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It is difficult to estimate dehydration status accurately in a severely malnourished child. Loss of elasticity of skin may be due to loss of subcutaneous fat as in marasmus or loss of ECF as in dehydration We assume that all severely malnourished children with watery diarrhea have some dehydration.

Signs of dehydration
Dry oral mucosa Weak pulse Oliguria Thirst Hypothermia

IAP recommends the use of a single solution for all types of diarrhea Reduced osmolarity ORS (RO-ORS) with potassium supplements is beneficial in severe malnutrition

Correction of dehydration
Corrected over a period of 12 hours Some by RO-ORS -Given orally or by nasogastric tube -at 5 ml/kg every 30 mts for 1st 2 hours -then 5-10 ml/kg every hour for next 4-10 hours -replace ongoing stool losses by 5-10 ml/kg of ORS after each watery stool IV therapy should be given only for severe dehydration & shock or if enteral route cannot be used

Breast feeding should be continued during the rehydration phase Refeeding must be initiated with starter F75 formula within 2-3 hrs of starting rehydration Feeds must be given on alternate hrs(2,4,6) with reduced osmolarity ORS(1,3,5) Once rehydration is complete,feeding is continued & ongoing losses repleced with

Progress of rehydration monitered half hourly for first 2 hrs then hourly for the next 4-10 hrs Pulse rate Respiratory rate Oral mucosa Urine output/frequency Frequency of stools & vomiting

Signs of overhydration -increased resp rate by 5/min -pulse rate by 15/min -increasing edema -periorbital puffiness May lead to heart failure In case of overhydration,ORS should be stopped immediately & child reassessed after 1 hour Diuretics are never used

Indicators of rehydration
Increase in urine output Return of tears Moist oral mucosa Less sunken eyes& fontanellae Improved skin turgor

Once any 4 signs of hydration -child less thirsty -passing urine -eyes less sunken -faster skin pinch Are present,ORS is stopped & continued only to replace the ongoing losses

Treatment of severe dehydration with shock

After providing supplemental oxygen,children treated with IV fluids Ideally ringers lactate with 5% dextrose used Half normal saline with 5% dextrose /RL also used 5% dextrose is not used

Given as slow iv infusion at the rate of 15 ml/kg over the first hour with continuous monitoring At the end of 1st hour if there is improvement,the rehydrating fluid is repeated at the same rate over next hour This is followed by reduced osmolarity ORS at 5-10ml/kg/hr orally

Septic shock

If at the end of 1st hour of IV rehydration,there is no improvement, septic shock must be considered & appropriate treatment started