1. WHO recommends ReSoMal for malnourished children(1). The solution is not available in India. There are no studies that have compared the reduced osmolarity ORS with ReSoMal in severely malnourished children with diarrhea. There is a study by Dutta et al that found reduced osmolarity ORS to be superior to standard WHO ORS in severely malnourished children with diarrhea(2). In absence of evidence and particularly for the purpose of program feasibility, the expert group recommended the use of reduced osmolarity ORS with added KCl. To ensure safe use in severely malnourished children, the Task Force has recommended that the ORS for rehydration is given over 8-10 hours(3). At the same time the guidelines have highlighted the WHO recommendations.

2. There is no evidence for the WHO guidelines for the management of septic shock; there is greater emphasis on use of blood after one fluid bolus which is not supported by any data and appears to be impractical. The Task Force has based its recommendations on the available guidelines on management of septic shock(4) but recommended a slower fluid infusion rate and the need for monitoring. The WHO guidelines appear to be based on kwashiorkor cases. Marasmic children with circulatory collapse may tolerate a rapid infusion of 10- 20 mL/kg of Ringer's lactate, and may need more, but should not continue to have rapid rates of infusion once the condition has improved.

3. The major emphasis in the management of a child with septic shock is on use of crystalloids. The recommendation to consider blood transfusion are based on the published guidelines for management of septic shock(4) and the rationale is to improve the oxygen carrying capacity to improve the tissue oxygenation. However, one may individualize the therapy based on the child’s condition and availability of facilities for safe transfusions.

4. Once the shock is corrected, the malnourished child may receive maintenance fluids as N/5 in 5% or 10% dextrose with added KCl and need for further fluids is decided by the child’s condition. If there are ongoing stool losses, the same should also be replaced with N/2 in 5% dextrose solution.

5. The guidelines recommend that steroids in low doses may be considered in a child with septic shock who has features suggestive of adrenal insufficiency (hypoglycemia, hyponatremia, hyperkalemia in combination). The guidelines do not recommend steroids for all children with septic shock.