WHO and UNICEF recommended management of Childhood Diarrhoea. HLFPPT has been implementing Childhood Diarrhea management programmes with UNICEF and Micronutrient Initiative.

1. Acute Diarrhea
Management

2. Reduce Child mortality

7. What is Diarrhea ?
It is defined as 3 or more watery stool in 24 hrs
Other names
More common when child is on cow’s milk/formula feed

8. 0-2 months 2months-5 years
BF Infant Many times but not
Semisolid /not watery
watery
Every time after
feeding
What is and what is not diarrhea?

9. Acute watery diarrhea- If <14 days
,sever dehydration Ecoli,cholera
,malnutrition
 Persistent diarrhea-If >14 days, 20-30
% death, under nourished and HIV
exposed
Dysentery-(atisar)with blood ,with or
without mucus 10%-15 % of deaths
Types of serious diarrhoea in
children

10. Lets look at the important microbial causes of
acute diarrhea in < 5 years
Rotavirus: 5-10% : community, 25-30% in
dehydrating diarrhea
ETEC : 20%
Shigella: 5-10% of acute diarrhea; Most common
cause of dysentery
EPEC, LA-EC, Campylobacter, Salmonella: 5-7%
G. lamblia, E-histolytica: < 2%
Eh - uncommon cause of dysentery <5%
V. cholerae (01 & 0139): 5-10% (endemic)

11. Proportion of water is more in children ,so
dehydration occur early.
Child can loose 5ml-200 ml liquid in 24 hrs
Metabolic rate is high and use more water
as compared to adults
Kidney can conserve less water ,so loss is
more
Sodium loss can be 70-110 m mol/kg
Chloride and potassium loss is balanced
&same
Why are children more prone to
diarrhoea

12. Did child vomit in past 6-8 hrs?
Did child pass urine in past 6-8 hrs?
What type of liquids did the child get ?
Did the child get sufficient food before this
episode ?
During diarrhea is child getting food that is
different and is less calorie dense?
Look for cough ,fever ,otitis media ,sepsis
,h/o measles
Weight /nutrition
Assessment of diarrhea

13. ASSESS:
Degree of Dehydration
DECIDE:
Plan of treatment

14. Does the child have diarrhea?
If yes, ask:
◦ For how long? How many?
◦ Has the child been vomiting
◦ Is there blood in stool?

15. LOOK
 LOOK AT THE CHILD’S GENERAL
CONDITION
IS THE CHILD
◦ Lethargic or Unconscious?
◦ Restless or Irritable?
 LOOK FOR SUNKEN EYES
 Look for skin pinch -goes
back
promptly/slowly/ very slowly
 OFFER THE CHILD FLUID TO DRINK –
THIRSTY
Not able to drink or drinking
poorly?
Drinking eagerly, appears thirsty?
Drinking normally?

16. Look at Eyes for Dehydration
Shrunken Eyes
Normal eyes

19. Degree of Dehydration

20. Degree of dehydration decided
on:
Two or more of the following
Some Dehydration Severe Dehydration
•Restless, Irritable •Lethargic or unconscious
•Sunken Eyes •Sunken Eyes
•Drinks eagerly, Thirsty •Not able to drink or drinking
poorly
•Skin Pinch goes back
“slowly” •Skin Pinch goes back “very
slowly”
OR NO DEHYDRATION

22. Film Clip: assessment of dehydration

23. No Dehydration: PLAN-A
Some Dehydration: PLAN-B
Severe Dehydration: PLAN-C

24. PLAN – A
Treat Diarrhea at Home.
4 Rules of Home Treatment:
GIVE EXTRA FLUID
CONTINUE FEEDING
WHEN TO RETURN [ADVICE TO
M OTHER]
GIVE ORAL ZINC FOR 14 DAYS

25. Give extra fluid
 TELL THE MOTHER:
Breastfeed frequently and for longer at each feed
If exclusively breastfeed give ORS for replacement of stool
losses
If not exclusively breastfed, give one or more of the
following:
ORS, food-based fluid (such as soup, rice water,
coconut water and yogurt drinks), or clean water.
 TEACH THE MOTHER HOW TO MIX AND GIVE
O.R.S
 AMOUNT OF FLUID TO GIVE IN ADDITION TO THE
USUAL FLUID INTAKE:
Up to 2 years: 50 to 100 ml after each loose stool.
2 years or more: 100 to 200 ml after each loose stool.

26. Continue feeding
 Continue usual feeding, which the child
was taking before becoming sick 3-4
times
(6 times)
 Upto 6 months of age:
Exclusive Breast feeding
6 months to 12 months of age :
add Complementary Feeding
 12
months and above :
Family Food

27. When to Return
[Advice to mother]
Advise mother to return immediately if
the child has any of these signs:
 Not able to drink or breastfeed or drinks poorly
 Becomes sicker
 Develops a fever
 Blood in stool
[IF IT WAS NOT THERE EARLIER]

28. PLAN – B
 Plan-B is carried out at ORT Corner in
OPD/clinic/ PHC
 Treat ‘some’ dehydration with ORS (50-100
ml/kg
 Give 75 ml/kg of ORS in first 4 hours
 If the child wants more, give more
 After 4 hours:
Re-assess and classify degree of

29. Signs of sever dehydration
Child not improving after 4 hours
Refer to higher center –give ORS on
way /keep warm /BF
When child comes back follow up as other
children
PLAN -C

