Who Readings On Diarrhoea Student Manual 1992

WHO Library Cataloguing in Publication Data Readings on diarrhoea: student manual. 1. Diarrhea.

ISBN

Infantile-programmed

92 41544449

instruction

(NLMClassification:

WS

18)

The World Health Organization welcomes requests for. permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications. World Health Organization, Geneva, Switzerland, which will be glad to provide the latest information on any changes made to the text. plans for new editions, and reprints and translations already available. @ World Health OrGanization

1992

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with the

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers Of boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. Typeset in India Printed in Belgium 91/8972-M acm ilia nlCeuteric k-9QOO

Cc)ntents

v

Preface

vi

Acknowledgemen~s

Units 1. The epidemiology

and etiology

2. Pathophysiology

of diarrhoea

of watery diarrhoea:

dehydration

and 15

rehydratipn 3. Assessing

the patient

4. Treatment

of diarrhoea

5.

of

Treatment

6. Dysentery,

47

at home

dehydrated

persistent

31

with diarrhoea

63

patients

diarrhoea,

and diarrhoea

associated

79

other illnesses 7.

Diarrhoea

and

8. Prevention

with

93

nutrition

109

of diarrhoea

Annexes 1.

Diarrhoea

2.

Growth

case

record

125

form

128

chart

3. How to determine

whether

4.

Intravenous

rehydration

5.

Nasogastric

rehydration

6. Antimicrobial

agents

a child

i$ malnourished

130 132

used to treat specific

causes

of diarrhoea

Answers to exercises

143

Preface

This manual is intended for medical students, especially during their clinical training in paediatrics. It will also be useful for physicians participating

in training courses on the

management of diarrhoea in children. The materials in this book are compatible with other WHO publications that concern

on the management and prevention of diarrhoea. The units

the management

of children with diarrhoea

are based on the WHO

treatment chart .'Management of the Patient with Diarrhoea" (19~2), portions of which are reproduced

at appropriate

places in this text.

This book may be used as a source of practical

information

and as a manual of

guidelines for treating patients with diarrhoea. It will be more effective, however, if used in combination

with organized teaching

lectures, discussions,

demonstrations,

activities on diarrhoeal and supervised

Readers are urged to check their understanding

practice

diseases, such as in treating

cases.

of the material by answering the

questions that follow each unit. A companion book References on diarrhoea contains related background information

articJes that summarize current research and provide additional

on most topics covered in this text. This is available1 to medical school

libraries and other j.nstitutions conducting training in diarrhoea case management. An .jnstructor's manual is also available,1 which provides guidance for medical~faculty and other teachers about how the material in each unit of the text may be most effectively taught.

'Available

on request from the Division 01 Diarrhoeal

1211 Geneva n

and Acute Respiratory

Disease Control, World Health Organization,

Switzerland,

v

This

publication

Technology

is based

for Primary

has been reviewed Indies,

Trinidad

University trics,

Diarrhoeal Hospital,

vi

of

Diseases Pakistan

a manual

Tobago;

Umea,

Research, Institute

by

(PRITECH),

Department

Dr R. S. Northrup under

of Paediatrics,

Dr W. A. M. Cutting,

Edinburgh,

Umea,

prepared

Care Project

by Dr D. Bratt,

and

of Edinburgh,

University

on

Health

Scotland;

Dr L. Gothefors, Dr D. Habte,

Dhaka.

Bangladesh; Sciences,

University

Department

Sweden;

of Medical

contract

of the West

of Child

Department International

of the

from WHO. It

Health,

of PaediaCentre

for

and Dr M. Khan, The Children's

Karachi,

Pakistan.

UNIT 1 The epidemiology

alnd

etiology

of ,diarrhoea

3

Introduction T'~pes

4 4 4 4

of diarrhoea Acute

watery

Dysentery Persistent

diarrhoea

diarrhoea

5 Epidemiology Trarlsmission Host factors

of agents that cause diarrhoea that increase susceptibility to diarrhoea

Age Seasonality Asymptomatic

5 5 6 7 7 7

infections

Epidemics 7

E:tiology General considerations Pathogenetic mechanisms

7 9 9

Viruses

9

Bacteria

9

Protozoa Important eJ")teropathogens Rotavirus Enterotoxigenic Escherichia Shigella Campylobacter Vibrio cholerae

10 10 10

coli (ETEC)

10 10

jejuni 01

11 11

Salmonella

11

Cryptosporidium Implications

for treatment

Treatment

and I)revention

Measures

that strengthen

11 11

of diarrhoea

Prevention of diarrhoea Measures. that interrupt

IExerclses

of diarrhoea

12

the transmission host defences

of pathogens

12 12

13

1

THE EPIDEMIOLOGY

AND ETIOLOGY

OF DIARRHOEA

Introduction Diarrhoea

IS a leading

countries, occur

where

cause

an estimated

of illness

and

1.3 thousand

death million

among

children

episodes

in developing

and 3.2 million

each year in those under five years of age. Overall. these children

average

Of 3.3 episodes

nine episodes than 15%of occur

of diarrhoea

their days with diarrhoea

in the first 2 years

dehydration. Other

per year. but in some areas the average

per year. Where episodes

which

important

young

(Fig. 1.1 ). About

of life. The main

results

causes

are frequent.

cause

children

80% of deaths

of death

from

from the loss of fluid and electrolytes

of death

are dysentery.

malnutrition

deaths

experience

an

exceeds

may spend

more

due to diarrhoea

acute

diarrhoea

in diarrhoeal

and serious

is

stools.

infections.

such as pneumonia. Diarrhoea

is an

diarrhoea nutrient

their

cause

of

ability

malnutrition.

to absorb

This

nutrients

requirements

are increased

as a result

contributes

to malnutrition;

when episodes

diarrhoea growth

important

eat less and

is because is reduced;

of the infection. are prolonged,

patients

with

moreover,

their

Each

episode

of

their impact

on

is increased.

Diarrhoeal

disease

In many countries, patients

also represents

an economic

more than one-third

with diarrhoea.

fluids

and

ineffective

adults

than to children.

These .patients drugs.

Although

burden

of hospital are often

for the developing

beds for children treated

diarrhoeal

it can also affect a country's

disease

with expensive is usually

economy

countries.

are occupied

Intravenous

less harmful

by reducing

by

to

the health

of its workforce.

Fig.

1

Prevalence

of diarrhoea

in different developing

countries

Source~ohde. J & Norlhrup. R.S. Diarrhoea is a nutritiof.lal disease. In Ladislaus-Sal'e' ~ & S,:ully P.E e(j ICORr " Proceedings~Second Inlernational Conference on Oral R~hydralion Therapy. Washington DC 10-13 December 1985 Washington.

DC. Agency for International

D~velopment.

198/0 pp.30-41

READINGS

ON DIARRHOEA

Fortunately,

simple and effective

treatment

reduce

number

caused

the

unnecessary status.

epidemiology principles

preventive

and severity and

measures

etiology

make

episodes.

of diarrhoea

admission

to hospital on nutritional

that substantially

This unit provides

that

that can markedly

effect of diarrhoea

can also be taken

of diarrhoeal

of treatment

are available

by diarrhoea,

in most cases. and prevent the adverse

Practical

incidence

of deaths

measures

is essential

reduce

information

for

the

on the

understanding

the

and prevention.

Types of diarrhoea Diarrhoea

is usually defined

loose or watery shape

stools in a 24-hour

of a container.

diarrhoea,

However,

depending,

or there is vomiting.

whether

a child

in stool

may

use a variety

upon whether

Infants

that

take the

to describe bloody

or

with these terms when asking

who are exclusively

or liquidity

of terms

the stool is loose, watery,

to be familiar

bre~st-fed

stools each day; for them, it is practica!

f!equency

of three or more

period, a loose stool being one that would

It is important

has diarrhoea.

several soft or semi-liquid

studies as the passage

mothers

for example,

mucoid,

increase

in epidemiological

is considered

normally

pass

to define diarrhoea

as an

abnormal

by the mother.

Three clinical syndromes of diarrhoea have been defined, each reflecting .a different pathogenesiS and requiring different approaches

to treatment. These are described

briefly below and considered in detail in Units 3-6.

Acute watery diarrhoea This term refers to diarrhoea

that begins acutely, lasts less than 14 days (most

episodes last less than 7 days), and involves the passage of frequent loose or watery stools without visible blood. Vomiting may occur and fever may be present. Acute watery diarrhoea causes dehydration; when food intake is reduced, it also contributes to malnutrition.

When death occur's, it is usually due to acute dehydration.

The most

important causes of acute watery diarrhoea in young children in developing countries are rotavirus, enterotoxigenic Cryptosporidium.ln

Escherichia coli, Shigella, Campylobacter

jejuni, and

some areas, Vibrio choleraeO1, Salmonella and enteropathogenic

E. coli are also important.

Dysentery This is diarrhoea anorex(a, bacteria.

invasive

with visible blood weight

A number

dysentery

young

rapid

loss, and

of other complications

is Shigella;

other causes

E. coli or Salmonella. adults

in the faeces. damage

effects of dysentery mucosa

may also occur.

are Campylobacter

Entamoeba

but is rarely a cause

Important

to the intestinal

,histolytica

of dysentery

jejuni

The main cause

of acute

and, infrequently.

entero-

can cause

in young

include

by the invasive

serious

dysentery

in

children.

Persistent diarrhoea This is diarrhoea

that begins acutely but is of unusually

days). The episode may begin either as watery diarrhoea 4

long duration

(at least 14

or as dysentery. Marked

THE EPIDEMIOLOGY

weight loss is frequent. Diarrhoeal dehydration.

AND ETIOLOGY

OF DIARRHOEA

stool volume may also be great, with a risk of

There is no single microbial

cause for persistent diarrhoea;

aggregative Eo coli. Shigella and Cryptosporidium

may playa

entero-

greater role than other

agents. Persistent diarrhoea should not be confused with chronic diarrhoea, which is recurrent or long-Iasting diarrhoea due to noninfectious causes. such as sensitivity to gluten or inherited metabolic disorders.

Epidemiology Transmission

of agents that cause diarrhoea

The infectious route, which contact

agents includes

.Failing

behaviours

developing

of faecally

contaminated

promote

.Using

exclusively

severe diarrhoea

infant

feeding

contaminated;

temperature,

bottles.

it may surfaces

bacteria

when

of enteric

pathogens

and

months

in infants

of life. The

risk

of

who are not breast-fed

the risk of death from diarrhoea

temperature.

easily

contaminated

is also

bacterial

multiply

is kept

bac-

it becomes

occurs.

and then saved to

example,

by contact

for several

hours

with

at room

many times.

with faecal

storage

container

for

bottle

growth

When food is cooked

If food

with faecal

to an unclean

be contaminated,

in it can

or during

become

immediately,

0! conta!ners.

the storage

into contact

.Failin{;1

4-6

When milk is added

contaminated

nated at its source

comes

first

breast-fed;

These easily

to clean.

drinkiflg-water

occur

the

is many times greater

food at room

later,

contaminated

Using

water or food, and direct

the transmission

for

if it is not consumed

cooked used

by the faecal-oral

greater.

teria and are difficult

.Storing

spread

These incJude:

in those who are exclusively

substantially

be

are usually

the risk of diarrhoea.

to breast-feed

.than

diarrhoea

faeces.

of specific

thus increase

cause

the ingestion

with infected

A number

that

bacteria.

Water

may be contami-

in the home. Contamination is not covered.

or when

with the water while collecting

in the home may

a contaminated

hand

it from the container.

to wash hands after defecation, after disposing of faeces or before handling

food. .Failing

to dispose

that infant of infectious

faeces

of faeces (including are harmless,

viruses

or bacteria;

infant

whereas animal

faeces)

hygienically.

they may actually faeces

It is often believed

contain

can also transmit

large

enteric

numbers' infections

to humans.

Host factors that increase s,usceptibility to diarrhoea Several

host factors

diarrhoea.

are associated

with increased

incidence,

severity,

or duration

of

They include: 5

READINGS

ON DIARRHOEA

.Failing that

to breast-feed protect

against

until at least 2 years of age. Breast certain

types

of diarrhoeal

disease.

milk contains such

antibodies

as shigellosis

and

cholera.

.Malnutrition.

The severity, duration,

in malnourished

.Measles.

Diarrhoea

measles from

children,

and

dysentery

or who have had measles

immunological

Immunodeficiency viral infections

impairment

(e.g. measles), syndrome

are more

by unusual

frequent

in the previous

caused

are increased

or severe

4 weeks. This presumably

This may be temporary,

with results

e.g. after certain

as in people

When immunosuppression

pathogens

in children

by measles.

or it may be prolonged, (AIDS)

from diarrhoea

those with severe malnutrition.

or immunosuppression.

immunodeficiency can be caused

and risk of death

especially

with acquired

is severe, diarrhoea

and may also be prolonged.

4

Age Most diarrhoeal episodes occur during the first 2 years of life. Incidence is highest in the age group 6-11 months, when weaning often occurs (Fig. 1.2). This pattern reflects the combined effects of declining levels of maternally acquired antibodies. the lack of active immunity in the infant. the introduction

of food that may be contaminated

witr,

faecal bacteria. and direct contact with human or animal faeces when the infant starts to crawl. Most enteric patho'gens stimulate at least 13artial immunity against repeated Infection or illness, which helps to explain the declining Incidence of disease in older children and adults.

Fig. 1 2 Estimated age,

median

diarrhoeal

morbidity

rates

for children

under

5 years

of

by age group .

Source Snyder, J.D.& Merson, M.H The magnitude of the globalprobl!!m of acute diarrhoeal surveillance data Bulletin of the World HeaHh Organization, 60 605-613 (1982)

6

disease: a review of active

THE EPIDEMIOLOGY

AND ETIOL,DGY OF DIARRHOEA

Seasonality Distinct seasonal patterns of diarrhoea occur in many geographical ate climates, bacterial

diarrhoeas

areas. In temper:.

occur more frequently during the warm season,

whereas viral diarrhoeas, particularly diarrhoea caused by rotavirus, peak during the winter. In tropical areas, rotavirus diarrhoea occurs throughout

the year, increasing in

frequency during the drier, cool months, whereas bacterial diarrhoeas peak during the warmer, rainy season. The incidence of persistent diarrhoea follows the same seasonal pattern as that of acute watery diarrhoea.

Asymptomatic infections Most .enteric infections are asymptomatic,

and the proportion

that is asymptomatic

increases beyond 2 years of age owing to the development of active immunity. During asymptomatic infections, which may last for several days or weeks, stools contain infectious viruses, bacteria, or protozoal cysts. People with asymptomatic

infections

play an important role in the spread of many enteric pathogen~, especially as they are unaware of their infection, take no special hy~ienic precautions

and move normally

from place to place.

Epidemics Two enteric pathogens,

Vibrio cholerae 01 and Shigella dysenteriae type 1, cause

major epidemics in which morbidity and mortality in all age groups may be high. Since 1961, cholera caused by the eltor biotype of V. cholerae 01 has spread to countries in Africa, Latin America, Asia, and the Eastern Mediterranean,

and to some areas in

North America and Europe. During the same period, S. dysenteriae type 1 has been responsible

for large epidemics of severe dysentery in Central America, and more

recently in Central Africa and southern Asia.

Etiology ';eneral

considerations

Until a few years ago, pa1hogenio.organisms

could be identified in the faeces of only

about 25% of patients with acute diarrhoea. Today, using new techniques, experienced laboratory technicians can identify pathogens in about 75% of cas.es seen at a treatment faciJity and up to 50% of milder cases detected in the commumty: The organisms

most frequently

associated

with diarrhoea

in young

children

in

developin.g countries are shown in Table 1.1. Several of these pathogens are important causes of acute diarrhoea in all developing countries. They are: .rotaviru$ .enterotoxigenic .Shigella .Campylobacterjejuni .Cryptosporidium.

Escherichia

coli

READINGS ON DIARRHOEA

Table 1.1 Pathogens

frequently

treatment

centres

Viruses Bacteria

identified

in children

in developing

with

acute

diarrhoea

seen

at

countries

Pathogen

Percentage of cases

Rotavirus

15-25

Enterotoxigenic Escherichia coli

10-20

Shigella

Recommended antimicrobial based on clinical signsa

None

5-15

Trimethoprimsulfamethoxazo!e nalidixic

Campylobacter jejuni

Protozoa

acid

10-15

Vibrio cholerae 01

5-10b

TetracyclineC

Salmonella (non-typhoid}

1-5

None

Enteropathogenic Escherichia coli

1-5

None

Cryplosporidium

5-15

Nqne

20-30

None

No pathogen found

aForsensitivestrains bin endemicareas;maybe higherduringepidemics. cAlsoeffectiveqre furazolidone, trimethoprim-sulfamethoxazOle. erythromycin and chloramphenicol. Others may be of local importance; during foods

epidemics), are widely

infections health

non-typhoid

these include Salmonella

(in areas

used), an9 enteropathogenic

involving

II: choleraeO1 where

(in endemic commercialJy

E. coli (in infants

two or more enteropathogens

occur

areas and processed

in hospitals).

in 5-20%

of cases

~Aixed seen at

facilities.

.A number of other pathogens are not shown in Table 1.1. In general, their role in the etiology of acute diarrhoea in children in developing countries is either minimal or not yet well defined. They include: .viruses: .bacteria:

Norwalk

agent,

Aeromonas

enteric

hydrophila,

sive E. coli, enterohaemorrhagic non-O1, .protozoa:

\I: parahaemolyticus, Giardia

adenoviruses;

Jamblia,

enteroaggregative

Escherichia

E coli, Flesiomonas Yersinia

Entamoeba

shigelloides,

coli, enteroinvaVibrio cholerae

enterocolitica; histolytica,

Isospora

belli.

Enteric pathogens can also be found in about 30% of healthy children under 3 years of age, making it difficult to know whether a pathogen

isolated from a c~ild with

diarrhoea is actually the cause of that child's illness. This is especially true for Giardia lamblia, cysts of which are found nearly as often in healthy children as in those with diarrhoea; it is also true for enteropathogenic E coli or C. jejuni isolated from children older than 1 year. On other hand, Shigella and rotavirus are rarely identified in healthy children; their presence in a child with diarrhoea is strong evidence that they are causing the illness. Table 1.1 shows that antimicrobial Shigella or v: choleraeO1

agents are recommended only when infections with

are suspected on the basis of clinical signs. For all other

agents, and thus for the majority of acute diarrhoeal 8

episodes

in young

children,

THE EPIDEMIOLOGY

antimicrobials

AND ETIOLOGY

are either ineffective (e.g. rotavirus) or the appropriate

can only be selected after the agent has been identified enterotoxigenic

OF DIARRHOEA

antimicrobial

by stool culture

(e.g.

E. coli). For some agents (e.g. Salmonella), the use of an antimicrobial

can actually prolong the intestinal infection. For all of these reasons, antimicrobials should not be given "blindly" or routinely to patients with diarrhoea. The few instances in which antimicrobials

should be used are consider~d further in Units 5 and 6.

Pathogenetic mechanisms Microbial

agents

considered

cause

diarrhoea

by a number

of mechanisms.

several

of which

are

below.

Viruses .Viruses, such as rotavirus, replicate withln the villous epithelium of the small bowel, causing patchy epithelial cell destruction and villous shortening. The loss of normally absorptive

villous cells and their temporary

replacement

by immature,

secretory; crypt-Iike cells ,causes the intestine to secrete water and electrolytes. Villous damage may also be associated-with the loss of disaccharidase enzymes, leading to reduced absorption of dietary disaccharides, especially lactose. Recove,ry occurs when the ~illi regenerate and the villous epithelium matures.

Bacteria .Mucosa/adhesion.

Bacteria that multiply within the small intestine must first adhere

to the mucosa to avoid being swept away. Adhesion is through superficial hair-like ~ntjgens, ter~ed pili or fimbriae, that bind to receptors on the;intestinal surface; this occurs, for example, with enterotoxigenic

E. co/i and lI: cho/erae 01. In some

instances, mucosal adherence is associated with changes in the gut epithelium that may reduce its absorptive capacity or cause fluid secretion (e.g. in infection with enteropathogenic .Toxins i

that cause secretion.

bacteria

produce

absorption crypts,

or e1lteroaggregative

toxins

of sodium

causing

.Mucosal

Enterotoxigenic

that alter epithelial

E. coli, \I: cholerae cell function.

by the villi and may increase

secretion

when the affected

E. coli).

of water

cells are replaced

the secretion

and electrolytes by healthy

reduce

of chloride

(see Unit 2). Recovery

ones after 2-4

invasion. Shigella, C. jejuni. enteroinvasive

cause bloody diarrhoea

01 and some other

These toxins

the

in the occurs

days.

E. coli and Salmonella

can

by invading and destroying mucosal epithelial cells. This

occurs mostly in the colon and the distal part of the ileum. Invasion may be followed by the formation of microabscesses

and superficial ulcers; hence the presence of

red and white blood cells, or visible blood, in the stool. Toxins produced

by these

organisms cause tissue damage and possibly also mucosal secretion of water and electrolytes. Protozoa .Mucosal epithelium

adhesion. and

G. lamblia

cause

and

shortening

Crypfosporidium \ of the

villi.

which

adhere may

to the small be

how

they

bowel cause

diarrhoea. 9

READINGS

ON DIARRHOEA

.Mucosal

invasion.

colon

(or

however, human invasion present

E. histolytica

ileum) when

and

the infecting

infections

causes

Gausing

strain

the strains

and no symptoms

diarrhoea

microabscesses

by invading

epithelial

and

This

of E. histolytica

are nonvirulent;

occur, although

ulcers.

is virulent.

in such

amoebic

cases

cells in the

only

happens,

In about

there

90%

of

is no mucosal

cysts and trophozoites

may be

in the faeces.

Important enteropathogens Rotavirus Rotavirus is the most important cause of severe, life-threatening

diarrhoea in children

under 2 years of age worldwir:fe.There are four serotypes of human rotavirus; infection with one serotype causes a high level of immunity to that serotype, and partial protection against the other serotypes. Nearly all children are infected at least once before the age of 2 years, and repeat infections are common. Usually only the first rotavirus infection causes significant illness. About one-third of children under 2 years of age experience an episode of diarrhoea due to rotavirus. Rotavirus is probably spread by person-to-person Enterotoxigenic

transm(ssion.

E~;cherichia coli (ETEC)

Enterotoxigenic E coli (ETEC) is an important cause of acute watery diarrhoea in adults and children in developing c.ountries. ETEC does not invade the bowel mucosa and the diarrhoea it causes is mediated by toxins. There are two ETEC toxins, heatlabile (L T) and heat-stable (ST). Some strains produce only one type of toxin, some both. The L T toxin is closely related to cholera toxin, ETEC is spread mostly by means of contaminated

food and water.

Shigella Shigella episodes,

is the most

important

and in nearly

are four. serogrolJps:

cause

of dysentery.

all severe episodes;

S. sonnei.

S. boydii.

watery

S. flexneri

being

found

diarrhoea

in about

60% .of all

may afso occur.

There

and S. dysenteriae.

S. flexneri is the most common serogroup in developing countries, but S. dysenteriae type 1, which occurs In regional epidemics, causes the most severe disease. Tissue destruGtion and possibly watery diarrhoea are caused in part by the extremely potent Shiga toxin, produced in relatively large amoun,ts by S.dysenteriae type 1. Shigella are spread mostly by person,.to-person transmission. Antimicrobials to which Shigella are sensitive provide effective treatment, but antimicrobial resistance is common. Resistance to multiple antimicrobials most useful antimicrobials

may occur, especially among S. dysenteriae type 1. The

are trimethoprim-sulfamethoxazole

and nalidixic

acid;

ampicillin is effective in some areas.

Campylobacter jejuni ln developing countries" C. jejuni causes disease mostly in infants.- C. jejuni also inf~cts animals, especially chickens and dogs, and is spread by contact with their faeces C': consumption of contaminated food, milk, or water. C. jejuni can cause watery diarrhoea (two-thirds of cases) or dysentery (one-third of cases). Fever may be 10

THE EPIDEMIOLOGY

present.

Episodes

shortens because other

are not usually

the illness

if given

cases caused

agents:

confirmed

severe and

soon

after

days, Although

the symptoms

by C, jejuni cannot

'erythromycin

last 2-5

if therapy

erythromycin

sta~t. it is not recommended

be distinguished

is ineffective

AND ETIOLOGY OF DIARRHOEA

clinically

is delayed

from those due to

until

the diagnosis

is

by a laboratory,

Vibrio cholerae 01 v cholerae01,

the cause

serotypes

(Ogawa

mediated

by cholera

in the small

occurs

infections. adults

Diarrhoea

mostly

case

resistance

usually

01

a profuse

may be severe,

(classical

and eltor)

is non-invasive, secretion

leading

adults

areas.

epidemics

Antimicrobials

management.

having

cause

Tetracycline

collapse

In endemic

immunity

disease

with

the duration

(or doxycycline)

being

of water and electrolytes

to dehydration,

substantial

can shorten

and two

diarrhoea

if the lost fluids and salts are not replaced.

has been observed

furazolidone,

has two biotypes

V cholerae

in children,

In nohendemic

and children.

simplify

Inaba).

toxin which causes

bowel.

dea1h within a fewhou!s cholera

of cholera,

and

areas.

from previous

equal

frequency

Wl

of (he illness and thus is most

widely

used,

in some areas; in this event. other antimicrobials

trimethoprim-sulfamethoxazole.

and

erythromycin,

but

such as

or chloramphenicol

are

effective.

~,a'mone"a Most non-typhoid nated

animal

products.

developing

foods

infections

but

may

are widely

Antimicrobials

can be traced

Salmonella .

countries,

processed occur.

salmonella

are

unusual

be important

used.

and

cause

animals

of

in communities

Diarrhoea

are not effective.

from the intesiinal

an

to infected

is usually may delay

diarrhoea

where

watery,

or contami-

but

in

most

commercially' dysentery

the clearance

may

of Salmonella

tract.

(;ryptosporidium This is a coccidian and a variety

parasite

of domestic

that causes animals.

most episodes

of illness occur

asymptomatic.

Diarrhoea

deJicient

patients.

diarrhoea

In developing

in infants.

immunodeficient

countries

infection

in the first year of life. Thereafter.

is usually

neither

severe

Cryptosporidium

is an important

Implications

for treatment

cause

of persistent

and

are usually

except

in immuno-

or AIDS. In such individuals.

diarrhoea

and prevention

Is freguent.

infections

nor prolonged.

such as those with severe malnutrition

patients.

with wasting.

of diarrhoea

Treatment of diarrhoea Routine

determination

the clinical

aspects

of the etiology

made

with confidence.

based

on the major

pathogenetic

.Watery

of diarrhoea

of the illness do not permit The treatment

features

mechanisms.

of patients

of the disease The main

in a labor.atory a specific with

diarrhoea

and an understanding

principles

is not practical,

etiological

of treatment

diagnosis must

therefore

and to be be

of the underlying

are as follows:

,

diarrhoea requires repjacement of fiuids and eJectro\ytes-Jrrespectiveof

it~ etiology, 11

I READINGS

ON

DIARRHOEA

.Feeding

should be continued during all types of diarrhoea to the greatest extent

possible, and should be increased during c;:onvalescence so as to avoid any adverse effect on nutritional status. .Antimicrobials

and antiparasitic

sodes, including

agents st:lould not be used routinely; most epi-

severe diarrhoea

and diarrhoea

with fever, do not benefit from

such treatment. The exceptions are: -dysentery,

which

should

the few patients or treated

cholera

-persistent

diarrhoea,

E. histolytica

The

treatment

diarrhoea

when trophozoites

are seen in faeces

of patients

further

or cysts of Giardia

or intestinal

fluid, or when

or trophozoites pathogenic

of

enteric

by stool culture.

with

acute

in detail

watery

diarrhoea,

dysentery,

and

persistent

in Units 4-7.

infectious

the

faecal-oral

pathways,

the transmission measures

that

of proven

microbial

clean

.washing

feeding

related

are all transmitted

water, food, and hands. agents

should

focus

by common

Measures

taken

on these pathways.

include: months

of life;

bottles;

to the preparation

contamination

water

hands

efficacy

milk for the first 4-6

practices

minimize

diarrhoea

of the causative

the use of infant

.improving

cause

such as contaminated

only breast

.avoiding

of pathogens

agents

to interrupt

.using

be studied

of diarrhoea

The various

.giving

should

for Shigella;

with severe dehydration;

that interrupt

Important

to this treatment

effective

amoebiasis:

are identified

is considered

Prevention

with an antimicrobial

who do not respond

for possible

-suspected

bacteria

be treated

and

storage

of weaning

foods

(to

and growth);

for drinking;

(after defecation

or disposing

of faeces,

and before

preparing

food

impaired

host

or eating); .safely

disposing

of faeces.

including

Measures

that strengthen

host defences

A number

of

for

defences.

risk

Measures

risk of diarrhoea .continuing .improving and giving .immunizing

factors

frequent

that can be taken

of infants.

or severe

to improve

diarrhoea

reflect

host defences

and thus diminish

the

include:

to breast-feed nutritional children against

for at least the first 2 years of life;

status

(by improving

the nutritional

value

of weaning

more food); measles.

Measures to prevent diarrhoea

12

those

are considered in greater detail in Un!t 8.

foods

THE EPIDEMIOLOGY

AND ETIOLOGY

OF DIARRHOEA

Exercises 1. For which public

of the following

health

problem?

reasons

is diarrhoea

in young

children

(There may be more than one correct

an' impor1ant

answer.)

A. It places a heavy burden on health facilities and resources. B. It is a major cause of mortality in young children. C. It contributes to malnutrition in young children. D. It accounts for a large proportion of the days of illness in young children 2. Mohan

is 9 months

The episode vomited

old and was healthy

began

several

until he developed

times

in the past week.

His mother

much 'as usual and seems to have lost weight. cow's

milk 6 weeks

A. Acute

diarrhoea.

B. Acute

dysentery.

C. Chronic

diarrhoea

with stools that were ioose and sometimes

ago. What type of diarrhoea

says that

He was weaned does Mohan

watery.

3 weeks ago. Mohan

has

he is not eating from breast

as

milk to

have?

diarrhoea.

D. Allergic

diarrhoea.

E. Persistent

diarrhoea

3. List the 5 most important causes of acute diarrhoea among children in developing countries (including viral, bacterial, and protozoal agents). A. B. C. D. E. 4. In what proportion determined

of cases can the etiology

on the basis of the clinical

of acute watery diarrhoea

features

be correctly

of the illness?

A. 0%. B. 10c/o. C.25%, D.40% E.75%.

5. In which ot the following situations is it correct to give an antimicrobi~1 to a child with diarrhoea? (There may be more than one correct answer.) A. The child

has had bloody

B. The child

has watery

diarrhoea

C. .The child D. The child

has had watery diarrhoea with fever for 2 days. has severe dehydration from acl:Jte watery diarrhoea

diarrhoea

with fever for 2 days.

and the family

keeps chickens.

cholera have recently been confirmed in the area. E. The child has had diarrhoea for 12 days and shows weight

signs

and

cases

of dehydration

of

and

loss.

