Rehydration and Early Feedingã The Trustee of the Wellcome Trust 1998 Reviewed by: Dr R H Behrens, Hospital for Tropical Diseases, London and Dr W A M Cutting, Department of Child Life and Health, The University of Edinburgh, UKPicture: Oral rehydration therapy being given to a 9-month-old girl with diarrhoeal dehydration.Copyright Image from Cutting WAM.Image references ################ .\IMAGES\T44894.jpg Contents Click on the underlined text to jump to that screen. Screen 3 Objectives 4Introduction 5Overview of the Management ofDiarrhoea 9 Treatment Plan A: No Signs ofDehydration 14 Assessments 16 Oral Rehydration Salts Solution 23 Assessments 25 Treatment Plan B: SomeDehydration 33 Assessments 35 Treatment Plan C: SevereDehydration 44 Assessment 45Tutorial Assessments47SummaryUnderlined text is interactive. Click on underlined text to view extra information or to jump to another screen. Intravenous rehydration.Copyright Copyright Image from Centers for Disease Control and Prevention.Image references ################ .\IMAGES\T33079.jpg Objectives At the end of this tutorial you should be able to: 1. summarize the management of a patient with diarrhoea according to the degree of dehydration 2. indicate the rationale for oral rehydration therapy (ORT) and early feeding 3. make up and administer oral rehydration salts (ORS) solution 4. recognise the indications for intravenous rehydration 5. understand the rationale for specific intravenous solutions 6. put up and manage an intravenous infusion Image references ################ Introduction Diarrhoea Diarrhoea is: · an increase in the number, volume and water content of stools · a global cause of much illness and death· a major factor in childhood malnutrition This tutorial is about the treatment of dehydration due to acute diarrhoea by rehydration and early restarting of feeding.Picture: Breast feeding in an oral rehydration clinic. Breast feeding reduces the severity and duration of diarrhoea, and minimizes its impact on nutritional status.Copyright Image from Guidelines for Conducting Clinical Training Courses at Health Centres and Small Hospitals (Transparency Set). Programme for Control of Diarrhoeal Diseases, World Health Organization 1992.Diarrhoea morbidity and mortality Each year there are: · approximately 3.3 million deaths due to diarrhoea, 80% in children under 2 years of age · over 1 billion episodes of diarrhoea, most in the developing world · 5 - 10 million travellers affected by diarrhoea Image references ################ .\IMAGES\T45262.jpg Overview of the Management of DiarrhoeaOverview of the Management of Diarrhoea Image references ################ Overview of the Management of Diarrhoea - 1 Clinical assessment Clinical assessment of a child with diarrhoea should: · determine the degree of dehydration (see picture)· diagnose the clinical type of diarrhoea · determine the nutritional status and evaluate feeding practices · diagnose any concurrent illness · determine the immunization status, especially with regard to measlesFor related tutorials.Picture: Clinical assessment to determine the degree of dehydration. The very slow return of a skin pinch in this child with diarrhoea indicates severe dehydration.Which other signs of severe dehydration does this child have? Copyright Image from International Centre for DiarrhoealDisease Research, Bangladesh. Clinical type of diarrhoeaThe three clinical types of infectious diarrhoea are: · acute watery diarrhoea · acute bloody diarrhoea (dysentery)· persistent diarrhoea All of these can cause dehydration, although dehydration is most common in patients with acute watery diarrhoea such as rotavirus infection or cholera.Related tutorials Refer to the tutorial Diarrhoeal Diseases: Clinical Assessment.Other signs Further signs of severe dehydration in this child are: · very sunken eyes · reduced consciousness Image references ################ .\IMAGES\T45895.jpg Overview of the Management of Diarrhoea - 2 Aims of treatment Treatment of a child with acute diarrhoea aims to: · prevent dehydration if there are no signs of dehydration present · treat dehydration when it is present· prevent nutritional damage · give antimicrobials for specific enteric infections· treat associated infections or complications For related tutorials covering treatment of malnutrition. Picture: A boy in a cholera cot, which contains a plastic sheet to collect the stool in a bucket below a hole in the bed. Note the bottle of rehydration solution and cup by the bedside.Copyright Image from Bryceson ADM. Treat dehydration The aim of rehydration is to replace lost: · water· electrolytes (Na+, Cl-, K+, HCO3-)Prevent nutritional damage Diarrhoea worsens nutritional status through: · reduced dietary intake, due to anorexia and incorrect treatment during the diarrhoea episode · increased metabolism · direct losses from the damaged bowel mucosa · reduced digestion and absorption of nutrients due to damaged small bowel mucosa The effects of diarrhoea on nutritional status are reduced by restarting feeding early. Enteric infections Antimicrobials should not be routinely given to patients with diarrhoea. The only acute enteric infections for which drug treatment is indicated are: · suspected cholera · dysentery - treat for shigellosis · amoebic dysentery Refer to the Diarrhoeal Diseases tutorials: · The Role of Diet and Drugs · Acute Watery Diarrhoea · Acute Bloody DiarrhoeaRelated tutorials For details of the dietary management of children with severe malnutrition, refer to the tutorial Diarrhoeal Diseases: The Role of Diet and Drugs. Image references ################ .\IMAGES\T39733.jpg Overview of the Management of Diarrhoea - 3 Prevention and treatment of dehydration The degree of dehydration is assessed as one of three categories using a standardized World Health Organization (WHO) chart. The table shows the treatment plan for each category of dehydration. This tutorial describes the three strategies, called by the WHO treatment plans A, B and C. Management of Dehydration (WHO 1995) Degree of Loss in Estimated dehydration body weightfluid deficit Treatment plan No signs <5% <50 ml/kgA. Home therapy to of dehydration prevent dehydrationand malnutrition Some 5 - 10% 50 - 100 ml/kgB. Oral rehydrationdehydration1 therapy with oralrehydration saltssolution Severe >10% >100 ml/kgC. Urgent dehydration1 intravenousrehydration1. A child with some or severe dehydration should be weighed to estimate how much fluid to give for rehydration. For an example. Related tutorialsRefer to the tutorial Diarrhoeal Diseases: Clinical Assessment.Estimation of fluid deficit For example, a child with some dehydration who weighs 5 kg unclothed has a fluid deficit of: Fluid deficit= [50 - 100] ml/kg x 5 kg = 250 -500 ml If a scale to weigh the child is not available, the child’s weight should be estimated from a growth chart. Image references ################ Treatment Plan A: No Signs of DehydrationTreatment Plan A: No Signs of Dehydration Image references ################ Treatment Plan A: No Signs of Dehydration - 1 Plan A: Home therapy to prevent dehydration and malnutrition. Mothers should be taught three basic rules (see table) for managing these children at home, and why these actions are important. Three Rules for Managing a Child with No Signs of Dehydration Rule 1 Give the child more fluids than usual,to prevent dehydration. Rule 2 Continue to feed the child, to preventmalnutrition. Rule 3 Take the child to a health worker ifsigns of dehydration or othercomplications appear.Need to prevent dehydrationIf extra fluid and salts are not given to a child with diarrhoea, he or she may rapidly become dehydrated and could die. Image references ################ Treatment Plan A: No Signs of Dehydration - 2 Volumes of fluidto give per stool 50 - 100 ml100 - 200 ml As much as wanted Rule 1: Give the child more fluids than usual, to prevent dehydration. Several home fluids should be given, at