What is the appropriate IV plan for a 9.5kg child patient with moderate dehydration, vomiting, and Lower Bowel Movement (LBM) due to a systemic viral infection?

IV Fluid Management for 9.5kg Child with Moderate Dehydration

For this 9.5kg child with moderate dehydration from viral gastroenteritis, administer 100 mL/kg (950 mL total) of isotonic crystalloid (normal saline or Ringer's lactate) over 2-4 hours, followed by ongoing replacement of 60-120 mL oral rehydration solution (ORS) for each diarrheal stool or vomiting episode. 1, 2

Initial Rehydration Phase

IV Fluid Administration

• Administer 950 mL (100 mL/kg) of isotonic crystalloid over 2-4 hours for moderate dehydration (6%-9% fluid deficit) 1, 2
• Use normal saline or Ringer's lactate as the initial IV fluid 1
• If the child shows signs of shock or severe dehydration (≥10% deficit with altered mental status, prolonged skin tenting >2 seconds, poor perfusion), give 20 mL/kg boluses (190 mL) rapidly until vital signs normalize, then continue with the remaining deficit 1, 2

Monitoring During Rehydration

• Reassess hydration status after 2-4 hours by checking skin turgor, mucous membranes, urine output, capillary refill, and mental status 1, 2
• If still dehydrated after initial therapy, reestimate the fluid deficit and restart rehydration 1
• Once clinical signs normalize (improved skin turgor, moist mucous membranes, adequate urine output), transition to oral rehydration therapy 2

Transition to Oral Maintenance

When to Transition

• Once the child is alert and able to drink, transition from IV to oral rehydration even if IV therapy is ongoing 2
• For children under 10kg, this transition should occur as soon as mental status and perfusion normalize 2, 3

Oral Rehydration Protocol

• Administer 60-120 mL of ORS (Pedialyte) for each diarrheal stool or vomiting episode 2, 3
• Alternative calculation: 10 mL/kg (95 mL) for each watery stool and 2 mL/kg (19 mL) for each vomiting episode 2
• Start with small volumes (5 mL every 5 minutes) if vomiting persists, then gradually increase to 10-15 mL every 10-15 minutes as tolerated 3

Ongoing Loss Replacement Strategy

Algorithmic Approach

1. Replace each stool/vomit immediately with 60-120 mL ORS 2, 3
2. Continue replacement as long as diarrhea or vomiting persists 2
3. Maximum daily ORS volume approximately 500-600 mL for ongoing losses in addition to maintenance needs 3

If Vomiting Prevents Oral Intake

• Consider nasogastric administration at 15 mL/kg/hour (143 mL/hour) if the child cannot tolerate oral intake but is not in shock 2, 4
• This allows continuous rehydration without requiring IV access 4

Nutritional Management

Feeding During Illness

• Resume age-appropriate diet within 3-4 hours after rehydration is complete 2, 4
• Do not delay feeding until diarrhea stops—continue age-appropriate feeding throughout the illness 4
• If breastfeeding, continue nursing throughout the illness in addition to ORS 2, 3

Critical Pitfalls to Avoid

Inappropriate Fluid Choices

• Never use apple juice, Gatorade, sports drinks, or soft drinks for rehydration—these have inappropriate electrolyte content and high osmolality that can worsen diarrhea 2, 4, 3
• Only use commercially available low-osmolarity ORS formulations like Pedialyte 2, 4

Medication Errors

• Do not use anti-diarrheal medications in children with acute diarrhea 2, 4, 3
• Do not restrict fluids—adequate hydration is essential for recovery 4, 3

Electrolyte Considerations

• Add dextrose to IV fluids to prevent hypoglycemia in young children 2
• Consider potassium supplementation once urine output is established 2
• Measure serum electrolytes if there are clinical signs suggesting abnormal sodium or potassium concentrations 1

When to Escalate Care

Red Flags Requiring Immediate Attention

• Severe lethargy or altered mental status 1
• Inability to keep down ORS despite small-volume administration 3
• Worsening dehydration signs (prolonged capillary refill, cool extremities, decreased perfusion) 1
• Signs of acidosis (rapid, deep breathing) 1