Plan A B C for diarrhea
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WHO Plan A Plan B Plan C diarrhea management dehydration treatment protocol
I have sufficient information from the textbooks and my training knowledge on the WHO Plan A/B/C framework. Here is the comprehensive overview:
WHO Plan A / B / C for Diarrhea Management
The WHO classifies diarrhea management into three treatment plans based on the degree of dehydration. The first step is always to assess hydration status.
Dehydration Assessment
| Feature | No Dehydration | Some Dehydration | Severe Dehydration |
|---|---|---|---|
| General condition | Well, alert | Restless, irritable | Lethargic/unconscious |
| Eyes | Normal | Sunken | Very sunken & dry |
| Thirst | Normal | Drinks eagerly, thirsty | Drinks poorly/unable |
| Skin pinch | Returns quickly | Returns slowly (< 2 sec) | Returns very slowly (≥ 2 sec) |
| Assessment | No signs | 2 or more signs | 2 or more signs |
| Plan | Plan A | Plan B | Plan C |
Plan A — No Dehydration (Home Treatment)
Goal: Prevent dehydration and malnutrition; treat at home.
Three key rules:
- Give more fluids than usual — offer ORS or home fluids (rice water, yogurt drinks, plain water) after every loose stool.
- Child < 2 years: 50–100 mL ORS per stool
- Child 2–10 years: 100–200 mL ORS per stool
- Child > 10 years / adult: as much as desired
- Continue feeding — do not restrict food; breastfeeding continues. Offer BRAT-type diet (bananas, rice, apples, toast). Resume normal diet as soon as tolerated.
- Return signs — advise the caregiver to return if:
- Child cannot drink or breastfeed
- Becomes sicker
- Develops fever
- Has blood in stool
- Signs of dehydration appear
Zinc supplementation:
- 10 mg/day for infants < 6 months
- 20 mg/day for children > 6 months
- Duration: 10–14 days (reduces duration and severity; decreases recurrence for 2–3 months)
Plan B — Some (Moderate) Dehydration (ORS in Clinic/Hospital)
Goal: Rehydrate with ORS over 4 hours under observation; then reassess.
ORS volume:
- 75 mL/kg over 4 hours (or use approximate volumes below)
| Age | Weight | ORS Volume (4 hrs) |
|---|---|---|
| < 4 months | < 5 kg | 200–400 mL |
| 4–11 months | 5–7.9 kg | 400–600 mL |
| 12–23 months | 8–10.9 kg | 600–800 mL |
| 2–4 years | 11–15.9 kg | 800–1200 mL |
| 5–14 years | 16–29.9 kg | 1200–2200 mL |
| ≥ 15 years | ≥ 30 kg | 2200–4000 mL |
Administration technique:
- Give by cup or spoon; syringe/dropper for very young infants
- If vomiting occurs: wait 10 minutes, then resume slowly
- Continue breastfeeding throughout
Ongoing losses: Replace each stool with 10 mL/kg and each vomit with 2 mL/kg of ORS.
Reassess after 4 hours:
- No dehydration → move to Plan A, send home
- Still some dehydration → repeat Plan B for another 4 hours
- Severe dehydration → move to Plan C
Contraindications to ORS (switch to IV): Shock, severe dehydration, lethargy, inability to drink, suspected ileus/obstruction, persistent vomiting.
Plan C — Severe Dehydration (IV Rehydration)
Goal: Rapid IV fluid replacement to restore circulation.
IV Fluid Protocol (Ringer's Lactate preferred; if unavailable, 0.9% NaCl):
For infants (< 12 months):
| Phase | Volume | Rate |
|---|---|---|
| First: 30 mL/kg | Over 1 hour | IV bolus |
| Then: 70 mL/kg | Over 5 hours | Infusion |
| Total: 100 mL/kg | Over 6 hours |
For older children (≥ 12 months) and adults:
| Phase | Volume | Rate |
|---|---|---|
| First: 30 mL/kg | Over 30 minutes | Rapid IV |
| Then: 70 mL/kg | Over 2.5 hours | Infusion |
| Total: 100 mL/kg | Over 3 hours |
Reassess every 15–30 minutes:
- If pulse not detectable → repeat 20 mL/kg rapid bolus
- Once pulse improves → continue infusion
- Once child can drink → begin ORS (5 mL/kg/hr) alongside IV
After IV rehydration is complete → reassess and apply Plan A, B, or C accordingly.
Special note for cholera: Use Ringer's Lactate (NOT plain normal saline) and ensure antibiotics (azithromycin/doxycycline) are given promptly.
ORS Composition (WHO Low-Osmolarity Formula)
| Component | Amount per 1 L water |
|---|---|
| Sodium chloride (NaCl) | 2.6 g |
| Trisodium citrate | 2.9 g |
| Potassium chloride (KCl) | 1.5 g |
| Glucose (anhydrous) | 13.5 g |
| Osmolarity | 245 mOsm/L |
The low-osmolarity formula (245 mOsm/L) is preferred over the older high-osmolarity formula — it reduces stool output and vomiting, and decreases the need for unscheduled IV therapy.
Quick Summary
| Plan | Dehydration | Treatment | Setting |
|---|---|---|---|
| A | None | Home fluids + feeding + zinc | Home |
| B | Some/Moderate | ORS 75 mL/kg over 4 hrs | Clinic / OPD |
| C | Severe | IV Ringer's Lactate 100 mL/kg | Hospital / Emergency |
Sources: Rosen's Emergency Medicine, 9th Ed.; WHO Diarrhea Treatment Guidelines; — Rosen's Emergency Medicine, block 27 & 167
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