least one of which should normally contain salt. Suitable fluids that contain salt include: · salted yogurt drink (‘butter-milk’)· salted vegetable or chicken soup · oral rehydration salts solution Suitable fluids that contain little or no salt include: · clean plain water · unsalted soup and yogurt · green coconut water · unsweetened weak tea or fresh fruit juice Picture: Click on each child for a guide of how much fluid to give. Which fluids are not suitable? Copyright Image from The Wellcome Trust. Several fluids By giving several fluids the mother is more likely to give a large enough total volume. This is important because mothers often fail to give sufficient volumes of fluid.Salt Salt encourages the uptake of fluids and nutrients. This is because there is linked uptake (cotransport) in the small bowel of: · Na+ and water · Na+ and glucose · Na+ and amino acids Refer to the tutorial Diarrhoeal Diseases: Organisms and Pathophysiology.Unsuitable fluids Fluids that should be avoided include: · any drinks sweetened with a lot of sugar· carbonated (‘fizzy’) soft drinks · coffee· medicinal teas These drinks may have harmful osmotic, stimulant, diuretic or purgative effects.Children aged under 2 years Give as much fluid as the patient wants while the diarrhoea lasts. As a rough guide, after each loose stool the mother should give 50 -100 ml or¼- ½ of a large cup by spoon.Children aged 2 - 10 years Give as much fluid as the patient wants while the diarrhoea lasts. As a rough guide, after each loose stool the mother should give 100 - 200 ml or ½ - 1 large cup.Older children and adults These patients can ask for more to drink and should be given as much fluid as they want while the diarrhoea persists. These patients can ask for more to drink and should be given as much fluid as they want while the diarrhoea persists.Image references ################ .\IMAGES\Kidsage.jpg Treatment Plan A: No Signs of Dehydration - 3 Rule 2: Continue to feed the child, to prevent malnutrition. During an episode of diarrhoea: · breast feeding should be continued · feeding of solid food should continue and be increased afterwards· food should never be withheld and the child’s usual foods should not be diluted The child should be given as much nutritious food as he or she will accept. Picture: Click on each child for recommendations.Copyright Image from The Wellcome Trust. Breast feeding Breast feeding throughout an episode of diarrhoea reduces the: · severity and duration of diarrhoea · risk of dehydration · risk of diarrhoea worsening nutritional statusWithholding & dilution of food It is common practice in many societies to reduce the food given to a child with diarrhoea by: · diluting the child’s usual food · withholding solid food completely to ‘rest the bowel’ These practices are of no benefit and are likely to worsen nutritional status.Feeding solid food If food is given little and often during diarrhoea: · significant amounts of nutrition are absorbed · intestinal function recovers more rapidly · the impact on nutritional status is reduced Refer to the tutorial Diarrhoeal Diseases: The Role of Diet and Drugs.Breast feeding infantsInfants of any age being exclusively breast fed should be: · allowed to breast feed as much as they want · encouraged to breast feed more than usual Exclusive breast feeding should be promoted for at least the first 4 - 6 months of life.Infants below 4 - 6 months taking breast milk and solidsInfants below 4 - 6 months taking breast milk and solid foods should be: · encouraged to take more breast milk · fed less solid food as production of breast milk increases Exclusive breast feeding should be promoted for at least the first 4 - 6 months of life.Infants taking animal or formula milkInfants being fed animal or formula milk should be: · given their usual feed at least every 3 hours · fed by cup rather than bottle if possible Significant intolerance to the lactose in milk is usually not a problem in children with acute diarrhoea, although it may be important in persistent diarrhoea.Children over 6 months taking solidsChildren over 6 months should be: · started on solid foods, if they are not already eating solids, during the diarrhoea episode · given milk and easily digestible foods (cereals, vegetables etc) of high energy and micronutrient content Image references ################ .\IMAGES\Kidsdiet.gif Treatment Plan A: No Signs of Dehydration - 4 Rule 3:Take the child to a health worker if signs of dehydration or other problems appear. The mother must take her child to a health worker if he or she: · starts to pass many watery stools · has repeated vomiting · becomes very thirsty · does not pass urine · is eating or drinking poorly · develops a fever · has blood in the stool (see picture)· still has diarrhoea after 3 more daysPicture: A stool from a patient with acute bloody diarrhoea. Copyright Image from Bennish M. Blood in the stool If a child with watery diarrhoea begins to pass bloody stools: · shigellosis must be suspected · antibiotic therapy is necessary Refer to the tutorial Diarrhoeal Diseases: Acute Bloody Diarrhoea. Image references ################ .\IMAGES\T45899.jpg Treatment Plan A: No Signs of Dehydration. Assessment - 1A 9-month-old boy is brought to your clinic with a history of watery diarrhoea for 2 days. The boy normally eats a mixed diet of cow’s milk, rice, pulses and vegetables. During the illness his mother has given him only boiled rice and tea. She has also bought a medicine from the chemist ‘to stop the diarrhoea’. On physical examination the boy has no signs of dehydration and is well nourished.Are the following statements true or false? To return to the start of the section. Click on the True or False button for each statement. 1. The boy should be admitted to the clinic for oral rehydration under supervision.2. You must find out what medicine was taken and give another medicine to counter its effects.3. The boy should be brought back if he does not eat or drink normally at home, or starts to pass bloody stools.Correct Text 11 pt Arial dark blue goes here Incorrect The boy has no signs of dehydration and should be treated at home. The mother should be encouraged to give: · extra fluids · frequent nutritious food and milkIncorrect Text 11 pt Arial dark blue goes here Correct The boy has no signs of dehydration and should be treated at home. The mother should be encouraged to give: · extra fluids · frequent nutritious food and milkCorrect Text 11 pt Arial dark blue goes here Incorrect You should ask the mother what she has given him and be aware of possible adverse effects. However, the boy should be given no further medicine unless he has suspected cholera or dysentery.Incorrect Text 11 pt Arial dark blue goes here Correct You should ask the mother what she has given him and be aware of possible adverse effects. However, the boy should be given no further medicine unless he has suspected cholera or dysentery.Correct The mother should also bring the child back if he:· starts to pass many watery stools · has repeated vomiting · becomes very thirsty · does not pass urine · develops a fever · still has diarrhoea after3 more days Incorrect Text 11 pt Arial dark blue goes here Incorrect The mother should also bring the child back if he:· starts to pass many watery stools · has repeated vomiting · becomes very thirsty · does not pass urine · develops a fever · still has diarrhoea after3 more days Correct Text 11 pt Arial dark blue goes hereImage references ################ Treatment Plan A: No Signs of Dehydration. Assessment - 2Are the following statements true or false? Suitable home fluids for giving to a child with diarrhoea but no signs of dehydration include: Click on the True or False button for each statement. To return to the start of the section. 