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UPSC MainsMEDICAL-SCIENCE-PAPER-II201310 Marks
Q4.

Childhood Diarrhea: Dehydration Assessment & Management

An 8-month-old child, weighing 8 kg, is brought with loose motions 6 per day, mixed with blood, for last 2 days. There is no history of vomiting. (i) Enumerate the 4 most important signs you will look/feel for to assess the severity of dehydration. (ii) Assessment of dehydration reveals SOME dehydration. Write the initial prescription for appropriate management of this child.

How to Approach

This question requires a two-part answer. Part (i) focuses on clinical assessment – identifying key signs of dehydration in a pediatric patient. The answer should be concise and list the most crucial indicators. Part (ii) demands a practical, immediate management plan for ‘some’ dehydration, including fluid resuscitation and ongoing monitoring. The response should demonstrate understanding of pediatric fluid management principles and appropriate prescription writing. A structured approach, detailing assessment followed by a clear prescription, is essential.

Model Answer

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Introduction

Acute gastroenteritis is a common illness in infants and young children, often leading to dehydration due to fluid loss from diarrhea and sometimes vomiting. Prompt and accurate assessment of dehydration severity is crucial for effective management. Dehydration can rapidly progress to become life-threatening, particularly in infants. The World Health Organization (WHO) classifies dehydration into three categories: mild, moderate, and severe, guiding the appropriate level of intervention. This case presents an 8-month-old with bloody diarrhea, necessitating a careful evaluation and initiation of rehydration therapy.

(i) Assessing Severity of Dehydration: 4 Most Important Signs

To assess the severity of dehydration in this 8-month-old child, I would look for the following four key signs:

  • General Appearance & Activity: The child’s level of alertness, responsiveness, and activity level are crucial. A severely dehydrated child will be lethargic, irritable, or even comatose.
  • Respiratory Rate: Increased respiratory rate is an early sign of dehydration as the body attempts to compensate for reduced blood volume. Tachypnea (rapid breathing) is a significant indicator.
  • Capillary Refill Time: A prolonged capillary refill time (greater than 3 seconds) suggests poor peripheral perfusion due to decreased blood volume. This is assessed by pressing on the nail bed and observing the time it takes for color to return.
  • Skin Turgor: Assessing skin elasticity. In dehydration, the skin loses elasticity and returns slowly to its normal position after being pinched. However, this is less reliable in malnourished children.

(ii) Initial Prescription for ‘Some’ Dehydration

Based on the assessment revealing ‘some’ dehydration, the following initial prescription is recommended. ‘Some’ dehydration corresponds to a 5-10% fluid deficit.

1. Oral Rehydration Solution (ORS) Therapy

ORS Dosage: 50-100 ml/kg body weight over 4 hours. For an 8 kg child, this translates to 400-800 ml of ORS over 4 hours.

Administration: Administer ORS frequently in small sips. For example, 5-10 ml every 5-10 minutes initially, gradually increasing the amount as tolerated. Avoid forcing fluids.

ORS Composition: Use a standard WHO-recommended ORS packet. Ensure proper preparation by mixing one packet with 1 liter of clean, potable water.

2. Continued Breastfeeding/Formula Feeding

Continue breastfeeding or formula feeding as frequently as the child desires. Do not interrupt feeding unless the child is vomiting excessively.

3. Monitoring & Reassessment

Vital Signs: Monitor respiratory rate, heart rate, and capillary refill time every 30-60 minutes initially, then every 2-4 hours as the child improves.

Urine Output: Assess urine output. Decreased urine output is a sign of worsening dehydration.

Stool Frequency & Consistency: Monitor stool frequency and consistency. Note any changes in the presence of blood.

Weight: Daily weight monitoring is crucial to assess response to therapy.

4. Zinc Supplementation

Dosage: Zinc 20mg daily for 10 days. Zinc supplementation has been shown to reduce the duration and severity of diarrhea in children.

5. Prescription Example:

Rx

  • ORS sachets – 5 (Prepare 5 liters with clean water)
  • Zinc Sulfate 20mg – 10 tablets (one daily for 10 days)
  • Instructions: Administer ORS 400-800ml over 4 hours in small frequent sips. Continue breastfeeding/formula. Monitor vital signs and urine output. Return if condition worsens.

Important Note: If the child is unable to tolerate oral fluids due to persistent vomiting or shows signs of worsening dehydration (e.g., lethargy, sunken eyes, significantly decreased urine output), intravenous (IV) fluid resuscitation should be initiated immediately.

Conclusion

Effective management of dehydration in infants with acute gastroenteritis requires a prompt and accurate assessment of dehydration severity, followed by appropriate fluid resuscitation with ORS. Continuous monitoring of vital signs, urine output, and overall clinical status is essential to guide further management. Zinc supplementation is a valuable adjunct therapy. Early recognition of worsening dehydration and timely escalation to IV fluids are crucial to prevent serious complications.

Answer Length

This is a comprehensive model answer for learning purposes and may exceed the word limit. In the exam, always adhere to the prescribed word count.

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Additional Resources

Key Definitions

ORS
Oral Rehydration Solution: A specific formulation of electrolytes (sodium, potassium, chloride) and glucose designed to replace fluids and electrolytes lost due to diarrhea and vomiting. It is a cornerstone of dehydration management.
Perfusion
Perfusion refers to the passage of fluid through the circulatory system or lymphatic system to an organ or a tissue. Adequate perfusion is essential for delivering oxygen and nutrients and removing waste products.

Key Statistics

Diarrheal diseases are the second leading cause of death in children under five years old globally, accounting for approximately 1.5 million deaths annually (WHO, 2023 - knowledge cutoff).

Source: World Health Organization (WHO)

Approximately 80% of diarrheal deaths are attributed to rotavirus in children less than 2 years of age in developing countries (CDC, 2022 - knowledge cutoff).

Source: Centers for Disease Control and Prevention (CDC)

Examples

Rotavirus Gastroenteritis

Rotavirus is a common cause of severe diarrhea in infants and young children, particularly during the winter months. It often presents with vomiting, fever, and watery diarrhea, leading to rapid dehydration. Vaccination against rotavirus is highly effective in preventing severe disease.

Frequently Asked Questions

▶What if the child continues to vomit despite ORS administration?

If the child continues to vomit persistently, preventing adequate ORS intake, consider temporarily stopping oral fluids for 30-60 minutes and then restarting with smaller, more frequent sips. If vomiting persists, IV fluid resuscitation should be initiated.

Topics Covered

PediatricsGastroenterologyDiarrheaDehydrationFluid Therapy
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