These children with 2 or more clinical signs of ‘some’ dehydration should initially be managed in a clinic or hospital if possible as they can progress to ‘severe’ dehydration:

1. They can be treated with oral rehydration solution with a close watch for repeated vomiting or a refusal to drink. It is best if the oral rehydation solution is given by cup and/or spoon.
2. 80 ml/kg of oral rehydration solution should be given over 4 hours, i.e. about 20 ml/kg each hour. More can be given if the child wants to drink more. It is best if the child has frequent, small sips. If the child vomits, wait for 10 minutes and then try again more slowly.
3. The degree of dehydration must be assessed after 4 hours.
4. If the child takes the oral rehydration solution well, is not vomiting and there are no longer signs of dehydration (and the child has gained weight) after 4 hours, the child can be sent home and return to be assessed the next day. At home the child should be managed with oral rehydration solution (as for diarrhoea with ‘no visible’ dehydration). The decision to send the child home will depend on the home circumstances. The mother must bring the child back immediately if the diarrhoea gets worse, the child vomits everything or signs of dehydration appear.
5. It is important that the child continues to receive regular feeds (especially breastfeeds) plus oral rehydration solution until the diarrhoea stops. Oral rehydration solution does not cause the fluid loss in the stools to increase.
6. The mother must know how to make up the rehydration solution correctly and how much to give.

If the infant refuses to drink fluids or vomits repeatedly after drinking, a continuous nasogastric drip should be started. If there are still signs of ‘some’ dehydration after 4 hours, continue with the oral or nasogastric rehydration solution and assess again after a further 4 hours. If signs of severe dehydration develop, manage the child for ‘severe’ dehydration.

The lives of most children with diarrhoea can be saved by the simple, cheap use of oral rehydration therapy at home or in a local primary care clinic.