1. plain water 2. a fizzy soft drink 3. salted chicken soup4. sweetened teaCorrect Plain water is suitable for preventing dehydration. It should be given with drinks that contain salt.Incorrect Text 11 pt Arial dark blue goes here Incorrect Plain water is suitable for preventing dehydration. It should be given with drinks that contain salt.Correct Text 11 pt Arial dark blue goes here Correct Text 11 pt Arial dark blue goes here Incorrect Carbonated (fizzy) drinks are not suitable for preventing dehydration.Incorrect Text 11 pt Arial dark blue goes here Correct Carbonated (fizzy) drinks are not suitable for preventing dehydration.Correct Salted soup is suitable for preventing dehydration. It should be given with drinks that do not contain salt.Incorrect Text explaining the answer (11-pt plain blue) Incorrect Salted soup is suitable for preventing dehydration. It should be given with drinks that do not contain salt.Correct Text explaining the answer (11-pt plain blue) Correct Incorrect Sweetened tea is not suitable for preventing dehydration, although unsweetened weak tea is a suitable drink. It should be given with drinks that contain salt. Incorrect Text explaining the answer (11-pt plain blue) Correct Sweetened tea is not suitable for preventing dehydration, although unsweetened weak tea is a suitable drink. It should be given with drinks that contain salt. Image references ################ Oral Rehydration Salts SolutionOral Rehydration Salts Solution Image references ################ Oral Rehydration Salts Solution - 1 Composition of ORS solution(g/l)Oral rehydration salts (ORS) solution What is ORS solution? ORS solution given by mouth is effective in replacing water and electrolyte losses due to diarrhoea. It works because: ·coupled uptake of Na+ and glucose by the small bowel favours the uptake of water and other electrolytes·the Na+, K+ and Cl- in ORS solution replace losses of these electrolytes in the stool ·the citrate helps correct acidosis KCl Trisodium citrate 1.5 2.9 3.5 NaCl 20.0 GlucoseConcentration of ORS solution (mmol/l)120600 111 90 802010 GlucoseNa+K+ Cl- Citrate Copyright Images from The Wellcome Trust. Coupled uptake Refer to the tutorial Diarrhoeal Diseases: Organisms and Pathophysiology.ORS solution ORS solution is a solution of glucose and electrolytes in defined amounts (see pie chart and graph). This formula has been developed after repeated clinical trials and physiological studies over more than 30 years. Image references ################ .\IMAGES\Orspiegf.gif Oral Rehydration Salts Solution - 2Other solutions recommended for oral rehydration Certain solutions other than ORS are suitable for oral rehydration or prevention of dehydration (see table). A product that contains only the active ingredients shown in the specified concentrations may legally carry the statement: ‘The composition of this product yields substance concentrations within the limits recommended by WHO.’Composition of Alternatives to ORS Solution Concentration Standard ORS Component range (mmol/l)solution (mmol/l) Glucose1 < 111 111 Na+ 60 - 902 90 K+ 15 - 2520 Cl- 50 - 80 80 Citrate8 - 1210 Total200 - 330 311 1. The glucose concentration should be at least equal to the Na+ concentration. 2. 60 mmol/l Na+ is recommended in developed countries. Developed countries A Na+ level of 60 mmol/l is recommended in developed countries because: · standard ORS solution may cause hypernatraemia (high blood sodium) · salt losses in the stool are generally less than in regions where cholera is common Image references ################ Oral Rehydration Salts Solution - 3 Global access to ORS and use of ORT. Improved oral rehydration solutions A major limitation of standard ORS solution is that it does not reduce the:·stool volume ·stool frequency ·duration of diarrhoea This makes ORS solution less acceptable to mothers, who want to see the diarrhoea ‘getting better’. Two modifications of the standard solution partly overcome these problems: · reduced osmolarity glucose based ORS solution · cereal based ORS solution How would improved solutions help?80604020 0 Data from WHO 1982-1990. Access (%) Use (%) 1984 1985 1986 1987 1988 1989 1990 Year Copyright Image from The Wellcome Trust modified from World Health Organization. CDD Programme Annual Reports, 1982 - 1990.Improved oral rehydration solutionsBy reducing the duration or severity of diarrhoea, these improved solutions could: · increase the acceptability and usage rate of ORT (see graph showing current use) · reduce the inappropriate use of antidiarrhoeal drugs such as loperamide Refer to the tutorial Diarrhoeal Diseases: Prevention and Control.Limitations of standard ORS The high concentration of salts and glucose in standard ORS solution acts as an osmotic load in the bowel lumen. This can limit absorption of water and electrolytes to some extent.Image references ################ .\IMAGES\Useofor2.gif Oral Rehydration Salts Solution - 4Comparison of reduced osmolarity and standard ORS solutions.Reduced osmolarity glucose based ORS solutions How do these differ from standardORS solution? In children with acute non-cholera diarrhoea, reduced osmolarity glucose based ORS solutions significantly reduce the: · stool output (see graph - left axis)· duration of diarrhoea (see graph - right axis)· need for intravenous rehydration WHO may soon adopt a glucose based reduced osmolarity ORS solutions as the preferred formulation for non-cholera and cholera diarrhoea. Data from International Study Group 1995. Duration (hours) Stool output (g/kg) 100 80 60 Standard ORS Low osmolarityORS 50 4030 Stool output Duration Copyright Image from The Wellcome Trust modified from International Study Group on Reduced- osmolarity ORS solutions. Lancet 1995;354: 282-5. Reduced osmolarity ORS Compared with the standard formulation, reduced osmolarity ORS solutions have a lower: · glucose concentration: 75 - 90 versus 111 mmol/l · Na+ concentration: 60 - 75 versus 90 mmol/l · osmolarity: 225 - 250 versus 311 mOsmol/lORS solutions for cholera Trials are currently testing whether reduced osmolarity ORS solution is appropriate for cholera, where losses of water and electrolytes are often greater than in other forms of diarrhoea. Image references ################ .\IMAGES\Lowosm.gif Oral Rehydration Salts Solution - 5 Comparison of cereal based and standard ORS solutions: meta-analysis of 13 trials. Data from Gore et al 1992.Cereal based ORS solutions How do these differ from standardORS solution? Trials suggest that rice based ORS solutions (see graph) are: · better than standard ORS in adults and children with cholera · no better in children with acute non-cholera diarrhoea These results are dependent on early feeding after rehydration, as recommended by WHO. Cereal based ORS solutions remainunder development. 24 hour stool output relative to standard ORS (%) +40 +20 0 -20 -40 -60 CholeraNon-cholera Copyright Image from The Wellcome Trust modified from Gore SM, Fontaine O, Pierce NF. BMJ 1992;304:287-91. Cereal based ORS solutions Compared with the standard formulation, cereal based ORS solutions: · provide more carbohydrate (50 - 80 g/l of cooked rice powder versus 20 g/l of glucose - the rice is broken down to glucose at the brush border membrane) · have much lower osmolarityCereal based ORS solutions in non-cholera diarrhoea In non-cholera diarrhoea: · mucosal damage may reduce the breakdown of polysaccharides in rice · the carbohydrate stored in cereal based ORS solutions may not be releasedOutstanding questions and future developments · Can a commercial formulation containing precooked rice be developed? · Can a standardized product be developed? · How stable will such a product be? · How much more than ORS will it cost? Image references ################ .