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Editor,—In his otherwise excellent systematic review of the management of acute gastroenteritis,1 Murphy has overlooked the consensus about the assessment and management of dehydration that forms the basis of the World Health Organisation’s programme for the case management of diarrhoea contained within the guidelines for the newly developed Integrated Management of Childhood Illness (IMCI) strategy.2 The IMCI strategy contains similar but simplified recommendations to those contained in Murphy’s systematic review, and are produced primarily for use by front line health workers in developing countries. However, hospital based paediatricians need to be conversant with this strategy to be able to train and supervise health workers in its use. My personal experience of managing diarrhoea cases in the UK indicates that the IMCI diarrhoea case management guidelines are equally applicable in developed countries.
The IMCI guidelines first seeks to classify the child with diarrhoea into three categories: acute diarrhoea, persistent diarrhoea, and dysentery. The degree of dehydration is then assessed according the presence or absence of four clinical signs: neurological condition, sunken eyes, degree of thirst, and skin turgor, and classified as being “severe”, “some” or “no” dehydration. The child is treated according to the degree of dehydration.
Children with diarrhoea but no signs of dehydration are treated according to plan A—home based treatment with extra fluids including oral rehydration solution or home based fluids and continued feeding; those with some dehydration according to plan B—supervised oral rehydration over four hours with calculated volumes of oral rehydration solution in a health care facility; those with severe dehydration according to plan C—intravenous rehydration with Ringer’s lactate.
These instructions are contained in WHO diarrhoea case management charts with their characteristic three colour triage design, which are commonly found in health facilities throughout the developing world.3 These clinical guidelines provide an effective framework for improved diarrhoea case management leading to reduced mortality from one of the major causes of child death worldwide.
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