags
- Lethargy, drowsiness or unconsciousness
- Unable to drink or drinking poorly
- Skin pinch goes back very slowly (>2 seconds)
- Signs of shock (rapid weak pulse, low BP, cold extremities, poor capillary refill)
- Persistent vomiting
- Convulsions
Signs and symptoms
- Thirst (may be absent in severe dehydration or infants)
- General condition: Alert (none), Restless/irritable (some), Lethargic/drowsy/unconscious (severe)
- Sunken eyes
- Sunken fontanelle (infants)
- Reduced tears
- Dry mucous membranes (mouth, tongue)
- Skin pinch / Turgor: Returns immediately (none), Slowly <2s (some), Very slowly >2s (severe)
- Ability to drink: Normally (none), Eagerly/thirsty (some), Poorly/unable (severe)
- Pulse: Normal (none/mild), Rapid (moderate/severe), Thready/absent (severe)
- Breathing: Normal (none/mild), Deep/rapid (acidotic breathing in severe)
- Blood Pressure: Normal (none/mild/moderate), Low/unrecordable (severe)
- Urine output: Normal (none), Reduced/dark (some/moderate), Minimal/absent (severe)
Risk factors
- Vomiting
- Diarrhoea (e.g., gastroenteritis, cholera)
- Decreased fluid intake
- Excessive loss of fluids (e.g., polyuria in diabetes, excessive sweating from high fever, burns)
Diagnosis
Clinical assessment
Assessment based on history of fluid losses (diarrhoea, vomiting, intake) and specific clinical signs to classify severity. Use UCG tables for children <5 (No/Some/Severe - Plan A/B/C) and older children/adults (Mild/Moderate/Severe).
Investigations
- Clinical assessment of hydration status (general condition, eyes, fontanel, tears, mucous membranes, skin turgor, ability to drink)
- Vital signs monitoring (Pulse rate, BP, Respiratory rate)
- Urine output monitoring
- Weight measurement (especially useful for monitoring response in children)
- Consider blood glucose (especially if altered mental status)
- Consider electrolytes and renal function tests in severe dehydration or if IV therapy required
Diagnostic criteria
Specific criteria based on combination of clinical signs as outlined in UCG 2023 tables for classifying dehydration severity in children <5 years (p. 8) and older children/adults (p. 13).
Management
Non-pharmacological management
- Encourage continued feeding (especially breastfeeding in infants) during rehydration.
- Provide nutritional support once rehydrated.
- Treat underlying cause (e.g., infection).
Pharmacological treatment
- Rehydration based on severity:
- Plan A (No dehydration / Prevention): Counsel on home care - Give extra fluids (ORS, safe water, soup etc.) as much as tolerated, especially after each loose stool/vomit (Child <2y: 50-100ml; 2-5y: 100-200ml). Continue feeding. Zinc supplementation for diarrhoea in children <5y (10mg daily <6m, 20mg daily >6m, for 10 days). Advise when to return.
- Plan B (Some dehydration): Give ORS solution over 4 hours in clinic. Amount based on weight (approx. 75 ml/kg) or age (see UCG table p.10). Give frequent small sips. Reassess frequently. After 4 hours, reassess hydration status and select appropriate plan (A, B, or C). Begin feeding in clinic.
- Plan C (Severe dehydration): Requires urgent rehydration, preferably IV. IV Fluids: Ringer’s Lactate (preferred) or Normal Saline 0.9%. Children: 100 ml/kg IV divided based on age (Infants <1yr: 30ml/kg over 1 hr, then 70ml/kg over 5 hrs; Children >1yr: 30ml/kg over 30 mins, then 70ml/kg over 2.5 hrs). Adults/Older Children: 50 ml/kg IV in first 4 hours (give rapidly initially until pulse/BP improve, then adjust rate). Start ORS (5ml/kg/hr) as soon as patient can drink.
- Plan C (Severe - IV unavailable): If child can drink or NGT available: Start ORS via NGT or mouth (20 ml/kg/hour for 6 hours). Reassess every 1-2 hours. If vomiting or distension, slow rate. If not improving in 3 hrs, refer urgently for IV. If IV available nearby (<30 min): Refer urgently, giving ORS sips during transport if possible.
- Follow specific Ugandan treatment algorithms/guidelines.
Monitoring
Frequent reassessment of hydration status (using clinical signs), vital signs, and urine output is crucial during rehydration. Monitor for signs of fluid overload. If possible, observe children for at least 6 hours after rehydration (Plan C) to ensure mother can maintain hydration with ORS.
Complications
- Hypovolaemic shock
- Electrolyte imbalances (e.g., hypo/hypernatremia, hypokalemia)
- Acute kidney injury
- Seizures (due to electrolyte imbalance or cerebral oedema from rapid correction)
- Death
Prevention
- Promote exclusive breastfeeding for first 6 months
- Ensure access to safe water and sanitation
- Promote handwashing
- Vaccination (e.g., Rotavirus)
- Educate caregivers on early recognition of dehydration and home management with ORS (4 Rules: Extra Fluids, Continue Feeding, Zinc, When to Return)
Patient education
- Teach caregivers how to recognize signs of dehydration (none, some, severe)
- Teach how to prepare and give ORS correctly (frequent small sips)
- Emphasize the 4 rules of home treatment for diarrhoea: 1. Give Extra Fluid (ORS), 2. Continue Feeding, 3. Give Zinc (if child <5), 4. Know When to Return immediately (danger signs).
- Stress importance of completing Zinc course.
Uganda-specific notes
Use the specific UCG assessment tables for children <5 and older children/adults. ORS is the cornerstone of treatment for no/some dehydration. Ringer's Lactate is preferred IV fluid for severe dehydration. Zinc supplementation is standard for diarrhoea in children <5 years. Consider underlying causes like malaria, sepsis, malnutrition.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 1, Sections 1.1.3, 1.1.3.1, 1.1.3.2 (including assessment tables and Plans A, B, C)