\IMAGES\Cereals.gif Oral Rehydration Salts Solution - 6Preparations that are not recommended for oral rehydration The efficacy of ORS solution is not improved by adding: · colouring· flavouring · vitamins · minerals In addition, ‘sports drinks’ are of no value for the treatment of diarrhoeal dehydration. Colouring and flavouring Use of ORS solution with added colouring and flavouring agents, aimed at improving its acceptability to children: · has no benefits over standard ORS · increases costs · may lead to allergies and other adverse effectsVitamins and minerals The exception to this is dehydrated children wth severe malnutrition. These children are given a special oral rehydration solution to which vitamins and minerals have been added to correct micronutrient deficiencies. Refer to the tutorial Diarrhoeal Diseases: The Role of Diet and Drugs. ‘Sports drinks’A clear distinction must be made between: · products for treatment or prevention of diarrhoeal dehydration - if of suitable composition these may carry the WHO approved wording (see screen 18) · sports drinks for replacing water and salt lost during exercise - labels on these should make no reference to diarrhoea Image references ################ Oral Rehydration Salts Solution: Assessment - 1Are the following statements about ORS solution true or false?To return to the start of the section. Click on the True or False button for each statement. 1. A problem with promoting ORS solution is that it does not reduce the volume or duration of diarrhoea.2. Reduced osmolarity ORS solutions are less effective than the standard formulation in children with non-cholera diarrhoea. 3. A drawback of preparing cereal based ORS solutions is the need for cooked rice.4. Vitamins added to standard ORS solution are an alternative to starting feeding early.Correct ORS solution: · replaces losses of water and electrolytes due to diarrhoea, so correcting dehydration · does not reduce the duration or volume of diarrhoeaIncorrect Text 11 pt Arial dark blue goes here Incorrect ORS solution: · replaces losses of water and electrolytes due to diarrhoea, so correcting dehydration · does not reduce the duration or volume of diarrhoeaCorrect Text 11 pt Arial dark blue goes here Correct Text 11 pt Arial dark blue goes here Incorrect Compared with standard ORS solution in children with acute non-cholera diarrhoea, reduced osmolarity ORS solution reduces the: · stool output · duration of diarrhoea · need for intravenous rehydrationIncorrect Text 11 pt Arial dark blue goes here Correct Compared with standard ORS solution in children with acute non-cholera diarrhoea, reduced osmolarity ORS solution reduces the: · stool output · duration of diarrhoea · need for intravenous rehydrationCorrect This makes cereal based ORS solution more time consuming to prepare than standard ORS solution made from a prepacked sachet.Incorrect Text explaining the answer (11-pt plain blue) Incorrect This makes cereal based ORS solution more time consuming to prepare than standard ORS solution made from a prepacked sachet.Correct Text explaining the answer (11-pt plain blue) Correct Incorrect Vitamins added to ORS solution have no benefit. (But note that dehydrated children with severe malnutrition are given an oral rehydration solution with added micronutrients to correct micronutrient deficiencies.)Incorrect Text explaining the answer (11-pt plain blue) Correct Vitamins added to ORS solution have no benefit. (But note that dehydrated children with severe malnutrition are given an oral rehydration solution with added micronutrients to correct micronutrient deficiencies.) Image references ################ How do the different components in ORS solution work? Click your mouse on a component box below.Hold the mouse down and drag the box to the description that best describes how the component works.To return to the start of the section. Component Correct(s) electrolyte deficiency Taken up to correctdehydration Coupled uptake of this with Na+ favours absorption of water and electrolytes Correct(s) acidosis Oral Rehydration Salts Solution: Assessment - 2Glucose Na+, K+ and Cl- Citrate Water Yes. That's right. Yes. That's right. Yes. That's right. Yes. That's right. No. That's wrong. Try again. Well done. You have now finished this assessment.Image references ################ Treatment Plan B: Some DehydrationTreatment Plan B: Some Dehydration Image references ################ Treatment Plan B: Some Dehydration - 1 Plan B: Oral rehydration treatment (ORT) to correct ‘some dehydration’ Patients with ‘some dehydration’ need to drink ORS solution. This is called oral rehydration treatment (ORT). Tasks for the health worker for Plan B are to: · prepare ORS solution from a sachet · estimate how much ORS solution to give in the first 4 hours · show the mother how to give ORT · monitor the child’s rehydration · instruct about continuing treatment at home· identify patients who cannot be treated by oral rehydration Should ORS solution be given to childrenwith severe malnutrition? Picture: A 6-year-old boy being given oral rehydration for acute watery diarrhoea. Note the sunken eyes.Copyright Image from Cutting WAM. Treatment at home ORT should ideally be: · started under supervision in a health clinic · finished at home under the mother’s carePatients who cannot take ORTRehydration in these children is by: · nasogastric tube · intravenous infusion See screen 36 for details.Children with severe malnutrition Standard ORS solution: · is not suitable for children with severe malnutrition (eg. it contains too much Na+) · should be replaced with a modified ORS solution of different composition Refer to the tutorial Diarrhoeal Diseases: The Role of Diet and Drugs. Image references ################ .\IMAGES\T44893.jpg Treatment Plan B: Some Dehydration - 2 How to make ORS solution from a packet Health workers must be able to make ORS solution and teach a family member how to do so.To prepare ORS solution: 1. read the instructions on the packet: how much ORS solution does the packet make?2. measure the correct volume of water (usually 1 litre) into the container3. place the contents of the packet into the water 4. shake or stir the container to make sure that the salts are completely dissolved 5. cover the container to prevent dust and other contamination What do you need? Picture: A sachet of ORS solution promoted by WHO. Such sachets are made by a range of companies. The ORS used should be approved by WHO or the Ministry of Health.Is ‘sugar-salt solution’ an alternative to ORSsolution? Copyright Image from WHO Photo Library. What you need to make ORS solutionTo make ORS solution requires: · a source of clean water suitable for drinking, but not necessarily boiled · a clean container to measure 1 litre · a prepacked sachet of ORS (see picture)Sugar-salt solution In trials of sugar-salt solution (SSS) made from home ingredients: · mothers found preparation of the solutions too difficult · the Na+ concentration of the solutions varied dangerously widely Allthough some national diarrhoea control programmes still promote SSS, WHO does not favour mothers making oral rehydration solutions from home ingredients. Prepacked ORS and home available fluids are preferred.How much solution to use Most packets contain salts for dissolving into 1 litre of water, but this must be checked.Cover the container ORS solution made in this way must be used within 24 hours. Image references ################ .\IMAGES\T34928s.jpg Treatment Plan B: Some Dehydration - 3 Guidelines for Treating Patients with Some Dehydration (WHO 1995) Volume to giveAge1 Weight (kg) in first 4 hours (ml)2 < 4 months < 5.0 200 - 400 4 - 11 months 5.0 - 7.9 400 - 600 12 - 23 months 8.0 - 10.9 600 - 800 2 - 4 years 11.0 - 15.9 800 - 1200 5 - 14 years 16.0 - 29.9 1200 - 2200 > 15 years > 30.0 2200 - 4000Volume of ORS solution to give The volume of ORS solution needed for rehydration is based on the child’s: · weight - if this is known· age (see table) - if the weight is not known The table and calculation give estimates. The health worker should also be guided by the: · degree of dehydration · number of watery stools· child’s thirst For general notes. 