13

6. Which of the following in young correct

children

agents

in most

B. Yersinia

or dysentery

may be more

than

one

histolytica.

C. Enterohaemorrhagic

E. Plesiomonas

children?

B. Bathing

Escherichia

Escherichia

coli.

coli.

shigelloides.

of the following

A. Washing

(There

hands

factors

can reduce

the incidence

may be more than

after defecation

one correct

and before

or severity of diarrhoea answer.)

preparing

food.

the child frequently.

C. Exclusive

1A.

(There

enterocolitica.

D. Enterotoxigenic

young

causes of acute diarrhoea

countries?

answer.)

A. Entamoeba

7. Which

are important

developing

breast-feeding

for the first 4-6

D. Immunizing

against

diphtheria.

E. Immunizing

against

measles.

pertussis

months

of life.

and tetanus

(DPT).

in

UNIT 2 Pathophysiology

of

dehydration

a~d

Intestinal physiology Normai intestinal Intestinal

secretion

Secretory

rehydration

fluid balance

~,bsorption

of

17

of water and electrolytes of wat'er and electrolytes

watery

20

Consequences

of watery

Isotonic

dehydration

21

diarrhoea

21

(hypernatraemic)

dehydration

Hypotonic (hyponatraemic) dehydration Base-deficit acidosis (metabolic acidosis) Hypokalaemia .

Rehydration therapy Oral rehydration fherapy (OAT) Oral rehydration salts (GAS) Composition sodium

of GAS

concentration

Home fluids Limitations

of OAT

Intravenous therapy Preferred solution Acceptable Unacceptable

Exercises

17

20

diarrhoea

Hypertonic

17

20

diarrhoea

diarrhoea

Osmotic

diarrhoea:

17

Inte~tinal

Mechanisms

watery

solutions solution

22 22 22 23

23 23 25 25 25 26 27 27 27 28 28

29

'5

PATHOPHYSIOLOGY

Ilr1testinal

OF WATERY DIARRHOEA:

DEHYDRATION

AND REHYDRATION

physiology

Watery diarrhoea is caused by a disturbance in the mechanism of transport of water and electrolytes in the small intestine. Intestinal transport basis for the management otdrarrhoea,

mechanisms are also the

through oral rehydration therapy and feeding.

It is therefore important to understand some of the normal mechanisms of intestinal transport and how they are altered during di,arrhoea.

Normal intestinal fluid balance Normally, absorption

and secretion of water and electrolytes occur throughout

the

intestine. For example, a healthy adult takes in about 2 litres of fluid each day. Saliva and secretions from the stomach, pancreas, and liver add about 7 litres, making a total of about 9 litres .of fluid that enter the small intestine every day. There, water and electrolytes are simultaneously

absorbed by the villi and secreted by the crypts of the

bowel epithelium. This causes a two-directional

flow of water and electrolytes between

the intestinal lumen and the blood. Since fluid absorption is normally greater than fluid secretion, the net result is fluid absorpt!on (see Fig. 2.1, part 1). Usually, more than 90% of the fluid entering the small intestine is absorbed, so that about 1 litre reaches the large intestine. There, further absorption occurs, only 100 to 200 millilitres of water being excreted each day in formed stools. Any change in the two-directional

flow of water and electrolytes in the small intestine (i.e. increased

secretion, decreased absorption, or both) results in either reduced net absorption actual net.secretion

or

and causes an increased volume of fluid to enter the large

.~ntestine. When this volume exceeds the limited absorpti~e

capacity

of the large

intestine. diarrhoea occurs.

Intestinal absorption

of water and electrolytes

Absorption of water from the small intestine is caused by osmotic gradients that are created when solutes (particularly

sodium) are actively absorbed

from the bowel

lumen by the villous epit':lelial cells. There are several mechanisms whereby sodium is absorbed in the small intestine (see Fig. 2.2, part 1). To enter the epithelial cells, sodium is linked to the absorption of chloride ion (example A), or absorbed directly as sodium ion (example B), or exchanged absorption

of organic

ample D). The addition absorption

for hydrogen

substances

ion (example C), or linked

such as glucose

of glucose to an electrolyte

or certain solution

amino

to the

acids (ex-

can increase sodium

in the small intestine as much as threefold.

After t>eing absorbed. sodium is transported out of the epithelial cells by an ion pump referred to as Na + K +A TPase. This transfers sodium into the extracellular fluid (ECF), elevating its osmolality and causing water and other electrolytes to flow passively from the small bowel lumen through intercellular channels and into the ECF (see Fig. 2.2, part 1). This process maintains an osmotic balance between fluid in the bowel lumen and the ECF. Intestinal

secretion

of water

an,d electrolyles

Secretion of water and electrolytes normally occurs in the crypts of the small bowel epithelium, where sodium chloride is transported

from the ECF into the epithelial cell 17

I

READiNGS

ON

DIARRHOEA

Fig. 2.1 Absorption and secretion intestinal epithelium 1. Normal

small intestine

of electrolytes

and water

by

-

4

2.

Secretory

diarrhoea

CONTINUED OR INCREASED SECRETION

~

-,

across its basoJateral membrane (see Fig. 2.2, part 2). The sodium is then pumped back into the ECF by Na + K + A TPase. At the same timeJ secretory stimuli cause chloride ions to pass thFOUgh the luminal This creates passively 18

an osmotic

gradient

membrane that

from the ECF into the bowel

of the crypt cells, into the bowel

causes lumen

water through

and

other

electrolytes

the intercelJular

lumen. to flow

channels.

PATHOPHYSIOLOGY

Fig. 22

Mechanisms water

1. Sodium

of absorption

in the small

absorption

in the

bowel villous .

OF WATERY DIARRHOEA:

and secretion

DEHYDRATION

of electrolytes

AND REHYDRATION

and

epithelium epithelium

:+

A.

B.

EXTRACELLULAR FLUID

SMALL BOWEL LUMEN

c.

D. ~~D

2.

Chloride

secretion

the crypt epithelium a-

Eo

Na+

t~~*~!i

a-

!;:{',~

SMALL BOWEL LUMEN

.--

EXTRAcELLULAR FLUID

p ASSIVE FLOW OF WATER AND ELEcrROL YrES ~89962

19

READINGS

ON DIARRHOEA

Mechanisms

of watery

There are two principal and (ii) osmotic secretory

action.

diarrhoea

diarrhoea

mechanisms Intestinal

being

by which

watery

diarrhoea

occurs:

(i) secretion,

infections

can cause diarrhoea

by both mechanisms,

more common,

and both may occur

in a single

individual.

Secretory diarrhoea Secretory

diarrhoea

the small

bowel.

is caused

by the abnormal

This occurs

while the secretion

when

of chloride

body

changes

as watery

stools;

mechanisms

which

this causes

may result from the action

those of Escherichia

of water and electrolytes

of sodium

in the crypt cells cont1nues

pan 2). The net result is fluid secretion, the

secretion

the absorption

or is increased

(see Fig. 2.1,

leads to the loss of water and salts from

dehydration.

In infectious

on the bowel mucosa

coli and Vibrio cholerae

into

by the villi is impaired

of bacterial

01, or of viruses,

diarrhoea, toxins,

these such as

such as rotavirus;

other

may also be imponant.

Osmotic diarrhoea The small bowel mucosa is a porous epithelium, across which water and electrolytes move rapidly to maintain osmotic balance between the bowel contents and the ECF. Under these conditions,

diarrhoea

can occur when a poorly absorbed. osmotically

active substance is ingested.1f the substance is taken as an isotonic solution, the water and solute will simply pass through

the gut unabsorbed,

causing diarrhoea

(see

Fig. 2.3, A). Purgatives. such as magnesium sulfate, work by this principle. The same

Fig.

2.3

Mechanisms

of osmotic

diarrhoea

INTAKE:

RESm.T~

DIARRHOEA

MORE DIARRHOEA

NO DEHYDRATION

HYPERNA TRAEMIC DEHYDRATION

I+t-V

20

-3

PATHOPHYSIOLOGY

OF WATERY DIARRHOEA:

DEHYDRATION

A..D REHYDRATION

process may occur when the solute is lactose (in children with lactase deficiency) or glucose (in children with glu~ose malabsorption); both conditions are occasional complications of enteric infections. If the poorly absorbed substance is taken as a hypertonic solution, water (and some electrolytes) will move from the ECF into the gut lumen, until the osmolality of the intestinal contents equals that of the ECF and blood. This increases the volume of the stool and, more importantly, causes dehydration owing to the loss of body water (see Fig. 2.3, 8). 8ecause the loss of body water is greater than the loss of sodium chloride, hypernatra~mia

(:onsequences

of watery

also develops (see below).

diarrhoea

Patients with watery diarrhoea produce stools containing chloride, potassium, and bicarbonate

ions (see Table 2.1 ).

Table 2.1

in acute

Electrolyte

content

oral rehydration

of stool

watery

large amounts of sodium,

diarrhoea

and of

salts solution

~verage

electrolyte

content. mmol/l

Ha+

K+

CI-

HCO3

140 101

13 27

104 92

44 32

56

25

55

14

90

20

80

30a

Cholera Adults Children Non-cholera Children

,ORS

.Or

(below

5 years)

diarrhoea (below

5 years)

solution

cltrate. 10 mmol/l.

All the acute effects of watery diarrhoea

are caused

by the loss of water and

electrolytes from the body in liquid stool. Additional amounts of water and electrolytes are lost when there is.vomiting, and water losses are also increased by fever. These losses cause dehydration

(due to the loss of water and sodium chloride), base-deficit

acidosis (due to the loss of bicarbonate), and potassium depletion. Among these, dehydration is the most dangerous because it can cause decreased blood volume (hypovolaemia),

cardiovascular

types of dehydration

!3(jlonic

collapse, and death if not treated promptly. Three

are considered

below.

dehydration

This is the type of dehydration most frequently caused by diarrhoea. It occurs when the net losses of water and sodium are in the same proportion ECF. The principal features of isotonic dehydration

as normally found in the

are:

.there is a balanced deficit.of water and sodium; .serum sodium concentration is normal (130-150 mmol/l); .serum osmolality is norm~1 (275-295 mOsmol/I); .hypovolaemia occurs as a result of a substantial loss of extracellular fluid. 21

I

READINGS

ON DIARRHOEA

Isotonic dehydration is manifested first by thirst, and subsequently by decreased skin turgor, tachycardia, dry mucous membranes, sunken eyes, lack of tears when crying, a sunken anterior fontanelle in infants, and oliguria. The phy~1~signs of isotonic dehydration begin to appear when"the fluid deficit approaches 5%-'o~body weighl and worsen as the deficit increases. As Ihe fluid deficit approaches 10%\, of body weight, . dehydration becomes severe, and anuria, hypotension, a feeble and very rapid radial pulse, cool and moist extremtti~s. diminished consciousness, l~nd other signs of hypovolaemic s~ock appear. A 'fl'uid deficit thai exceeds 10% of body weight leads rapidly to death from circulatory collapse.

Hypertonic (hypernatraemic) dehydration Some children

with diarrhoea,

especially young

infants, develop

hypernatraemic

dehydration. This reflects a net loss of water in excess of sodium, when compared with the proportion normally found in ECF and blood. It usually results from the ingestion during diarrhoea of fluids that are hypertonic (owing to their content of so~ium, sugar: or other osmotically active solutes) and not efficiently absorbed, and an insufficient intake of water or other low-solute drinks. The hypertonic

fluids create an osmotic

gradient that causes a flow of water from the ECF into the small intestine, leading to a decrease in the ECF volume and an increase in sodium concentration (see Fig. 2.3, B). The principal features of hypernatraemic .there

dehydration

within the ECF are:

is a deficit of water and sodium, but the deficit of water is greater;

.serum

sodium concentration

.serum

is elevated ( > 150 mmol/l);

osmolality is elevated (>295

.thirst

is severe and out of proportion

mOsmol/I); to the apparent degree of dehydration;

the

child is very irritable; .seizures

may occur, especially when the serum sodium concentration

exceeds

165 mmol/l.

Hypotonic

(hyponatraemic)

dehydration

Children w!th diarrhoea who drink large amounts of water or other hypotonic fluids cpntaining very low concentrations of salt and other solutes, or who receive intravenous infusions of 5% glucose in water, may develop hyponatraemia. This occurs because water is absorbed from the gut while the loss of salt (NaCI) continues, causing a net loss of sodium in e-xcess of water. The principal dehydration .there

features of hyponatraemic

are:

is a deficit

of

water

and

sodium,

but

the

deficit

of

sodium

i~ greater;

.

.serum sodium concentration is low ( < 130 mmol/l); .serum osmolality is iow ( < 275 mOsmol/l); .the child is lethargic; infrequently, there are seizures.

Base-deficit acidosis (metabolic acidosis) During diarrhoea, a la,rge amount of bicarbonate may be (ost in the stool. If the kidneys continue to function normally, much of the lost bicarbonate is replaced and a serious base deficit does not develop. However; this compensating 22

mechantsm falls whe!:l

PATHOPHYSIOLOGY

renal function

deteriorates.

hypovolaemia.

Then.

from excessive

production

as happens

bClse deficit

features

of base-deficit

.serum

bicarbonate

OF WATERY DIARRHOEA:

when

there

and acidosis

is poor

develop

ren~1 blood

rapidly.

of lactic acid when patients acidosis

DEHYDRATION

AND REHYDRATION

flow due to

Acidosis

also results

have hypovolaemic

shock.

The

include:

concentration

is reduced -it

may be less than 10 mmol/l;

.arterial pH is reducedit may be less than 7.10; . .breathing becomes deep and rapid. which helps to raise arterial pH by causing a compensating .there

respiratory alkalosis;

is increased vomiting.

l'fypokalaemia Patients

with

diarrhoea

often

potassium

ion in the faeces;

dangerous

in malnourished

diarrhoea

starts.

does not usually

When

bicarbonate.

children.

who

and

causes

potassium

range.

However,

when

is rapidly

reversed,

time. The signs

by replacing of hypokalaemia

to large

are lost together. acidosis

to move

intracellular

from

the serum

acidosis

before

hypokalaemia .fluid

to ECF in

level in a normal is corrected

hypokalaemia

and correcting

of

that results from the

potassium

and serious

losses

and can be especially

potassium-deficient

the base-deficit

the base-deficit

potassium

owing

in infants

are frequently

ion, thus keeping

this f:'ift

can be prevented

depletion

bicarbonate

This is because

for hydrogen

even elevated

potassium

these losses are greatest

potassium

develop.

loss of bicarbonate exchange

develop

by giving

can develop.

the base deficit

or

This

at the same

may include:

..general muscular weakness; ..cardiac arrhythmias; .paralytic ileus, especially when drugs are taken that also depress peristalsis (such as opiates).

I~ehydration

therapy

The goal in managing fluid

and

further

dehydration

electrolytes

losses

rapidly

as they occur

Fluid losses can be replaced needed

only for initial

Oral rehydration OAT is based electrolytes

Thus,

remains

either

on the principle

orally

therapy")

stops

(termed

or intravenously;

of patients

that intestinal

existing

and

then

who are severely

deficits

of

to replace

"m~intena.nce the latter

(which

is derived

other

with

a source

absorption

therapy").

route

is usually

dehydrated.

from the breakdown from the breakdown

this process

continues

pathways

of intestinal

secretory

diarrhoea

of glucose

or amino

in the gut; ultimately

of sodium

by the active absorption

acids (which are derived

if patients

.'rehydration

is to correct

therapy (aRT)

whereas

not contain

by diarrhoea

until diarrhoea

rehydration

Fig. 2.2, D). Fortunately, diarrhoea,

(termed

and water) is enhanced

such as glucose or L-amino

caused

adding

of sucrose

absorption an isotonic sodium

to the volume

food molecules

or cooked

of proteins

to function

drink acids,

(and thus of other

of certain

normally

during

of sodium salt

(see

secretory

are impaired.

solution

is not absorbed

of stool passed

starches)

and peptides)

that

does

and the fluid

by the patient

(see 23

I

READINGS

ON

DIARRHOEA

Fig. 2.4, A, B). However, when a balanced isotonic solution of glucose and salt is given, glucose-linked

sodium absorption occurs and this is accompanied

of water and other electrolytes

(see Fig. 2.2, D and Fig,2.4,

existing

deficits

of water

and electrolytes

Fig. 2.4

Effect

of glucose

on intestinal

INTAKE:

and

replace

absorption

by the absorption

C). This process further

faecal

of salt and water

NONE

can correct

losses

in most

during

IC SALT !.v...u .10N

A:

B:

CfROL'rTES

.YIES

DlARRROEA

RESULT:

ISOTONIC DEHYDRATION

fuNIC

DE

INTAKE:

I~ONIC

SOU

IVI~

OF SAL T

C:

SOLUTION ' ~.!.:,ISOTONIC OF SAL T ,:c:;~

D.

.,~:.~

A ~

ND

GL

!,1,; c"

,:,

.jf:

;" :' f' , 7

(iltl! , : 2,

1I.II

GL

1',: -ELL -J A'TER..1.1--'.

~~~~};

,: WATER, .~; ELE---

,.;~

2

) )

, ,.,-.,...,... .,..c; WATER, 1.lc ,1:1ii ,.-' El--"

1

YfES

LJ~~~~;~ "' ..: . "' , ..;.:,. ..'.'..,

SMALL

;1 ~C

.i;:'C

,.,~..,J, .'.';:'.i:"

~

,

,uc ,~,

C"

" t

I.!.,,;, ."...'j,!..,.",..., ~%i~i~r~~f:~~)~:Wi~~

1

"'"'.-"!:1.:. :...;."1'..

~v'.'".,

s~l~ ,II

RESULT:

DIARRHOEA

~-

24

PATHOPHYSIOLOGY

patients

with secretory

diarrhoea,

OF WATERY DIARRHOEA:

irrespective

of the cause

DEHYDRATION

of diarrhoea

AND REHYDRATION

or the age of

the patient.

IOral rehydration Composition

salts (ORS)

of ORS. The principles

underlying

OAT have been applied

to the

development of a balanced mixture of glucose and electrolytes for use in treating and preventing dehydration, potassium depletion, and base deficit due to diarrhoea. To attain the latter two objectives, potassium and citrate (or bicarbonate) salts have been included, in addition to sodium chloride. This mixture of salts and glucose is termed oral rehydration salts (OAS}; when OAS is dissolved in water, the mixture is called ORS solution

(Table

2.2). The

WHO/UNICEF-recommended .the

following

guidelines

were

used

in

developing

the

OAS solution:

solution should have an osmolality similar to, or less than, that of plasma, i.e.

about 300 mOsmol/1 or less; .the

c~ncentration

of sodium should be sufficient to replace efficiently the sodium

deficit in children or adults with clinically significant dehydration; .the

ratio of glucose to sodium (in mmol/l) should be at least 1: 1 to achieve

maximum sodium absorption; .the

concentration

of potassium should be about 20 mmol/l to replace potassium

losses adequately: .the

concentrati()n

of base should be 10 mmol/l for citrate or 30 mmol/l for bicarbo-

nate, which is satisfactory for correcting base-deficit acidosis due to diarrhoea. The use of trisodium

citrate, dihydrate, is preferred, since this gives ORS packets a

longer shelf-life. Table 2.2 Composition of the oral rehydration salts solution recommended and UNICEF

Amounts gll

Ingredients

Sodium chloride Trisodium citrate, dihydrat~ Potassium chloride

a Or 2.5 9 sodium bOr

30 mmol

90 20 10b 80 111

Sodium Potassium Citrate Chloride Glucose

2.98 1.5

Glucose (anhydrous)

Concentration mmol/l

Ions

3.5

20.0

by WHO

bicarbonate.

bicarbonate.

Sodium concentration.

ORS solution

diarrhoea

etiologies

of different

has been used to treat millions of cases of

in patients

of all ages, and has proved to be

remarkably safe and effective. Nevertheless, because stool electrolyte concentrations vary in different types of diarrhoea

and in patients of different ages, doctors

are

sometimes concerned about using. a single ORS solution" in all clinical situations. T able 2.1 (page 21) compares the composition of ORS solution with the average electrolyte composition of stool in different kinds of acute watery diarrhoea. The stools of patients with cholera contain relative.ly large amounts of sodium, potassium, and bicarbonate.

In children

sodium, bicarbonate,

with acute non-cholera

diarrhoea,

the concentrations

and chloride in the stool are lower, although

of

they vary con-

siderably. 25

READINGS

ON DIARRHOEA

A child with dehydration dueto diarrhoea has deficits of sodium and water. In cases of severe dehydration, the sodium deficit has been estimated to be 70-110 mmol for each 1000 ml deficit of water. The sodium concentration

of 90 mmol/1 in ORS solution is

within this range and hence it is suitable for the treatment of dehydration.

During the

maintenance phase, however, when ORS sol(:Jtion is used to replace continuing losses of water and electrolytes in the stool, the concentration of sodium excreted in the stool averages 50 mmol/l. Although

this loss could be corrected with a separate solution

containing 50 mmol/1 of sodium, the same result can be obtained by giving the standard ORS solation with a normal intake of water or breast milk. This approach reduces the ~verage concentration

of sodium ingested to a range that is both safe and

effective, and any modest excess of sodium or water is excreted in the urine; this is especially important in young infants, in whom renal function is not fully developed. A major advantage of this approach is that it avoids confusing mothers, nurses, and doctors, who might other\A/ise have to use different or~1 solutions for the rehydration and maintenance phases of treatment. Home fluids Although their composition

is not as appropriate

as that of OAS solution for treating

dehydration, other fluids such as soup, rice water, yoghurt drinks, or plain water may be more practical and nearly as effective for OAT to prevent dehydration. These home fluids should be given to children to drink as soon as diarrhoea starts, with the goal of giving more fluid than usual: Feeding should also be continued. therapy can prevent many patients from becoming dehydrated

Such early home

and it also facilitates

continued feeding by restoring appetite. Food-based however,

fluids'

factors

ing specific should

are most effective

other than relative

home fluids

preferably

3.0 g of common

Food-based

be about

when

fluids

provided

that

into glucose,

remains

a fluid

contains

proteins,

When only salt-free

fluids

diarrhoea cause

breast-fed.

I "Food-based"

this

within

salt-free

fluids,

absorbed.

Breast-feeding

during

means that a fluid contains

starch

with

of sodium by dissolving

containing

sucrose,

down

within

of the fluid in the situation

exists

The proteins

break

so that the osmolality

of the

legumes.

quickly,

may also

are given.

is broken

Thus, the osmolality

a safe range.

is less effective

Infants

as water,

300 mas mil). A similar

made

is severe; if given in large amounts hyponatraemia.

is obtained

to those

when

are absorbed

recommend-

salt concentrations

such

are preferred Moreover,

when

some salt:

salt, the concentration

are given, the diet should,

combination

from food items such as yoghurt

?h

be considered

This concentration

e.g. soups

acids, which

when they contain

Fluids with higher

starch

it is rapidly

remains

However,

should

at a safe level (i.e. less than

fluid in the intestine

also

other

contain

down slowly into amino

food.

50 mmol/l.

they have a lower osmolality.

the intestine intestine

efficacy

(see Unit 4). If fluids contain

salt in 1 litre of water.

be safe and effective,

because

for. home therapy

with

without

dietary

diarrhoea

should

diarrhoea

carbohydrates

if possible. in preventing

is an

or proteins.

important

contain

some salted

dehydration

salt, salt-free always source

when

fluids might

continue of water

to

be and

It does not always mean that the fluid is made

or cereals; fluids such as green coconut

water are included

as well.

PATHOPHYSIOLOGY

r1"titf-ients, provides

OF WATERY DIARRHOEA:

some salt, and can actually ' c ', .i":

of illness.

decrease

DEHYDRATION

st9o1 volume

AND REHYDRATION

and the duration

There are also some fluids that should not be given to children with diarrhoea. These include sweetened commercial fruit drInks or soft drinks, which are usually hyperosmolar owing to their high sucrose content. These fluids can cause osmotic'diarrhoea hypernatraemia. Limitations

Other fluids to avoid are purgatives, and stimulants such as coffee.

of ORT

In at least 95%

of episodes

of wa1ery diarrhoea,

prevented

using only OAS solution

ineffective

in certain

ORT

of severe

very rapidly

.patients

with paralytic who

ORT

OAT is either

through

a nasog~strrc

dehydration,

intravenous

ileus and marked

are unabJe to drink

is ineffective

.patients

(life-threatening)

(this requires

.patients patients

(or OAT}. However,

qan

be corrected

or

inappropriate

or

for:

treatment

replaced

dehydration

situations.

is inappropriate

.initial

and

infusion

abdominal

(however,

because of water

fluid

must

be

and electrolytes);

distension;

ORS solution

tube, if intravenous

can

treatment

be given

to such

is riot possible).

for:

with very rapid stool loss ( > 15 mi/kg of body weight per hour); such

patients may be unable to drink fluid at a sufficient rate t6. repiace tneir iosse's; .patients

with severe, repeated vomiting (this is unusual); generally, m9st of the fluid

take~ orally is absorbed despite vomiting, and vomiting stops as dehydration electrolyte imbalance are corrected; .patients with glucose malabsorption

and

(also unusual) ; in such cases ORS solution

causes stool volume to rncrease markedly and the stool contains large amounts of glucose; dehydration

may ~Iso wOrsen (see Fig.2.4, D).

Intravenous therapy Intravenous to restore number

fluids are required rapidly

their

blood

of intravenous

the electrolytes diarrhoea solution

solutions

required

(see Table should

only for patients volume

with severe dehydration.

and .correct

are available.

to correct

found

adequate

be given as soon as the patient

Ringer's

deficit provides

solution

available

sufficient

dehydrated

a

by acute

replacement;

is able to drink. therapy. available

Although

In at least some of

some

ORS

even while the initial

The following solutions.

is a brief .

solution lactate

commercially

in patients

electrolyte

fluid requirement is being provided by intravenous discussion of the relative merits of the most widely

Preferred

shock.

they are all deficient

the deficits

2.3). To ensure

hypovolaemic

and then only

lactate,

acidosis.

(also solution.

which However,

called

Hartmann's

It supplies

is metabolized

an

to bicarbonate,

the concentration

no g1ucose to prevent

solution

adequate

hypoglycaemia.

ot

is the best sodil,lm \

for the Correction

of potassium Ringer's

for injection)

concentration

is low

lactate

and

solutior

and

of base-

the solution can be used \27

I READINGS

ON

Table

DIARRHOEA

2.3

Electrolyte

content

of Intravenous

infusion

solutions

Electrolyte Solution A.

content, mmol/l

Na'

K+

130

4

109

28

154 61 77

O 18 O

154 52 77

O 27 0

0

0

0

0

Lactate

CI

Preferred Ringer's

lactate

(Hartmann's

solution)

B.

Acceptable Normal

saline

Half-strength Half-normal

c.

(9 9 NaCI/I)

Darrow's solution saline (4.5 9 NaCI/I)

Unacceptable Glucose

(dextrose)

solutions

in all age groups to correct dehydration

due to acute diarrhoea

of any cause. Early

provision of ORS solution and early resumption of feeding will provide the required amounts of potassium and glucose.

Acceptable

solutions

When Ringer's lactate solution is not available, normal saline, half-strength solution,

or half-normal

appropriate

saline solution

Darrow's

may be used; however, these are less

as regards content of sodium, potassium, or a base precursor (see Table

2.3). .Normal

saline (also called isotonic or physiological

saline) is often available. It

does not contain a base to correct acidosis, nor does it replace potassium lo~ses. Sodium bicarbonate

or sodium lactate

(20-30 mmol/l)

(5-15 mmol/l) 9an be added to the solution, appropriate .Half-s!rength

and potassium

chloride

but this requires a supply of the

sterile solutions. Darrow's solution

(also called lactated potassic saline) contains less

sodi~m chloride than is needed to correct efficiently the sodium deficit in patients with severe dehydration. It is prepared by diluting full-strength Darrow's solu!ion with an equal volume of glucose solution (50g/1 or 1OOg/I). .Half-normal

saline with 50 g or 100 g of glucose per litre, like normal saline, does not

correct acidosis, nor does it replace potassium losses. It also contains less sodium chloride .than is needed for optimal correction

Unacceptable

of dehydration.

solution

Plain glucose (dextrose) solution should not be used because it provides only water and glucose. It does not contain electrolytes and thus does not replace the electrolyte losses or correct acidosis. It does not effectively correct hypovolaemia. 28

PATHOPHYSIOLOGY

OF WATERY DIARRHOEA:

DEHYDRATION

AND 'REHYDRATION

1

Exercises Indicate whether the following features are most characteristic 'of secretory or osmotic diarrhoea. Place an S (for secretory) or an O (for osmotic) against each, as appropriate. A. Hypernatraemic B. Isotonic

dehydration.

dehydration.

C. Non-absorbed

solute.

D. Impaired

sOdium

E. Lactose

intolerance

2. Which

absorprion. is a cause.

of the following

intestine?

(There

A. Cooked

can increase

the efficacy

of sodium

may be more than one correct

absorption

in the small

answer.)

rice starch.

B. Palm oil. C. Plain sugar. D. Some amino

acids.

E. Glucose.

3. Which

one of the following

A. Potassium

effects

of severe diarrhoea

is most dangerous?

depletion.

B. Anorexia. C. Base-deficit

acidosis.

D. Fever. E. Hypovolaemia.

4. Which of the following than one correct

are features

of hypertonic

dehydration?

(There

may be more

answer.)

A. Extreme thirst. B. Serum sodium

concentration:

140 mmol/l.

C: Very ,irritable child. D. Serum potassium concentration: E. Lethargic

5. For which

3.8 mmol/l.

child.

of the following

may be more than

situations

one correct

is OAT using

OAS solution

effective?

(There

answer.)

A. Maintenance therapy for an infant with diarrhoea due to rotavirus. B. Rehydration of a child with cholera who is alert and able to drink. C. Rehydration of a child with diarrhoea, paralytic ileus and abdominal D. Rehydration of a comatose child with severe dehydration

distension.

and shock due to

rotavirus diarrhoea. E. Maintenance therapy of a child with cholera. after being rehydrated.

6. Which of the following amount

of water

and

might

happen

used

to treat

if ORS was mixed with only half of the required a young

child

with

rotavirus

diarrhoea

and

29

READINGS

ON DIARRHOEA

dehydration?

(There may be more than one correct answer.)

A. The solution would be even more effective. causing

the stool volume to be

reduced and the duration of diarrhoea to be shortened. B. The child would develop hypernatraemia. C. The child would refuse to drink the solution. D. The child would develop paralytic ileus and abdominal

distension.

E. The child would become extremely thirsty. 7. Which of the following .'home fluids" can be safely used to prevent dehydration children with diarrhoea? (There may be more than one correct answer.) A. Rice water. B. Water. C. Cola drink. D. Soup

made

E. Sweetened

30

from cooked commercial

legumes. fruit drink.

in

UNIT 3 Assessing

the

patient

with

diarrhoea

33

Introduction

33 Assessing the child for dehydration Ask, look, and feel for signs of dehydration Determine the degree of dehydration and select a Treatment Column

C -Severe

dehydration

Column Column

B -Some dehydration ANo signs of dehydration

the

Dysentery Persistent

child

for

other

37 37 38 38

problems

39 39

diarrhoea

39

Feeding

history

Physical

findings

Vitamin

40 41

A deficiency

43 43

Fever

EXE!rcises

Plan

39

Malnutrition

Measles

35

38

Weigh the child Assessing

35

vaccination

status

43

43

31

ASSESSING THE PATIENT WITH DIARRHOEA

Introduction Every child brought

to a he"alth facility because of diarrhoea

should be carefully

assessed before his or her treatment is planned. In most cases the information gained by spending a f~w minutes asking for details of the illness, and observing and examining the child for specific signs (e.g. of dehydration or m~lnutrition), is sufficient to make a diagnosis and develop a plan. for treatment. The clinical assessment consists of taking a brief history and examining the child. Its objectives are: .to

detect dehydration,

.to .to .to

diagnose dysentery, if present; diagnose persistent diarrhoea, if present; evaluate feeding practices and determine the child's nutritional status, especially

.to .to

if present, and determine its degree of severity;

to detect severe malnutrition; diagnose any concurrent illness; determine the child's immunization

history, especially as regards Immunization

for measles. Depending upon what is found. the clinical assessment should lead directly to' .a .a .a

plan for treating or Rreventing dehydration; plan for treating dysentery, if present; plan for treating persistent diarrhoea. if present;

.recommendations .a

plan for managing any concurrent

.recommendations .a

for feeding during and after diarrhoea; illness;

regarding measles immunization;

plan for fol\ow-up.

This unit explains how the clinical assessment should be performed and interpreted, in order to ensure that the above objectives are achieved. Treatment plans for d~hydration and other problems associated with diarrhoea, and for the maintenance of nutrition in patients with diarrhoea, are considered in Units 4-7. Using

the

diarrhoea

management

chart

and

patient

record

form

The WHO chart .'Management of the Patient with Diarrhoea" is designed to help guide the evaluation and treatment of patients with diarrhoea. It summarizes the questions to be asked and the signs to be observed in a manner that helps the doctor or health worker to remember the most important

points and to follow a standafd

pattern in

patient evaluation. It also shows how to use the results of the evaluation to determine the most appropriate treatment. This approach should be used for all children who are seen at a treatment facility with a complaint of loose or watery stools or loose stools with blood. The top part of the chart shows how to assess patients for dehydration

(Fig. 3.1 ). and

how to assess and manage other important problems that patients with diarrhoea may have (Fig. 6.1. page 82). The clinical features described in these figures are the ones that are most important and can be most reliably assessed by doctors and other health workers. 33

34

READINGS

ON DIARRHOEA

c o = . .. '0 >.c Q) '0 .. 0 UI C Q) = ca Q. UI UI Q) UI UI ca o -

~ 0 %

..Cf) CI i:i:

u

m

«

ii ~ o u ., c o U C ~

O U '61~ '->~a. .Ca. -0 0>..J~

. ~ :0 ~ ~ m ~ .!! "Gi GI a:

~ "0 "0 c "' c Q! oX c :J (/)

~ ~

c GI (/) .c ~

E 01 "' .0 «

E ~ U) ~ ~

c: Q) ~ c: ~ 00

"iO E O z

11i 1-

t 0) -a

~

(/) w >w

C:-0 C:Q) >

~ o

~ ...~ 0 ~ >-~ -"0 O o 0-

~

0-.!! ~.Q ~ m ~~ 0 C~

. >0;: ~ 01 la ~ ~ oX C 0;: "0 > . ~

:E ~

~ ""iU E

0

~?:c ~ III .~:5 C -+-

:r: ...

1(1) Ir

Oc

~ >'i o "i ~ II > ~ () m .c m II 0 O ~

. >"i o "ii ~

u m .c . 0> 0 ~

aI ~ aI

.-

.-C>-

°Cw Eoa: ~-w °~> °alw !=(/) (/)IU(/) IU CI .CCalQ

a.

C'g~,< al-.-0 -C IU .-

"

Z

a: O

0

aI(/)OII

~(/)~

Z

.cC-W -.QI

~ OQ) Ec: ~o o-w o:!d~ ~Q)O +=-(/) UIall11 .~

O

.cOlQ)O -.5 ~ c-cQ)1-: .~ .2 ,s '« 1Uo -a: a..5 .O

0

z

Q)UlC:>.cc.2':I: -01.'W -.-Ul«

-u.

~ 00 Z>1/1 :I: alW .Co .~o

a.z

iU(/)

Q)~ .c-

~ 1Q)Z UlW ='~ "Ca: ~:> cU .~ C m~ a. a. Q).c:C -Q) .c:E 01.-111 Q) Q) ~.==

.0; m III C

a>" :0

E

O.aI 0.~a.. c QI .g!; E -aI aI a.QI QI~ .c

-QI .c III 01=' "ii u ~ ~

< c: 11! 0: E CD E iU CD .= CD UI :J

> :x u "3 0" ~ u as .0 U) 0> O (!J

1--(/)

iii .0 ~

~

~ a: 1-

(/) a:

w c (3 w c

:1: () z ii: z ~ 00

M

w :) (!) z o ... '0 i :I: ... :) 0 ~

:.J UJ UJ 11.

""(5

z O ~ a z 0 u

"'

~

9

!'.,: "« ~ 0

~

t

.

ASSESSING

Information

on the history.

summarized Modified

.a

on a .'patient

versions

~xamination,

and

treatmen-t

record form". An example

THE

.Q.t each

PATIENT

patient

WITH

DIARRHOEA

should

be

of such a form is given in Annex

of this form may be used, but they should

include

1.

at least:

brief history of the diarrhoeal episode, including its duration and whether blood has been seen in the faeces;

.the child's pre-illness feeding pattern; .the child's immunization history, especially as regards measles; .important findings during examination of the child, especially signs of dehydration .a

or malnutrition, and the child's weight; summary of fluid intake and output, and the evolution

of clinical findings

in

patients given rehydration therapy at the health facility; .a

description of food given at the health facility;

.a description of any medicines given at the health facility; .recommendations for treatment, feeding, and follow-up after the child leaves the health facility. When the form is completed promptly and accurately, it provides a valuable record of the child's progress during treatment at the health facility. It also helps to remind the health .worker of all the steps that should be taken in the evaluation and management of the patient. Completed forms should be kept at the health facility and reviewed regularly to identify areas in which case management

practices could be improved.

Forms completed by students should be checked by a supervising physician; this can serve as an important means of evaluating the student's skills in patient evaluation and case management.

j~ssessing Patients

the should

commonty treatment

child first

for

be evaluated

associated

with

history

and doing without

for

dehydration

diarrhoea.

is given. However,

started

dehydration

when

a thorough

Usually,

a child

and

both

then

steps

is severely

for

are

dehydrated.

other

problems

completed taking

before

a complete

examination

must be deferred

so that treatment

can be

delay. Seeing

a stuporous

child.

that the condition

began

with diarrhoea

and vomiting,

and quickly

give sufficient

information

requires

an intravenol,Js

physical

examination

to indicate

confirming

that

that the skin turgor

the patient

drip at once. When

should

confirming

the drip

has severe is running

is very poor

dehydration

well. the history

and and

be completed.

Ask, look, and feel for signs of dehydration The detection examined.

of dehydration

is based

The signs that should

.Condition behaviour.

and

behaviour.

Does the child

entirely

be evaluated

Carefully appear

observe

on signs

observed

in every patient the

child's

whel'1 the child

is

are as follows: general

condition

and

to be:

35

READINGS

ON DIARRHOEA

Note that it is sometimes difficult to determine whether a child is abnormally lethargic or just sleepy. This can often be decided by asking the mother whether her child is lethargic or only sleepy. .Eyes.

Are the child'.s eyes

-normal

?

-sunken? -very

sunken

and dry?

Note that some children have eyes that are normally slightly sunken. It is often helpful to ask the mother whether her child's eyes are normal or more sunken than usual. .Tears.

Does the child

.Mouth

and tongue.

have tears when

he or she cries vigorously?

Are these:

.wet? .dry? very

dry?

Note that this sign can be affected by events other than dehydration.

The mouth and

tongue will be moist if the child has been drinking or has recently vomited; they will be dry if the child is breathing through the mouth. .Thirst.

Offer the child

observe

whether

-drinks

some water

or ORS solution

in a cup or from

a spoon

and

the child:

normally, accepts the fluid without particular interest, or refuses to drink;

-drinks eagerly, grasps the cup or spoon, or is unhappy when the fluid is removed; -is unable to drink or drinks poorly, because he or she is very lethargic or semiconscious. ..Skin

pinch

released.

(skin

turgor ). When

does the fold flatten

the skin of the abdomen

or thigh

is pinched

and

and disappear:

This Sig.l is usually very helpful, but obese children may fail to show diminished skin turgor even when dehydrated, owing to the layer of fat under their skin, and skin turgor may appear poor in children with marasmus even when there is no dehydration Unit 7). Additional

(see

signs that are not listed in Fig. 3.1 but can also be of help in assessing

hydration include: .Anterior

fontanelle.

sunken

.Arms 36

than

usual;

In infants when

with some dehydration

dehydration

and legs. The skin of the lower

and dry; the colour

is severe,

the anterior

fontanelle

is more

it is very sunken.

parts of the arms and legs is normally

of the nail beds is normally

pink.

When

dehydration

warm

is severe

ASSESSING

and there is hypovolaemic

THE PATIENT WITH DIARRHOEA

shock. the skin becomes cool and moist. and the nail

beds may be cyanosed. .Pulse.

As dehydration

increases,

rapid. When dehydration When there is hypovolaer'lic however,

remains

.Breathing. due

the radial

shock,

indrawi,ng

pulse becomes

it may disappear

pulse become very rapid

completely.

more

and weak.

The femoral

pulse,

palpable.

The rate of breathing

in part

pulse and femoral

is severe, the radial

to their

is increased

base-deficit

helps to differentiate

The assessment of hydration

acidosis.

in children

with severe dehydration,

The absence

these children

of cough

from children

or subcostal

w'lth pneumonia.

st~tus fs difficult in children with severe malnutrition

because many of the signs described

above are altered by malnutrition.

This is

especially true for signs related to the child's general condition or behaviour, sunken eyes, absence of tears and diminished skin turgor. This topic is considered in greater detail in Unit 7.

Determine

the

After a patient determine should

degree

of dehydration

with diarrhoea

the degree

and

select

has been examined.

of dehydration

(if any)

and

a Treatment

the findings

Plan

should

the appropriate

be reviewed Treatment

to

Plan

be selected.

The signs that indicate dehydration into three columns

are shown in Fig. 3.1, where they are organized

(A, B. and C) according

to the degree of severity. During the

examination of the patient, each sign listed on the left of the figure should be evaluated and a circle placed aro.und the descriptive term in column A, B, or C that best describes that sign in the patient. Signs that are most valuable in assessing dehydration, termed "key signs'.. are marked with asterisks (*) and printed in bold

type.

Two or more

circled signs in one column, including at least one key sign, mean that the patient falls in that category of dehydration

and requires the corresponding

Treatment Plan. If

signs are noted in more than one column. as often occurs, the category of dehydration is the one farthest to the right (among columns A, B, and C) in which two items. including at least one key sign, are circled.

Column C-Severe

dehydration

Look first at column C. If two or more signs are circled in that column, including at least one key sign, the patient has severe dehydration. Patients with severe dehydration

have a fluid deficit equal to more than 10% of their

body weight. They are usually lethargic. stuporous or even comatose. The eyes are deeply sunken and without tears; the mouth and tongue are very dry. and breathing is rapid and deep. Patients who are awake are very thirsty; however. when there js stupor . the patient may drink poorly or be unable to drink. A skin pinch flattens very slowly (more than 2 seconds). The femoral pulse is very rapid and the radial pulse is either 37

READINGS ON DIARRHOEA

very rapid and feeble or undetectable. In infants the anterior fontanelle is very sunken. The patient may have passed no urine for 6 hours or longer. When there is hypovolaemic shock, the systolic blood pressure taken in the arm is low or undetectable. the arms and legs are cool and moist. and the nail beds may be cyanosed. Severe

dehydration

Treatment

requires

urgent

treatment

with

intravenous

fluids,

following

Plan C (see Unit 5).

Column B -Some

dehydration

If severe dehydration is not present, look next at column B. If two or more signs listed in that column

are circled,

including

at least one key sign, the patient

has some

dehydration. Note that patients may have signs in both columns B and C. If the signs in column C are not sufficient to diagnose severe dehydration. they should be counted as belonging to column B. Patients with some dehydration

have a fluid deficit equal to 5-10%

weight. This category includes both "mild" and "moderate"

of their body

dehydration.

which are

descriptive terms used in many textbooks: .

"Mild"

dehydration

(5-6~~

thirst and restlessness. ated with dehydration

.

"Moderate" "fussy",

when

offered radial

thirst: fluid

slowly.

The

pulse

infants

is more sunken

loss of body weight)

from

Patients with some dehydration

causes

sunken

older patients

mostly

by increased

Other

signs

children

and the mouth

ask for water and young

a cup or spoon.

is detectable, than

decreased.

associ-

present.

The eyes are somewhat

dry. There is increased eagerly

(7-10%

is manifested

may be slightly

are not usually

dehydration

or irritable.

loss of body weight)

Skin turgor

but

A skin pinch

rapid,

and

to be restless, and tongue children

flattens

the anterior

are drink

somewhat

fontanelle

in

usual.

should be treated with ORS solution given by mouth,

following Treatment Plan B (see Unit 5). Column

A -No

If neither patient

severe

signs

of dehydration

dehydration

has no signs

nor

some

dehydration

is present.

conclude

that

the

of dehydration.

Patients with diarrhoea but no signs of dehydration

usually have a fluid deficit, but it

equals less than 5% of their body weight. Although

they lack

distinct

signs of

dehydration, they should be given more fluid than usual to prevent s)gns of dehydration from developing. Patients

with no signs of dehydration

should

be treated

at home, following

Treatment

Plan A (see Unit 4).

Weigh the child Patients who are found to have some dehydration

or severe dehydration

should be

weighed, if an accurate scale is available; children should be weighed unclothed. The 38

ASSESSING T~E PATIENT WITH DIARRHOEA

body weight is important for determining the amount of oral or intravenous fluid to be given ir, Treatment Plans B and C (see Unit 5). If no scale is available, the body weight should be estimated on the basis of the child's age (see Fig. 5.1, page 66), and treatment should be given without delay. :

The weight taken when a child is dehydrated should not be recorded on a growth chart, as it will be IQ,werthan normal owing to dehydration. Instead, the child should be reweighed after rehydration has been completed and that weight should be recorded on the chart. If possible, children with no signs of dehydration should also be weighed and the results recorded on their growth charts.

Assessing

the child for other problems

After the patient diarrhoea Fig.6.1

should (page

has been evaluated be considered.

for dehydration.

The assessment

82) and discussed

other problems

for other problems

associated

with

is summarized

in

below.

Dysentery The health worker should ask whether the diarrhoea stools have contained any blood. If possible. a fresh StOOlspecimen should ajso be examined for signs of blood. If blood is present. the patient should

be considered

described in Unit 6. If dehydration

to have dysentery and treated

as

is present with the dysentery, it should also be

treated immediately.

Persistent diarrhoea The health worker

should

ask when the present

that have lasted at least 14 days should treatment

should

whether

a child

diarrhoea. although

follow

the guidelines

has persistent

Patients

with

the number

or is having

diarrhoea

usuaJly

per day may vary considerably.

may have normal

stools for 1 or 2 days after which

normal

stools

(formed)

of diarrhoe~

does not exceed

have

episode.

However.

if the period

any subsequent

diarrhoea

should

be considered

loose

Sometimes.

diarrhoea

of normal

and

to determine

episodes stools

of acute every

however.

resumes. should

Episodes

diarrhoea

it is difficult

sequential

2 days. the illness

single diarrhoeal

began.

to be persistent

in Unit 6. Sometimes

diarrhoea

persistent

episode

be considered

day,

the child

If the period

of

be considered

a

stools is longer

than 2 days.

to be a new episode.

Malnutrition A brief nutritional assessment should be carried out for each child with diarrhoea identify those with nutritional problems and obtain the information dietary recommendations.

necessary to make

The minimum goals should be: (i) to determine whether the

usual feeding pattern is appropriate malnutrition,

to

if present. If conditions

for the child's age, and (ii) to detect severe permit, a more thorough

assessment should be

performed as described below. 39

I

READINGS

ON

DIARRHOEA

Feeding

history

Determine current

both the child's

episode

of useful

questions

.Pre-illness

usual

of diarrhoea.

(pre-illness)

diet and the feeding

The main points that follow

are provided

for each

should

pattern

be covered.

during

point.

feeding:

-Breast-feeding Is the child breast-feeding ? How frequently is breast milk given ?

-Animal

milk or infant

Are either

-For

formula

of these given ?

powdered milk or formula

How is the milk prepared (i.e. how much powder and water) ? Is boiled water used ? How much milk is given and how often ? Is the milk given in a feeding bottle, or by cup and spoon ? -Solid

foods (for children aged 4-6 months or older)

What foods does the child usually take? Are the usual foods liquid, soft, or semi-solid? Is oil added"to the child's food? How much food is given and how frequently? Is the child given food from the family pot?

.Feeding

during

diarrhoea:

-Breast-feedlng Is breast milk given more often, as usual, or less often ? Does the child breast-feed well? -Animal

milk or infant formula

Has the amount given been more, the same, or less than usual? Has the milk or formula been made with more water than usual ? -Other

liquids

Has.the child been given water qr other drinks? Has the amount of liquid given been more, the same, or less than usual? -Solid

foods

Has the amount given been more, the same, or less than usual? How frequently has food been offered? What types of food has the child accepted ?

.Mother's -What other

40

beliefs

about

feeding

does the mother fluids

or foods

during

believe during

diarrhoea:

about

diarrhoea

giving ?

breast

milk, animal

the

Examples

milk or formula.

ASSESSING

Which

fluids

or foods

during

diarrhoea

does she consider

acceptable

THE PATIENT WITH DIARRHOEA

and which

unacceptable

?

Physical findings First. determine

whether

have the features

.Signs

there is obvious

of marasmus,

severe protein-calorie

kwashiorkor,

or both

malnutrition.

This may

(see Fig. 3.2).

of marasmus include:

-"old

man's

-extreme -very

face";

thinness,

"skin

thin extremities,

-absence

distended

of subcutaneous

-fretful,

.Signs

and bones"

irritable

appearance;

abdomen;

fat; the skin is very thin;

behaviour.

of kwashiorkor include:

essential features: oedema; miserable, apathetic, listless behaviour; .other possible features: thin hair with rc:ddish discoloration: flaking, dry skin; enlarged liver. Then. determine whether there is a less serious degree of malnutrition. This may not be possible in all settings. but should be done where conditions examinations

may be performed:

.Weight-for-age. not

T~is is the simplest

distinguish

respond

between

to increased

increased a growth

feeding

shows

Mothers

of young weight

nutritional

feeding)

whether children

recent

growth

is not increasing

however,

loss

which

(i.e. wasting,

is most valuable

pattern

is satisfactory

is below

or is decreasing

for

not

which on

over several

(see Annex

2).

70% of the standard,

or

over time, should

be seen regularly

it does

does

when recorded

over time; a series of points

weight-for-age

should

status;

(i.e. stunting,

weight

Weight-for-age

whose

receive

for follow-up

special

until a normal

is established.

arm using

scale is not required)

However,

it is not useful

.Weight-for-height/length, tects children

with

ments are required difficult

This iest involves

a standard

weighing

is more

and

of nutritional

damage

or not the growth

arm circumference.

of the upper

measure

nutritional

is important).

advice. The children

rate of growth .Mid-upper

past

chart and used to monitor

months

whose

permit. The following

tape

and valuable

for monitoring

measurement

(see Annex

as a screening

growth

(i,e" weight

to measure

ratio

loss (wasting);

than

(a

test for malnutrition.

is valuable

however,

and height/length), accurately

to perform

over time.

A low weight-for-height rec~nt. weight

of the circumference

3). It is simple

two accurate

Unfortunately,

weight,

because

Mothers

it de-

measure-

height of children

or length whose 41

READINGS

ON DIARRHOEA

Fig.

3.2

Clinical

features

of marasmus

and

kwashiorkor

Kwashiorkor

Source

King

M et al. Pnmary

child

care

A manual

for health

wOrkers

Book

one. Oxford.

Oxford

weight-for-height ratio. is below 75% of the standard snould r]utritional advice and the children should be followed up. Each of the above measurements

