Initial Treatment for a 2-Year-Old with Moderate Dehydration from Gastroenteritis
Begin oral rehydration therapy (ORT) immediately with 100 mL/kg of oral rehydration solution (ORS) containing 50-90 mEq/L sodium, administered over 2-4 hours. 1, 2
Clinical Assessment
This child presents with moderate dehydration (6-9% fluid deficit) based on:
- Capillary refill 2-3 seconds (prolonged) 1
- Decreased tears (though still present) 1
- Nothing kept down for 24 hours with ongoing losses 2
- Alert mental status (rules out severe dehydration) 3
The combination of these findings—particularly the prolonged capillary refill and reduced tear production—indicates moderate rather than mild dehydration, warranting more aggressive fluid replacement. 4
Rehydration Protocol
Start small and increase gradually:
- Use a teaspoon, syringe, or medicine dropper to give small volumes initially (e.g., one teaspoon) 2
- Gradually increase the amount as tolerated 3
- For a 2-year-old (approximately 12 kg), this translates to roughly 1200 mL total over 2-4 hours 2
Replace ongoing losses concurrently:
- Give 10 mL/kg (approximately 120 mL) of ORS for each additional diarrheal stool 2
- Give 2 mL/kg (approximately 24 mL) of ORS for each vomiting episode 3
Reassessment
After 2-4 hours, reassess hydration status: 3, 2
- If rehydrated (improved capillary refill, moist mucous membranes, normal skin turgor): transition to maintenance therapy
- If still dehydrated: reestimate fluid deficit and restart rehydration therapy 2
- If worsening (altered mental status, shock): switch immediately to IV boluses of 20 mL/kg Ringer's lactate or normal saline 3
Feeding During Treatment
Continue age-appropriate nutrition:
- Offer age-appropriate foods every 3-4 hours as tolerated during rehydration 2
- Do not "rest the bowel"—feeding should begin as soon as appetite returns 1
- Avoid soft drinks due to high osmolality 3
Common Pitfalls to Avoid
Do not delay ORT due to vomiting: Most children with vomiting can still tolerate small, frequent volumes of ORS given slowly. 5 The key is starting with very small amounts (teaspoon-sized) and increasing gradually. 2
Do not jump to IV therapy prematurely: ORT is equally effective as IV rehydration for moderate dehydration and has significant advantages including faster initiation, less invasiveness, and ability to continue at home. 4, 5 Reserve IV therapy for severe dehydration (≥10% deficit), shock, altered mental status, or ORT failure. 2
Monitor weight changes throughout therapy to objectively assess response to treatment. 2
When to Escalate Care
Switch to IV rehydration if: 2
- Progression to severe dehydration or shock
- Altered mental status develops
- Persistent vomiting prevents ORS intake despite proper technique
- No improvement after 2-4 hours of adequate ORT
The sick contacts at daycare and clinical presentation strongly suggest viral gastroenteritis, making this an ideal scenario for ORT rather than IV therapy. 5