1. The patient’s age should be used only when their weight is not known.2. Instead of ‘ml’ other measures that are familiar locally can be used. General notes1. A patient who wants more ORS solution than shown should be given more. The health worker must be aware of the signs of overhydration, such as puffy eyelids. If this occurs: · ORT should be stopped and replaced with milk orwater, and food · ORS solution or home fluids should be restartedwhen the puffiness has gone 2. Mothers should be encouraged to continue breast feeding. 3. Infants under 6 months who are not breast fed should also be given 100 - 200 ml of clean water during this 4 hour period. Weight If the weight is known, the volume of ORS solution to give over the first 4 hours is: Volume (ml)=Weight (kg) x75 ml/kg For example, a child weighing 5 kg requires 375 ml. Image references ################ Treatment Plan B: Some Dehydration - 4 How to give ORS solution ORS solution should be given in frequent small amounts (see video). What action should be taken if the child: · refuses to take fluids? · vomits during ORT? · becomes sleepy, drowsy or unconscious?Video: Giving ORS solution by the cup and spoon method. The health worker should teach a family member how to prepare and give ORS solution. To run the video.Copyright Image and video from United Nations Children's Fund, India. Frequent small amounts Fluids should be given: · with a teaspoon every1 - 2 minutes to children under2 years (feeding bottles should not be used) · as frequent sips from a cup for older children and adults ORT requires patience and perseverance on the part of the carer. Refuses fluids A child may refuse ORT because he or she: · does not like the unfamiliar taste of the fluid: patience and perseverance are needed · is irritable for some other reason, eg. infection elsewhere · is rehydrated and no longer thirstyVomiting Vomiting is common if the ORS solution is drunk too quickly, especially early during rehydration. The carer should: 1. wait 5 - 10 minutes2. start giving ORS solution again, but more slowly 3. not give antiemetic drugs, which cause drowsiness Vomiting rarely prevents successful rehydration as most of the fluid is absorbed. Sleepy, Drowsy or Unconscious Child Condition of child Action to take Sleeping Dehydrated Gently wake up for more ORT Well hydrated1 Allow to sleep Drowsy and weak Consider rehydration by nasogastric tube UnconsciousLook for other causes (meningitis, cerebral malaria, sedation) 1. Shown, for example, by recent passage of urine.Image references ################ .\IMAGES\Diarrh5.jpg Treatment Plan B: Some Dehydration - 5 Monitoring the progress of ORT The child should be checked from time to time during rehydration to: · ensure that the ORS solution is being taken · check for signs of dehydration After 4 hours of ORT the degree of dehydration should be assessed fully and acted on as shown in the flow chart. Feeding of children above 6 months should be started after 4 - 6 hours of ORT, except where severe dehydration has developed.Flow chart: Management of a patient after 4 hours of ORT.4 hours of ORT No signs of Some Severe dehydration dehydration dehydrationSwitch to Repeat Switch toPlan APlan BPlan C Copyright Image from The Wellcome Trust. DehydrationIf at any time during ORT the child becomes severely dehydrated, treatment Plan C (intravenous rehydration) should be started immediately.Early feedingPicture: Early feeding after initial rehydration.Image from United Nations Children's Fund, India. Giving children some food before they are discharged helps reinforce to the mother the importance of feeding at home (Plan A). Treatment plan AThe mother should be taught how to manage her child at home and given enough packets of ORS for 2 days of treatment.Treatment plan BPlan B should be modified to include food, milk and other fluids (as for Plan A).Treatment plan CIt is unusual for children who are taking ORT well to need intravenous rehydration. Image references ################ .\IMAGES\Flowchtb.gif .\IMAGES\T45967p.jpg Treatment Plan B: Some Dehydration - 6Talking to mothers about ORT Health workers should reinforce correct practice during ORT, especially: · continuing breast feeding during ORT · how to make ORS solution correctly · the volume of ORS solution to give · early feeding of solid food after initial rehydration How should health workers promote ORTto mothers? Picture: A health worker showing a mother how to give ORS solution by the cup and spoon method.Copyright Image from Behrens RH. Volume of ORS solution Even where ORT is given, a common problem is mothers not giving sufficient volumes. In a study in Pakistan, 19% of mothers using ORT thought that the correct dose was 1 - 2 teaspoons of ORS solution given two or three times per day. Promoting ORT to mothers A health worker talking to a mother should: · explain that ORT does not stop diarrhoea but does greatly reduce the risk of dehydration and death · show her how to prepare and give ORS solution correctly · ask her to demonstrate what she has learned Health workers should be aware that mothers may: · have a low opinion of ORT · expect to pay for drugs to cure the diarrhoea Image references ################ .\IMAGES\T45359.jpg Treatment Plan B: Some Dehydration - 7Supplying normal fluid needs Rehydration replaces deficits of water and salts. Meanwhile a child needs to have its normal fluid requirements. These can be met according to the child’s age and condition (see picture). Picture: Click on each child for details of normal fluid needs. Copyright Image from The Wellcome Trust. Breast fed infantsPicture: An infant breast feeding during ORT.Image from Guidelines for Conducting Clinical Training Courses at Health Centres and Small Hospitals (Transparency Set). Programme for Control of Diarrhoeal Diseases, World Health Organization 1992. Breast fed infants should continue breast feeding during ORT (see picture).Non-breast fed infantsThese children should be given 100 - 200 ml of clean drinking water during ORT.Older children and adultsThese patients should be allowed to drink as much clean water as they want during ORT. Image references ################ .\IMAGES\Kidsvol.gif .\IMAGES\T45262p.jpg Treatment Plan B: Some Dehydration. Assessment - 1A 3-year-old girl is brought to your clinic after 4 days of loose stools, treated for the past 48 hours at home. Her diarrhoea has worsened and you assess her as having some signs of dehydration, needing ORT. The girl weighs 10 kg. How much ORS solution does the child need in the first 4 hours of rehydration? Type your answer (in ml) and then press Enter.How should the girl’s mother be advised to give the ORS solution? For the answer. To return to the start of the section.Answer: How to give ORS The mother should be told to give ORS solution in small amounts by cup. ORS solution should: · be given to children under 2 years by spoon· never be given by bottle Correct Yes. {EntryText@"Question text6"} ml is right. The correct answer is calculated as: 75 ml/kg x 10 kg = 750 ml The answer is ....................... Explanation..... Wrong again. The answer is ................ Explanation .................... You may want to revise this section (click Revise button). Incorrect No. {EntryText@"Question text6"} ml is not right. The correct answer is: 75 ml/kg x 10 kg = 750 mlImage references ################ Treatment Plan B: Some Dehydration. Assessment - 2After 4 hours of ORT you reassess the child. She has had one loose stool during this period. She has no signs of dehydration and her eyelids are a little puffy. Are the following statements true or false? To return to the start of the section. Click on the True or False button for each statement. 