should

be interpreted

tables. These may be either national or international

Press

1978

receive special

using standard

charts or

standards. If the latter are used.

national guidelines must be followed for their interpretation 42

Universlly

in the local setting.

ASSESSING THE PATIENT WITH DIARRHOEA

Vitamin

A deficiency

.Night

blindness.

Ask the mother

with night blindness find their food

do not move about

or toys. Night

not yet old enough .Bitot's

if her child is able to see normally

blindness

In the

in the dark and may be unable

is difficult

to recognize.

in children

to

who are

to walk.

spots. These are dry, grey-white,

located

normally

at night. Children

temporal

part

foamy-appearing

of the scleral

areas, triangular

conjunctiva.

Usually

in shape,

both

eyes

are

affected. .Corneal

xerosis

and

ulceration.

These

are

areas

of the

cornea

that

are

roughened

or ulcerated.

Children should

who

have

be treated

night

blindness,

immediately

Bitot's

spots,

with therapeutic

or corneal

doses of vitamin

xerosis

or ulceration

A (see Unit 7).

Fever The mother The child's and

can

should

should

be asked whether

temperature be disinfected

be measured

with a temperature children

should

should

e.g. pneumonia,

her child

has had fever during

also be measured.

after

use, they

in the axilla

are preferable,

(armpit).

of 38 °C or greater

Any child

should

also be carefu11y checked

the past 5 days.

If rectal thermometers Otherwise,

with a history

be managed

the temperature of recent

as described

for signs or symptoms

are available

fever or

in Unit 6. Such

of other

infections.

malaria.

Measles vaccination status The mother

should

The child's

immunization

should

be asked whether record

receive measles vaccine

For unimmunized

children,

visit to the treatment

her ch11d has been immunized

should

also be consulted,

at 9 months

against

if it is available.

of age or as soon as possible

the best time to give the vaccine

measles.

is during

Children thereafter.

the child's

current

facility.

Exercises Which

of the following

A. The skin pinch

are signs

goes back

B. The child

is very lethargic.

C. The child

is unable

D. The eyes are slightly E. The mouth 2. Marina, When

slowly

(within

2 seconds)

to drink. sunken.

and tongue

are very dry.

aged 2 years, is brought you examine

of severe dehydration?

to you because

she has had diarrhoea

her you note that she is irritable

for 3 days.

and fussy and that

her skin

43

READINGS

ON DIARRriOEA

pinch

goes back

dehydration

rather

would

A. Normal

slowly.

Other

findings

most consistent

with her degree

of

be:

eyes, tears are present

when

she cries, and her mouth

and tongue

are

moist. B. Her eyes are very sunken,

tears are absent

when she cries, and she is unable

to

drink. C. He~ eyes are more sunken her mouth D. She

and tongue

has

a fever

interested

A mother diarrhoea

(38.5 °C),

in drinking

brings

than usual, she drinks water eagerly

are rather

dry.

her stool

her 2-year-old

her eyes are not sunken,

daughter,

from

A. Asita

has severe dehydration.

B. Asita

has no signs

C. Asita

has some dehydration.

D. Asita should

to you

and

she

because

she

her you note that she is irritable

a cup. Her skin pinch

what conclusions

be treated?

is not

has

had

and fussy,

is somewhat

goes back

rather

dry,

slowly.

(There

would

you draw about

may be more than

Asita's

condition

one correct

answer.)

of dehydration.

be treated

E. More information

Asita,

blood,

to be malnourished.

Based on these findings, and how she should

some

she has tears when she cries, her mouth

eagerly

Asita does not appear

contains

water.

for 2 days. When you examine

and she takes water

from a cup, and

i

according

is needed

to Treatment

to determine

Plan A.

.

how Asita should

be treated.

4. Bantu, aged 14 months, is brought to the health centre because of diarrhoea, which began 3 days ago. At first the stools were only loose, but yesterday his mother saw blood in them. She believes Bantu has a fever. He has also vomited two or three times. When you examine Bantu you note that he is alert, but irritable and restless. His eyes are not sunken, he has tears when he cries, his mouth is moist (but he has vomited recently), and he will drink some water, but not with much interest. His skin pinch goes back quickly. His temperature is 39°C. Which

of the following

correct

answer.)

A. Bantu

has some dehydration.

are cor:rect?

B. Bantu

should

be treated

for dysentery.

C. Bantu

should

be treated

according

D. Bantu

should

be examined

pneumonia. E. Bantu has no signs

5. Which

of the following

has been assessed answer.) . A. Ask whether

44

statements

(There

to Treatment

for possible

infectiOn

may be more

than

one

Plan B. outside

the intestinal

tract. e.g.

of dehydration.

should

for possible

there

f

be done

after an 11-month:.old

dehydration

has been any blood

child

with diarrhoea

? (There may be more than one correct

in the stool

ASSESSING

B. Ask how long the diarrhoea C. Examine

the child

PATIENT

WITH

DIARRHOEA

has lasted.

for signs of severe malnutrition.

D. Take the child's temperature. E. Determine whether the child ommended

THE

has

received

measles

vaccine

(and

other

rec-

immunizations).

45

UNIT

4

Treatment

of

diarrhoea

at

home

49

Introduction Treating

diarrhoea

at home -Treatment

Plan A

Give the child more fluids than usual

49

How much fluid and how often

52 53 53

What foods to give How much food and how often "Antidiarrhoeal'. Problems

drugs, antiemetics

in treating

diarrhoea

with mothers

Using examples,

about

Asking checking questions Providing illustrated instruction

Exercises

worker

home treatment

demon~trations,

encouragement

and antimicrobials

at home

When to take the chjld to a health

Giving

49

What fluids to give Give the child plenty of food

Talking

49

and practice

53 54 54 54 55 56 57

leaflets

and assistance

58 58

60

47

TREATMENT

OF DIARRHOEA

AT HOME

Introduction Home treatment is an essential part of the correct management of acute diarrhoea. This is because diarrhoea

begins at home and children seen at a health facility will

IJsually continue.to have diarrhoea after returning home. Children must receive proper treatment at home if dehydration and nutritional damage are to be prevented. Mothers who are able to carry out home treatment should begin it before seeking medical care. When early home therapy is given. dehydration and nutritional damage can often be prevented. Each mother whose child is treated for acute diarrhoea at a health facility should be taught how to continue the treatment of her child at home, and how to give early home therapy for future episodes of diarrhoea. When properly trained, mothers should be able to:

.prepare and give appropriate rluids for OAT; .feed a child with diarrhoea correctly: .recognize when a child should be taken to a health worker. The steps involved in home therapy, the information

and skills that mothers need to

carry it out, and the ways in which these can be effectively communicated

to them, are

the subjects of this unit.

Treating

diarrhoea

Treatment

at home

Plan A

The management of acute watery diarrhoea at home (Treatment Plan A) is outlined in Fig. 4.1. This plan should be used to treat children: .who .who

have been seen at a health have

been

treated

dehydration is corrected; .who have recently developed

The three basic

facility

at a health

diarrhoea,

rules of home therapy

and found Jacility

to have no signs of dehydration;

with

Treatment

but have not visited

are considered

.below.

Plan

B or C until

a health

facility.

These are:

.give

the child more fluids than usual, to prevent dehydration;

.give .take

the child plenty of nutritious food, to prevent malnutrition; the child to a health iacin{y if the diarrhoea does not get better, or if signs of

dehydration

IGive the

child

or another serious illness develop.

more

Children with diarrhoea

fluids

than

usual

need more fluid than usual to replace that being lost in

diarrhoeal stools and vomit. If suitable fluids are given in adequate volumes soon after diarrhoea starts, dehydration

can often be prevented.

'Nhat fluids to give Various home fluids can be given as early treatment to prevent dehydration. countries have specific recommendations,

Many

such as rice water, SOUp, yoghurt drinks, 49

I

~

4

50

TREATMENT

and plain water; some recommend food.

it is also an important

In contrast.

patients

ORS solution.

who have .been treated

be given ORS solution

including

AT HOME

breast milk is considered

a

be given freely.

for dehydration

at home until the diarrhoea

also advise the use of ORS solution facility,

Although

home fluid and should

OF DIARRHOEA

at a health

facility

should

stops (see Unit 5). Some countries

for home treatment

of all patients

seen at a health

those with no signs of dehydration.

In all situations home fluids must meet certain criteria. The main points to remember are that home fluids must be: .Safe

when

given

commercial

their high sugar worsening

content

action,

utensils

.Acceptable.

Fluids

than

others.

contain

depending

foods

The composition

upon

are described

.Water,

Although

water

prOvides

by mothers,

available

Water

be familiar

and

ingredients

their and

is willing

to give freely to a

accept.

However,

composition.

some are more effective

Most

fluids

effective

are

fluids

that

nearly the same benefit

are given freely along

treatment

in Unit 2. FJuids suitable

with

no salt

water

or source

for the majority always

be one

of glucose,

it is universally

a child with diarrhoea

is rapidly cooked

for home

efficacy:

large volumes'to

Moreover,

should

with

and inexpensive.

of increasing

with a diet that contains

be adequate

should

and some salt. However,

in order

accepted

dehydrated,

to

diarrhoea,

are fluids

or time. The required

is considered

and the idea of giving

would

fluids

work

and other salt-free

fluids

below,

owing

salt.

available

given

their

and protein,

of home

sweetened

osmotic

to be avoided

be ones that the mother

when water

therapy

.when

much

be readily

that contain

and

such as coffee.

that are safe are also effective.

may be obtained weaning

Also

and that the child will readily

carbohydrate

drinks,

They can cause

for food-based

The fluids should

child with diarrhoea

.Effective.

300 mOsm/I).

not require should

tea, soft

These are often hyperosmolar

hypernatraemia.

The recipes

should

measuring

(above and

Very sweet

be avoided.

and stimulants,

to prepare.

preparation

volumes.

should

dehydration

purgative

.Easy

in large

fruit drinks,

absorbed

cereals,

from the intestine

preferably

of children

is generally

with added

with diarrhoea

of the fluids

and, salt,

who are not

recommended

for home

therapy, .Food-based

fluids. Examples

or water in whiCh other cereals should

be prepared

of mothers.

fluids are home-made

have been cooked.

in the traditional

fluids can be increased training

of food-based

'by adding

way and

soups. rice water

and yoghurt-based not diluted.

arinks.

The efficacy

of these

some salt (up to 3 g/l), but this requires

unless the fluid is normally

prepared

These.

special

with salt. e.g. a vegetable

soup. .5ugar-salt preventing

solution

(555). The composition

dehydration.

However,

of sugar-salt

its preparation

requires

solution

is nearly ideal for

three correct

measure-

READINGS ON DIARRHOEA

ments -sugar, membering solutions

that

solution small

salt

are

amounts

.ORS

recipe.

and

Although

facilities

not usually

Packets

home therapy. positions

differ

usual,

acceptable

sufficient

as much

are

This

both

such

.Potential

for home

status.

or water,

to teach

recommend

do not involve

used. For example,

ORS solution

a

can be

who

have

not

at

become

who have been rehydrated commercially

be based

at

for use in early

products

on national

recommendations

will take.

usually

have com-

recommendations..

include:

This is most

water

and

two

is to give more

likely to happen

or three

familiar

if

and

as:

of ingredients

for food-based

to teach

mothers

fluids; to prepare

special

recipes

correctly; of an efficient

system

below 4-6

months fluids.

Infants

in addition

good

fluid",

glucose-electrolyte

not be given food-based to frequent

with proper feeding

weaning

a home fluid. nor should being

sugar-salt

for its distribution.

if ORS is

use.

interference

efforts

now

sucrose,

patients

of patients

considerations

of ORS and

milk should

solution

countries

volume. A major goal of home therapy

and use the fluids

and feeding

breast

in

often give relatively

of ORS may be dispensed

be available

as the child

to m~thers

-the availability

to treat

usually

-the cost in time, effort and resources

selected

,with

in reresult

fluids.

includes

-the availability

accurately

may

from ORS and may be less satisfactory:

recommended.

food-based

.Feasibility.

problems

a "home

Packets

when establishing

of giving fluids

considered

some commercial

of home fluids should

than

many

difficulty

this

and mothers

do not require

the treatment

appreciably

to be considered

.Importance

have

correctly;

Other

reasons,

of ORS may also

However,

which

The selection

.Age

frequently

unsafe.

dehydration.

for use at home,

the facility.

fluid

and

as these

to prevent

and to continue

several

mothers

the solution.

For these

water,

dehydrated

Factors

and

and are less likely to be unsafe.

in the home

health

hyperosmolar

of the fluid.

fluids

solution.

used

water-

or in preparing

are that sugar or salt may be unavailable,

food-based special

and

the recipe

made to discourage

foods

take only

be given only ORS

breast-feeds.

feeding.

practices

of age who normally They should

Home

during

(e.g. porridges)

dilute gruel or similar their use as weaning

fluids

that

may

and after diarrhoea should

drinks foods

not.be

interfere should

diluted

to prepare

be used when efforts because

with not be

are also

of their low nutrient

content.

How much fluid and how often Provide more fluid than usual. The general rule is to give the child as much fluid as he or she wants and to continue usirlg ORT until diarrhoea stops. Remember that a child under 2 years of age cannot ask for something to drink; however, irritability and fussy behaviour are often signs of thirst. Young children must be offered fluids to determine whether they are thirsty and want to drink. When a child no longer accepts fluid it is

4

TREATMENT

usually

because

Infants

should

The following

enough

has been taken

be allowed

to breast-feed

to replace

OF DIARRHOEA

the losses caused

AT HOME

by diarrhoea.

as often and for as long as they want.

is a general guide for the amount of ORS solution or other fluid to be

given at home after each loose stool: .children

under

2 years: 50-100

.children

aged

.children

10 years

mi;

2-10 years: 100-200

ml;

of age or older and adults

should

take as much

as they want.

Show the mother how to measure the approximate amount of fluid to be given after each loose stool using a cup or some other container available to her at home (or that she can take home). Explain that the fluid should be given by teaspoon to children under 2 years of age: a teaspoonful every 1-2 minutes. Feeding bottles should not be used. Older chHdren should take the fluid directly from a cup, by frequent sips. If vomiting occurs, the mother should stop giving the fluid for 10 minutes and then start again, but give it more slowly, e.g. one teaspoonful

every 2-3 minutes.

If ORS solution is to be used at home, show the mother how to measure the correct amount of water, using a type of container available to her at home, and then how to mix the solution. Then give her enough packets to last 2 days. This should be enough to provide 500, 1000, or 2000 mi/day for children aged less than 2 years, 2-10 years, and 10 years or older and adults, respectively. When providing packets of ORS, explain to the mother that the entire packet must be mixed at one time and that any ORS solution that has not been" used after 24 hours must be thrown away. Thus, if a packet makes 1 litre of solution, a child requiring 500 mi/day would still need two packets, one for each day. If diarrhoea continues after the packets have been used up, the mother should give the child the recommended home fluids or return to the health facility for more packets.

Give the child plenty of food What foods to give Breast-feeding should be continued without interruption. Formula or cow's milk should be given as usually prepared. Children who are 6 months of age or older (and younger infants who have already begun to take soft foods) should also be given soft or semi-solid weaning foods. In general, such foods should provide at least half of the energy in the diet. If possible, salted foods should also be included, or weaning foods should be salted to taste. Guidelines

conc.erning

the type o.f foods to be given are shown

in Fig. 4.1 and

discussed in detail in Unit 7.

How much food and how often Duri.ng diarrhoea, give the child as much food as he or she wants. Offer food every 3-4 hours (six times a day). Small, frequent

feedings

are tolerated

better than large 53

I READINGS

ON

DIARRHOEA

feedings

given less frequently.

Many children

have anorexia:

they need to be coaxed

to

eat.

After the diarrhoea has stopped, give the child at least one more meal than usual each day for 2 weeks, using the same nutrient-rich foods that were given during diarrhoea; malnourished children should follow this regimen for a longer period (see Unit 7). The child should continue to receive these food mixtures as his or her regular diet, even after extra meals are no longer required.

"Antidiarrhoeal"

drugs, antiemetics and antimicrobials

A wide variety of drugs and combinations diarrhoea

and vomiting. °Antidiarrhoeal"

of drugs are sold for the treatment of acute drugs

include:

antimotility

agents

(e.g.

loperamide, diphenoxylate, codeine, tincture of opium), adsorbents (e.g. charcoal, kaolin, attapulgite, smectite), and live bacterial cultures (e.g. Lactobacillus, Streptococcus faecalis). Antiemetics include promethazine and chlorpromazine. None of these has been proved to have practical benefits for children with acute diarrhoea, and some may have dangerous side-effects. These drugs should never be given to children below 5 years of age. Antimicrobials also should not be used routinely; they are of benefit only to patients with dysentery or suspected cholera and severe dehydration, and in selected patients with persistent diarrhoea (see Units 5 and 6). Antiprotozoal

drugs are rarely indicated;

their use is also described in Unit 6. The overuse of antidiarrhoeal

and antiemetic drugs, antimicrobials

and anti protozoal

agents often delays the initiation of OAT or a visit to the health facility to seek help: it also wastes the precious financial resources of the family.

Problems in treating diarrhoea at home The mother may encounter a variety of problems in treating her child with diarrhoea at home. Most of these can be avoided or solved by ensuring that she understands

the

importance of home treatment, is able to carry.it out, knows what difficulties to expect, and receives constructive

help and encouragement

when problems arise. Table 4.1

describes some of the problems that are encountered

most frequently and possible

ways of solving or preventing them.

When to take the child The

mother

dehydration,

.the

should

to a health

be taught

or other serious

to

54

watch

problems.

passage of many watery stools;

.repeated vomiting; .increased thirst; .failure to eat or drink norma fly.

worker for

symptoms

Symptoms

of

the mother

worsening can recognize

diarrhoea, include:

~

TREATMENT

Table

4.1

Some

difficulties

encountered

in home

therapy

OF DIARRHOEA

AT HOME

for diarrhoea

Difficulty

Possible

.The mother is disappointed because she is not given a prescription for drugs or the child does not receive an injection.

Explain that the diarrhoea will stop by itself after a few days. Also, explain that drugs do not help to stop diarrhoea, but that fluid replacement and con. tinued feeding will help to shorten the illness and also maintain her child's strength and growth.

.The i"T1otlierbelieves that food should not be given during diarrhoea.

Ask her to explain her beliefs about how diarrhoea should be treated. Discuss with her the importance of feeding in order to keep her child strong and support normal growth, even during diarrhoea.

.The mother does not know what fluids to give her child home.

Ask her what fluids she can prepare at home and reach agreement on appropriate fluids for her child.

at

solution

.The mother does not have the ingredients to make a recommended fluid.

Ask her if she can obtain the ingredients easily. If she cannot, suggest another home lluid;

.The child vomits after drinking ORS solution or other fluids.

Explafn that more fluid is usually kept down than is vomited. Tell the mother to wait 10 minutes and then start giving fluid again. but more slowly.

.The

A child who has lost fluid will usually be thirsty and want to drink, even when there are no signs of dehydration. If the child is not familiar with the taste of ORS solution, some persuasion may be needed at firs'!. When a child drinks well to begin with, then loses interest in drinking, it usua)ly means that sufficient fluid has been given.

child refuses to drink.

E.xplain that after the ORS has been used up she should givea recommended home fluid (such as rice water) or water: or she could return to the health facility for more packets of ORS, in any event, she should continue to give extra fluid until the diarrhoea stops.

.The mother is given some packets of ORS for use at home but is afraid they will be used up before the diarrhoea stops.

Children

with dehydration

mother

should

not improve should

the child

no interest facility

described

if other

problems

develop,

about

home

treatment

such

in playing.

if the diarrhoea opposite

The does

appear.

She

as:

in the stool.

Talking

with

Effective

mothers

home treatment

caregiver). nutritious,

well-prepared centre.

what

learn about

of diarrhoea

It is she who

treatment clearly

and show

to bring her child to a health

after 3 days. or if any of the symptoms

also bring

.fever; .blood

may also be irritable

be instructed

must foods,

The mother

can be given only by the child's

prepare and can

the oral

fluid

and

give

mother

(or other

it correctly,

provide

decide

when

the child .needs

do these

tasks

correctly

only

needs to be done and how to do it. The best opportunity home treatment

of diarrhoea

is when she brings

to return

to the

if she understands for a mother

to

her child to the treatment

55

READINGS

ON DIARRHOEA

centre

because

the child

because

doctors

mothers

frequently

children

effectively.

or hearth workers return

There are a number For example,

have

Unfortunately,

not

why doctors

mothers

and

poorly

often

as a result,

treating

their

with mothers.

speak

in technical

by telling them what to do. In contrast,

mother's

perspective

terms, she may be easily frightened demonstration

often communicate perspective

technical through

how to continue

lost

they are busy and have little time to spend with each

and they often "educate" is usually

is often

well with mothers;

understanding

a "scientific"

figures,

this opportunity

do not communicate

home

of reasons

doctors

terms, they are authority mother,

has diarrhoea.

traditional

and prac1ice

and unscientific, by authority

she does not understand figures,

in an atmosphere

the

and she learns

of patience,

best

encouragement,

and understanding.

A doctor them

who cannot

to carry

doctors .to

communicate

well with mothers

out home treatment.

(and other

health

To improve

workers)

listen to the mother

.to

speak

be supportive

and encouraging,

.to

use teaching

methods

In rea/-life mother other

communications

with

mothers.

seriously;

to her in terms she can understand:

situations,

health

giving

that require

doctors

how to carry

be done

their

in preparing

must learn:

and, take her concerns

.to

will be ineffective

her active

workers.

However,

and help rather than criticism:

participation.

are rarely abl~ to spend

out. home treatment

successfully

her praise

the time required

of diarrhoea:

doctors

must supervise

if they themselves

understand

to teach

this must usually this activity

each

be; done

by

and thfs can only

the principles

of effective

com-

munication.

Some specific

approaches

and, especially,

that can be taken to improve

communications

to help them to learn how to treat diarrhoea

with mothers

at home are considered

below.

Using examples, demonstrations, and practice Giving

clear

represents

instructions

use of examples, process. home

make

(with

hold

mother

her child

practise

the message

can

explain

56

the it.

and worker clearer

out

home

of mothers. practice

and

how frequently

worker

correctly,

how

could

with a spoon

the

parts

they

health

facilitate

worker

learning

out OAT at

her to give her

be encouraged

to watch

so that she can see how to of fluid.

She should

from the health

be done. can

but

with the

(100 ml) of OAS

of the task the mother

should

the

how to carry

instructing

to give the spoonfuls

can see ~hich

is important, instruction

her a half-cup

level) while

to her own child, with guidance

or demonstrate task

greatly

a mother

by showing

OAS solution

treatment Combining

can

teaching

the appropriate

an infant

giving OAS solution

performed learned

to carry

after each loose stool. Or, a mother

giving

this way, the health and

a health

a Jine marking

child that amount another

how

demonstratlons,

For instance,

can

solution

:.on

only the first step in the training

Once

be confident

then

worker.

In

finds difficult.

the mother that

she

has has

TREATMENT

Examples, demonstrations, .Showing

pictures:

OF DIARRHOEA

AT HOME

and practice may include:

use a drawing or a poster of a mother breast-feeding

while

discussing the importance of this practice for an infant's health. .Using

specific

names

or instruc(ions

stating

a general

(which

are rich in potassium),

explain "more

rule): advise the mother

that she should often

appropriate

than

.Demonstrating

instead

to local circumstances

to give "banana

of simply

feed her child

telling

(instead

or green coconut

water"

her to give her child

"six times a day"

instead

of

"fruit";

of "frequently"

or

usual",

a task:

water for preparing

show

the mother

ORS solution,

how to measure

using a container

the correct

amount

of a type that is available

of

to her

at home.

.Showing

an object:

this should spoon

show the mother

not be used for giving

an infant

feeding

bottle

when explaining

milk or other fluids to her infant.

that

Show a cup and

for comparison.

.Telling

a story: a story of how another

treating

mother

her child at home can help to prepare

to face. Stress that giving baby to continue

.Practising

9lowing,

a procedure:

to her child

food

using

and fluids

dealt with problems a mother

that arose while

for difficulties

will keep the baby

she may have

strong

and

help the

even while he or she has diarrhoea.

let the m.other practise

preparing

and giving

ORS solution

a cup and spoon.

Asking checking questions Asking

simple

has learned diarrhoea

checking

about

at home, the doctor

for Ana"

is a very effective For example,

question

"yes" or "no".

should

For example,

that mean you should

If a nurse

or other

be phrased

what a mother

how to treat the child's

how you would

you should

bring

prepare

Ana back

in such a way that the answer

it is not effective

the drink to me",

cannot

to ask: "Do you understand

bring Ana back to see me?" The mother

she understands

questions

that mean

way of confirming

after explaining

might ask: "Describe

or "Tell me the symptoms

A checking

whether

questions

home therapy,

be just

the symptoms

is likely to answer

"yes",

them or not.

staff

member

can be used to monitor

is responsible

for

teaching

his or her effectiveness.

3-year-old Ma was treated for dehydration

mothers,

checking

For example:

and is now ready to go home. The nurse

has talked to his mother about what she should do at home to care for Ma. The doctor solution?",

should

not ask the mother,

or "Do

you

probably

be reluctant

as "How

much

know

how

to answer

"Did the nurse explain

to mix ORS solution?",

"no",

Instead,

the doctor

water will you mix with that ORS packet?",

will you give to Mo?",

"How

long

did the nurse

to you how to mix ORS since

should "How

the

mother

ask questions much

tell you to continue

would such

of the solution giving

the ORS

57

READINGS ON DIARRHOEA

solution?'..

"What

Mo back

Providing

illustrated

A specifically

diarrhoea

mothers

summarize and should

is being

and "When

will you bring

of a mother's

There

are many

(or card)

can greatly

the important have words

is shown

improve

elements

and

communication

of caring

pictures

it should

its messages.

pamphlet

reasons

leaflets

developed,

understand

layout

.The

pamphlet

It should at home,

a pamphlet

whether

instruction

prepared

the mother.

When

else will you give him to eat and drink?'

to see the nurse again?'.

that

for a child

illustrate

be carefully

An example

with

these

tested

with

points.

to determine

of the possible

content

and

in Fig. 4.2.

why a mother's

pamphlet

is useful.

For example'

pamphlet will simplify the task of training health workers in the messages to tell

mothers. .Referring giving

.When

to the pamphlet instructi{)ns

she is at home. the pamphlet

the treatment disagree

.Mothers

to mind

the main

points

to be covered

when

facility,

will remind the mother

and support

her if other

family

of what she was taugnt

members

or friends

at

should

with her treatment.

who cannot

neighbour

.If

will bring

to mothers.

read will find the pictures

can read out the written

helpful;

instructions.

otherwise

and learn

a family member

from the pamphlet

or too.

the mother keeps the pamphlet. the next time her child has diarrhoea she can refer to it and remind herself what to do.

.The

mother

will appreciate

not given a medicine

being given something

during

her visit. especially

if she is

for the child.

Giving encouragement and assistance Using examples, demonstrations,

and a mother's pamphlet,

and asking checking

questions can help to ensure that a mother understands home therapy, but they do not guarantee that she will practise it. There are a number of reasons why a mother may not carry out the instructions

.Home

received at a health facility. For example:

treatment may seem to be unrewarding

.she may expect

OAT to stop the diarrhoea.

OAT may appear

to have

undesirable

and be discouraged

effects,

such

as r;naking

when it does not; the child

vomit

more; home treatment

is time-consuming

and may be difficult:

coaxing

a sick child

to

eat can be frustrating. .The

necessary

or a container 58

materials

for OAT are not available:

to measure

water.

she may not have salt at home

TREATMENT

Fig. 4.2 1,

How to treat

diarrhoea

at home

AS ~)OON AS DIARRHOEA STARTS, GIVE YOUR CHILD MORE FLUIDS THAN USUAL:

(mother's

OF DIARRHOEA

At HOME

pamphlet) 2.

GIVE YOUR

CHILD

PLENTY

OF

FOOD

Breast-feed frequently GIVE: If not breast-feeding,

~ive the usual milk.

ORS solution If your child is 6 months or 0lder, or already taking solid food, also give: .

Food-based fluids, such as soup, rice water and yoghurt drink

cereal

.

or another

Plain water

vegetables,

If the child js under 6 months old and takin~ only breast milk, give only ORS solution or plain water, in addition to breast milk. ,

freshly

fresh fruit juice ground

OF THESE

FLUIDS

3. TAKE YOUR CHILD TO THE HEALTH

4.

YOU

CAN

foods.

mixed

with pulses,

banana

cooked

and

mashed

or

well

. small

an extra meal stops. ..,

AS YOUR

food

and a little oil

or mashed

prepared

frequent,

GIVE AS MUCH CHILD WANTS.

starchy

meat or fish,

r1'Ieals (at least 6 per day) each

day for 2 weeks

after diarrhoea

c

PREVENT

DIARRHOEA

BY'

WORKER IF THE CHILD: Does

not get better

in 3 days

Passes many watery stools Vomits

.

or

Starting foods listed in seCtion 2 of this card at 4-6 months

repeatedly

Is very thirsty Eats

Giving only breast milk for the first 4-6 months and continuing to breast-feed for at least 2 years"

drinks

poorly

Has a fever

Giving freshly prepared foods and clean drinking water -" '-. 'v,f Giving milk and otherffuids by' cup and spoon instead of feeding bottle Having all family members wash hands after passing stools and before preparing or eating food

Ha~; blood in the stool.

DO NOT GIVE DRUGS FOR DIARRHOEA UNLESS RECOMMENDED BY A HEALTH WORKER

Having

all family

Putting them

a young

Having

your

recommended

members child's

child "

use a latrine

stools

immunized

in a latrine

against

measles

or burying

at

the

age:

1

~.:\ ~

1 ~:.:\

t~, J

}!

I .c9.~ --==.;~

-.

~a

READINGS

ON DIARRHOEA

These problems can best pe overcome by giving the mother encouragement support. Several approaches .Emphasize

the positive.

continued whole

feeding

child.

contented treatment

.Give

should be used: Explain

praise.

PJ~ise is essential

a checking

that

the food

prepare

Assist

is suitable,

.Avoid

Ask

giving

remember

suggest

confidence

a practical

when

task correctly

(even

management

choice.

to determine

e.g. a container might

too much information

Also

Ask, for

answers,

discuss

confirm

how

will reinforce

she will

4

the mother's

whether

the

to measure

mother

has

the

water. If the items are

be obtained.

at one time. Teach the mother that mothers

on how to prevent

know

home therapy.

recommendations.

and use. It is most important

who already

her

occur

When the mother

diarrhoea

how to treat their child

only what she can

understand

food to give at home. and what signs mean they should

mothers

more

that she can

of diarrhoea

the health worker

questions

hbwthey

health centre. Messages

and

as this is the case,

to praise the mother

on aspects

another

interest,

items for home therapy,

not available.

be less fussy

how she will practise

or suggest

out treatment

with problems.

necessary

that

stop.

performs

foods will you give your child?"

to carry

should

and

to look at the

feeding.

the food. By showing

commitment

corre~tiy,

stronger

the mother

up a mother's

or replies correctly

Discuss with the mother

"What

the child

so long

will soon

in building

question

was provided),

interest.

example,

that,

at home. Opportunities

at home, s.uch as continued

.Show

The child

Explain

and the diarrhoea

trea1 her child successfully she answers

OAT will make

stools.

OAT .and feeding.

is successful

if guidance

that

will help the child to grow. Encourage

not just the child's after

and

what

fluids

and

bring the child back to the

should

usually

be reserved

for

at home.

Exercises A mo!her child

has brought

has diarrhoea.

the health child

centre

her 11-month-old The mother

and might.not

gets worse.

~he mother

when she has diarrhoea,

The health decides

worker

assesses

the child

ORS solution

cooked breast

60

that

the child

according

gives

days. even if the

her child

for signs of dehydration,

breast-feeding

but finds

Plan A. Which

the child

weak

has something

as often

tea

better.

none.

He

of the following

take? (There may be more than one correct

to continue

the

She says she lives far from

she usually

to Treatment

because

answer.)

and as long as

wants.

B. Give the mother

C. Advise

the child.

centre

be able to come back for several mentions

the health worker

A. Advise the mother

breast-feeds

to a health

but has heard that the health centre

to treat the child

steps should

daughter

enough

packets

and how much

the mother vegetables,

to give and,

milk. These should

of ORS to last 2 days. Show her how to prepare

