What is the initial treatment for a 2-year-old child with dehydration, characterized by being alert but tired, having free tears, and a capillary refill time of 2-3 seconds?

Initial Treatment for a 2-Year-Old with Mild-to-Moderate Dehydration

Administer oral rehydration solution (ORS) at 50-100 mL/kg over 2-4 hours, starting with small frequent volumes (5 mL every few minutes), then gradually increase as tolerated. 1, 2

Clinical Assessment

This child presents with mild-to-moderate dehydration based on:

• Alert but tired mental status 2
• Presence of tears (indicates not severely dehydrated) 2
• Capillary refill 2-3 seconds (borderline but not severely prolonged) 3

The capillary refill of 2-3 seconds is at the upper limit of normal (goal ≤2 seconds), suggesting mild volume depletion without shock. 3

Oral Rehydration Protocol

Start with small volumes immediately:

• Begin with 5 mL of ORS (like Pedialyte) every 5 minutes using a syringe or medicine dropper 1
• Gradually increase volume as tolerated over the first 30-60 minutes 1
• Target total volume: 50-100 mL/kg over 2-4 hours 1, 2
• For a typical 2-year-old (12 kg), this equals approximately 600-1200 mL total 1

Replace ongoing losses concurrently:

• Give 60-120 mL of ORS for each diarrheal stool 1
• Give 60-120 mL of ORS for each vomiting episode 1

Critical Implementation Points

Use only commercially available ORS formulations (Pedialyte, WHO-ORS) containing 75-90 mEq/L sodium—never use apple juice, Gatorade, or soft drinks due to inappropriate electrolyte content and excessive osmolality. 1, 2

If vomiting is present, start with very small volumes (5 mL) and consider ondansetron to facilitate oral intake, as this has been shown to be as effective as IV rehydration in mild-to-moderate cases. 4

Continue age-appropriate feeding within 3-4 hours after starting rehydration—do not withhold food during the rehydration phase. 1, 2

When to Escalate to IV Therapy

Switch to IV rehydration if:

• Unable to tolerate oral fluids despite small-volume attempts 1, 2
• Mental status deteriorates (becomes lethargic or unresponsive) 2
• Capillary refill worsens to >3 seconds 3
• Signs of shock develop (cool extremities, weak pulses, hypotension) 3, 2

IV protocol if needed:

• Administer 20 mL/kg boluses of isotonic crystalloid (0.9% normal saline or Ringer's lactate) 3, 1, 2
• Repeat boluses until perfusion normalizes 3, 2
• Children commonly require 40-60 mL/kg in the first hour for moderate dehydration 3, 4

Monitoring and Reassessment

Reassess after 2-4 hours:

• Check skin turgor, mucous membrane moisture, mental status 2
• Verify urine output >1 mL/kg/hour 3
• Confirm capillary refill has improved to ≤2 seconds 3
• Monitor for signs of fluid overload (increased work of breathing, rales, hepatomegaly) 3

If dehydration persists after the initial rehydration period, restart ORS therapy and reassess the fluid deficit. 1

Common Pitfalls to Avoid

• Do not use IV fluids as first-line therapy in a child who can drink—oral rehydration is equally effective and less invasive for mild-to-moderate dehydration 1, 2, 4, 5
• Do not give anti-diarrheal medications in children with acute diarrhea 1
• Do not delay rehydration to obtain laboratory tests—clinical assessment guides therapy 5
• Do not use hypotonic fluids for IV rehydration if needed—only isotonic crystalloid 3, 1