1. ORT with ORS solution should be continued, but fluid given more slowly.2. ORS solution should be stopped and water given. The girl should be sent home with ORS when all puffiness has gone. 3. All fluids should be stopped until the puffiness goes. ORS solution should then be restarted. Correct Text explaining the answer (11-pt plain blue) Incorrect The puffy eyes are a sign of overhydration. You need to: · stop giving ORS solution · give fluids that do not contain salt · send the child for home treatment when the puffiness has goneIncorrect Text explaining the answer (11-pt plain blue) Correct The puffy eyes are a sign of overhydration. You need to: · stop giving ORS solution · give fluids that do not contain salt · send the child for home treatment when the puffiness has goneCorrect The puffy eyes are a sign of overhydration. You need to: · stop giving ORS solution · give fluids that do not contain much salt · send the child for home treatment when the puffiness has goneIncorrect Text explaining the answer (11-pt plain blue) Incorrect The puffy eyes are a sign of overhydration. You need to: · stop giving ORS solution · give fluids that do not contain much salt · send the child for home treatment when the puffiness has goneCorrect Text explaining the answer (11-pt plain blue) Correct Text 11 pt Arial dark blue goes here Incorrect The puffy eyes are a sign of overhydration. You need to: · stop giving ORS solution · give fluids that do not contain much salt · send the child for home treatment when the puffiness has goneIncorrect Text 11 pt Arial dark blue goes here Correct The puffy eyes are a sign of overhydration. You need to: · stop giving ORS solution · give fluids that do not contain much salt · send the child for home treatment when the puffiness has gone Image references ################ Treatment Plan C: Severe DehydrationTreatment Plan C: Severe Dehydration Image references ################ Treatment Plan C: Severe Dehydration - 1 Who needs intravenous rehydration? Clinical assessment should identify children with: · severe dehydration· shock or circulatory collapse These children are at immediate risk of death and need urgent intravenous rehydration. Intravenous rehydration should also be considered in a child: · who has not improved after 2 - 4 hours of adequate ORT· in whom ORT greatly increases stool volume· with abdominal distension Setting up an intravenous infusion into the scalp vein of an infant with severe dehydration.Copyright Image from Cutting WAM. Shock or circulatory collapse Signs of shock or circulatory collapse are: · rapid weak (or absent) radial pulse · unrecordable blood pressure· reduced consciousness or lethargy · cool and moist hands or feet · slow capillary refilling of nailbeds (more than 2 seconds)No improvement with ORTCommon causes of failure of ORT are: · continuing rapid stool loss, eg. due to cholera · poor uptake of ORS solution due to fatigue or lethargy · frequent severe vomiting These patients should be given intravenous rehydration or ORS solution by nasogastric tube.Greatly increased stool volumeORT in a few children will fail because of impaired absorption of glucose due to monosaccharide intolerance. ORS solution in these children causes: · greatly increased stool volume · increased thirst · worsening dehydration · unabsorbed glucose in the stool These children need intravenous rehydration until ORS solution can be taken.Abdominal distensionAbdominal distension in a child with diarrhoea may be caused by: · antimotility drugs, eg. codeine and loperamide · bowel obstruction - this is rare but may require urgent surgery In either case intravenous rehydration should be given. (Distension can also be caused by K+ deficiency - if the child can take oral fluids and food, this should be corrected by feeding sources of K+ such as ORS solution and banana.)Image references ################ .\IMAGES\T23740.jpg Treatment Plan C: Severe Dehydration - 2 Practical administration of intravenous solutions Important technical aspects include: · training · sterile technique and equipment · sites for venous access · marking bottles and bags · operative access to cannulate a vein · intraosseous infusionPicture: Intravenous rehydration into the forearm vein of an Indonesian boy.Copyright Image from Bryceson ADM. Training Specific training is needed to give an intravenous infusion. Inserting a needle or cannula into a suitable vein requires practice, especially in a patient with circulatory collapse.Sterile conditionsTo prevent serious local and systemic infection requires use of sterile: · solutions · needles · tubes · bottles or bags These should not be reused unless so designed, and then only after sterilization. Venous access sites Preferred veins are in the: · back of the hand · forearm (see picture) · side of the scalp in infants · front of the elbow in older children and adults Adults with severe circulatory collapse may initially need two intravenous lines at once. Marking bottles and bagsThe rate of fluid flow into the patient can be monitored by: · using input-output charts (see screen 42) · marking the bottles and bags containing the intravenous solution to indicate how much should be given by particular times CannulationWhen intravenous access is difficult because of circulatory collapse: · cut down on a vein (eg. long saphenous vein just anterior to the medial malleolus) · insert a cannula for infusion of solution This minor operation: · is appropriate in a patient with life threatening shock · requires sterile technique, local anaesthetic and suitable instrumentsIntraosseous infusion Image from The Wellcome Trust modified from World Health Organization. Readings on diarrhoea. Student manual. Geneva: WHO, 1992. Intraosseous infusion can be life-saving in children with circulatory collapse. It requires: · insertion of a special needle into the medulla of a long bone, eg. the medial tibia· care not to injure the growing bone plate near the knee This technique: · should be used only if intravenous access cannot be obtained · allows rehydration as quickly as the intravenous route · should be available in an emergency department Image references ################ .\IMAGES\T39734.jpg .\IMAGES\Intraoss.gif Treatment Plan C: Severe Dehydration - 3Composition of Intravenous Rehydration Solutions Cations (mmol/l) Anions (mmol/l) Solution Na+K+Ca2+ Cl-Lactate Glucose Preferred Ringer’s lactate 130 4 2 109 280 or Ringer’s lactate 130 4 2 109 28 278 with 5% dextroseAcceptable Normal saline 154 0 0 1540 0 Not acceptable 5% glucose (dextrose) 0 0 0 0 0 278Ringer’s lactate Ringer’s lactate (Hartmann’s solution for injection): · is one of two preferred solutions for rapid rehydration · contains adequate Na+ and K+ to correct deficits of these · contains lactate, which is metabolized to bicarbonate to correct acidosis Ringer’s lactate with dextroseRinger’s lactate with 5% dextrose: · is preferred over Ringer’s lactate without dextrose· contains glucose (dextrose) to help prevent hypoglycaemiaNormal salineNormal saline (0.9%, isotonic or physiological saline): · can be used if Ringer’s lactate is not available · contains enough Na+ but neither K+ nor base (to correct acidosis) · can be supplemented with added K+ and lactate or bicarbonate, but this requires extreme care in measuring and mixing the solutions5% glucose Plain glucose (dextrose) solution: · is often available but should not be used · contains none of the essential electrolytes to replace losses or correct acidosis · does not effectively correct low circulating volume Image references ################ Treatment Plan C: Severe Dehydration - 4Volume of intravenous fluid to give Intravenous rehydration must be started immediately and a total of 100 ml/kg (see table) given over: · 6 hours in infants · 3 hours in older children and adults Guidelines for Intravenous Rehydration (WHO 1995)1 Time forTime for initial infusion subsequent infusion Age of 30 ml/kg of 70 ml/kgUnder 12 months 1 hour2 5 hours Over 12 months 30 minutes2 2.5 hours 1. More rapid infusion may be necessary in patients with severe cholera. 