to give after each her daughter

if possible, be given

loose

rice with

some

stool.

added

well-grour'ld

in small feedings.

vegetable meat,

oil, well-

in addition

to

at least six times a day.

4

TREATMENT

OF DIARRHOEA" AT HOME I

D. Explain that, if the diarrhoea continues after the ORS has been used up, she should give rice water (or another recommended

home fluid) in its place, whil~

continuing to give breast milk and other foods. E. Explain that if the diarrhoea continues for 3-4 days. she should discontinue breast-feeding 2. Which than

until it stops.

of the following one correct

fluids are acceptable

for OAT at home?

(There may be more

answer.)

A. Water. B. Rice water. C. A sweetened

commercial

fruit drink.

D. Soup. E. A soft drink.

3. Harish, aged 9 months, has had watery diarrhoea for 2 days. He has been weaned and takes a mixed diet of rice, pulses, vegetables, and cow's milk. During the illness, however, his mother has given him only soft, boiled rice and tea. She has also obtained a medicine from the chemist which is given to stop the diarrhoea. When seen at the health centre, Harish has no signs of dehydration and is well nourished. Which of the following

recommendations

are appropriate?

(There may be more

than one correct answer.) A. The mother should be encouraged

to give Harish extra fluids at home. for

example some soup or rice water after each watery stool. B. The medication obtained from the chemist should be stopped. C. Harish should resume his normal diet. D. Harish should be brought back to the clinic if he does not eat or drink normally at home. or if he starts to pass many watery stools. 4. Juma. a 14-month-old boy, has had diarrhoea for 3 days and has been assessed as having some dehydratiol:l. He has been treated with ORS solution at the clinic. his signs of dehydration

have disappeared.

and he is now ready to go home. The

doctor wishes to do everything possible to ensure that Juma will be well treated at home and will not need to return to the clinic. Which of the following steps would be appropriate?

(There may be more than one correct .answer.)

A. Give Juma's mother enough packets of ORS for 2 days. show her how to prepare and give ORS solution, and explain how much should be given after each loose stool. B. Give Juma an antimicrobial C. Explain

to Juma's

mother

to help stop his diarrhoea. the importance

of continuing

to give him plenty

. of

food. D. Teach Juma's mother the symptoms that mean she should bring him back to the clinic.

R1

l

1'

!f

READINGS ON DIARRHOEA

5. If a mother is to be successful in carrying out OAT at home, it is important that she learns how this is done. Which one of the following

methods is most effective in

teaching mothers how to give ORT? A. The doctor

explains

B.

the

Posters

on

clinic

now ii is done. walls

show

,

how

OAT

is

C. A nurse or health worker demonstrates OAT. ..; , D. The mother practises givirlg'6AT with the guidance E, The mother out.

62

is given

an illustrated

pamphlet

., ' ,\,

given.

of a health

that explains

worker.

how OATls

'carried

IJNITS Treatment

of

dehydrated

patients

65

Introduction Treatment

of patients

Tasks involved

with some dehydration in Treatment

How much ORS solution Giving

ORS solution

Monitoring

should

Tasks involved

65

be given?

67

and other fluids

68 68 at the treatment

with severe in Treatment

dehydration

-Treatment

69 71

Nasogastric replacement Oral replacement

71 71

intravenous

Putting up an intravenous drip Deciding how much intravenous Alternative

Nasogastric

fluid to give

73,

rehydration

Possible

complications Electrolyte Failure Seizures

Exercises

cholera

72

73

of rehydration

of suspected

71

72

Oral rehydration Giving breast milk and water Transition 10 Treatment Plans B and A Treatment

fluid

71

the patient

methods

69

69

replacement

Reassessing

Plan C

69

Plan C

Intravenous rehydration Selecting an appropriate

69

centre

how fluid will be given

Intravenous

65 65

treatment

of patients

Deciding

Plan B

Plan B

Reassessing the patient Patients who cannot remain Treatment

-Treatment

.

73 73 73 74

74 and

of oral

acid-base rehydration

abnormalities therapy

74 74 75

76

63

TREATMENT

OF DEHYDRATED

PATIENTS

Introduction Dehydration occurs when the water and electrolytes lost during diarrhoe~are

not fully

replaced. As dehydration develops. various signs and symptoms appear which can be used to estimate the extent of dehydration

and guide therapy. Three categories of

dehydration can be recogni~ed. each of which is associated with a specific treatment plan (see Unit 3). In increasing order of severity. these are:

" No signs of dehydration--' follow Treatment Plan A Patients in this category have a fluid deficit equal to less than 5% of their body weight. 'I Some dehydration- folloW Treatment PJan B Patients in this categ9ry have a fluid deficit equal to 5-10% of their body weight. . .Severe dehydration ~ follow Treatment Plan C Patients in this category have a fluid deficit equal to more than 10% of their body weight. Treatment

Plan

A (for

treatment

of diarrhoea

at home) ,

is described

in Unit

4c This

unit

(jescribes the treatment at a health facility of infants and children with somedehydralion or severe dehydration. using Treatment Plans B and C. respectively.

Treatment 'Treatment

of patients Plan B

with some dehydration

Children with signs indicating that there is some dehydra!ion usually do not need to be admitted to hospital. They can be treated in a special area of the clinic known as the "OAT corner" or the i'oral rehydration area", Mothers should stay with their children to help wjth the treatment

and learn how to continue

it at home, after the child is

rehydrated.

Tasks involved

in Treatment

Plan B

The main tasks of Treatment Plan B (Fig. 5.1) are: .to

estimate

the

amount

of QRS ,; ."

solution

to

be

given

during

the

first

4 hours. ,

for

.to .to .to

rehydration; '.; show the mother ho-w to give ORS soJution; continue breast-feeding and give other fluids, a~ required; , , monitor treatment and reassess. the' child periodically until rehydration

.to

completed; identify patients who c~nnot be treated satisfactorily with ORS solution by mouth

.to

and adopt a more approprtate method of tr~atment; give instructions for continuing the treatment at home after rehydration c compJeted, following Treatment Plan A.

How much

ORS solution

should

is

is

be given ?

When there is some dehydration the deficit of water is between 50 and 100 mi for each kg of body weight. If the child's weight is known, the amount of ORS solution required 65

"Fjg. .5..1 Treatment

66

Plan B: for patients

with

some

dehydration

TREATMENT

for rehydration

OF DEHYDRATED

can be estimated, using 75 mI/kg as the approximate

PATIENTS

deficit. The

approximate

volume of ORS solution (in ml} can be calculated by multipjying the . weight (in kilogram.s} by 75; Thus, a child weighing 8 kg would require about 600 ml (i.e. 8 x 75} of ORS solution. If the child's weight is not known, the estimated deficit can be determined

using the child's age, although

this approaGh is less precise. Both

methods are shown in Fig, 5.1, which indicates the range of fluid volumes that is usually appropriate

for a child of a given weight or age.

It should be emphasized

that the range of fluid volumes shown in the table is an

estimate of wha~ is needed and shoujd be used only as a guide. The actual amount given should be cietermined by how thirsty the patient is and by monitoring the signs of dehydration, bearing in mtnd that larger volumes will be required by larger patients, those with more advanced signs of dehydration, and those who continue to pass watery stools during rehydration. The general rule is that patients should be given as much ORS solution

as they will drink. and the signs of dehydration

should

be

monitored to confirm that they are improving.

Giving ORS solution and other fluids The estimated amount of ORS solI,Jtion to be given during the first 4 hours should I;>e explained to the mother, using measuring units with which she isfamlliar,

e.g: 4 cups,

2 glasses, etc.

Fig. 5.2 Using

a cup and spoon

to give

ORS solution

to a young

child

67

READINGS

ON DIARRHOEA

The mother should then learn how to give ORS solution to her child (Fig. 5.2): This is best done by means of a brief demonstration

by a nurse or health worker. following

which the mother should give her child the solution, under supervision, observing the following guidelines: .Give

one teaspoonful every J-2 minutes to children under 2 years of age, or offer

frequent sips from a cup to older children. Adults may drink the solution freely. Try to give the estimated amount of ORS solution in 4 hours. .If the child vomits, wait 10 minutes, then continue giving ORS solution, but more slowly: one teaspoonful every 2-,3 minutes. .If the child will drink more than the estimated amount of ORS solution and is not vomiting, give more; If the child refuses to drink the estimated amount; and the.signs of dehydration have disappeared, rehydration is completed: shift to Treatment Plan A. .If

the child normally breast"feeds, continue breast-feeding during therapy with ORS

solution. .For infants under 6 months of age who are not breast-fed, also give 100-200 ml of clean water during the first 4 hours. , When the mother has learned to give the fluid and the child is taking it well, she should be shown how to prepare ORS solution using contafners of a type available in her ,. home or that sHe can obtain easily. The health worker should demonstrate the, method by mixing a packet. Then the mother should prepare the solution herself to ensure that she understands.

Monitoring treatment During rehydration with ORS solutiqn the child's treatment and progress should be monitored as follows: .Check

regularly to be certain that the mother ts giving ORS soluti,on correctly and

the child is' taking it satisfactorily. .Record

.Watch

the amount

of solution

taken

and t-he number !

of diarrhoea

for problems. such as signs of worsening dehydration

stools

passed.

(e.g. further loss of

skin turgor. increasing lethargy) or increasing stool output. which. may indicate that OAT will not be successful. The management of such patients is discussed later in this unit. .Watch

for puffy eyelids, which are~ a sign of overhydration;

treatment with ORS solution should be stopped, although

if these are seen,

breast-feeding

and the

provision of plain water should continue. When the puffiness is gone, the child should

be considered

to be rehydrated

and further

treatment

should

follow

Treatment Plan A.

Reassessingthe patient After 4 hours. carefully reassess the child's hydration status following the assessment chart in Fig. 3.1 (page 34): 68

TREATMENT

.If

the child has no signs o\dehydration.

OF DEHYDRATED

PATIENTS

rehydration is complete. The child may be

sent home after a health worker has carefully shown the morher how to continue treatment at home with ORSsolution and feeding following Treatment Plan A. given her enough packets 01 ORS for 2 days. and explained the signs that mean the child should return to the health ce~tre (see Unit 4). .If

signs i~dicating some dehydriiliQn are still present. continue rehydration 1herapy by again giving the volume of OOScsolution estimated from Treatment Continue this approach

Plan B.

until the signs of dehydration have disappeared. Also start

to offer food and drink as described in Treatment Plan A. .If

the child is passing watery stools frequently and the signs of dehydration worsened. OAT should be temporarily

stopped ~nd the child rehydrated

have intra-

venously as described in Treatment Plan C (see Fig. 5.3).

Pai'lents who cannot remain at the treatment centre If the mother

.Show

must leave before

rehydration

therapy

is completed:

her how much ORS solution to give the child to complete the initial 4-hour

treatment at home. If possible. she $houJd make up some sotutiontJnder supervision and give it during the journey. 4. Give

her enough

additional

.Explain

packets

days: show

to her

Treatment

how

of ORS to complete

her how to prepare

to continue

the

the initial

rehydration

and

for 2

the solution.

treatment

of her child

at home

following

Plan A.

"rreatment ,rreatment

of patients Plan C

with severe

dehydration

(~hildren with signs of seyere dehydration can die quickly from hypovolaemic

shock.

l-hey should be treated immediately. following Treatment Plan C (Fig. 5.3).

1rasks Involved

in Treatment

Plan C

The main tasks of Treatment Plan C are: .to

decide how fluid will be given: (a) by irltravenous drip, (b) by nasogastric infusion, or (c) orally;

.to

decide how much intravenous fluid (or ORS solution) to give; then to give the fluid and reassess the patientfrequent!y;

.to

shift to Treatment Plan B or A when the child is no longer severely dehydrated;

.to

treat suspected cases of cholera with an appropriate

antimicrobial.

r.'ecldlng how fluid wIll be given Intravenous replacement The treatment

of choice

for severe dehydration

is intravenous

(lV) rehydration,

because it is the most rapid way to restore the depleted blood volume. IV rehydration is 69

Fig, 5,3 Treatment,

Plan C:for

patients

with

TREATMENT TO

SEVERE

severe

PLAN

C

ir

TREAT

DEHYDRATION

FOLLOW THE ARROWS.

dehydration

QUICKLY

IF ANSWER IS "YES", GO ACROSS.

IF "NO", GO DOWN

START HERE IVEs ..

NO ".,

Ives..

Ives..

"t~~:

I . I Canthepatient I Ives.. I drink? I

70

I ff

TREATMENT

especjally impoJtant if there are signs of hypovolaemicshock.(i.e.

OF DEHYDRATED

PATIENTS

:1

the patient has a very

rapid and weak, or absent radial pulse, cool and moist extremities, and is very lethargic or unconscious).

Atternative routes for fluid replacementshould

rehydrat,ion is riotposslbleor

I~asogastric

th~reris

satisfactory

cannot be obtained nearby, within 30 minutes.

replacement

If IV th,erapy is not possible, pr
only be used when1V

a nasog8:str1Q (NG) tube can be used to giveORS

a, pe!sor;J traineQ, iJ;l it~~8e,

as iv infusion

time is required

because

Ho\¥ever.

the fluid cannot

for it to be absorbed per hour;

be give~ a,s rapidly

the intestine,

The maximum

with

higher

abdominal

is about

20 mi/kg

repeated

vomiting

are frequent,problem,s",

rates,

c ."';~.' """'!"{',;~i;'-;

i~. not, as ,1

8!ld additional

from

infusion

solution,

,t~is approach

rate of fluid

distension

-',

"",,,;

and .(.,'

~Jr\

'~J.

IDral

repl8ceri1ent

If IV and NG therapy are not possible; or will be delayed, and the child is able to drink, ORS solution should be given by mouth at a rate of 20 ml/kg per hour. This approach has the same di8advantages

as,NG t,herapy;,moreov~r, it cannot be used for patiefits

whp .~re cvery lethargic or unconsci9us,Ghlldren solu)ion by.,spoon,about

under 2 y~ars &I'loujd be given ORS

one t~aspoonful per ~jnute;; older children and adults may

take the.soJu!i9.n irom a cup. Pati~nJswith ~bdomjnal distension caused by paralytic ileus should not be giyen OR$,solutioneJther If fluid replacement nearest

centre

is not possible

by anyof

where IV, or NG therapy

orally 9r: by NG tube.

these routes, refer the child

urgently

to the

can be given.

Intravenous rehydration ~Selectlng an appropriate A variety of different not contain caused

saline

solutions

appropriate

by diarrhoea.

inje.ction)

intravenous

(9 g NaCr/I),

half-normal only dextrose

Ringer's

(glucose)

.IV

(50 gar

should

(also

available

(see Unit 2). However, required called

solution.

solution

with

to correct Hartmano's

s~olut!On f9~

If it is not available, dextrose

(25 9 or

100 g/l) may be used. IV solutionS

some do

the deficits

normal 50 g/l)

. or

containing

not be us~d.

drip

be given,only

(see also Annex

solution

Darrow's

c .. saline with dextrose

IV therapyshQ!Jl,d

.Needles,

lactate

half-strength

for IV infusion

of the electroly.tes

commercially

Put11ng up an intravenous

below

is available

amounts

is the preferred

fluid

by trained

persons.

Some points

to re~ember

are give~

4):

tubing, b'ottles, and fluid must be sterile

therapy can be given in any convenient vein. Those most suitable are in front of the elbow (antecubital vein) or, in infants. on the scalp. In cases of hyPQvolaemic shock, particularly in adults, simultaneous infusion into two .veins ma'y help to restore blood volume rapidly. 71

.When

a peripheral vein cannot be found because of seve!e hypovolaemia, a needle

may be introduced into the femoral vein where it must be held firmly in place. (The femoral vein is located ju.st medial to the femoral artery, which can be easily identified by its pulsation.) A large amount of fluid can then be infuse~ very rapidly. The infusion site should be changed to a peripheral vein as soon as one becomes evident. A venous incision ("cIJt-down") should not be necessary; this takes longer to perform and is liable to become infected. .If

IV therapy will be delayed and the patient is able to drink, start giving ORS solution by mouth until the drip is running.

Deciding

how much Intravenous fluid to give, , , , ,; ," ' ',' , It possible, patients: should be weighed so iha{ their fluid requ:iremerits can :be

determined accurately. The flui,d deficit in severe dehydr~t1on equals 10% of pody weight (j.e. 100 mi/kg). Infants should be given IV fluid at a rate of 30 mllkg in the first hour, followed by 70 mi/kg in the next 5 hours, thus providing

a total of 100 mI/kg in 6 hours. Older

children and adults should be given IV fluid at a rate of 30 mi/kg within 30 minutes. followed by 70 mi/kg in the next 2.5 hours, thus providing

a total of 100 mi/kg i~ 3

hours. For all patients it is useful to mark the IV fluid bottle. indicating the level theftuid should reach after each hour of infusion. After the first 30 mi/kg have been given, a strong radial pulse should

be readily

palpable. If it is still very weak and rapid, a second infusion of 30 mi/kg should be given at the same rate; however, this is rarely necessary. Small amounts of ORS solution should also be given by mouth (about 5 mi/kg per hour) as soon as the patient is able to drink, in order to provide additional

potassium and base; this is usually possible

after 3-4 hours for infants and .1-2 hours for older patients.

Reassessing

the patient

During rehydration. the patient's progress should be assessed at least hourly until there is a definite improvement. Particular attention should be paid to: .the

signs of dehydration

.the

number

.any

difficulty

and nature in giving

Signs of a satisfactory

(see Fig. 3.1, page of the stools

34 );

passed;

fluids.

response to rehydration

improved level of consciousness,

are: return of a strong radial pulSe,

increased ability to drink, much improved skin turgor,

and passage of urine. When these are seen, the interval between reassessments can be lengthened. If the signs of dehydration

remain unchanged

or become worse, and especially if the

patient has also passed several watery stools, the rate of fluid administration total amount given for rehydration 72

should be increased.

and the

TREATMENT

J"ternative

methods of rehydration

t.lasogastric

rehydration

,A.n NG tube (2.0-2.7 positioned

mm in diameter

by a person

trained

head

entering

the lungs.

Patients

with severe dehydration

should

be

be kept slightly

over 6 hours. reduced

should

administered

only

4.0-6.0

in its use (see Annex

patient's

body weight

.should

for a child,

if there

raised

receive about

is repeated

mm for an adult)

PATIENTS

should

I

be

5). While the tube is in place, the

to reduce

at a steady

OF DEHYDRATED

the risk of regurgitated

120 ml of ORS solution rate of 20 mi/kg

vomiting

or

fluid

per kg of

per hr. This rate

increasing

abdominal

distension.

P;2tients

should

treatment

be reassessed

1-2

hours

is seen. If the signs of dehydration

hours of attempted patient

every

should

NG rehydration,

be sent urgently

a satisfactory

fail to improve

this approach

to a facility

until

where

or become

response

worse after 3

is not likely to be successful IV treatment

to

is possible.

and the .

Oral rehydration The amount of fluid to be given orally and the monitoring rehydration

of patients during oral

are the same. as described above for NG rehydration.

It is helpful to

measure out the amount of fluid required each hour fn.t9 a glass or other container, even though it may be given by spoon. If a patient cannot drink the required amount of fluid or vomits frequently,

the rate of administration

should

be slowed and the

rehydration period lengthened. If sIgns of dehydration fail to improve or become worse after 3 hours of attempted oral rehydration, the patient should be sent urgently to a facility where IV treatment is possible.

Giving

brea.st

Breast-feeding 6 months during given

milk should

and

water

be resumed

as soon

of age who are not breast-fed

as an infant

should

can suck.

be given

the first 6 hours, once they are able to drink; older children watef

to drink

(This is in addition

Trcrnsition

as soon

as they desire

to any ORS solution

to Treatment

At the end of the planned

Plans

it, provided

being

Infants

100-200ml

less than

of plain

water

and adults should

that vomiting

be

has subsided.

given.)

B and A

rehydration

period

(usually 3-6

hours), the p~tient's

hydration status should be carefully reassessed. If signs of severe dehydration are still present, rehydration therapy must be continued following Treatment Plan C. Otherwise, further treatment should follow Plan B or Plan A, depending, respectively, on whether signs of some dehydration

remain or there are no signs of dehydration.

In

either case, OAS solution should be used and the patient should be given food and drink. Before removing the IV drip, it is wise to give OAS solution for at least 1 hour to be certain OAT is feasible. If possible, patients presenting with severe dehydration

should

stay in the health facility until the diarrhoea

subsides. Otherwise, they should be

observed for at least 6 hours after rehydration

before returning home, to make sure

that the mother can maintain their hydration using ORS solution. 73

'AEADINGS

ON DIARRHOEA

Treatment

of s,uspected

cholera

Children over 2 years. of age and adults with severe dehydration

caused by acute

watery diarrho~a, who live in an area where cholera is present. should be given an appropriate .oral antimicrobial

after vomiting subsides. This would usually be tetra-

cycline, or trimethoprjm-sulfamethoxazole , ' d.oxycycfil:1e , .., in the area are known to be resistant may be used. Treatment

of cholera

the dur':ttion

of dlarrhQea.

Po~sibl,e

complic.8,tions

A number specific

of problem.s

treatment.

to these agents.

furazolidone

with an appropriate

but does not dlmjnish

may arise during

In general,

(see Annex 6). If V. choleraeO1 ' , or chloran:lphenicol

antimicrobial

helps to shorten

the need for careful

rehydration

therapy,

fluid replacement.

some of which

these fall into the three categories

discussed

require. below.

Electrolyte and acid-base abnormalities These include hypernatraemia,

hyponatraemia,

hyperkalaemia,

hypokalaemia,

and

base-deficit acfdosis. The. pathogenesis and clinical features of these dis;orders are described in Unit 2. Usually they arise as dehydration is developing or when the fluids used for rehydration

do not have an appropriate

clinical features may suggest a particular natraemja or hyponatraemfa,

composition.

diagnosis

Although

cer1ain

(e.g. seizures suggest hyper-

and paralytic ileus suggests hypokalaemla),

these signs

are not specific and a dragnosis can be made with certainty only by measuring serum electrolytes, bicarbonate, or pH. tt is important to understand, however, that these disorders .are all corrected When ORS soluti9n is used to treat dehydration as . described in this unit and kidney function is normal.

Failure of oral rehydration

therapy .

A small

number .

ORS so(ution lactate

of patients

by mouth

solution

determine

whether

unable

(frequent

sufficient

be treated

adequately

They should

receive

with

Ringer's

over 3-4

hours)

and th~n

or IV treatment

should

be continued.

Patients

that

liquid

Patients

who

rates

ORS solution

with IV fluid, untl11he

.Persistent

IV (or NG) therapy.

passage

high

that their signs of dehydration hours

cannot

be reassessed

to

may have:

stOols at very

1odrlnk

dehydration

intravenously

ORT is possible

rates of purging

pass watery

some

and require

(70 mi/kg

fall into this category .High

with

worsen.

of voluminous (e.g. exceeding to replace

vomiting. Vomiting

15 ml/kg

per hour)

their continuing

Such patien1s

rate of purging

stools).

should

may be

stool JosseS, so

be treated

fOr several

decreases.

does not usually prevent successful OAT because

most of the fluid taken is retained aQ,d absorbed, despite the obvious losses. When vomiting is frequent. the first step is to stop gjving OASsolution then 10 resume giving it, butmore'slowly;

mosrpatlents

fuJfy 'inlhis effective oral rehydration.

for 10 minutes. and

can be managed successvomiting

If the clinical signs of 'dehydration

prevents

do not improve, or

TREATMENT

OF DEHYDRATED

PATIENTS

~ become

worse,

fluids

Remember

that

disappears

as water

control

vomiting

become

depression

induced

who

Candida,

distension

tended,

OAS solution

tinues

to increase

ileus with absent should

.Glucose during

acute

a marked

glucose

However,

drink

in the stool and worsening

to

(due.

nervous drugs)

Is comatose.

starts

for

system

should

be

fluid should

be

and especially should

when it does occur,

discon-

is paralytic and fluid

by opiate

drugs

(e.g.

together.

is unusual

the use of OAS solution

signs of dehydration

amounts

may

of unabsorbed

(see Fig. 2.4, page 24). The

and very thirsty.

Special

in the stool. Tests for reducing

until diarrhoea

if there be stopped

malabsorption

with large

malabsorption

distension

by both acting

glucose

diarrhoea

to become

If abdominal

or, more frequently,

hy.pernatraemic glucose

be given intravenously until thirst

the child

of stomatitis

or central

ileus may be caused

significant

in watery

be used (see Unit 7). When glucose should

cause

or antimotillty

the patient

more slowly.

Paralytic

Clinically

child may also become

because fatigue,

OAT or NG therapy

hypokalaemia,

increase

drink

well developed,

sounds,

diarrhoea.

can be used to detect

usually

never be given to

and often

ileus. If the abdomen

be given

or is already bowel

malabsorption.

cause

subsides.

and

or by NG tube.

and paralytic

loperamide),

the vomiting

dehydration

Drugs should

(such as antiemetics

should

be given intravenously.

codeine,

cannot

by NG,tube,lf

if possible.

.Abdominal

are replaced.

or herpesvirus).

by drugs

ihtravenously.

until

during

ORT more difficult.

given IV fluid or ORS solution given

severe

they are not very effective

Patients

to measles,

intravenously

most

and electrolytes

making

to drink.

example,

be given

is often

because

sleepy.

.Inability

should

vomiting

prevents

subsides.

tapes or test sticks

substances successful

can also OAT, fluids

Water may also be given to

is satisfied.

S'eizures Dehydrated dration

children

therapy.

occasionally

develop

convulsions

Some possible

causes

of seizures

This occurs

mostly

in malnourished

either

before

or during

and their appropriate

rehy-

treatment

are

as follows: .Hypoglycaemia. therapeutic glucose 2.5 mi/kg

test solution

for

hypoglycaemia

(200 g/l)

of the solution

conscipusness. to prevent

After waking

infants

in a comatose

ir}travenously; over 5 minutes

child

and young

up, the child should

cause

A

giving

sterile

is the

cause,

giving

if hypoglycaemia should

children.

involves

a rapid

be fed and/or

improvement

in

given ORS solution

alecurrence.

.Hyperthermia.

Some young

children. (especially

have a fever; the risk is greatest of high fever involves

giving

infants)

develop

seizures

when the fever is high, i.e. exceeds

paracetamol,

or cooling

by sponging

when they

40 °C. Treatment with tepid water

and fanning.

.Hypernatraemia

or hyponatraemia.

See Unit 2 for a discussion of these conditions.

The preferred treatment is with ORS solution, unless glucose malabsorption

occurs

I READINGS

ON

DIARRHOEA

Fig. 5.4 Correction

of hypernatraemic

or hyponatraemic

dehydration

in infants

with

ORS solution

Source Pizarro, D. el al. Oral dehydration in hypernatraemic diseases of childran, 137. 730-734 (1983),

(see page restore 24-48

75). When

normal hours

developed

amounts

function,

serum

how

serum

hypernatraemic

were treated

.Central

sufficient

kidney

and any modest

Fig. 5.4 shows

excess

sodium

diarrhoeal

are given sodium

.to correct

levels

will

of sodium

or water

concentration

was

or hyponatraemic

dehydration

American journal 01

dehydration

become

normal

is excreted corrected

dehydration

owing

and within

in the urine.

in infants

who

to diarrhoea

and

with ORS solution.

nervous

meningitis.

and hyponalraemlC

system

Approprjate

conditions

unrelated

anticonvulsant

to diarrhoea.

and antimicrobial

such

therapy

as epilepsy should

or

be given.

Exercises 1. Ahmed weighs

has diarrhoea

6 kg. Approximately

first 4 hours

of treatment?

A. 200-400

mi.

B. 400-600

mi.

C. 600-800

mi.

D. 300-400

mi.

2. A mother

has brought

has been assessed 76

and

signs

of some

how much

ORS solution

(Use the table

her 2-year-old

and found

dehydration.

in Fig.5.1

daughter.

He is 8 months

should

old

and

he be given during

the

to determine

Maria.

your answer.)

to the health

to have signs of some dehydration.

facility.

She weighs

Maria 12 kg.

TREATMENT

While at the facility,

her mother

has given her 800 ml of ORS solution

After 4 hours, Maria still has signs of some dehydration, that the mother more than

can stay at the facility,

one correct

OF DEHYDRATED

what should

within 4 hours.

but is improving. be done

PATIENTS

next?

Assuming

(There

may be

answer.)

A. Stop ORT and give 500 mi of Ringer's

lactate

solution

intravenously

during

the

next 3 hours. B. Repeat

Treatment

Plan

B, giving

800-1000

mi of ORS solution

in the

next

4 hours. C. Pass an NG tube and give 900-1200

mi of ORS solution

by this route in the next

4 hours. D. Start to feed the child

3. John, an 18-month-old by his grandmother.

as described

child with diarrhoea,

of some dehydration.

The grandmother home. What

more than

answer.)

one correct

an antimicrobial

B. Give the grandmother John

during

I::;. Explain

4. Balaji

centre,

ORS solution

how John

to a small health

and cannot

should

should

worker

the last bus; it is

do?

(There

and show

may be

her how to give it to

be fed when

they return

of ORS for use in treating

B. 20 mi/kg,

i.e. 180 ml. i.e. 90 ml.

D. As much

as possible,

is a 4-month-old

baby

3 hours and is improving.

home"

John at home

be treated resume

C. He should

receive

weighing 25d'ml

with signs of severe dehydration 9 kg. There is no IV equipment

the NG tube in the first hour?

distension occurs

4 kg who

of Ringer's

one correct according

at

how to use an NG tube. How much

was severely

lactate

dehydrated

solution

He can now drink. What treatment

may be more than

B. He should

knows

U'ntil abdominal

He has received

centre

He weighs

worker

be given through

C. 10 mi/kg,

A. He should

drink).

but the health

i.e. 270 mi.

(There

the health

to treat his infection.

two 1-litre packets

A. 30 mi/kg,

diarrhoea.

must leave soon to catch

should

the next 2 days, after he has been rehydrated.

(he is very drowsy

5. Omo

to the he'alth centre

and found to have signs

the next 4 hours.

to the grandmother

has been brought

the health

has been brought

700 ml of ORS solution

D. Give the grandmother during

Plan A.

He weighs 9 kg. He has been assessed

too far for her to walk

A. Give the child

in Treatment

due to

intravenously

should

over

be given next?

answer.)

to Treatment

Plan B.

breast-feeding. 150 ml of Ringer's

lactate

solution

intravenously

in the next 3

hours. D. He shpuld

6. Sanjay

begin taking

is a 3-month-old

given 400 mi of Ringer's

small amounts

boy weighing lactate

may be more than

solution

one correct

about

4 kg, who was severely intravenously

ing, but still has signs of some dehydration. (There

of ORS solution,

dehydrated.

over 6 hours

What treatment

answer.)

20 ml each

should

hour.

He was

and is improvhe receive

now?

READINGS

ON DIARRHOEA

A. He should be given 200-400 mi of ORS solution over the next 4 hours. B. He should continue to receive IV treatment, following Treatment Plan C. until all signs of dehydration

have disappeared.

C. He should be given an antidiarrhoeal

drug or antimicrobial

diarrhoea. D. His mother should resume breast-feeding

to help stop his

him if she has not done so already.

7. You are a doctor working in an urban clinic. Ria, an 8-month-old

girl, is b!ought to

you. She is comatose, with a very rapid h~art rate; yo~ cannot feel her radial pulse; the skin of her arms and legs is cool and moist and her skin pinch goes back very slowly; her abdomen is distended and there are infrequent bowel sounds. Ria has been having profuse, watery diarrhoea and severe vomiting for the past 2 days. The local pharmacist

prescribed anJiemetjc drops and a suspension

com~ining

co-

deine. The baby has a temperature of 38 °C and weighs 6 kg. A. What type of dehydratfon B. How much

fluid is needed

C. How should D. Over what

time periods

diarrhoea stopped

lives

in an

started giving

her deficit?

her food,

where

ml

but started

all morning.

IV fluid

her rehydration

health

facility.

cholera

has

and she has passed

has dry and very. sunken

back very slowly.

you divide

of Ria's abdominal

to a local area

yesterday

had severe vomiting sleepy,

would

cause

has been brought

12 kg. She

to replace

-

the fi.uid be given ? ..

E, What is the probable

8. Hawa

does Ria have?

She is 3 years

old and weighs

recently

diagnosed.

been

six large watery

her extra

As you examine

liquids.

at the health

stools.

Her

Her mother

However,

her, you notice

eyes, and a very dry tongue;

is available

A. What type of dehydration

giving

therapy?

distension?

Hawa

has

that she is very

her skin pinch

goes

facility.

does Hawa have?

B. You decIde to give IV treatment, but Ringer's lactate solution is not available. What solution would be your next choice? -~

-

C. You suspect that Hawa may have cholera. What treatment her? --

should you give

D. When should you start to give Hawa ORS solution by mouth?

9. Ali is 5 months ~Id and weighs 4.5 kg. His mother breast-feeds him. His diarrhoea started last night, and he has passed eight very watery stools. His mother said there was no blood in the stools. As you examine Ali, you find that his skin pinch goes back slowly, his eyes are a little sunken, and he drinks some ORS solution ve~y eagerly. Ali does not have a fever. A. What type of dehydration

does Ali have?

~

B. Which treatment plan should be followed for Ali? C. .Approximately 4 hours?

how

much

ORS solution

should

-Ali

receive

in

the

first

.ml

D. When should the mother start to breast-feed Ali again? E. If Ali has no signs of dehydration followed next?

after 4 hou~s, what treatment plan should be

81

Introduction 81

Dysentery Definition, Clinical

etiology,

features

and importance

and diagnosis

Management Antimicrobial

81 81 83 83

therapy

84

Fluids

84

Feeding

84

Follow-up Prevention

84

85 Persistent diarrhoea Definition. etio1ogy. and importance Risk factors Nutritional

85 85 85

impact

Management History

86 86

and examination

Laboratory

Fluid and electrolyte Nutritional

86

studies replacement

therapy

86 87 88

Drug therapy Diarrhoea

associated

with

Measles-associated

other diarrhoea

illnesses

88 89 89

Pneumonia Fever

and

and. diarrhoea

89

diarrhoea

90 EXE!rcises

79

DYSENTERY,

PERSISTENT

DIARRHOEA,

AND DIARRHOEA

ASSOCIATED

WITH OTHER ILLNESSES

Introduction F:or some children with diarrhoea,

the combination

of rehydration

and diet therapy

described in Treatment Plan A (see Unit 4) is not sufficient treatment. This applies in particular

to children

complicated

with dysentery or persistent diarrhoea,

by severe malnutrition

or whose illness is

or an infection outside the intestinal tract. While

