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Describe the plans A, B, C of Acute Diarrhoea — Assessment of Dehydration & WHO Management.

Pediatrics · Final Professional

Diarrhoea is the passage of 3 or more loose or watery stools in a 24-hour period (or a change from the normal pattern that the mother considers abnormal).
Acute diarrhoea lasts < 14 days.
It is a leading cause of under-5 mortality in India, chiefly through dehydration and its consequences.

Viral (commonest): Rotavirus (the leading cause of severe dehydrating diarrhoea in infants), norovirus, adenovirus.
Bacterial: enterotoxigenic E. Coli (ETEC), Shigella (dysentery), Vibrio cholerae (rice-water stools), Salmonella, Campylobacter.
Parasitic: Giardia lamblia, Entamoeba histolytica, Cryptosporidium.
Non-infective: antibiotic-associated, feeding errors, food allergy, malabsorption.

Secretory — enterotoxins (e.g. Cholera toxin) activate cAMP → active Cl⁻ and water secretion → voluminous watery stools that persist with fasting.
Osmotic — unabsorbed solutes (e.g. Lactose in disaccharidase deficiency) draw water into the lumen; stops with fasting.
Invasive/inflammatory — mucosal invasion (Shigella, Entamoeba) → blood, mucus and pus in stool (dysentery).

The single most important step is to assess the degree of dehydration, which then guides the treatment plan:

Sign	No dehydration	Some dehydration	Severe dehydration
General condition	Well, alert	Restless, irritable	Lethargic / unconscious
Eyes	Normal	Sunken	Very sunken & dry
Thirst	Drinks normally	Thirsty, drinks eagerly	Drinks poorly / unable
Skin pinch	Goes back quickly	Goes back slowly	Goes back very slowly (> 2 s)
Fluid deficit	< 5%	5–10%	> 10%

Age	First give 30 mL/kg in	Then give 70 mL/kg in
< 12 months	1 hour	5 hours
≥ 12 months	30 minutes	2½ hours

Reassess every 15–30 min; if not improving, give fluids faster.
Start ORS (~5 mL/kg/hr) as soon as the child can drink; give zinc when feeding resumes.
If IV access is impossible → ORS by nasogastric tube (20 mL/kg/hr).

Dehydration → hypovolaemic shock, acute kidney injury, and death.
Electrolyte disturbances — hypo/hypernatraemia, hypokalaemia (ileus, weakness), acidosis.
Persistent diarrhoea; malnutrition; secondary lactose intolerance; seizures (dysnatraemias).

Exclusive breastfeeding; safe complementary feeding; hand-washing and safe drinking water & sanitation.
Rotavirus vaccine and measles vaccine; vitamin A; use of ORS + zinc at community level.

Frequent loose/watery stools with or without vomiting; the history should note the number, volume and character (watery vs bloody) of stools and vomits.
Features of dehydration — irritability or lethargy, sunken eyes, dry mouth, reduced urine output, thirst.
Fever, abdominal pain and, in dysentery, blood/mucus in the stool with tenesmus.
Signs of associated problems — malnutrition, respiratory infection, or systemic sepsis.

Most acute watery diarrhoea needs no investigation — assessment of hydration is clinical.
Stool examination (microscopy/culture) if the stool is bloody, in suspected cholera, in persistent diarrhoea, or in an immunocompromised child.
Serum electrolytes, blood glucose & renal function in severe dehydration, altered sensorium, convulsions, or before/during IV therapy.
Blood counts and a septic screen if systemic infection is suspected.

One of the most damaging traditional practices in India is understanding why withholding food from a child with diarrhoea — done with the best intentions, to 'rest the bowel' — is actively harmful and kills children.
It is intuitive to think that if food goes in and diarrhoea comes out, stopping the food will stop the diarrhoea.
But this is wrong on every count.
First, the absorptive capacity of the gut is largely preserved even in acute diarrhoea — 60–90% of nutrients continue to be absorbed.
Second, the gut mucosa depends on luminal nutrition to maintain itself: starving it causes villous atrophy, which impairs absorption further and prolongs the diarrhoea.
Third, and most importantly, the child is catabolic and is losing protein and nutrients — so a few days of starvation, repeated with each episode of diarrhoea (and Indian children may have several episodes a year), is precisely how acute diarrhoea converts a normally-nourished child into a malnourished one, and a malnourished child into a dead one.
Hence the rule: continue breastfeeding and feeding throughout, and give an extra meal a day for two weeks afterwards to catch up.

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