2. Repeated once if a strong radial pulse is not detected. Patients should also be given some ORS solution (5 ml/kg/hour) by mouth when they can take it. ORS solutionORS solution provides base (to correct acidosis) and K+. Depending on the intravenous solution used, these may not be adequately supplied by the intravenous infusion.Image references ################ Treatment Plan C: Severe Dehydration - 5Monitoring the progress of intravenous rehydration During rehydration the patient’s pulse should be checked and the rate of infusion adjusted accordingly. After 100 ml/kg of fluid has been given the degree of dehydration should be assessed fully and acted on as shown in the flow chart. Flow chart: Management of a patient after 100 ml/kg of intravenous rehydration.100 ml/kg of intravenous fluid No signs of Some Severe dehydration dehydration dehydrationSwitch to Switch toRepeatPlan APlan BPlan C Copyright Image from The Wellcome Trust. PulseThe radial pulse should be checked: · initially every 15 - 30 minutes until a pulse is detected · thereafter every hourTreatment plan BThe child should be observed for 6 hours while the mother gives ORS solution, or the mother taught how to do this at home.Treatment plan CIt is very unusual for repeat of intravenous rehydration to be necessary (only children who are passing frequent large volume watery stools). Image references ################ .\IMAGES\Flowchtc.gif Treatment Plan C: Severe Dehydration - 6 Limitations and complications of intravenous rehydration Intravenous infusion requires: · a hospital or health centre facility · trained staff · sterile equipment Problems with intravenous infusion include: · blockage or thrombosis of a vein· displacement of the cannula · double puncture· overload of the circulation Picture: A Jamaican child with severe malnutrition being rehydrated by nasogastric tube. Intravenous rehydration of a child with severe malnutrition can cause heart failure. Copyright Image from Golden M. Blockage or thrombosis Blockage or thrombosis: · can occur after a needle or cannula has been in a vein for a few hours · is not very serious unless many or major veins are blocked because alternative vessels open up, especially in children Overload of the circulationOverload of the circulation: · can occur if fluid is given too quickly · may cause congestive heart failure, especially in a small child or patient with a weak heart or severe malnutrition · can be avoided by looking for: - puffiness of the eyes Primarily in- liver enlargement children. - rapid breathing - cough and ‘moist crackles’ due to fluid in the lungDouble puncture Double puncture occurs when the needle passes through the vein and out of the other side. It causes: · rehydration fluid to enter tissue instead of the circulation · slowing in the drip rate and swelling near the site of the needleSterile equipmentWithout sterile technique there is a risk of: · infection at the site of the needle or cannula· an infection getting into the bloodstream, which can be very serious Image references ################ .\IMAGES\T27811.jpg Treatment Plan C: Severe Dehydration - 7 Use of input-output charts Which patients need these? The input side records the:· type of fluid to be given · volume of fluid to be given · route for fluid to be administered · volumes actually given · times at which fluids were administered The output side records:· the volume of urine passed · any vomits and their approximate volume · any stools, and their approximate volume and nature What is done with such information? Date: 9/7/97Weight:9.0 kg Patient’s name: M. Khaled DoB: 21/6/96 Observations Orders 0900 Severe dehydration IV Ringer’s 900 ml over 3 hours 1200 Some dehydration ORS solution 675 ml over4 hours Fluid Output Fluid Intake Vomit Urine Stool Total MouthIntravenous Total 0900100ml 900 ml Ringer’s 1045100ml 113050ml 3 h 150ml 250ml 900ml Balance = 650ml 1200ORS50ml 1230ORS80ml 1300ORS 100ml 100 ml Copyright Image from The Wellcome Trust. Use of input-output chartsInput-output charts should be used to: 1. compare the total input and output volumes over a period of time 2. adjust the rate of rehydration if necessary Adjustments may be necessary for: · an initial miscalculation · a change in the patient’s condition Careful use of input-output charts is vital for monitoring effective rehydration.Input-output charts Any child who is ill enough to require intravenous rehydration should have a proper record of fluid input and output for the duration of the procedure (see picture). Image references ################ .\IMAGES\Inoutcht.gif Treatment Plan C: Severe Dehydration - 8What if intravenous access is notavailable? For severe dehydration, intravenous rehydration is the treatment of choice. If access to this method is lacking, the protocol shown in the flow chart should be followed.Can IV fluids be given immediately? Can IV fluids be given immediately? Start IV fluids immediately (see screens 37 - 42 for details). YES YES YES YES NO Send the patient immediately for IV treatment. Give ORT during the journey if possible. IsIV treatment available within 30 minutes? NO Start nasogastric rehydration with ORS solution. Reassess every 1 - 2 hours. Are you trained in nasogastric rehydration? NO Start ORT with ORS solution. Reassess every 1 - 2 hours. Can the patient drink? NO Send the patient for urgent IV or nasogastric treatment.Flow chart: Management of severe dehydration where treatment facilities are limited. Copyright Image from The Wellcome Trust modified from World Health Organization. Readings on diarrhoea. Student manual. Geneva: WHO, 1992.Image references ################ .\IMAGES\Ltdiv.gif Treatment Plan C: Severe Dehydration. AssessmentAre the following statements true or false? Click on the True or False button for each statement.Intravenous rehydration should be given:To return to the start of the section. 1. to any patient with shock or circulatory collapse2. by community health workers at rural health clinics3. with 5% dextrose (glucose) solution4. initially as 30 ml/kg over 5 minutes in an infantCorrect These patients are at immediate risk of death. Intravenous fluids should also be considered in a child: · who has not improved after 2 - 4 hours of adequate ORT · in whom ORT greatly increases stool volume · with abdominal distensionIncorrect Text 11 pt Arial dark blue goes here Incorrect These patients are at immediate risk of death. Intravenous fluids should also be considered in a child: · who has not improved after 2 - 4 hours of adequate ORT · in whom ORT greatly increases stool volume · with abdominal distensionCorrect Text 11 pt Arial dark blue goes here Correct Text 11 pt Arial dark blue goes here Incorrect Intravenous rehydration requires: · a hospital or well equipped health centre · specific training · sterile technique and equipmentIncorrect Text 11 pt Arial dark blue goes here Correct Intravenous rehydration requires: · a hospital or well equipped health centre · specific training · sterile technique and equipmentCorrect Text 11 pt Arial dark blue goes here Incorrect Solutions that contain only glucose are ineffective and should not be used. Preferred intravenous solutions are: 1. Ringer’s lactate with or without 5% glucose 2. normal salineIncorrect Text 11 pt Arial dark blue goes here Correct Solutions that contain only glucose are ineffective and should not be used. Preferred intravenous solutions are: 1. Ringer’s lactate with or without 5% glucose 2. normal salineCorrect Incorrect Rates of intravenous infusion in an infant are: 1. 30 ml/kg over the first hour 2. 70 ml/kg over the next 5 hours Rates in adults are greater as the risk of overhydration is usually lower.Incorrect Text explaining the answer (11-pt plain blue) Correct Rates of intravenous infusion in an infant are: 1. 30 ml/kg over the first hour 2. 70 ml/kg over the next 5 hours Rates in adults are greater as the risk of overhydration is usually lower. Image references ################ Tutorial Assessment - 1A 10-month-old boy is brought to your clinic with severe diarrhoeal dehydration. He is very floppy with a weak pulse, has very sunken eyes and is unable to drink. The boy weighs 6 kg. Are the following statements true or false?The recommended treatment is:Click on the True or False button for each statement. To return to the start of the tutorial. 