such patients may need rehydration, they may also require special approaches feeding, antimicrobial

to

therapy, or other treatment. This unit describes the management

of children with dysentery, persistent diarrhoea, or other infections that may accompany. or predispose to diarrhoea

(see Fig. 6.1 ). The management

diarrhoea and severe malnutrition

is considered in Unit 7.

of children with

Dysentery Definition,

etiology,

and importance

[)ysentery is defined as diarrhoe.a with visible blood in the stools. The most important a,nd most frequent cause -of acute dysentery is Shigella, especially S. flexneri and S. dysenteriae type 1. Other causes include Campylobacter jejuni, especially in infants, a,nd, less frequently, Salmonella; dysentery caused by the latter agents is usually not severe. Enteroinvasive Escherichia coli is closely related to Shigella and may cause severe dysentery. However, infection with this agent is uncommon. Entamoeba histolyn;ca causes dysentery in older children and adults, but rarely in children underS years of age. [tysentery is an important cause of morbidity and mortality associated with diarrhoea. ,A.bout 10% of all diarrhoeal

episodes in children under 5 years are dysenteric. but

these cause about 15% of all deaths attributed to diarrhoea. Dysentery is especiaHy severe in infants and in children

w~o are malnourished,

develop clinically

evident

dehydration during their illness. or are not breast-fed. It also has a more harmful effect on nutritional

status than acute watery diarrhoea.

Dysentery occurs with increased

frequency and severity in children who have measles or have had measles in the preceding month. and diarrhoeal episodes that begin with dysentery are.more likely to become persistent than those that start with watery stools.

C~/inica'features and diagnosis The clinical diagnosis of dysentery is based solelyon in the diarrhoeal morphonuclear

the presence of visible blood

stool. The stool will also contain

numerous

pus cells (poly-

leukocytes) which are visible with a microscope, and it may contain

large amounts of mucus; these latter features suggest infection with a bacterial agent that invades the intestinal mucosa (such as Campylobacter

jejum or Shige!la), but

alone are not sufficient to diagnose dysentery. In some episodes of shigellosis, the stool is initially watery, becoming bloody after 1 or 2 days. This watery diarrhoea sometimes severe and may cause dehydration. bloody stools are passed and dehydration

Usually, however, numerous

defecation, or attempted defecation

small

does not occur. Patients with dysentery

frequently have fever, but sometimes the temperature the most serious cases. Cramping

is

abdominal

is abnormally

low, especially in

pain and pain in the rectum during

(tenesmus), are also common; however, young

children are unable to describe these complaints. 81

Fig.

6.

Evaluation

and management

diarrhoea,

severe malnutrition

of patients with bloody diarrhoea, or fever

persistent

DVSENT~RY,

PERSISTENT DIARRHOEA,

AND DIARRHOEA

ASSOCIATED

WITH OTHER ILLNESSES

A number of severe and potentially fatal complications can occur during dysentery, I~speciarly when the cause is Shigella. They include intestinal perforation, toxic megacolon, rectal prolapse, con-vulsions (with or without a high fever), septicaemia, haemolytic-uraemic syndrome, and prolonged hyponatraemia. A major complication of dysentery is weight loss and rapid worsening of nutritional status. This is caused by anorexia (which may be marked), the body's increased need for nutrients to fight Infection and repair damaged tissue, and the loss of serum protein from the damaged intestine (i.e. protein-losing

enteropathy). Death from dysentery is usually caused by

:(:xtensive damage to the ileum and colon, complications (e.g. pneumonia),

or severe malnutrition.

of sepsis, secondary infection

Children convalescing

from dysentery are

also at increased risk of death from other infections, owing perhaps to their poor nutritional state or impaired immunity. The cause of an episode of dysentery often goes undetermined. Stool culture. to dete<;t pathogenic

bacteria, is often impossible. Moreover. at least 2 days are required before

results of a culture are available. whereas a decision on antimicrobial therapy must be made immediately. Stool microscopy to detect protozoa may also be unavailable

or

unreliable. Amoebiasis can only be diagnosed

of

with certainty when trophozoites

E. histolytica containing red blood cells are seen in fresh stools or in mucus from reCtal ulcers (obtained during proctoscopy). The detection of cysts alone is not sufficient for a diagnosis

of amoebiasis.

Amoebiasis

should

be suspected

dysentery does not improve following appropriate antimicrobial

when a child with

therapy for shigellosis.

Ma'nagement Children with dysentery should be presumed to have shigellosis and treated accordingly. This is because shigellae cause about 60% of dysentery cases seen at health facilities

and nearly all cases of severe, life-threatening

disease. If microscopic

examination of the stool is performed and trophozoites of E. histolytica containing erythrocytes are seen; antiamoebjc therapy should also be given (see below). The four key components of the treatment of dysentery (see Fig. 6.1) are:

.antimicrobials .fluids; .feeding; .follow-up. Antimicrobial

therapy

Early treatment of shigellosis with an appropriate

antimicrobial

of the illness and reduces the risk of serious complications

shortens the duration

and death; however, such

treatment is effective only when the shigellae are sensitive to the antimicrobial given. If treatment is delayed or an antimicrobial

that is

is given to which the shigellae are not

sensitive, the bacteria may cause extensive damage to the bowel and enter the general circulation,

causing

complications

septicaemia,

prostration,

and sometimes septic shock. These

occur more frequently in children who are malnourished

or in infants,

and may be fatal. Since the antimicrobial

sensitivity of the infecting strain of Shigella is not known for

each case, it is important to use an oral antimicrobial

to which most shigellae in the 83

READINGS

ON DIARRHOEA

area are known to be sensitive. Trimethoprim-sulfamethoxazole but ampicillin

is the usual choice,

is effective in some areas (see Annex 6). Although

treatment

is re-

comm~nded for 5 days, there should be a substantial improvement after 2 days, i.e. reduced fever, less pain and faecal blood, and fewer loose stools. If this does not occur, the antimicrobial should be stopped ard a different one used; in many areas this would be nalidixic acid. Although other bacteria, such as Campylobacter jejuni and Salmonella, can cause dysentery, the disease is usually relatively mild and selflimiting. Young children with dysentery should not be treqted routinely for amoebiasis. Treatment should be given only when E histolytica trophozoites containing red blood cells are identified in faeces or when bloody stools persist after consecutive treatment with two antimicrobials

(each given for 2 days) that are usually effective for Shigella. The

preferred treatment for amoebic dysentery is metronidazole (see Annex 6). If dysentery is caused by E histolytica, an improvement will occur within 2-3 days of starting treatment. Fluids

Children with dysentery should be evaluated

for signs of dehydration

and treated

accordingly (see Units 3-5). All patients with dysentery should be offered water and other recommended fluids during their illness. especially if they have fever.

Feeding Children with dysentery should continue to be fed in order to prevent or minimize nutritional

damage. Feeding may be difficult.

however, because of anorexia.

The

general feeding guidelines in Treatment Plan A (Units "4 and 7) should be followed. Follow-up Most patients

with dysentery show substantial

improvement

within 2 days after

beginning treatment with an effective antimicrobial, These patients should complete the 5-day treatment, and do not usually require follow-up. Other patients should be followed closely, particularly children who do not show a clear improvement within 2 days, and children known to be at high risk of death or other complications, children (i.e, infants, malnourished been dehydrated) hospital,

should

High-risk

children, those not breast-fed, and any who have

be monitored

fre'quently as outpatients

Patients with dysentery and severe malnutrition

should

or admitted

to

be admitted

to

hospital routinely. Children showing no improvement after the first 2 days of antimicrobial treatment should be given a different antimicrobial, as described above, Prevention The microorganisms

that cause dysentery are spread by faecally contaminated

hands,

food, and water. The spread of shigellosis by hands is very efficient because the number of shigellae required to cause disease is very small (as few as 10-100 organisms). Important measures to prevent shigellosis include careful hand-washing and use of latrines; these are described in Unit 8.

DYSENTERY,

Persistent

PERSISTENT DIARRHOEA,

AND DIARRHOEA

ASSOCIATED

WITH OTHER ILLNESSES

diarrhoea

Definition, etiology, and importance Persistent diarrhoea is a diarrhoeal episode that lasts for 14 days or longer (see Unit 1). About 10% of acute diarrhoeal episodes become persistent. Persistent diarrhoea often causes nutritional

status to deteriorate and is associated with increased mortality. It

causes about 35% of all diarrhoea-associated

deaths, and as many as 15% of

,episodes of persistent diarrhoea result in death. There is no single microbial cause, although Shigella, Salmonella and enteroaggregative E. coli probably playa greater role than other agents; Cryptosporidium may also be important in severely malnourished or immunodeficient protozoa diarrhoea,

patients. A number of other

are found with nearly equal frequency

pathogenic

bacteria

and

in cases of acute and persistent

but their role in the etiology of this disease is unclear. Irrespective of its

cause, persistent diarrhoea is associated with extensive changes in the bowel mucosa, especially flattening

of the villi and reduced production

of disaccharidase

enzymes;

these cause reduced absorption of nutrients and may perpetuate the illness after the original infectious cause has been eliminated.

Risk factors A number of risk factors for persistent diarrhoea .Malnutrition-

have been identified

this delays the repair of damaged

intestinal epithelium,

causing

diarrhoea to be prolonged. .Recent

introduction

of animal milk or formula-this

could

reflect lactose in-

tolerance, hypersensitivity to milk protein, bacterial contamination

of the milk, or

some other mechanism. Animal milk appears to be an important factor in 30-40% of episodes of persistent diarrhoea. .Young

age-

most episodes

occur

in children

under

18 months

of age.

.Immunological impairmentthis is seen in severely malnourished children, during or following measles or some other viral infections. and in patients with the acquired immunodeficiency .Recent

syndrome (AIDS).

diarrhoea -this

includes children who have experienced a recent episode

of acute diarrhoea or a previous episode of persistent diarrhoea. Knowledge of these risk factors helps to identify children who are most likely to develop persistent diarrhoea and, in some instances, to guide treatment.

Nutritional impact Persisient diarrhoea

is largely a nutritional

disease. It occurs

more frequently

in

children who are already malnourished and is itself an important cause of malnutrition. A single episode of persistent diarrhoea

can last 3-4 weeks or longer and cause

dramatic weight loss, sometimes leading rapidly to severe malnutrition,

i.e. marasmus. 85

READINGS

ON DIARRHOEA

Weight loss during

persistent diarrhoea

is caused

by reduced

absorptton

nutrients, but especially of fat and, in some ch4Jdren, lactose,Otherc9ntributjng include poor food intake, owing to anorexia or withholding

of all factor:s

of food, or giving .dilute,

low-energy foods, Patients are ~Iso likely to be deficient in various vitamins and minerals: those of particular importance because of their role in ~he renewal and repair of the intestinal mucosa 'and/or their ro)e ih normal immunological responses include folate, vitamin B12' vitamin A, zJric andiron,

MBnagement The initial management of children with persistent diarrhoea is summarized in Fig. 6.1 and discussed below. History and examination These should cover the same areas as in cases of acute diarrhoea, but with special attention to the following questions: .How

many days has this episode

of diarrhoea

lasted ?

.What

is the child being fed, breast milk or animal milk? If over 4-6 months of age,

aFe the type and amount of weaning food adequate?

How many meals are given

each day? How is the child's appetite? .Was

animal milk or formula introduced

recently? Does the diarrhoea

seem to be

worse soon after animal milk or formula is given?

.Is

blood present in the stool?

.If

this is a repeat visit, has the mother noted any change since the last visit in frequency of diarrhoea, blood in the stool, or tM child'i appetite? Could she follow the advice given at that time about treating the child ?

.Is

the child

.What

dehydrated?

is the child's nutritional

and plot weight-for-age

status? Has it declined during this illness? Measure

(and weight-for-height.

if possible).

Laboratory studies For all patients. it is important to observe whether the stool is bloody. The use of other laboratory examinations will depend upon their availability. Some of the most useful ones are summarized in Table 6.1. Fluid and efectrolyte

replacement

The child's hydration status should be assessed as described in Unit 3. ORS solution is satisfactory

for replacing

losses of water and salts in most children with persistent

diarrhoea; a few patients have severe glucose malabsorption

(see Unit 5) and require

intravenous fluid therapy. Some patients with persistent diarrhoea develop dehydration and continue to pass stools rapidly after rehydration; they should be admitted to 86

DYSENTERY,

Table

6.1

PERSISTENT DIARRHOEA,

Laboratory

examinations

in persistent

What

Examination

Observation

culture

and

ASSOCIATED

WITH OTHER ILLNESSES

diarrhoea

the examination

will

reveal

Blood suggests infection with Shigella.

of stool

Red blood cells or white blood cell.s (polymorphonuclear leukocytesj suggest an invasive bacterial infection, such as shige!losi~. Cy~ts or trophozo,tes of Giardia, or trophozoites of E. histolytica, ~uggest they may playa role in the disease.

Stool microscopy

Stool

AND DIARRHOEA

Bacterial pathogens are detected and their antimicrobial sensitivity determined.

sensitivity

Stool pH of less than 5.5 and a large amount of reducing substances in the faeces indicate carbohydrate (most likely lactose) malabsorption. These findings do not mean, however, that this is necessarily the cause of the diarrhoea (see Unit 7).

Stool pH. reducing substances

hospital and may require treatment with intraver)ous fluids until th~ rate of purging declines. Nutritional Proper

therapy

feeding

persistent

is the most

diarrho~a.

Many

important

can

be

treated

aspect on

an

of treatment outpatient

for most

basis

with

children

food

with

available

in

,

the home; however, best evidence goals

some require speci.alized

that dietary

of nutritional

therapy

management

care in hospital.

Is effective,

Weight

even before

gain provides

di~rrhoe§

the

stops. The

are:

.to

reduce temporarily the amount. of animal milk (or lactose) in the diet;

.to

provide a sufficient intake of energy, protein, vitamins, and minerals to facil!tgte the repair process in the damaged gut mucosa and !mprove nutritional

.to .to

status;

avoid giving foods, or drinks that may aggravate the diarrhoea; , ensure that the child's food intake during convalescence is adequate to correct any malnutrition.

The general guidelines for feeding during and after diarrhoea given in Treatment Plan A (see Unit 4) should be followed. Some important exceptions and additional

guide-

lines are shown in Fig. 6.1 and given below. .Children

under 6 months of age or with evidence

of dehydration

should

be

rehydrated and referred to hospital for further management. They may require special measures to maintain hydration, replacement of animal milk with lactosefree or milk-free formula, special diets, laboratory

studies to identify pathogenic

bacteria or protozoa in their faeces, or other specialized procedures.

.For

older children, the mother should be instructed to'

-continue breast-feeding: -give only half the usual amount of animal milk or replace it with a fermented milk product. such as yoghurt. This reduces by ha)f the amount of lactose in the child's diet. In many cases, this step will cause the diarrhoea to subside rapidly; 87

READINGS

Drug

ON DIARRHOEA

therapy

Patients

with persistent

Shigella

should

bacterial

pathogen,

agent is sensitive

are seen

antiprotozoal

therapy

antimicrobials

88

in the faeces should

be given

or antiprotozoal

drugs,

antisecretory

with persistent

diarrhoea;

agents worse. drugs such

in the stool or a stool culture

for shigellosis.

It stool culture

cy.sts, or trophozoites

or small

bowel

(see Annex

and drugs

a course

and should

adsorbents) should

has

any

not be given

Giardia

or

of appropriate

"blind"

no "antidiarrhoeal"

for

another

to whichl that

of either

6). However,

is not effective Similarly,

fluid,

positive

yields

£ coli, arJ oral antimicrobial

be given. If Giardia

may make the'.illness

antimotility patients

and blood

e.g. enteropathogenic

should

E: histolytica

treatment

diarrhoea

receive an antimicrobial

therapy

with

not be given;

such

drug

(including

proven

value

in

(see also Unit 4).

DYSENTERY,

PERSISTENT DIARRHOEA,

AND DIARRHOEA

ASSOCIATED

WITH OTHER ILLNESSES

Measles-associated diarrhoea The incidence of diarrhoea is increased during measles, during the 4 weeks following the illness, and possibly for up to 6 months after the measles episode. Measlesassociated diarrhoea

is often severe and of longer than usual duration; the risk of

death is also substantially and is probably

higher than with diarrhoea that is not related to measles,

even greater when children

are also malnourished.

incidence of measles is high, measles-associated

Where the

diarrhoea can account for one-third

or more of diarrhoea-associated

deaths in young children.

measles is therefore an important

measure for preventing both diarrhoeal

and diarrhoea-associated

Immunization

against episodes

deaths, as well as for preventing measles (see Unit 8).

The mechanisms by which measles predisposes to diarrhoea

are not clear but may

include: (i) a direct effect of measles virus on the bowel epithelium, and (ii) virusinduced immunosuppression,

which can last for several months after an episode of

measles and reduces the child's defences against a variety of pathogenic bacteria and protozoa.

Patients with measles-associated

diarrhoea

frequently

pass blood in the

stool, suggesting that Shigella is an important causative agent. The

evaluation

of

children

with

diarrhoea

should

measles. Treatment of measles-associated .treatment

of dehydration

.adequate

feeding

.oral

(as described

care for patients

.administration

and dysentery.

when

in Treatment

with stomatitis.

of a prophylactic

include

an

enquiry

about

.

recent

diarrhoea should include: present; Plan A, Fig. 4.1. page 50);

so that this does not interfere

dose of vitamin

with eating;

A (see Unit 7).

Pneumonia and diarrhoea Diarrhoea

with severe dehydration

diagnosis

of pneumonia.

causes

rapid breathing

However, in pneumonia

that may suggest

the respiratory

rate equals

a or

exceeds 40 breaths per minute (50 breaths per minute for infants aged 2-11 months), the child is coughing, and subcostal chest indrawing

may be seen. In children with

severe dehydration,

rapidly when dehydration

the breathing

pattern

improves

corrected. If pneumonia is confirmed, an appropriate

antimicrobial

is

should be given.

Fever and diarrhoea Fever is frequent in patients with diarrhoea.

It is often present when diarrhoea

is

caused by rotavirus or an invasive bacterium such as Shigella, Campylobacter jejuni or Salmonella. Fever may also accompany

dehydration

and disappear during rehydra-

tion. Fever in a patient with diarrhoea

may also be a sign of another infection such as

'pneumonia, otitis media, or malaria. Patients with diarrhoea examined for other infections and treated appropriately. to give antimicrobials

to patients with diarrhoea

and fever should

be

However, it is not appropriate

simply because they have fever. A

more specific indication is required, such as pneumonia

or bloody stools. If one is not 89

READINGS

ON DIARRHOEA

found,

the patient

continued,

should

be observed,

and

the search

for the cause

of the fever

if it persists.

Children 2 months of age or older, who have fever (38 °C or above) or a history of fever during the past 5 days and who live in an area where there is falciparum

malaria,

should be given an antimalarial or managed according to the recommendations

of the

national malaria control programme (see Fig. 6.1). If the child's temperature is 39 °C or greater, the child should

be treated

to reduce it. This may be done by giving

paracetamol or, when fever is very high, by also sponging the head and abdomen with tepid water and fanning. Inf~nts less than 2 months of age, who have a temperature of 38°C or above. should be treated for severe dehydration, cetamol or antimalarial

if present. and then referred to hospital.

Para-

drugs should not be given before referral.

Exercises 1. Aya~. who diarrhoea

is 2 years

old.

with blood

is brought

to the health

in the stool for 3 days. The health

because

worker

he has

assesses

finds that he has no signs of dehydration

and is neither

What should

may be more than one correct

the health

worker

do? (There

A.

Treat Ayaz with metronidazole

B.

Refer Ayaz to the nearest

C. Advise

the mother

for possible

hospital

to continue

feeding

E. Advise stool

Pedro

fs

the mother

to bring

Ayaz

febrile

amoebiasis.

for a stool

back

effective

if blood

had

Ayaz and

nor malnourished

since

examination

Ayaz a nutrient-rich

D. Treat Ayaz for 5 days with an antimicrobial

2.

centre

answer)

h.e has no fever.

and culture. diet.

for Shigella

in the area.

has not disappeared

from

ago

stopped

the

after 2 days of treatment.

9

months

old.

He

was

well

until

3

months

when

his

mother

.

breast-feeding and began giving him cow's milk with other food. Since then Pedro has had three episodes of diarrhoea, the current one having begun 18 days ago. Pedro still takes cow's milk but his mother has reduced his intake of solid food since the diarrhoea

began. There has been no blood in the stool. Pedro weighs 6 kg.

What should the health worker do? A. Prescribe place

a special

of the cow's

B. Give Pedro

increas~

and advise

the mother

to give this in

to give Pedro

giardiasis.

half the usual amount

foods

Of. milk each day and to

in his diet, e.g. by adding

some vegetable

oil to

cereal.

D. Tell the mother so that

for possible

other energy-rich

his cooked

formula

milk.

metronidazole

C. Advise the mother

to give Pedro sweetened

he receives

E. Tell the mother

90

lactose-free

enough

to bring

3. Maria.

aged

16 months.

noted

some

blood

in the stool

or SQft drinks, which

he likes,

fluid.

Pedro

began

fruit drinks

back

having and

in 5 days.

watery

brought

diarrhoea.

After 2 days, her mother

her to the health

centre.

The doctor

DYSENTERY,

PERSISTENT

DIARRHOEA,

AND DIARRHOEA

ASSOCIATED

WITH OTHER ILLNESSES

noted that Maria had a fever (39 °C) and saw that the stool contained There was no evidence sulfamethoxazole,

of malnutrition.

The doctor

blood:

gave her trimethoprim-

but her mother came back after 2 days saying Maria had not

improved and the stool was still bloody. What should the doctor do next? A. Tell the mother is supposed

to continue

g)ving Maria trimethoprim-sulfamethoxazole,

to be given for 5 days and she has given

B. Send Maria

to the hospital

C. Treat

Maria

with metronidazole

D. Stop

the

which

most Shigella

it for only 2 days.

for a stool culture. for possible

trimethoprim-surfa:methoxazole

amoebiasis, and

in the area are sensitive,

E. Treat Maria with erythromycin

since it

for a possible

give

another

e.g. nalidixic

infection

antimicrobial

to

acid.

with Campylobacter

jejuni.

4. Alam is 7 months old and takes only formula milk. He has had watery diarrhoea for the past 14 days. During the illness, Atam has continued 10 take his formula. He has not had a fever. How should he be treated ? (There may be more than one correct answer) A. Alam should be given an antiprotozoal agent effective for Giardia. B. Alam's mother st)ould give him only half the usual amount of formula milk each day. She should aJso give him cooked cereal with oil and SOr1:1e well-cooked vegetables to ensure an adequate intake of nutrients. If the diarrhoea

has not

stopped in 5 days, he should be referred to hospital for further evaluation and treatment. C. Alam should be referred to hospital for special dietary care. This may require replacement of his usual milk with a Jactose-free or soya-based formula. D. Alam's stool should be cultured and examined for E. histolytica and Giardia. E. Alam shquld receive an antidiarrhoeal

drug to help control the diarrhoea.

5. Chinta is 14 months old. S~e has had a fever and watery diarrhoea

for 3 days.

Today someblo'od was seen in the stool. When seen in the health centre, she is well nourished, drinks ORS eagerly, and has reduced skin turgor. Chinta lives in an area where falciparum

malar!a occurs. Which of the following steps are appropriate?

(There may be more than one correct answer.) A. Chinta should

be given an antimalarial

m"anaged according

effective for falciparum

to the recommendations

programme. B. Chinta should receive oral rehydration

of the national

following

malaria

or

malaria control

Treatment Plan B for some

d~hydration. C. Chinta should receive treatment for shigellosis, using an antimIcrobial Shigella in the area are usually sensitive. D. Chinta's mother. should continue to give her a normal nutrient-rich

to which

diet, feeding

her frequent small meals. E. Chinta's mother should bring her back after 2 days of treatment to be certain she is responding adequ-ately.

91

UNIT

7

Diarrhoea

Interaction Causes

and

nutrition

of diarrhoea

of nutritional

and malnutrition

decline

during

diarrhoea

95 96 96

Reduced

food

Decreased

intake

absorption

97

of nutrients

97

Increased

Effects

nutrient

of feeding

requirements

during

Effect of feeding Effect of feeding

and after diarrhoea

on diarrhoea on nutritional

Food given during

Nutritional

management

97

status

98 98

diarrhoea

Food given after diarrhoea

97

stops

99

99

of diarrhoea

99

Feeding during di?rrhoea Breast milk Animal milk Of formula

100 100 100

Soft or solid foods

101

Milk intolerance Feeding during convalescence, Vitarn1n A deficiency

and fo1low-up

and diarrhoea

102 10Z

103

Assessment

of hydration

R~hydration

therapy

Feeding Associated

illnesses

status

103 103 104 105

Talking with mothers about feeding during diarrhoea

105 105

Exercises

93

DIARRHOEA

Interaction

of diarrhoea

AND NUTRITION

and malnutrition

Diarrhoea is an important cause of malnutrition. This is because nutrient requirements are Increased during diarrhoea, as during other infectious diseases, whereas nutrient intake and absorption

are usually decreased. Eac~ episode of diarrhoea can cause

weight loss and growth faltering. Moreover, if diarrhoea occurs frequently, there may be too 1ittle time to "catch up" on growth (i.e. to make up for the growth that failed to occur) between episodes. The result can be a flattening of the normal growth curve, as shown in Fig. 7.1. Children who experience frequent episodes of acute diarrhoea, or have persistent diarrhoea, are more likely to become malnourished than children who experience fewer or shorter episodes of diarrhoea. In general, the impact of diarrhoea on nutritional

status is proportional

to the number of days a child spends with

diarrhoea each year.

Fig. 7.1 Growth pattern infections

of a child

with

frequent

episodes

of diarrhoea

and

other

Source: Mata, L.J. Nutrition and infection. Protein Advisory Group bulletin. 11: 18-21 !)971).

Malnutrition also contributes substantially to the problem of diarrhoea. In children who are malnourished

as a result of inadequate

feeding, acute diarrhoeal

episodes are

more severe, longer lasting, and possibly more frequent; persistent diarrhoea

is also

more frequent and dysentery is more severe. The risk of dying from an episode of persistent diarrhoea or-dysentery malnourished.

is considerably

increased when a child is already

In general, these effects are proportional

being greatest when malnutrition

to the degree of malnutrition,

is severe. 95

READINGS

Fig.

ON DIARRHOEA

7.2

Interaction

of diarrhoea

and

malnutrition

WHO91816

Thus. diarrhoea andma'nutrition.combineto forma vicious circle (Fig. 7.2) which, if it is not broken, can eventually result in death; the Jinal event may be a particularly severe or prolonged another

episode of diarrhoea

or, when severe malnutrition

serious infection such as pneumonia.

Deaths from diarrhoea

is present, are, in fact,

usually associated ~ith malnutrition. In hospitals where good management otdehydration is practised, virtually all deaths due to diarrhoea occur in malnourished children. Diarrhoea is, in reality, as much a nutritional

disease as one of fluid and electrolyte

imbalance, and therapy is not adequate unless both aspects of the disease are treated. However, in contrast

to fluid replacement,

nutritional

management

of diarrhoea

requires good feeding practices both during the illness and between episodes of diarrhoea, when the child is not sick. When this is done, and malnutrition is either prevented or corrected, the risk of death from a fu/ure episode of diarrhoea is greatly reduced. This unit describes the factors responsible for nutritional decline during diarrhoea and considers

how this effect can be reversed, and nutritional

improved, by appropriate

Causes

of nutritional

status maintained

or

feeding during and after an episode of diarrhoea.

decline

during

diarrhoea

Reduced food intake Nutrient

intake may decline by 30% or more during

the first few days of acute

diarrhoea as a result of: .anorexia,

which is especiaJly marked in children wfth dysentery;

.vomiting, which discourages attempts at feeding; .withholding of food, based on traditional beliefs about the treatment of diarrhoea or on recommendations by health personnel to "rest the bowel": 96

DIARRHOEA

.giving

AND NUTRITION

foods with reduced nutrient value. such as gruel or soup that is diluted; this

may be done in the belief that a diluted food is easier to digest.

Decreased absorption

of nutrients

Overall nutrient absorption impairment

is also reduced by about 30% during acute diarrhoea, the

being greater for fats and proteins than for carbohydrates.

impairment can occur in malnourished

children with persistent diarrhoea,

more extensive damage to the gut mucosa. Decreased absorption

Greater reflecting

of nutrients

is

caused by: .damage

to the absorptive (villous) epithelial cells. which reduces the total absorp-

tive surface of the bowel; .dis8ccharidase deficiency. owing to impaired production

of enzymes by the dam-

aged microvilli (when severe. this can cause malabsorption particularly lactose); .reduced intestinal concentrations fats; .rapid

of disaccharide

sugars.

of bile acids. which are required for absorption of

transit of food through the gut, leaving insufficient

time for digestion and

absorption.

Increased nutrient requirements Nutrient requirements are increased during diarrhoea owing to: .the

metabolic demands asso9iated with fever;

.the .the

need to repair the damaged gut epithelium; need to replace serum protein lost through the damaged intestinal mucosa, as

occurs in dysentery.

Effects of feeding

during

and after diarrhoea

To prevent growth faltering, good nutrition must be maintained both.during an episode of diarrhoea. This can be achieved by ~ontinuing amounts ,of nutritious foods throughout the episode and during

and after

to give generous convalescence. In

general, the foods that should be given during diarrhoea

are the same as those the

child should receive when he or she is we". This approach

is based on evidence that,

during diarrhoea, the major proportion used, and that, during convalescence,

of most nutrients is digested, absorbed, and substantial recovery of lost growth is possible.

The effects of feeding on both the diarrhoeal

illness and the child's nutritional

status

are considered below.

Effect of feeding

on diarrhoea

The notion that feeding should be reduced or 5topped during diarrhoea

reflects a

common belief that giving food wili cause stool output to increase and thus make the diarrhoea worse, but this is not usually the case. For example: .Breast

milk is usually well tolerated during diarrhoea;

breast-feed during diarrhoea

actually

children

who continue

have reduced stool output

to

and a shorter

duration of illness than children who do not breast-feed. 97

.Feeding

hastens

pancreatic

leads to earlier

.Children

repair

of the intestinal

functioCI and production return

of normal

mucosa,

and stimulates

of brush-border

digestion

early recovery

disaccharidase

and improved

absorption

enzymes.

of This

of nutrients.

on mixed diets. e.g. cow's milk, cooked cereal, and vegetables, do not have

increased stool output. However, those taking only animal milk or formula may have some increase in stool volume. Food is usually well tolerated during diarrhoea, the major exception being clinically significant intolerance of lactose, and occasionally of protein in animal milk. This is unusual in acute diarrhoea, but can be a significant problem in children with persistent diarrhoea

(see page 101 and Unit 6).

Effect of feeding on nutritional

status

Food given during diarrhoea (1.substantial proportion of food given during diarrhoea is digested and absorbed. It is not surprising,

therefore, that children

given full-strength

feedings throughout

an

episode of diarrhoea gain weight at a near-normal rate, whereas those with a reduced intake gain much less or actually lose weight. Fig. 7.3 shows the growth pattern of

Fig. 7.3

Effect

of feeding

on weight

gain

during

diarrhoea

I -

00 >. (I! "0 c: °ca 0) .1:: 0) .Q) ~ c: (I! 0> ~

Day

Dietary intake (kcal/kg) on indicated day

Source Brown. K.H. et al Effect of continued feeding on clinical and nutritional outcomes of acute diarrhoea in children. Journal 01 pediatrics. 112. 191-200 (1988).

98

DIARRHOEA

AND NUTRITION

children given either a reduced or a full caloric intake during the first 4 days of an acl,Jte episode of diarrhoea. The figure shows that weight gain 8 days after starting treatment was greatest in those who received a normal caloric intake (110 kcal/kg per day) throughout

their illness, and less in those whose food was reduced (55kcal/kg

per day) or withheld during the first 2-4 days of treatment. Moreover, there was no appreciable difference in the amount of diarrhoeal stool passed when children were fed half-strength

or full-strength

diets. On the basis of studies such as this, it is now

clear that there is no evidence to support a reduction in food intake during diarrhoea. Instead, full-strength

feeding should

worsening of nutritional

be continued

so that growth

faltering

and

status can be prevented, or at least minimized.

Food given after diarrhoea

stops

Even when a child is given as much food as possible during diarrhoea, some growth faltering may OCCl!r, especially if the child h9S marked anorexia. Moreover, many children are malnourished prior to developing diarrhoea and will remain at increased risk of frequent, severe, or prolonged episodes of dIarrhoea until their nutritional status improves. The goal of feeding after diarrhoea stops is to correct malnutrition

and to

