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Care priority and warning signs
Care priority
Immediate Treatment (Plan C) / Refer URGENTLY
Red flags
- Lethargy / Unconsciousness / No movement
- Skin pinch > 2 seconds
- Signs of shock (cold periphery, poor capillary refill, weak pulse)
- Inability to feed/take fluids
- Associated signs of PSBI/Very Severe Disease
Assessment
- Ask: Does the young infant have diarrhoea? (Note: Stools are normally frequent/semisolid in breastfed babies. Diarrhoea is a change to many watery stools).
- Look/Feel: Look at the infant's general condition/movements. Is the infant lethargic or unconscious? Moves only when stimulated or no movement at all?
- Look/Feel: Look for sunken eyes.
- 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: (Movement only when stimulated or no movement at all / Lethargic or unconscious) OR (Sunken eyes) OR (Skin pinch goes back very slowly) -> SEVERE DEHYDRATION
Key features
- Requires TWO or more of the following signs: Lethargic/unconscious OR Movement only when stimulated/no movement OR Sunken eyes OR Skin pinch goes back very slowly (>2 seconds).
- Indicates severe fluid and electrolyte loss, which is particularly dangerous in young infants.
- Requires immediate fluid resuscitation, preferably IV or NG if trained (Plan C), and urgent referral.
Management
Non-pharmacological management
- If providing Plan C in clinic: Ensure immediate access to IV/NG equipment and ORS. Monitor closely.
- If referring: Keep infant warm. Continue ORS sips frequently if possible.
Pharmacological treatment
- TREAT WITH PLAN C (Young Infant Version - Page 41):
- If IV Therapy Possible Immediately: Start IV fluid. Give 100 ml/kg Ringer's Lactate Solution (or Normal Saline). Give 30ml/kg in 1 hour, THEN 70ml/kg in 5 hours.
- Reassess frequently (every hour initially). If hydration not improving, give IV drip faster.
- Also give ORS (about 5 ml/kg/hour) by mouth/NG tube as soon as infant can take it.
- Reassess dehydration status after 6 hours and choose appropriate plan (A, B, repeat C).
- If IV Therapy Not Available/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/distension, slow rate. If not improving after 3 hrs, refer urgently for IV.
- If NG tube not possible AND infant can drink: Refer URGENTLY. Give mother ORS and show how to give frequent sips during the trip.
- If infant also has another severe classification (e.g., PSBI): Refer URGENTLY after stabilizing airway/breathing and giving essential pre-referral treatments (e.g., antibiotic). Give frequent sips of ORS on the way if possible.
Pre-referral treatment
- If referring urgently: Ensure airway is clear. Give frequent sips of ORS on the way if infant can drink. Keep infant warm (Page 40). Give other essential pre-referral treatments based on other classifications (e.g., antibiotic for PSBI - Page 40).
Follow-up
- Managed initially under Plan C, then reassessed.
- If discharged on Plan A or B, follow-up as per those plans.
Counselling points
- Explain the seriousness of dehydration in a young baby and the need for urgent hospital treatment.
- Show how to give ORS sips frequently during transport if applicable.
- Advise on keeping infant warm.
- Advise mother to continue breastfeeding whenever infant wants.
Differential diagnosis
- Some Dehydration (Young Infant)
- Septic shock
- Other causes of altered consciousness/lethargy (PSBI, meningitis, hypoglycemia)
Complications
- Hypovolemic shock
- Acute kidney injury
- Severe electrolyte imbalance
- Seizures
- Death
Prevention
- Exclusive breastfeeding.
- Handwashing.
- Safe water/sanitation.
- Rotavirus vaccination (where available, consider age limits).
- Prompt management of diarrhoea with ORS and continued feeding.
References
IMCI Chart Booklet - Page 35, Page 41 (Plan C - Young Infant), Page 40 (Pre-referral Warmth/Antibiotic)