A 5-year-old child with watery diarrhea for 7 days, on examination, weight = 10 kg, hanging skin folds with normal skin pinch. The composition of sodium in the ORS should be -

Ans- C 45 meq/Lit Ideal Na concentration for dehydration in severe malnutrition is 45 mmol/L Ref 1 - WHO recommendations Children who are under 5 years of age with severe acute malnutrition who present with some dehydration or severe dehydration but who are not shocked should be rehydrated slowly, either orally or by nasogastric tube, with either ReSoMal, or half-strength standard WHO low-osmolarity oral rehydration solution with added potassium and glucose* at a rate of 5-10 mL/kg/h, for up to a maximum of 12 hours, unless the child has cholera or profuse watery diarrhoea. Children suspected of having cholera or have profuse watery diarrhoea should be given standard WHO low-osmolarity oral rehydration solution that is normally made, i.e. not further diluted. * standard WHO low-osmolarity oral rehydration solution (75 mmol/L sodium) should not be used ************* This is a summary of one of several WHO recommendations on the management of SAM in infants and children. The full set of recommendations can be found in 'Full set of recommendations' and in the guidelines and guidance documents under 'WHO documents' below. Full set of recommendations Ref 2- Fluid management in children with severe malnutrition and dehydration without shock 1. Children with severe acute malnutrition who present with some dehydration or severe dehydration but who are not shocked should be rehydrated slowly, either orally or by nasogastric tube, using oral rehydration solution for malnourished children** (5-10 mL/kg/h up to a maximum of 12 h). 2. Full-strength, standard WHO low-osmolarity oral rehydration solution (75 mmol/L sodium) should not be used for oral or nasogastric rehydration in children with severe acute malnutrition who present with some dehydration or severe dehydration. Either ReSoMal*** or half-strength standard WHO low-osmolarity oral rehydration solution should be given, with added potassium and glucose, unless the child has cholera or profuse watery diarrhoea. Dissolve one sachet of standard WHO low-osmolarity oral rehydration solution in 2 L water (instead of 1 L). Add 1 level scoop of commercially available combined minerals and vitamins mix1 or 40 mL of mineral mix solution (5), and add and dissolve 50 g of sugar. In some countries, sachets are available that are designed to make 500 mL of standard WHO low-osmolarity oral rehydration solution. In this situation, dilution can be revised to add 1 L. 3. ReSoMal (or locally prepared ReSoMal using standard WHO low-osmolarity oral rehydration solution) should not be given if children are suspected of having cholera or have profuse watery diarrhoea.**** Such children should be given standard WHO low-osmolarity oral rehydration solution that is normally made, i.e. not further diluted. Additionally (2-6): children with severe acute malnutrition and who have some or severe dehydration but no shock should receive 5 mL/kg ReSoMal every 30 min for the first 2 h. Then, if the child is still dehydrated, 5-10 mL/kg/h ReSoMal should be given in alternate hours with F-75, up to a maximum of 10 h; signs of improved hydration status and overhydration should be checked every half hour for the first 2 h, then hourly; ReSoMal can either be prepared from a ready-to-dilute sachet (as per supplier's instructions) or prepared with one sachet of WHO low-osmolarity oral rehydration solution plus 2 L of water with an added 50 g sugar and 40 mL mineral mix or one level scoop of combined minerals and vitamins; zinc (10-20 mg per day) should be given to all children as soon as the duration and severity of the episodes of diarrhoea start to reduce, thereby reducing the risk of dehydration. By continuing supplemental zinc for 10-14 days, this will also reduce the risk of new episodes of diarrhoea in the following 2-3 months. (Note, WHO-recommended therapeutic foods already contain adequate zinc, and children with severe acute malnutrition receiving F-75, F-100 or ready-to-use therapeutic food should not therefore receive additional zinc). Fluid management of children with severe acute malnutrition and shock 4. Children with severe acute malnutrition and signs of shock or severe dehydration and who cannot be rehydrated orally or by nasogastric tube should be treated with intravenous fluids, either: half-strength Darrow's solution with 5% dextrose, or Ringer's lactate solution with 5% dextrose. If neither is available, 0.45% saline + 5% dextrose should be used. Additionally (2-6): the general principles of resuscitation, in particular providing oxygen and improving breathing, similarly apply to children with severe acute malnutrition; the only indication for intravenous infusion in a child with severe acute malnutrition is circulatory collapse caused by severe dehydration or septic shock when the child is lethargic or unconscious (excluding cardiogenic shock); all children with severe acute malnutrition with signs of shock with lethargy or unconsciousness should be treated for septic shock. This includes especially children with signs of dehydration but no history of watery diarrhoea, children with hypothermia or hypoglycaemia, and children with both oedema and signs of dehydration; in case of shock with lethargy or unconsciousness, intravenous rehydration should begin immediately, using 15 mL/kg/h of one of the recommended fluids; it is important that the child is carefully monitored every 5-10 min for signs of overhydration and signs of congestive heart failure. If signs of overhydration and congestive heart failure develop, intravenous therapy should be stopped immediately; if a child with severe acute malnutrition presenting with shock does not improve after 1 h of intravenous therapy, a blood transfusion (10 mL/kg slowly over at least 3 h) should be given; children with severe acute malnutrition should be given blood if they present with severe anaemia, i.e. Hb <4 g or > 6g with signs of respiratory distress blood transfusions should only be given to children with severe acute malnutrition within the first 24 h of admission. * This is an extract from relevant guidelines and guidance documents as listed in 'References'. Additional guidance information can be found in these documents. ** A specific electrolyte-micronutrient product formulated according to WHO specifications for use in the management of children with severe acute malnutrition. *** ReSoMal is a powder for the preparation of an oral rehydration solution exclusively for oral or nasogastric rehydration of people suffering from severe acute malnutrition. It must be used exclusively under medical supervision in inpatient care, and must not be given for free use to the mother or caregiver. **** Three or more loose or watery stools in a day, for more than 14 days. References 1. WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children. Geneva, World Health Organization; 2013 ( style="font-family: Times New Roman, Times, serif"> infantandchildren/en/). 2. WHO. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva, World Health Organization; 1999 ( 3. WHO. Training course on the management of severe malnutrition. Geneva, World Health Organization; 2002 (updated 2009)( 4. WHO. Diarrhoea treatment guidelines including new recommendations for the use of ORS and zinc supplementation for clinic-based healthcare workers. Geneva, World Health Organization; 2005 ( 5. WHO. The treatment of diarrhoea: manual for physicians and other senior health workers. Geneva, World Health Organization; 2005 ( 6. WHO. Pocket book of hospital care for children: second edition. Guidelines for the management of common illnesses with limited resources. Geneva, World Health Organization; 2013 (