achieve and sustain a normal pattern of growth. This Is best done by ensuring that the child's normal diet provides enough energy and other required nutrients. This is most important for children older than 4-6 months of age receiving a mixed diet. The foods recommended for such children during diarrhoea (see below), are those recommended for normal feeding when the child is well. It is also helpful to give increased amounts of nutrient-rich food during the first few weeks of convalescence, when children are often very hungry and may readily consume 50% or even 100% more calories than usual and grow at several times their normal rate.

Nutritional

management

of diarrhoea

The vicious circle by which diarrhoea

and malnutrition

interact can be broken by

correct feeding practices: This requires that health workers advise mothers on the best way to feed their children normally, teach them the importance ofco~tinued, full. strength feeding during diarrhoea, and assist them in their efforts to follow this advice. The four key components of correct nutritional

management ofdiarrhQea

in children

are:

.assessing the nutritional status of the child; .appropriate feeding during the diarrhoeal episode; .appropriate feeding during convalescence. with follow-up; .effective communication of dietary instructions to the moth~r The first of these is considered in Unit 3; the remaining three topics are discussed below.

Feeding during diarrhoea Specific feeding recommendations

are determined by the child's age and pre-illness

feeding pattern. These are summarized in Table 7.1 and discussed below. 99

I READINGS

ON

Table

DIARRHOEA

7.1

Feeding

of infants

and

chIldren

with

Pre-iflness feeding

acute

diarrhoea

Age in months

Breast milk

Continue

Continue

Continue

Animal milk or fofmulaB

Continue as usual

Continue as usual

Continue usual

Soft or solid foodsB

None

Continue given .

if normally

Continue, or start if not yet given

be resumed

immediately

a These foods are not given during

rehydration.

but should

as

thereafter.

Breast milk During diarrhoea, breast-feeding should not be reduced or stopped, but allowed as often and for as long as the infant desires it. Breast milk should be given in addition to ORS solution, a recommended home fluid, or other fluids given to replace stool losses.

Animal milk or formula The infant should continue to receive the usual animal milk or formula. If dehydration develops, milk feeds should be stopped for 4-6 hours during rehydration, and then resumed. Special lactose-free or hydrolysed-protein formulas should not be used routinely, they are expensive and of no special value for most infants with acute diarrhoea. Occasionally, however, diarrhoea becomes worse when milk is given and signs of dehydration

may appe~r.

In such cases, the recommendations

diagnosis and treatment of milk intolerance, should be followed.

for the

given later in this unit (see opposite), "",

Soft or solid loods If the child is 4 months or older and already taking soft or solid foods these should be continued.

Infants 6 months or older should be started on soft foods. if this has not

already been done. If dehydration develops. these foods should be stopped for 4-6 hours during rehydration. and then resumed. At least half of the dietary energy should come from foods other than milk. Children should be given frequent small meals (e.g. six or more times per day) and they should be encouraged -selection of appropriate

.Use

to eat. Guidelines for the

foods are given below.

well-cooked local staple foods that can be easily digested, such as rice, corn,

sorghum, potatoes, or noodles.

.Give the staple food in a soft, mashed form; for infants use a thick pap; if soups are given to prevent dehydration, other nutrient-rich foods must be given to ensure adequate caloric intake. 100

DIARRHOEA

.Increase

AND NUTRITION

the energy content of the staple food by adding 5-10 ml of vegetable oil

per 100 ml serving; red palm oil is especially good because it is also a rich source of carotene. .Mix

the staple food with well-cooked

pulses and vegetables; if possible, include

eggs, meat, or fish.

.Give

fresh fruit juice, green coconut water, or mashed ripe banana to provide

potassium. .Avoid

foods

and drinks with .a high concentration

of sugar

(e.g. sweetened

commercial fruit drinks. soft drinks).

Milk intolerance A few children with acute diarrhoea. especially young

infants. show symptoms of

intolerance of animal milk. Th,is usually occurs when animal milk or formula is the only food given. Milk intolerance

occurs more frequently among children with persistent

diarrhoea (see Unit 6). It almost never occurs in children whose only milk is breast milk. The clinical manifestations .a

of milk intolerance are:

marked increase in stool volum.e and frequency when milk feeds are given, and a comparable

.worsening

decrease when tHey are stopped; of the child's clinical condition: signs of dehydration

When milk intolerance is due to lactose malabsorption,

may develop.

the stool pH is low (Ie'ss than

5,5; it turns litmus paper from blue to pink) and it contains a large amount of reducing substances

(unabsorbed

centrifuged

fresh liquid stool to 5 ml of Benedict's solution and boil the mixture for

sugars). To test for reducing

5 minutes; an orange-brown

substances.

add 8 drops of

colour indicates that the stool contains more than 0,5%

reducing substances, Clinitest tablets can also be used, but not most testing tapes, because they only detect glucose. Be aware, however, that milk intolerance

is often overdiagnosed.

fr~quency may increase slightly when children with diarrhoea

Stool volume and

are fed aggressively;

reducing substances may also appear in th~ stool and the faecal pH may become low. However, as long as the child is doing well clinically (i.e. is gaining weight, eating, alert, and active), these findings are not a cause for concern. To manage milk intolerance: .Continue

.For

breast-feeding.

infants under 4-6 months of age who take animal milk: replace cow's milk or formula with yoghurt or a similar fermented milk product. or dilute milk or formula with'an equal volume of water (add 8 g of sugar to each 100 ml to maintain energy content); provide small feeds ,every 2-3 hours; if there is no improvement after 2 days. refe( the infant to a centre where specialized treatment is possible. A lactose-free or milk.free diet may be required. 101

READINGS

ON DIARRHOEA

.For

infants and children who normally take soft foods with animal milk:

-give

only half the usual amount of animal milk or replace it with yoghurt or a

similar fermented milk product; -give

sufficient .amounts of well-cooked

cereals, pulses and vegetables, with

added vegetable oil, to ensure a normal caloric intake. Give these foods mixed with milk; -if

there is no improvement after 2 days, stop all animal milk products, replacing them with other energy-rich,

protein-containing

foods. such as a soya-based

formula or finely minced chicken meat. .Continue

the treatment for milk intolerance for 2 days after diarrhoea has stopped

then reintroduce the usual milk or formula gradually

Feeding

during

The child'.s jmprove

convalescence,

usual

diet should

its quality.

continued growth.

A practical

provide

an extra

recovering

from

recommended

is to give the child

each

persistent

until the malnutrition

the foods

and the mother

stops, and extra food should

approach meal

fo/1ow-up

be reviewed

In general.

after diarrhoea

and

day

for

diarrhoea,

over 2-3 days.

2 weeks. this should

advised

during

on how she can

diarrhoea

be given to support

as much If the

should

be

"catch

up"

as he or she can eat and to child

pe continued

is malnourished for a longer

or is period.

is corrected.

Ideally, the child should be seen regularly for follow-iJp so that his or her weight can be monitored. and encouragement

and advice on feeding given to the mother. If possible,

a growth chart should be used. especially if the child is malnourish~d,

and follow-up

continued until a normal rate of growth is established (see Annex 2). If these steps are not possible, the importance of giving extra food during convalescence

and how to

improve the quality of the child's usual diet should be explained to the mother; the best, and sometimes the only opportunity

to do this is when the child is being treated for

diarrhoea.

Vitamin

A deficiency

and diarrhoea

During diarrhoea, vitamin A absorption is reduced and greater amounts are used from body stores. In areas where vitamin A deficiency is a problem, diarrhoea a rapid depletion

of vitamin A stores, leading

can cause

to acute vitamin A deficiency

and

symptoms or signs of xerophthalmia.

Sometimes blindness develops rapidly. This is a

particular

occurs

problem when diarrhoea

during

children who are already severely malnourished;

or shortly

after measles, or in

it also occurs in children who have

persistent diarrhoea or frequent episodes of diarrhoea. Accordingly, children with diarrhoea who live in an area where vitamin A deficiency is a signiticant

problem

deficiency

(see Unit 3). If night .blindness

xerophthalmia,

should

be examined

for symptoms is present

and signs of vitamin

A

or there are any signs of

200000 units of vitamin A should be given by mouth; infants should

receive 100000 units. This dose should be repeated the next day and again after 102

DIARRHOEA

2 weeks. Children who have severe malnutrition

AND NUTRITION

or have had measles within the past

month should receive a single dose of vitamin A, as above (unless a dose has been given w!thin the past month). In areas where vitamin give their

children

A de.ficiency

foods

yellow or orange

vegetables

potatoes,

bananas)

yellow

Management Diarrhoea

is a problem,

rich in carotene,

mothers

the precursor

and fruits (e.g. carrots, and dark-green

of diarrhoea

should of vitamin

pumpkins,

be encouraged A: these

mangoes,

to

include

yellow sweet

leafy vegetables.

in children

with severe

malnutrition

is a ~erious and often fatal event in chHdren with severe malnutrition.

Although the main objectives in treating such patients are the same as for betternourished children, certain aspects of patient evaluation and management should be modified or given particular severe malnutrition

Assesslnent

attention. These are described below. The diagnosis

of

is describftd in Unit 3.

of hydration

status

Assessment of hydration status in severely malnourished children is difficult, beca:use a number of the signs normally used are unreliable. For example. children with marasmus have loose. lax skin and very little subcutaneous

fat; their skin turgor appears

poor. even when they are not dehydrated: On the other hand. sKin turgor may appear normal in children with oedema ,(kwashiorkor), even when they are dehydrated. Likewise. sunken eyes are an unreliable sign in marasmic children; and the apathy of children with kwashiorkor and the irritable. fussy behaviour of those with marasmus make the interpretation of mental state difficult. Absence of tears is difficult to assess in all children with severe malnutrition useful for detecting dehydration

because they do not readily cry, Signs that rema(n (nclude: dry mouth and tongue. arid eagerness to

drink (for children with some dehydration);

or very dry mouth and tongue. cool and

moist extremities. and weak or absent radial pulse (for those with severe dehydration). In children with severe malnutrition between some dehydration

it is often not possible to distinguish

reliably

and severe dehydration.

Rehydration therapy The guidelines for rehydrating children with diarrhoea and severe malnutrition

are as

follows: .Rehydration

therapy should take place at a hospital, if possible; if the patient is seen

at a health centre or clinic, he or she should be referred to hospital. The mother should be provided with ORS solution and shown how to give it to the child at a rate of 5 mi per kg of body weight per hour during the trip (see Fig. 6.1, page 82). .All

fluids should be given by mouth or nasogastric

tube. Intravenous

infusions

should not be used because fluid overload occurs very easily, causing heart failure, and their use also increases the risk of septicaemia; either everit is likely to be fatal. Oral rehydration is preferred for children who can drink; otherwise, a nasogastric tube should be used until the child is able to drink. 103

READINGS

ON DIARRHOI:A

.Rehydration should be done slowly, over a period of 12-24 hours. The approximate amount of ORS solution to be given during this period is 70-100 ml per kg of body weight, The exact amount should be determined by the quantity the child will drink " and by frequent, careful observation"of the child for signs of overhydration (increasing oedema). The child should remain at the treatment centre until rehydration is completed. .The

standard ORS solution should be used. Howeyer, additional

be given by mouth, since severely malnourished

potassium should

children are normallypotassium-

depleted, and this is made worse by diarrhoea. A convenient solution, containing 1 mmol of potassium per ml of solution, can be prepared by dissolving 7.5 g of potassium chloride in 100 mi of water; 4 ml of this solution per kg of body weight should be given each day for 2 weeks, in divided doses mixed with food. .Feeding shouJd

shOuld be resumed as soon as possible. Fasting, even for brief periods, be

avoided.

Breast-feeding

should

continue

throughout

rehydration

and

",

other food should be given as soon as it can be taken. Small amounts can usually be given within 2-3 hours after starting rehydration. The feeding guidellnes given below shoul-d be followed.

Feeding Children with severe malnutrition rehydration

is complete, nutritional

and diarrhoea rehabilitation

must be fed very carefully;

once

should take place, preferably at a

treatment centre with expertise in this area. Typically, children must speQd 12-14 hours a day at the centre for feeding and supportive care, returning each night to their homes, where frequent feeding is continued. If the child must be admitted to hospital, the mother should stay, if possible, to assist with feeding and provide emotional support; For chitdren with kwashiorkor, feed(ng should be resumed slowly, starting at 50-60 kcal per kg of body weight per day and reaching 110 kcal/kg per day after about 7 days; feeding usually has to be encouraged owing to the child's lack of interest in eating. For children with marasmus, feeding should be limited to 110 kcal/kg per day for the first week, but food can usually be given ad libitum thereafter. Semi-Ijquid or liquid foods must be given in numerous.small

feedings, e.g. every 2 hours, day and

night. Initially, eating may be difficult because of stomatitis; in such instances, the child must be fed by nasogastric tube for severa( days. A practical

diet

for

initial

feeding

can

be prepared

from:

ThiS contains 100 kcal per 100 m'. If possible, the skim milk should be prepared first and f~rmented to make a yoghurt-llke

drink before the sugar and 0;1 are added. This

reduces the lactose content of the diet, so that it ,$ better tolerated. The diet may also be prepared using fresh skim mjlk (brjefly boiled) In place of skim milk powder and water, The oil is an important insufficient energy. 104

ingredient.

as the diet would

otherwise

provide

DIARRHOEA

AND NUTRITION

In addition, the following mineral and vitamin s~pplements should be given: .iron

-60

.folic

acid -100

.vitamin

mg of elemental iron per day; A-

deficiency

J.lg per day;

200000 units once (100000 units for infants) in areas where vitamin A is prevalent. If signs of xerophthalmia

are present, the full treatment

course described earlier (see page 102) should be given; .vitamin

B complex, vitamin C, and vitamin D -as

daily multivitamin drops.

Further information on the nutritional management of children with severe malnutrition can be found in: The treatment and management of severe protein-energy tion, Geneva, World Health Organization,

malnutri-

1981.

Associated illnesses Children with severe malnutrition

and diarrhoea

frequently

have other serious ill-

nesses. especially infections. Most common are pneumonia. septicaemia, otitis media. pharyngitis. lonsillitis,

and urinary or skin infections. Severe infection often causes

hypothermia rather than fever. Patients should be examined carefully for evidence of infection and given appropriate

Talking

with mothers

antimicrobial

about feeding

therapy.

during

diarrhoea

Most societies have strong cultural beliefs about the feeding of infants and children during and after diarrhoea.

Feeding recommendations

must be nutritionally

sound,

but also compatible with the mother's beliefs and resources. In order to give effective dietary recommendations, .what

foods

the doctor must know:

are most commonly

used for children

at different

ages and the

nutritional value of these foods when prepared in the usual manner; .what

foods are commonly given or specifically prohibited during diarrhoea;

.what

specific combinations

can be recommended for nutrient-rich, low-bulk. soft, or

semi-liquid diets. using foods that are available. acceptable. and affordable; .how

much food should be given to children with diarrhoea.

The doctor should ask the mother about the child's usual diet and Bbout the food the child has received since diarrhoea began. The advice given should cover feeding both during diarrhoea and after diarrhoea stops; if possible, the recommendations

for these

two periods should be similar, with emphasis on a balanced. nutrient~rich diet that is appropriate

for the child's age. If the mother does not have or cannot obtain the

recommended foods, or is strongly opposed to giving certain items, the doctor should adjust the recommendations

to fit her situation. If she does not know how to prepare

certain foods, the doctor should ensure that she is given clear instructions and is able to follow them (see ..Talking with mothers about home treatment".

Unit 4),

Exercises Which one of the following

is the most important

cause of weight loss during

diarrhoea ? 105

READINGS

ON DIARRHOEA

A. Reduced

absorption

B. Increased

of nutrients.

metabolic

demands.

C. Vomiting. D. Anorexia. E. Reduced

2. Which

intake

of food.

of the following

(There

statements

may be more than

about

one correct

feeding

during

A. Feeding during diarrhoea does not appreciably B. Continuing

diarrhoea

are correct?

answer.)

feeding during diarrhoea

increase stool volume.

helps to hasten repair of the intestinal

mucosa, thus restoring the production

of disaccharidase

enzymes.

C. Food should be withheld when a child has anorexia. D. Special foods should be given during acute .diarrhoea; the diet is not the same as that recommended when the child is well. E. Doctors should insist that mothers follow their advice about feeding, irrespective of the mothers' beliefs about what foods should or should not be given during diarrhoea. 3. Yunus,

aged 9 months,

is brought

to you with watery,

he has had for 2 days. He has vomited of some dehydration. stopped

You rehydrate

breast-feeding

Yunus

then, he has been taking he started

(There

may be more than

A. Continue

should

to give Yunus

well-cooked

some fish or meat when D. Gradually.

resume

E. Give an extra

4. Which (There

serving

vegetables

usual

ago. Since

rice with the rest of the family. When

in your advice

of well-cooked

to Yunus's

diet as the diarrhoea

day for at least 2 weeks

statements

may be more than

says that she

to Yunus's

mother?

rice.

diet; give him an egg, or

possible.

Yunus's

meal each

of the following

2 months

milk feeds.

oil to each and

His mother

pregnant

which

shows evidence

answer.)

his normal

pulses

diarrhoea,

examination

his food.

be included

one correct

B. Add 5-10 ml of vegetable C. Add

she became

she stopped

points

non-bloody

him with ORS solution.

when

cow's milk and eating

to have diarrhoea,

Which of the following

twice. Physical

about

one correct

feeding

gets better.

after diarrhoea

stops.

after acute diarrhoea

are correct?

answer.)

A. An extra meal should be given each day for at least 2 weeks. B. Milk should be withheld for several days, to prevent diarrhoea from returning. C. The foods given should be of the same type recommended diarrhoea,

i.e. nutrient-rich

for use during

mixtures of a staple food, vegetable

oil, pulses,

vegetables and, if possibJe, meat, fish or egg; The usual milk should be given. D. Normal feeding should be resumed gradually, to prevent diarrhoea

from retur-

ning. 5. Roberto, aged 9 months, has had frequent episodes of diarrhoea. He cries a lot and is restless during the examination. eagerly, and his tongue

His skin pinch. goes back slowly, he drinks

is dry. His mother

says that he has had diarrhoea

frequently, "almost every month". He has been taking cow's milk from a feeding 106

DIARRHOEA

bottle since he was 1 month the age of 8 months. not need larger wearing

His mother

clothes

Roberto

as her previous

charm

started

to take soft and semi-solid

says that he seems to be growing

as often

the same protective

Since the diarrhoea "because

old, and he started

bracelet

his mother

AND NUTRITION

children

slowly,

did, and

food at he does

he has been

on his wrist since he was 4 months

old.

has given him some milk, but no solid food

he was not hungry",

weighs 4.7 kg and has a "skin and bones"

is severely

malnourished.

than one correct

What

should

appearance.

be done for Roberto?

It is obvious (There

that he

may be more

answer.)

A. He should be rehydrated orally with ORS solution at a rate of 70-100 mI/kg over 12-24 hours. 8. Food should be withheld until rehydration is completed. C. If Roberto does not take the estimated volume of ORS solution, the remainder should be given intravenously as Ringer's lactate solution. D. Roberto's treatment, including rehydration and nutritional management, should be given at a hospital or specialized treatment centre. E. Roberto should

be given supplemental

potassium

(a solution

of potassium

chloride added to his food) for 2 weeks. 6. Part 1: Kati is 7 months old. She is brought to you after 2 days with diarrhoea and has signs of severe dehydration.

You initiate intravenous

rehydration

and then

obtain further information from her mother. She says Kati was weaned to cow's milk 6 weeks earlier. Kati also eats well-cooked rice and vegetables and has continued to receive this diet during her illness. After rehydration

you advise Kati's mother on

home treatment, namely, feeding with cow's milk, rice, vegetables. and added oil. After 2 days, Kati's mother returns because Kati is still having frequent watery stools. The mother thinks these usually occur shortly after Kati takes milk. You think Kati may have milk intolerance.

What one step would

help most to confirm

this

diagnosis? A. Stop all food for 2 days and see whether B. Withhold

milk for 12 hours

diarrho~a

subsides,

then

the diarrhoea

(while continuing give it again

improves.

to give other foods)

to see whether

to see whether

the diarrhoea

promptly

worsens. C. Test the stool for pH and reducing D. Give a special

soya-based

substances.

milk and see whether

E. Give an antimicrobial

and see whether

Part 2: If the diagnosis

of milk

appropriate

for its treatment?

A. Give a special

soya-based

formula

B. Give Kati only half of her usual C. Provide added

Kati's

oil. Mix Kati's

or another

is confirmed.

of animal

what

steps

one correct

uhtil the diarrhoea

amount

stops.

stops.

may be more than

at least half of Kati's food energy vegetable

D. Give yoghurt E. Replace

the diarrhoea

intolerance

(There

the diarrhoea

would

be

answer.)

stops.

milk.

as cooked

cereal and vegetables,

with

milk with these foods.

fermented

milk with fruit juice

milk product

in place

of milk.

or tea.

107

I

UNIT

8

Prevention

of

diarrhoea

Introduction

111

Breast-feeding What mothers What

111

should

doctors

should

do

114

do

115

Improved weaning practices What mothers should do

115 115

When to begin weaning What foods

to give

Preparing and giving What doctors should do Proper

use of water What families

115

for hygiene should

do

should

do

should

do

116

weaning

foods

116

and drinking

Use

of

118 118

Hand-washing What

116

118 families

119

latrines 119

What

families

Safe disposal

of the stools

What families Measles

of young

should

do

children

121

families

should

do

What

doctors

should

do

Talkin~~ with mothers How doctors

120 120

immunization

What

Exercises

120

about

121 121

preventing

can help to prevent

diarrhoea

diarrhoea

121

122 122

109

PREVENTION

OF DIARRHOEA

Introduction Proper case management,

consisting of oral rehydration

therapy and feeding, can

reduce the adverse effects of diarrhoea, which include dehydration,

nutritional

dam-

age, and risk of death. Other measures are required, however, if the incidence diarrhoeal

episodes is to be substantially

reduced; these include interventions

either reduce the spre~d of the microorganisms

of that

that cause diarrhoea or increase the

child's resistance to infection with these agents. Prevention of diarrhoea,

properly

carried out, can be as important as case management, and may be the only way of avoiding deaths where treatment is not readily available. A number

of interventions

children,

most of which

hygiene,

cleanliness

immunization.

of food,

An analysis

intervention others

have been

involve

has shown

provision

for preventing

related

to infant

of safe water,

of the effectiveness,

or ineffective,

cluded

that efforts

proper

case management,

to prevent

diarrhoea,

should

identified

or require

effective

iurther

personal

of faeces,

whereas

The reviewl

deaths

and

proposed

and affordable,

evaluation.

and thus to reduce

for promotion

in young

practices,

and cost of each

focus on a few"interventions

as targets

diarrhoea

feeding

safe disposal

feasibility,

that some are particularly

are impractical

seven practices

proposed

measures

con-

not preven.ted

of proven

efficacy.

by The

are:

.breast-feeding; .improved weaning practices; .use of plenty of water for hygiene and use of clean water for drinking; .hand-washing; .use of latrines; .safe disposal of the stools of young children; .measles immunization. These topics are considered in detail in this unit.

Breast-feeding Although

breast

breast-feeding include formulas,

milk is the best and safest is declining

in most developing

the belief that bottle-feeding the need for mothers

breast-feeding

Nearly all women

can breast-feed

for both infant

and mother

and

breast-fed

thtaggressive

than babies

support

for mothers

satisfactorily

the incidence

episodes

for infants

who

benefits

of diarrhoea,

who are not breast-fed. severe diarrhoea

who want

and

promotion

are not breast-fed

than

of infant

adequately,

and

has many benefits

are that

during

admission for those

breast-fed risk of dying

what are the policy options? Health policy and planning,

babies from

the first 6 months

to hospital who

can be 30

are exclusively

(Fig. 8.2).

'Feachem. RG Preventing diarrhoea

for

to breast-feed.

a lower

For example,

that requires

of

for this decline

the lack of facilities

and breast-feeding

(Fig. 8.1 ). Some major

less severe

of life. the risk of having times greater

is .'modern'..

jnfants,

The reasons

at places of work, fear of not being able to breast-feed and nursing

diarrhoea

for young

countries.

to work away from their children,

a lack of medical

have fewer

food

1.109-117

(1986)

I READINGS

DN

Fig.

DIARRHOEA

has many advantages

8

Important

advantages

.Exclusive

of breast-feeding

breast-feeding

during

severe or fatal diarrhoea;

.Breast-feeding

are

the first 4-6

the risk of other

months

serious

greatly

infections

reduces

the risk of

is also reduced.

is clean; it does not require the use of bottles. teats. water. and

formula, which are easily contaminated .Breast

for both infant and mother

milk has immunological

.operties

with bacteria that may cause diarrhoea. (especially antibodies)

that protect the

infant from infection, and especially from diarrhoea; these are not present in animal milk or formula. .The

composition

of breast milk is ideal for the infant; formula or cow's milk may be

made too dilute (which reduces its nutritional value) or too concentrated

(so that it

does not provide sufficient water) and may provide too much salt and sugar. .Breast healthy benefit

milk is a complete infant

breast-milk the mother's

is cheap; substitutes.

it provides

the first 4-6 months

from the provision

.Breast-feeding

12

during

food;

all the nutrients of life. (However,

and

water needed

low-birth-weight

by a

infants

of iron, if available.)

there

are none

of the expenses

e.g. the costs of fuel. utensils,

time in formula

preparation.

associated

and special

with feeding

formulas,

and of

PREVENTION

Source Mahmood, D.A. et al. Infant feeding and risk of severe diarrhoea in Basrah city, Iraq: a case-control World Health Organizelion,

OF DIARRHOEA

study. Bulletin of the

17. 701-706 (1989).

.Breast-feeding helps with birth spacing; mothers who breast-feed usually have a longer period of infertility after giving birth than mothers who do not breast-feed. .Milk

intolerance rarely occurs in infants who take only breast milk.

.Breast-feeding

immediately after delivery encourages the .obonding ., of the mother

to her infant, which has important emotional benefits for both and helps to secure the child's place within the family. If possible. infants should be exclusively breast-fed during the first 4-6 months of life. This means that a healthy baby who is growing normally should receive only breast milk and no other fluids or foods such as water, tea, juices, or formula. Between 4 and 6 months of age. infants should start to receive cereals and other foods to meet their increased nutritional

requirements.

but breast-feeding

should be con-

tinued at least until 2 years of age. Breast milk given after the age of 6 months is an important

source of nutrients

and it continues

to help protect the child against

episodes of severe diarrhoea. Efforts to promote breast-feeding time of birth (breast-feeding problems are encountered difficulties

are especially important during pregnancy,

at the

should begin as soon as possible after birth) and when after breast-feeding

can be easily managed.

problems related to breast-feeding

has been established. Most of these

Some ways of helping

mothers to overcome

are summarized in Table 8.1. 113

READINGS

ON DIARRHOEA

Table If the

8.1

Common

difficulties

with breast-feedlng Then the health worker should: ~

mother:

Says she does not have enough breast milk

Determine

Has a sore or cracked nipple

whether

the baby

~

is gaining

weight

normally:

.If

the baby's weight gain is normal, try to find out why the mother is anxious. Reassure her that her baby is growing normally and that she is producing enough milk.

.If

the baby's weight gain is less than normal, suggest that she tries to increase the supply of milk by breast-feeding as often and as long as the baby wants, at least 6-8 times a day. If the baby still does not gain weight, supplement the breast milk with formula, offering it after the breast-feed. If the infant is at least 4 months old, supplement the milk with cereal, well-cooked vegetables, and other weaning foods (see Unit 7).

Show her how to continue nipple. Tell her to:

to breast-feed

without

injuring

the

.Make sure that when the baby feeds, the nipple and the areola are in the baby's mouth. The gums should close on the areola, not on the nipple. .Feed

the baby frequently

from the breast with the sore

nipple. .Change the position of the baby so the baby's mouth does not always hold the breast in the same way. .Let the nipple dry in the air after breast-feeding pressing milk.

or ex-

If she cannot breast-feed because of pain! show her how to express her milk manually and feed it to her baby. Has an engorged breast (the breast is too full of milk)

Show her how to express feed frequently.

Has an infected breast (Si9?S of infection include a swollen. painful. and reddened breast with tender lymph nodes under the arm)

Give her an appropriate antimicrobial (e.g. penicillin). Tell her to continue breast-feeding and explain that milk from the infected breast is still safe for her baby. Start feedings on the unaffected breast. then move the infant to the affected breast after milk let-down has occurred. Severe pain may. require the expression of some milk by hand.

milk manually.

Tell her to breast-

What mothers should do .Start

breast-feeding

.Breast-feed

.Breast-feed

.Express separation 14

on demand;

if possible,

more frequent

to take the baby

home, at night,

milk

after delivery

for the first 4-6

months.

and continue

for at least 2 years.

it is not possible returning

as possible

the baby exclusively,

breast-feeding

.If

as soon

manually

sucking

to work,

and at any other

to avoid

from the baby.

causes

breast-feed

time when

engorgement

the milk supply

of the

before

the mother

breasts

leaving

to increase

home,

on

is with the baby.

during

periods

of

PREVENTION OF DIARRHOEA

.Continue

breast-feeding

during

and after any illness of the baby, especially

diarrhoea.

What doctors should do .Encourage

hospital policies and routine procedures after delivery that promote the

breast-feeding of neonates. For example. allow mothers to start breast-feeding immediately after delivery; keep all healthy babies close to their mothers in the same room (termed "rooming-in"); do not allow any food or fluids except breast milk to be given to newborns; do not distribute (or allow sales representatives or nurses to distribute) samples of milk formula or feeding bottles to the mothers.

Improved Weaning

weaning is the process

diet. Dur~ng weaning, meet the child's important

practices by which an infant supplementary

increased

foods

nutritional

gradually

becomes

accustomed

to an adult

other than milk are introduced

demands.

However,

breast

milk

in order to remains

an

part of the diet.

Weaning is a hazardous period for many infants. This is because the child may not receive food of adequate nutritional value and the food and drinks provided may be contaminated with pathogenic microorganisms, including those that cause diarrhoea. The danger is that the child will become malnourished due to an inadequate diet and repeated episodes of diarrl:1oea, or will succumb to dehydration episode of diarrhoea.

Unfortunately,

increases the child's susceptibility prolonged

these processes are interrelated:

malnutrition

to infection so that the child experiences

and more severe episodes of diarrhoea,

development of malnutrition

caused by an acute.

and diarrhoea

more

accelerates the

(see Fig. 7.2, page 96).

Some specific problems associated with weaning that can lead to malnutrition

or

diarrhoea are: .delaying

the start of wean\ng beyond 4-6 months of age;

.weaning too abruptly'; .giving too few meals per day; .giving supplementary foods with a low content of protein and energy; .preparing and storing weaning foods in a way that permits bacterial contamination and growth; .giving milk or other drinks prepared with contaminated

water or in a contaminated

feeding bottle,

What mothers should do When to begin weaning Weaning should begin when the child is 4-6 months old. While continuing

to breast-

feed, the mother should give a little well-cooked soft or mashed food, such as cereal and vegetables, twice each day. When the child is 6 months of age, the variety of foods should be increased and meals should be given at least four times per day, in addition to breast-feeding. After 1 year of age, the child should eat all types of food; vegetables, i15

READiNGS

ON DIARRHOEA

What foods

to give

Cereals and starchy roots are the most w(dely used weaning foods, but these ar~ relatively low in energy. They should be given as a thick pap or porridge, using a spoon, and not as a dilute drink. The energy content should be increased by mixing one or two teaspoonfuls of vegetable oil into eaCh serving. The objective is to achieve an energy intake of about 110 kcal/kg per day. Between the age of 6 months and 1 year, pulses, fruit, green vegetables, eggs, meat, fish, and milk products added to the diet. In areas where vitamin A deficiency

should be

is a problem, the diet should include orange

or yellow vegetables and fruits (see page 103), and dark-green

leafy vegetables.

Weaning foods are considered in greater detail in Unit 7.