1. intravenous rehydration with Ringer’s lactate2. nasogastric rehydration with ORS solution3. intraosseous rehydration with normal salineCorrect Severe dehydration requires urgent intravenous rehydration where possible. Ringer’s lactate (with or without dextrose) is the preferred solution.Incorrect Severe dehydration requires urgent intravenous rehydration where possible. Ringer’s lactate (with or without dextrose) is the preferred solution.Incorrect Severe dehydration requires urgent intravenous rehydration where possible. Ringer’s lactate (with or without dextrose) is the preferred solution.Correct Correct Text 11 pt Arial dark blue goes here Incorrect The preferred method for severe dehydration is intravenous rehydration with Ringer’s lactate. Only if this is not available should nasogastric rehydration be used. Incorrect Text 11 pt Arial dark blue goes here Correct The preferred method for severe dehydration is intravenous rehydration with Ringer’s lactate. Only if this is not available should nasogastric rehydration be used. Correct Incorrect The preferred method for severe dehydration is intravenous rehydration with Ringer’s lactate. Only if this is not available, or a suitable vein cannot be found, should the intraosseous route be used.Incorrect Text explaining the answer (11-pt plain blue) Correct The preferred method for severe dehydration is intravenous rehydration with Ringer’s lactate. Only if this is not available, or a suitable vein cannot be found, should the intraosseous route be used. Image references ################ Tutorial Assessment - 2After 1 hour of intravenous fluid the child has improved a little. How much intravenous fluid should you give in the next 5 hours? Type your answer (in ml) and then press Enter. After this period of 5 hours you assess the child again. He has some dehydration but can take fluids by mouth and has passed urine. What is the recommended management at this time? For the answer. To return to the start of the tutorial. Answer: Management The correct treatment is to: 1. stop intravenous rehydration 2. give ORS solution and resume breast feeding3. observe the child for a few hours (start solid foods after4 - 6 hours of ORT) Correct Yes. {EntryText@"Question text8"} ml is right. The correct answer is calculated as: 70 ml/kg x 6 kg = 420 ml The answer is ....................... Explanation..... Wrong again. The answer is ................ Explanation .................... You may want to revise this section (click Revise button). Incorrect No. {EntryText@"Question text8"} ml is not right. The correct answer is: 70 ml/kg x 6 kg = 420 mlImage references ################ Summary Click on the buttons below for summary information. Picture: A young woman with suspected cholera being given ORS solution by cup.Overview of the Management of Diarrhoea Treatment Plan A Oral Rehydration Salts Solution Treatment Plan B Treatment Plan C Copyright Image from Cutting WAM. Overview of the Management of DiarrhoeaTreatment of a child with diarrhoea aims to: · manage dehydration (see table) · prevent nutritional damage· give antimicrobials for specific enteric infectionsDegree ofLoss inEstimated dehydration body weight fluid deficitTreatment plan No signs <5% <50 ml/kgA. Home therapy to preventof dehydrationdehydration and malnutrition Some5 - 10% 50 - 100 ml/kgB. Oral rehydration therapydehydrationwith oral rehydrationsalts solution Severe >10% >100 ml/kgC. Urgent intravenousdehydrationrehydrationTreatment Plan AHome therapy to prevent dehydration and malnutrition Three rules for home management of a child with ‘no signs of dehydration’. Rule 1. Give the child more fluids than usual, to prevent dehydration.· give plenty of home available fluids · avoid sweetened drinks, carbonated drinks and coffee Rule 2. Continue to feed the child, to prevent malnutrition. · give normal foods little and often, as much as the child will take · continue breast feeding Rule 3. Take the child to a health worker if signs of dehydration or other complications (eg. fever, bloody stool) appear. Oral Rehydration Salts SolutionORS solution: · contains glucose and electrolytes in defined amounts · favours uptake of water and other electrolytes by coupled uptake of · can be replaced with approved solutions of composition within permitted limits Improved oral rehydration solutions: · aim to reduce stool output, a major limitation of standard ORS solution · are of two main types: - reduced osmolarity glucose based ORS solution - cereal based ORS solutionNa+ and glucose Treatment Plan BOral rehydration therapy with ORS solution Health workers should be able to: · prepare ORS solution from a sachet and teach a family member how to do so · estimate how much ORS solution to give in the first 4 hours · show the mother how to give ORT in frequent small amounts from a teaspoon or sips from a cup · monitor the child’s rehydration · identify patients who cannot be treated by oral rehydrationTreatment Plan CUrgent intravenous rehydration Intravenous rehydration is essential for patients with severe dehydration, shock or circulatory collapse. It requires: · specific training · sterile technique and equipment· choice of site for venous access · choice of solution: Ringer’s lactate (with or without 5% dextrose) or normal saline · infusion at a rate dependent on the patient’s age and progress · regular monitoring and assessment · use of an input-output chart Alternatives to intravenous rehydration are: · intraosseous infusion · operative access to cannulate a vein · nasogastric intubation where facilities are limited Section 1 Section 2 Section 3 Section 4 jpg image goes here Copyright Copyright Image from ....... (copyright info) (10 point Arial, blue) Section 1 Pop-up text is in blue with a yellow title in 10 pt bold left aligned.The pop up is a display icon within the library, and if the text is too long then a scroll bar should be used, pop-up boxes can be larger. Section 2 Pop-up text is in blue with a yellow title in 10 pt bold left aligned.The pop up is a display icon within the library, and if the text is too long then a scroll bar should be used, pop-up boxes can be larger. Section 3 Pop-up text is in blue with a yellow title in 10 pt bold left aligned.The pop up is a display icon within the library, and if the text is too long then a scroll bar should be used, pop-up boxes can be larger. Section 4 Pop-up text is in blue with a yellow title in 10 pt bold left aligned.The pop up is a display icon within the library, and if the text is too long then a scroll bar should be used, pop-up boxes can be larger.Image references ################ .\IMAGES\T44898s.jpg You have now finished the tutorial Rehydration and Early Feedingã The Trustee of the Wellcome Trust, 1998 Further reading Further activities Restart tutorial Picture: A 2-year-old girl being given oral and intravenous rehydration for diarrhoea in Bangladesh.Copyright Image from Cutting WAM. Further reading Desjeux J-F, Briend A, Butzner JD. Oral rehydration solution in the year 2000: pathophysiology, efficacy and effectiveness. Baillieres Clin Gastroenterol 1997;11:509-27. Mahalanabis D. Current status of oral rehydration as a strategy for the control of diarrhoeal diseases. Indian J Med Res 1996;104:115-24. Richards L, Claeson M, Pierce NF. Management of acute diarrhea in children: lessons learned. Pediatr Infect Dis J 1993;12:5-9. World Health Organization. The treatment of diarrhoea - a manual for physicians and other senior health workers. WHO/CDR/95.3. Geneva: WHO, 1995. Further activities To look at pictures related to this tutorial, search the image collection using the following keywords: · treatmentImage references ################ .\IMAGES\T44896.jpg