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IMCI · Age: 2 months - 5 years

Severe Dehydration

Classification for a child with diarrhoea who exhibits two or more signs of severe dehydration, indicating a life-threatening fluid deficit requiring immediate IV fluid resuscitation (Plan C) or urgent referral.

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Care priority and warning signs

Care priority

Immediate Treatment (Plan C) / Refer URGENTLY if IV not possible

Red flags

  • Lethargic or unconscious state
  • Not able to drink or drinking poorly
  • Skin pinch goes back very slowly (> 2 seconds)
  • Signs of shock (cold extremities, weak/fast pulse, capillary refill > 3 sec)

Assessment

  • Ask: Does the child have diarrhoea?
  • Ask: For how long?
  • Ask: Is there blood in the stool?
  • Look/Feel: Look at the child's general condition. Is the child Lethargic or unconscious?
  • Look/Feel: Look for sunken eyes.
  • Look/Feel: Offer the child fluid. Is the child Not able to drink or drinking poorly?
  • Look/Feel: Pinch the skin of the abdomen. Does it go back Very slowly (longer than 2 seconds)?

Classification

  • Two or more of the following signs: (Lethargic or unconscious) OR (Sunken eyes) OR (Not able to drink or drinking poorly) OR (Skin pinch goes back very slowly) -> SEVERE DEHYDRATION

Key features

  • Requires TWO or more of the following signs: Lethargic/unconscious, Sunken eyes, Not able to drink/drinking poorly, Skin pinch goes back very slowly (>2 seconds).
  • Indicates significant fluid and electrolyte loss.
  • Requires immediate fluid resuscitation, preferably with IV fluids (Plan C).

Management

Non-pharmacological management

  • If providing Plan C in clinic: Ensure availability of IV fluids, cannulas, giving sets. Monitor hydration status closely.
  • If referring: Keep child warm during transport. Continue giving ORS sips frequently if the child can drink.

Pharmacological treatment

  • TREAT WITH PLAN C:
  • If IV Therapy Possible Immediately: Start IV fluid immediately. Give 100 ml/kg Ringer's Lactate Solution (or Normal Saline if RL not available), divided as follows: Age < 12 months: Give 30ml/kg in 1 hour, THEN 70ml/kg in 5 hours. Age 12 months - 5 years: Give 30ml/kg in 30 minutes, THEN 70ml/kg in 2 ½ hours.
  • Reassess the child every 1-2 hours. If hydration status is not improving, give IV drip more rapidly.
  • Also give ORS (about 5 ml/kg/hour) by mouth as soon as the child can drink (usually after 3-4 hrs for infants, 1-2 hrs for children).
  • Reassess dehydration status after the initial IV phase (e.g., after 6 hrs for infants, 3 hrs for children) and choose appropriate plan (A, B, or repeat C if needed).
  • If IV Therapy Not Available Nearby (<30 mins) or Not Possible:
  • If trained in NG tube insertion: Start rehydration by NG tube with ORS solution: give 20 ml/kg/hour for 6 hours (total 120 ml/kg). Reassess every 1-2 hours. If vomiting persists or distension occurs, slow the rate. If hydration not improving after 3 hrs, refer urgently for IV.
  • If child can drink: Refer URGENTLY to hospital for IV/NG treatment. Give mother ORS solution and show her how to give frequent sips during the trip.
  • If child is 2 years or older AND cholera is in your area: Give appropriate antibiotic for cholera (e.g., Erythromycin).
  • If child also has another severe classification (e.g., Severe Pneumonia): Refer URGENTLY after stabilizing airway/breathing and giving essential pre-referral treatments (e.g., antibiotic), give frequent sips of ORS on the way.

Pre-referral treatment

  • If referring urgently: Ensure airway is clear. Give frequent sips of ORS on the way if child can drink. Keep child warm. Give other essential pre-referral treatments based on other classifications (e.g., antibiotic for severe pneumonia).

Follow-up

  • Managed initially under Plan C, then reassessed and managed according to Plan A or B.
  • If discharged on Plan A or B, follow-up as per those plans.

Counselling points

  • If Plan C given in clinic: Explain the procedure and need for close monitoring. Reassure the mother.
  • If referring: Explain the seriousness of dehydration and the need for hospital treatment (IV fluids). Show how to give ORS sips frequently during transport. Advise on keeping child warm. Advise mother to continue breastfeeding whenever child wants.

Differential diagnosis

  • Some Dehydration
  • Septic shock (may mimic dehydration signs)
  • Severe malnutrition with oedema (skin changes may be misleading)
  • Other causes of altered consciousness (meningitis, severe malaria)

Complications

  • Hypovolemic shock
  • Acute kidney injury
  • Seizures (due to electrolyte imbalance or hypoglycemia)
  • Cerebral edema (if rehydrated too rapidly with hypotonic fluids, rare with ORS/RL/NS)
  • Death

Prevention

  • Exclusive breastfeeding for 6 months.
  • Use of safe water and sanitation.
  • Handwashing with soap.
  • Appropriate complementary feeding.
  • Measles vaccination.
  • Rotavirus vaccination (if available).
  • Prompt use of ORS and Zinc at the start of diarrhoea.
  • Continued feeding during diarrhoea.

References

IMCI Chart Booklet - Page 3, Page 13 (Plan C), Page 16

For learning and professional reference. Use current local guidance and clinical judgement.

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