Preparing Mothers minimize

.Preparing

.Cooking .If

and giving should

weaning

be taught

foods

ways of preparing,

the risk of bacterial

contamination.

the food in a clean

giving, These

and storing

weaning

foods

that

include:

place.

or boiling the food well.

possible, preparing the food immediately before it will be eaten

.If

cooked food was piepared more than 2 hours before it is used, reheating it until it is thoroughly

.Feeding

hot (and then allowing it to cool) before giving it to the baby.

the baby with a clean spoon, from a cup, or with a special feeding spoon

(Fig. 8.3). Feeding bottles should never be used. .Wa$hing uncooked food in clean Water before feeding it to the baby; an exception is fruit that is peeled before it is eaten, such as a banana.

What doctors should do .Make

the assessment

well-baby 116

programmes.

of weaning

diets and weaning

This should

be coordinated

education

a routine

with the use of growth

element

of

charts

to

PREVENTION

Fig.

8.3

How

to feed

liquids

to an

OF DIARRHOEA

infant

identify children with growth faltering, for whom improved feeding is especially important. .Evaluate

the nutritional

arm circumference,

-refer

status

of children

weight-for-age,

all children.with

with diarrhoea,

by measuring

mid-upper

or weight-for-height:

severe malnutrition

to a treatment centre where nutritional

rehabilitation is possible; -for moderately maln
foods. If possible, follow up the child after the

has stopped until the weight or rate of growth has become normal; provide advice on correct feeding during and after the episode of

diarrhoea (giving one extra meal each day for at least 2 weeks after the diarrhoea has stopped). 117

I READINGS

ON

DIARRHOEA

Proper

use

of

Most infectious

water

agents

transmission

from

to person,

person

A plentiful

such as hand-washing. can interrupt

facilitate

hygiene.

good although

drinking

both

and

drinking-water

supply

cleaning

the spread

of water of eating

qualities

helps

to encourage

Clean

that cause supply

water

route.

food, and hygienic

arid cleaning

agents

that the water

are desirable,

by the faecal~oral or contaminated

utensils.

of jnfectious

it is more important

and for preparing

drinking

are transmitted

by contaminated

these practices

clean.

hygiene

that cause'diarrhoea

This includes

practices,

for

of latrines;

diarrhoea.

be abundant

is essential,

To than

however,

for

food,

Families ,that have ready access to a generous supply of water, and to clean water for drinking

and preparing

food. have diarrhoea

less frequently

access to water is difficult or whose drinking-water

water supplies can result from government-sponsored and communities

may play an important

than families whose

is heavily contaminated.

Improved

programmes. in which families

role. or from other community

or family

efforts. such as collecting and storing rainwater.

What families should do .Use

the most readily available water for personal and domestic hygiene. If this water

is likely to be contaminated. preparing food.

.Collect

store it separately from water used for drinking

.

or

drinking-water from the cleanest available source.

.Protect

water sources

metres

by keeping

away and downhill,

..Collect

animals

away, by locating

and by digging

and store drinking-water

drainage

latrines

ditches

in clean containers.

more than

to divert

10

storm water.

Keep the storage container

covered and do not allow children or animals to drink from it. Do not allow anyone to put his or her hand into the storage container. Take out water only with a longhandled dipper that is kept especially for that purpose. Empty and rinse out the container every day. .Boil

water

that will be used to make

drinking-water seconds;

if sufficient

vigorous

fuel

boiling

food

or drinks

is available.

is unnecessary

for young

Water

needs

and wastes

children.

to boil

Boil other

for only

a few

fuel.

Hand-washing Parents

can

help to protect

hygienic

practices.

washing

is especially

important

cause

hand-washing

I Khan, HygIene,

M.U.

Inlerrupllon

78164-168

young

children

One very important

practice

effective

for preventing

of dysentery.

For example,

with

of (1982)

soap

shigellosis

and

by

water

hand-washlng

against

reduced

diarrhoea

is hand-washing

the spread a study

of Shigella,

in Bangladesh1

the incidence

Transaclions

by adopting

of

the

Royal

(Fig.

8.4). Hand-

which

is the most

has shown

of secondary

SocIety

certain

of

Tropical

cases

Medicine

that of

and

PREVENTION

Fig.8.4

Hands

should

and before

be washed

carefully

after

defecation,

before

handling

OF DIARRHOEA

food

eating

shigellosis

by a factor

shigellosis

had been detected.

Good hand-washing

of seven

(from

14%

to 2%)

in households

where

a case

of

requires the use of soap (or a local substitute), plenty of water,

and careful cleaning of all parts of the hands. If water is scarce, it can be used more than once to wash hands. it can then be used to wash the floor, to clean the latrine, or to irrigate the vegetable garden.

What families should do .Create

a place within the home for hand-washing.

container

.All

for water,

members

should

and soap

wash

(or a local

their hands

This should

have a wash basin, a

substitute).

well

-after cleaning a child who has defecated, or after disposing of a child's stool; -after defecating; -before preparing food; -before -before .An

adult

eating; feeding a child. or older sibling

should

wash

the hands

of young

children.

prevents

them from

Use of latrines Human

faeces

should

contact

with hands

be disposed

or contaminating

of in a way that a water

source.

coming

This is best achieved

into

through 119

READINGS

ON DIARRHOEA

What families should do .Have

a clean, functioning

latrine that is used by all members of the family old

enough to do so. Keep the latrine clean by regularly washing down fouled surfaces.

.If

there is no latrine: -defecate away from the house, and from areas where children play, and at least to metres from th~ water supply; .cover the faeces with earth; .do not allow children to visit the defecation area alone; keep children's hands off the ground near the defecation

In many communities

area.

the stools of infants

and young

children

are considered

harmless. However, young children are frequently infected with enteric pathogens and their stools are actually an important source of infection for others. This is true both for children with diarrhoea

and for those with asymptomatic

gienic disposal of the faeces of allyoung

infections. Therefore, hy-

children is an important aspect of diarrhoea

prevention. Education Is needed to warn families of the dangerous nature of young children's stools and to stress the impdrtance of disposing of them properly.

What families should do .Quickly

c" collect the stool of a young child or baby, wrap it in a large leaf or

newspaper, and put it in the latrine, or bury it. .Help

older children to defecate into a potty. Empty the stool immediately

latrine and wash out the potty. Alternatively, disposable surface, such as newspaper dispose of it in a latrine, or bury it.

have the child defecate

into a onto a

or a large leaf. Wrap up the stool and

.Promptly clean a child who has defecated. Then wash their own and the child's hands with soap and water: 120

PREVENTION

Measles Children

immunization

who have measles.

substantially

increased

is some

evidence

episode).

Because

Measles vaccine

the increased

risk

lasts

relationship

measles

immunization

against

and mortality

given at the recommended under

4 weeks.

after

the

and serious measles

associated

age can prevent

have a

or dysentery

up to 6 months

between

the morbidity

in children

in the previous

severe or fatal diarrhoea

of measles vaccine.

for reducing

deaths

What families .Have

risk of developing

that

measure

associated

or have had the disease

of the strong

and the effectiveness effective

OF DIARRHOEA

(there measles

diarrhoea.

is a very costwith diarrhoea.

up to 25% of diarrhoea-

5 years of age.

should do

children

immunized

against

measles

at the recommended

age.

What doctors should do .Include screening and referral for immunization, including measles immunization, as a routine practice in well-baby clinics. .Ask

mothers

always

clinic for any reason

to bring the child's

immunization

Check the immunization

that those who need it are immunized

during

against

to postpone

it. Diarrhoea

Talking

with mothers

Most activities mothers

and

have learned activity.

family

what this involves

Information

diarrhoea

members

meetings,

at this time the mother

is more likely to be interested episodes.

Care should

through

however,

in the home. prevention

However, until

they

how best to carry out each preventive can

schools, effective

is particularly

in knowing

be taken,

diarrhoea

of diarrhoea

centre. The latter may be especially

diarrhoea;

diarrhoea

practise

and understand

on the prevention

and make sure

immunization.

must take place

cannot

they come to the

the visit, unless there is a valid reason

about preventing

that help to prevent other

ways, e.g. at community health

is not a reason

card when

status of every patient

during

in a variety

of

home visits and visits to a

when the visit involves

aware

what

be provided

of the problem

a child with

of diarrhoea

steps she can take to prevent

not to overwhelm

the mother

and future

with informa-

tion, as she will also be given instructions concerning home treatment I possible, messages on prevention should focus on the interventions

of her child.

sidered

for preventive

most desirable

measures

that concern

for the particular feeding,

which

child; this is especially will depend

upon

important

the child's

that

If

are con-

age and feeding

status.

Discussions with mothers about preventing diarrhoea ples as those concerning supportive

home treatment

and understanding,

mother to understand

should follow the same princi-

of diarrhoea

(Unit 4). They should

be

not crit(cal. Remember that the goal is 10 help the

that she plays a very important

role in assuring

her child's

health. 121

READINGS

ON DIARRHOEA

How

doctors

can

help

Most of the interventions

to prevent

diarrhoea

described in this unit involve education -of

mothers in

particular, but also of other family members. The objective is to achieve a change in behaviour that diminishes the risk of diarrhoea, usually by reducing the transmission of infectious agents. In many situations this effort will be organIzed and led by doctors, and much of the educational activity will occur at health facilities. Specific ways in which doctors can help to organize or strengthen such educational ..Ensuring

appropriate

.mothers

about

hand-washing, should

and

oJganize

stand

in-service

preventive stool

regular,

them.

measures

during

Staff

examining

a patient

disposal,

should

staff: Most teaching weaning

out by health

facility

of the staff to ensure

should

also

facility

as breast-feeding,

training

mothers

their work,

of the health such

is carried

in-service

the key messages

,- conveying

training

measures;

efforts include:

receive

be taught

e.g. washing

and

hands

staff.

effective

appropriate

with

Doctors

that they under-

the most

to practise

their

of

practices,

soap

way~ of preventive

and water

after

with diarrhoea.

.Displaying promotional material on how to prevent diarrhoea. Educational posters should be displayed in areas of the health facility where they can be used to teach mothers

how to prevent

considered

.Being that

diarrhoea.

They should

a good

role model. Doctors diarrhoea

breast-feeding

should

and protect

for the first 4-6

role models safely,

maintained, .Taking taking

and latrines

for

in their own homes

measures

should

For example,

part

in community

activities

meetings

is an

such as appropriate

and other diseases,

should

and

way

of

in water supply

and

carefully

cleaned.

health.

practices,

for at

its staff are

be stored

and regularly

effective

as exclusive

and

be available

to promote

weaning

improvements

facility

water

should

such

breast--feeding

that the health

be well constructed

in community-oriented

measures,

of their children,

hand-washing

part

preventive measles

measures

of life and continued

ensure

for the community. facilities

encourage

the health

months

least the first 2 years. They should

handled

all the preventive

in this unit.

prevent

good

cover

Giving

talks

or

promoting

certain

immunization

against

and use, and construc-

tion and use of latrines.

.Coordinating

efforts

programmes.

for disease

Doctors

should

programmes cOncerned ot immunization, infant These programmes posters

le~rn

about

with and

those

of relevant

use the resources

government

of government

with disease prevention. This applies broadly to the areas feeding practices, hygiene, sanitation, and water supply.

are often valuable

or pamphlets

practices,

prevention

for

mothers,

e.g. on the most appropriate

sources and

may

weaning

of teaching also

materials,

provide

foods

such as wall

guidelines

or designs

for

local

for latrines.

Exercises 1. Which

of the following

diarrhoea 122

in young

measures

children?

are cost-effective

(There

with regard

may be more than

to the prevention

one correct

answer.)

of

PREVENTION

A. Control

OF DIARRHOEA

of flies.

B. Hand-\'{ashing C. Exclusive

after defeca1ion,

breast-feeding

before

preparing

for the first 4-6 months

food,

and before

of life; continued

eating.

breast-feeding

for at least 2 years. D. Immunizing

2. Which

against

of the following

may be more than A. The protection foods 8.

measles

C. Infants severe

infants

below 4 months drinks,

who are exclusively diarrhoea

bottle. D. Milk intolerance

against

are correct?

diarrhoea

is not affected

occurs

breast-fed

(There

when other

with

occur

have a greatly

infants

Which

during

taking

the period

period?

reduced

animal

be

from

and bottle-fed

of weaning,

factors

(There

risk of developing

milk or formula

in breast-fed

of the following

the weaning

but should

if they live in a hot. dry climate.

with equal frequency

of diarrhoea

during

of age do not need other foods,

especially

compared

is also most prevalent. malnutrition

breast-feeding

are given.

or other

3. Many episodes

concerning

age.

answer.)

of breast-fed

infants

given water

statements

one correct

or drinks

8reast-fed

at the reGommended

infants.

when malnutrition

help to cause

may be more

a

diarrhoea

than

one

and

correct

answer:) A. Storing giving B. Giving

cooked

weaning

them to the child weaning

C. Not washing

foods

foods

at room

without

reheating

the hands

before

drinks

preparing

D. Giving

milk or other

three meals a day to a 1-year-old

of the following

prevention

of diarrhoea

A. Stools

of infants

B. Where

water

in ,a feeding

statements are correct?

D. After cjeaning

purposes, 5. Hand-washing

that

the

at appropriate

following are important I correct answer.) A. Before

eating.

B. Before

breast-feeding

the child's

times

food.

child.

concerning

behaviour

that

is related

disease

than once

those

to the answer.)

of adults.

for washing

hands.

need not use a latrine.

cleanest

such as bathing

then

and protein.

(There may be more than one correct

a baby who has defecated,

hands. E. It is important

of energy

it may be used more than

C. At 5 or 6 years of age, children

hours;

bottle.

are less likely to cause

is scarce,

for severa)

them thoroughly.

that have a low content

E. Giving 4. Which

temperature

it is important

water

and washing times can

availa.ble

for a mother

be used

for

to wash her

all household

clothes.

help to prevent

for hand-washing?

(There

diarrhoea.

Which

may be more

of the

than

one

an infant.

C. After defecating. D. After disposing

of an infant's

E. Before

water.

drinkjng

stool.

123

ANNEX

1

Diarrhoea

case

record.

form

Registration No.

Hour Hour

Patient's

Age:

Name:

CHECK

FOR

SIGNS

OF

CONDITION

TEARS and

TONGUE

THIRST

2.

FEEL:

3

DECIDE

PLAN B *Restless,

Well, alert

EYES

MOUTH

SKIN PINCH

Plan Selected

(circle one)

Irrllable

PLAN c *

*Lelharglc

Normal

Sunken

Present Moist

Absent

Absenl Very

Dry

Drinks normally not lhirsly

*Thirsty,

Goes back quickly

*Goes

eagerly*

SPECIFY

.Yes.

The patient has

If rt'ie patient has two or

If the patient has two or

NO SIGNS OF

more signs, including

DEHYDRATION

one *.Ign*,

more signs, including at least one *sign*, there is

A

B

C

at least

there is

DEHYDRATION

Current temperature

.No

If Plan A, ask about the child's diet and advise the mother about home treatment If Plan B, amount of ORS to give in fIrst 4 hours:

ml

If Plan G, amount of IV fluid to be given

(tick one)

give ORS by nasogastric

tube:

ml per hour

give ORS by mouth to patient who can drink: -refer

patient

to

Medicines to give (name, dose and frequency):

2. Food to be given during treatment

(including

SEVERE

If Plan B or C selected, weight of child

DETAILS OF TREATMENT

If IV therapy not possible

dry

*Goes back very slowly*

back slowly*

days

Blood seen in stool?

floppy* and dry

*Drinks poorly or no1 able 10 drink *

drinks

CHECK FOR OTHER PROBLEMS Duration of diarrhoea:

or

unconSCious; Very sunken

SOME Treatment

-Month~

DEHYDRA TlON (Circle each sign that is present)

PLAN A 1. LOOK AT:

Years

breast milk)'

-ml

per hour

(see page 3).

DEHYDRATION kg

READINGS

ON DIARRHOEA

MONITOR

PROGRESS

Treatment

of dehydration:

Treatment

for other problems:

Reassessment

Food

given

Comments

1?R

of hydration

during

OF

PATIENT

status:

treatment

(Note any dlfflc;JItles

(Including

breast

and how managed):

mIlk):

DIARRHOEA

BEFORE

DISCHARGE,

ASK

MOTHER

ABOUT

Uqulda (~hlld.s usual diet

CASE RECORD FORM

SolId

-breast

milk

-animal -formula

milk or powdered

Foods

food taken

daily

milk

-other:

Diet since onset of diarrhoea

What types of fluid have been given at home since onset?

Has milk or formula been made with more water than usual?

Ilrnmunlzatlons

Has the amount of fluid

Has the amount of food

given been:

given been:

Are immunizations up-to-date? If NO, which vaccines are needed?

-Yes

Yes

-No

-No

THEN ADVISE MOTHER ABOUT HOME TREATMENT V"as the mother taught how to make ORS solution? Number of ORS packets given:

Yes

Packet size:

No

-mi

Fluids: to give:

Foods

to give:

a,ther advice:

Discussed with mother the signs that mean the child should return?

I"IMUNIZATIONS:

Needed

vaccines

given

or child

referred

for immunization?

-Yes

-No

.Yes

No

Slignature:

127

ANNEX

2

Growth

chart

An example

of a growth

of an infant important

or young

child

in the prevention

to start using a growth

is shown

chart.

particular

its principaJ

time. Rather.

Opposite). weight

The infant

erltered

is not to determine

(an example or young

on the chart

child

of the line joining

lines (arrows

A and C on the chart),

illness. slight

direction

successive

.are especially

in growth

The curved

lines that run across

Tne growth

curves

upper reason curve

line. If a child's for concern.

weight

However.

that is illO81 important.

weights

is upwards

on the chart

intervals

and the

to the ch,ld's

and parallel

satisfactorily.

age. If

to the solid

A horizontal

or

nutrition

and/or children

signalling

show the shape

below

at a

in the first year of life; in older without

children

is much

at regular

corresponding

occur

of a child

is shown

B) is a sign of inadequate

the chart

of most healthy

be weighed

is

time

over time by measuring

curve

column

helpful

normally

status

growth

growth

nutrition

is an excellent

used.

the nutritional

the child is growing

of the line (arrow

These patterns fluctuations

should

in the vertical

the direction

downwards

being

in body weight

of good

of diarrhoea

use is to monitor of a child's

the changes

As maintenance

an episode

if one is not already

chart

in weight

opposite.

of diarrhoea.

The .vaiue of a growth

changes

128

chart that can be used for plotting

will lie between th~ lower

danger.

of normal

growth

curves.

these lines or above

reference

even in this case it is the direction

line there of the child's

the

is some growth

~

GROWTH CHART

..01, 0'..

I;

I i ---11

~ I~

I,.,.-I~ : :'

:

'I...

i~

,

i

"'m-

i'

,

:

;

I

,

,

! N NNc

c

-o

,

,

,

,

' a>

m.

=;:fW

33 :

, , ,

., ~ < u -' <

I ~' ItI

, , ..CO)

~

-'-'--

,\1

,

-0

!

'

G)

m

~ ',i.

,

,

;

:

i .,

I\

i'i

0,

~ :--;-:

u w ~ cn ~ O ... cn

, N j

+

,

, , ,

,

,

,

.' .,

I

f~

I~ , I'

,

, , I~-=

,

LI~I~ 1

...I

,

-~ .I~~=

1

,

M

, .

-~ -m N

:\1 i

(1) :I: tz O ~

~ M

.~

N .~ 11(3-

r-;~ ~

M I:,,:.:: I, I ~ I I I I

~

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I I

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.

: \

,

w ~ 4

-;-+;-t~~

-ttt : I. .I

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~ ID --

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..,

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~ ON

~~ .,1.?0 "-IQ

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Im i I i

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~!!!

i

z

'~~ ,~ ~J.V I

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'g N

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.-

,

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..J.."'

I?~

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,-~i

.I I

1-

: : : ,

., E ..,Z

.E CI f

'0; ~

.c 1: CD

~~

J:

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~ w ~

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tr

;, I:

"5"3a

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,~ I. ~I .I -,--1

~

.c

.c

q

~ "0.-u .CQ. u"

~

(0)

N

.-~ S..YH90'1~

129

ANNEX How

3 to

determine

whether

a child

is

malnourished

The upper arm has a bone, muscles and falWhen

babies are about t "year old, they

have quite a lot of fat under the skin of their:arms. When they are 5 years old, there is much less fat and more muscle. The distance around t~ upper arm remains almost " the same between the ages ot 1 and 5 years. If a child is "tnajnourished, this distance is reduced, and the arm becomes thin. This is due to a reduction 1n muscle and fat. By placing a special measuring st!ip around the upper arm one can find out whether a child between the ages of 1 and 5 years i$ malnourished or not. ,

This measuring

A

strip is cal1ed a tricolQfured

tricoloured

arm

arm strip and

rooks like this

strip

RED

GREEN

YELLOW

Up to 40 cm

t Ocm

t 12.5

cm

t 13.5

cm WHO 91978

You can make one from a strip of material that does not stretch, being careful that the markings are accurate. To use this strip Put the strip around the O cm mark

130

the mid upper arm of the child and see Which colour

on the strip.

is touched

by

.

HOW TO DETERMINE WHETHER A CHILD IS MALNOURISHED

-If

the green part is touched, the child is well nourished.

-If -If

the yellow part is touched, the child is moderately malnourished. the red part is touched, the ctiild is severely malnourished. ,

This method of measuring the arm is useful because the health worker can identify. malnutrition in a child without using a scale or knowing the child's age. However, since it only shows large changes in a child's nutrition, it is not suitable for determining whether the child is improving or becoming worse.

131

.

ANNEX

4

Intravenous

rehydration

Intrav.enous rehydration must only be performed using needles, administration sets, and IV fluids that are sterile. Administration sets should never be reused. Needles should be reused only if carefully cleaned and resterilized. Care must be taken to avoid contact with the patient's blood while starting an IV infusion.

A. Peripheral vein infusion 1. Lay the child in a comfortable

position. Have an assistant hold the child.

2. Select a vein on the arm or leg that is easy to see; this is usually on the back of the hand or in the antecubital

fossa.

3. Use a tourniquet to make the veins enlarge and select the largest vein 4. Clean the skin with alcohoi or soap and water. 5. Stretch the skin over the vein and gently insert the needle into the vein.

6. If the needle is in the vein, blood should fill the needle's opening. If it does not, gently reposition the needle. 7. Release the tourniquet and attach the IV tubing to the needle, having first run fluid from the IV bottle through the tubing to remove the air. 132

i INTRAVENOUS

8. Slowly remove

9. Fasten board

run 0.5-1 ml of fluid it and start again

the needle

into

further

and tubing

to keep the joint

nearest

the vein.

If swelling

occurs

around

REHYDRATION

the needle,

up the vein.

firmly

to the skin with adhesive

the needle

from

tapec Use an arm

moving. 133

READINGS

ON DIARRHOEA

10. Regulate the flow ot fluid and check aga.in that therecis no swelling around the needle. 11. Gently restrain the child's arms or legs so that the needle will not be dislodged by movement.

B. Scalp vein infusion 1. Wrap the child in a sheet or blanket, but not so tightly that breathing is restricted. Lay the child down and have an assistant hold the child. 2. Select a vein (usually behind the ear) and shave the scalp over the vein. Clean the shaved area with alcohol or soap and water.

3. Stretch the skin over the vein and gently insert the scalp vein needle (or butterfly needle) into the vein. Placing a finger on the vein in front of where the needle will be inserted causes the vein to fill with blood and to be easier to enter. 134

INTRAVENOUS

REHYDRATION

5. When blood appears in the needle opening. connect the IV tubing to thf, needle, having first run fluid from t~e IV bottle through the tubing to remove the air.

""

6. Slowly run 0.5-1 ml of fluid into the vein. If swelling start again

with,,~riother

occurs.

remove

the needle

and

vein.

7. Fasten the needle firmly in place with adhesive tape. If necessary, place a gauze pad under the needle hub t,o support it in a position that allows fluid to flow freely into the vein. ~(, F!...

~"1

I)."-.. ~:

n . ,~ !.,(1\

"'-/\

\

"

...~',

\

~

!'~!P .,

.' ~1

~-~ \"'.\r

/

,. -" ...,. ",. ~:~.:!1;'",,1... "<:'"

i-:.."",0,,/

~-:!-!!!!!./

135

I

READINGS

ON

DIARRHOEA

8. Regulate the flow of fluid and check again that there is no swelling around the needle. 9. Fasten the tubing to the child's head, leaving a loop as shown,

c.

Femoral

vein

infusion

The femoral vein can be used as a temporary site for IV infusion in patients with severe hypovolaemia when no ve(f1can be found in the arms, legs or scalp. After a rapid IV infusion to correct shock, the needle should be removed from the femoral vein and . placed in a peripheral v~r.~Tt)e 1echnique for inserting a needle in the femoral vein is shown

136

oPPosite.

..c'.

'c

"

,

INTRAVENOUS

Technique

for inserting

A. The femoral B.

an intravenous

infusion

REHYDRATION

I

needle into the femoral vein

vein is next to the femoral artery, on its medial side.

Locate the pulsation of the 'femoral artery with the fingers of one hand, and insert the needle vertically just medial to that location with the other hand. W~n blood fills the needle opening it is correctly positioned and the IV tubing can be connected. The needle must be held firmly in place while the IV infusion is running.

1.37

ANNEXS Nasogastric

rehydration

1. Use a clean rubber or plastic nasogastric (NG) tube, 2.0-2.7 mm in diameter for a chi'd, 4.0-6.0 mm for an adult. 2. Place the patie'nt on his Of, her back, with the head slightly raised. Older children and adults may prefer to sit up. 3. Measure

the length

of tube which

the navel. Then stretch

the tubing

must be swallowed

the tip just above

over the back of the ear and forward

the nose. Mark the tube with a piece of tape where This mark shows the length

by placing

of tubing

needed

it touches

to reach

to the tip of

the end of the nose.

from the tip of the nose to

the stomach.

4.

Moisten

the

tube

with

a water-soluble

lubricant

or plain

water;

do

not

use

oil.

5. Pass the tube through the side of the nose with the largest opening, and gently advance &

it until the tip is in the back of the throat. '

Each time the patient,swallows. o c , .

advance the tube 3-5 cm; if the patient is awake, ask him or her to drink a little , water. ," ,;

,r, ! '"" " , "~!"j{~~'the!p~tieQtchok~$!

;, c.oughs

repeatedlyc

or has trouQle

, . bre~thing,the.t4be

has

probably passed into the trachea. Pull it back 2-4 cm until the coughing stops and the patient is comfortable, wait a minute, and then try again. 7. Advance the tube each tfmethe patient swallows until the tape marker reaches the nose. If the patient remains comfortable

and is not coughing, the tube should be in

the stomach. 8. Look into the patient's mouth to be certain the tube is not coiled in the back of the throat.

Confirm

that the tube is in the stomach

by attaching

a syringe and

withdrawing a little stomach fluid; or place a stethoscope just above the navel, inject air into the tube with an empty syringe and 1isten for the air entering the stomach. ,

9. Fasten the tube to the face with tape and attach IV tubing t~at is connected to a clean IV bottle containing

ORS solution. Regulate the infusion to a rate of 20 mi/kg

per hour, or less. 10. If an IV bottle is not available, a syringe (with the barrel removed) can be attached to the tube and used as a funnel- Hold the syringe above the patient's head and pour ORS solution into it at regular intervals.

138

NASOGASTRIC

'rechnique

Source

King,

for nasogastric

M et al

Primary

child

care:

REHYDRA

TION

rehydration

a manual

for health

workers

Book

One

Oxford,bxford

University

Press,

1978.

139

140


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ON DIARRHOEA

'i :g e u 'E = c c

I,

READINGS

'2' :J .!; ~ 8 <0 )( Q) c c ~

U

142

Answers

to

exercises

Unit 1 1. A, B, G, D

2. E

Mohan has persistent diarrhoea, i.e. diarrhoea that begins acutely and lasts at least 14 days. The term chronic diarrhoea should not be used in this case; it refers to diarrhoea of long duration that is due to a noninfectious

3.

Viruses-rotavirus; Shigella,

4. A

bacteria

Campylobacter

The answer specific.

cause.

jejuni;

protozoa-

is 0%. The features

It is not possible

an episode

-enterotoxigenic

of acute

to determine

of watery diarrhoea

Escherichia

coli,

Cryptosporidium. watery

djarrhoea

with certainty

are not

the etiology

on the basis of the clinical

of

features

of the Illness.

5. A, D

Antimicrobials

are indicated

only for dysentery

(in which case

treatment for shigellosis should be given) or for suspected cholera. Diarrhoea of longer than usual duration, diarrhoea with fever, and diarrhoea following exposure to animals do not benefit from antimicrobials.

6. D

Enterotoxigenic of acute None

diarrhoea

of the other

diarrhoea

7. A. C. E

Escherichia among

cases

detected

agents

listed

are

or dysentery

Some other protective

in young

behaviours

bottle to give milk formula, weaning

foods

coli (ETEC) is the m;ost frequent causes

surveys. of acute

children,

are the use of a cup rather than a

the use of clean drinking-water,

well, thoroughly

eaten immediately ad!,J1t, and animal

in community

important

cause

reheating

after being cooked, faeces. c

any foods

that

and safe disposal

cooking are not of infant,

Unit 2 1. A-O B-S C-O O-S E-O

2. A, C, D, E 143

READINGS

ON DIARRHOEA

3. E

Hypovolaemia.causes shock and cardiovascular collapse. This is the cause of death from severe dehydration due to diarrhoea.

4. A, C

5. A, B, E

Patients with paralytic ileus should not be given OAT; this will only make abdominal

distension

more severe. Patients

with severe

dehydration require very rapid replacement of water and salt to restore the blood volume and prevent death. OAT is not sufficiently rapid. Such patients need intravenous

fluid replacement,

if it is

available. 6. B, E

The child would probably develop hypernatraemia

because of the

high cOncentrations of salt and glucose in the solution. Extreme thirst is a sign of hypernatraemia.

7. A, B. D

Soft drinks and commercial

fruit drinks are often hyperosmolar

owing to their high sugar content. Such fluids can.cause

osmotic

diarrhoea and hypernatraemic dehydration. They also contain very little sodium to replace what has been lost.

Unit 3

1. B. C. E 2.

C

The signs are those of some dehydra!ion.

3.

C

The signs of some dehydration are: irritable, fussy behaviour; taking water eagerly from a cup; and some decrease in skin turgor. Thes~ are all key signs and are sufficient to make the diagnosis of some dehydration.

4. B, D, E

The treatment should follow Treatment Plan B.

Bantu has only one of the signs in Column B (irritable. restless behaviour); the rest are in Column A. Therefore. he has no signs of dehydration. As the stool contains blood he should be treated for dysentery. Because he has fever. a search should

be made for

evidence of an infection outside the intestinal tract. Pneumonia is an importan.t possibility, especially if he is coughing and breathing rapidly. 5.

A,

B,

C,

D.

Unit 4 1. A, B, C. D 144

E

ANSWERS TO EXERCISES

2. A, B, D

Commercial

..fruit ,

drinks

and

soft

drinks

are

often

hyperosmolar

owing to their high sugar content. They also contain sodium. )fgiven

little or no

to replace stool losses they could worsen the

situation by causing osmotic diarrhoea and hypernatraemic

dehy-

dration. 3. At Bt C. D

.

4. A. C. D

Antimicrobials They

should

suspected

5.

D

are not helpful be used

cholera

only

in most episodes for cases

of acute

of dysentery

diarrhoea.

and

cases

of

with severe dehydration.

All of the described methods are helpful, but the mosfeffective is letting the mother practise OAT under the supervision of a health worker,',

Unit 5 B

2. B, D

3. B, G, D

4. B 5. B, C, D

6. A,D

7.

A B C D

Ria has severe dehydration. She requires 100 mi/kg, for a total of 600 ml. The fluid should be given intravenously. She should receive 30 mi/kg in the first hour. and 70 mi/kg in the next 5 hours.

E 8. A B

Codeine. possibly combined with a potassium deficit. Hawa has severe dehydration,

possibly caused by cholera.

Normal saline solution (99 NaCI/I), half-stren9th with dextrose (25 9/J or 50 9/1) or half-normal

c

(509/1 or 1009/1). Hawa should receive an oral antimicrobial tetracycline or doxycycline, after rehydration

D

Darrow's solution

saline with dextrose for cholera,

usually

is complete and vomi-

tin9 has stopped. Give Hawa small amounts of ORS solution as soon as she is able to drink;

this should

be possible

after

1-2

hours

of rehydration

therapy. 145

READINGS

ON DIARRHOEA

9.

A

Ali has some dehydration.

B

Treatment

Plan B.

C

Ali should

receive

200-400

mi of OAS

solution

during

the

first

4 hours.

D

The

mother

continue E

should

resume

to breast-feed

Treatment

breast-feeding

during

Plan A should

at once

and

should

OAT.

be used.

Unit 6 1.

C.

Absence of fever is not unusual

D,E

in children

with shigellosis

or

dysentery caused by other bacteria, especially when disease is severe. Even in this situation, amoebiasis is very unusual. 2. C, E

4. B

Answer p would be correct only if reliable laboratory facilities were readily available. which is not usually the case.

5. A, B, C, D, E

The

reason

dysentery

Chinta

should

and was dehydrated

return

for

when

follow-up

is that

she

had

first seen.

Unit 7 1.

A-D also occur but only contribute

E

to weight loss if food intake is

decreased. When enough food is given, weight loss is prevented. 2. A, B

3. A. B, C. E

To avoid weight loss. Yunus should be given a nutrient-rich throughout

diet

the episode of diarrhoea.

4. A, C 5. A. D, E 6.

Part

Demonstrating

1-8

a close association

between diarrhoea

an~ milk

feeds is the most important. Testing the stool for pH and reducing substances is only helpful to confirm the diagnosis when it is clear that milk makes the diarrhoea Part 2-8, 146

C, D

worse.

ANSWERS

Unit 8 1. B. C. D

2.

C

Healthy, breast-fed infants below 4 months of age do not require any other food or fluids. Giving these increases the risk of diarrhoea.

3. A. B. C. D. E

4. B. D

5. A. C. D

147