30. PLAN – C
StartI. V. Fluid immediately
Give 100 ml/kg of Ringer’s Lactate
Age First give Then give
30ml/kg 70 ml/kg
in in
Under 12 1 hour 5 hours
months
12 months and ½ hour 2½ hour
older

31. Fluid therapy in severe
dehydration
Use intravenous or intraosseus route
Ringers Lactate with 5% dextrose or ½ normal saline with 5%
dextrose at 15 ml/kg/hour for the first hour
* do not use 5% dextrose alone
Continue monitoring every 5-10 min.
Assess after 1 hour
If no improvement or worsening If improvement(pulse slows/faster
capillary refill /increase in blood
pressure)
Consider septic shock Consider severe dehydration with shock
Repeat Ringers Lactate 15 ml/kg over 1 h
Switch to ORS 5-10ml/kg/hr orally or by
nasogastric tube for up to 10 hrs

32. Classify and Treat Diarrhea
Diarrhea •Persistent diarrhea •Give first dose of
Lasting 14 COTRIM/CIPROFLIX
days or more •Sever Persistent • Treat to prevent low sugar
diarrhea •Home foods
•ORS/ZN /BF/Vit A
•Do HIV RAPID TEST •Keep warm
•Refer to Hospital if sever
Blood in Stool •Dysentery Give COTRIM/CIPROFLOX
for
•Sever Dysentery 3 days
Change if no improvement
after 2 days
Prevent low blood sugar
Keep warm
Refer to Hospital if sever

34. Antimicrobials should be given during
diarrhea only for:
Dysentery
Cholera
Severe malnutrition
Associated systemic infection

35. Some key facts about feeding
during diarrhea
Feeding does not worsen diarrhea
Prevents malabsorption & facilitates
mucosal repair Isolauri et al. 1989. JPGN
Prevents growth faltering and
malnutrition Brown et al. 1988. J Pediatr

36. Some key facts about feeding during
diarrhea
• There is no basis for fasting in diarrhea
• Continue to breastfeed
• Encourage the child to drink & eat
• Be patient while feeding
• Feed small amounts frequently
• Give foods that the child likes
• Give a variety of nutrient-rich foods
• Do not dilute milk Brown et al. 1988. J Pediatr
• Routine lactose free feeding not required
• Do not give sugary drinks

37. Increase amount of calories during convalescence
with energy dense foods (enrich foods with fats and
sugar)
•Feed an extra meal (for at least 2 weeks after
diarrhea stops)
•Give an extra amount
•Use extra rich foods
•Feed with extra patience
•Give extra breastfeeds as often as child wants

38. Increase amount of calories during convalescence
with energy dense foods (enrich foods with fats and
sugar)
•Feed an extra meal (for at least 2 weeks after
diarrhea stops)
•Give an extra amount
•Use extra rich foods
•Feed with extra patience
•Give extra breastfeeds as often as child wants

39. Assessment of dehydration in
severely malnourished children
Basic format remains the same
Some signs unreliable
Mental state
Skin turgor
Edema and hypovolemia can coexist

40. Diagnosis of dehydration in
severely malnourished children
• History of diarrhea (with large volume of
stools)
• Increased thirst
• Recent sunken eyes
• Prolonged CFT, weak/absent radial pulse,
• Decreased or absent urine flow
Difficult using clinical signs alone
Best to assume that all with watery

41. Which ORS should be used in severe
malnutrition?
• Low osmolarity ORS with potassium
supplements given in addition to ORS
• ReSoMal :not available in India
no evidence

42. What Is ORS

43. Safe & effective
Can alone successfully rehydrate 95-97% patients
with diarrhea,
Reduces hospital case fatality rates by 40 - 50%
Cost saving
Reduces hospital admission rates by 50% and
cost of treatment by 90%
BUT

44. ORS use rates are dismally low in some
regions
> 50% Goa, Himachal, Meghalaya, Tripura,
Manipur
> 40% West Bengal, J&K, Mizo,
Chhattisgarh
> 20% Bihar, Orissa, Uttaranchal,
Punjab, Gujarat, MP, Southern States
< 20% Rajasthan, UP, Assam,
Jharkhand, Nagaland
Recent NFHS 3 data

45. Improved GI physiology in low osmolarity
ORS
Increase in
Gastric emptying
Low OSM
ORS
Availability of ORS
Prevents vomiting
210-260
mmol/L
Small bowel
290
mmol/L
Blood
Net flow of water into Blood
Decrease in Stool
Output

46. Composition of standard and low
osmolarity ORS solutions
Standard ORS Solution Low Osmolarity
ORS
(mEq or mmol/L)
Glucose 111 75
Sodium 90 75
Chloride 80 65
Potassium 20 20
Citrate 10 10
Osmolarity 311 245

47. Summary of results of published meta-analysis of all
randomized clinical trials (12) comparing low
osmolarity ORS (245mosmol/l) with standard WHO
ORS (311mosmol/l) in children with acute non-
cholera diarrhea:
39% reduction in need for unscheduled IV fluids
19% reduction in stool output
29% reduction in vomiting
Hahn et al, 2001; WHO/FCH/CAH 0.1.22, 2001

48. Low osmolarity ORS is safe and effective
for all ages
Should be given to young infants (< 2m)
including neonates if there is dehydration
In exclusively breastfed young infants
with no dehydration encourage exclusive
breastfeeding more frequently and for
longer

49. Film clip: ammaji kehti hain

50. Film clip: ammaji kehti hain

51. Making ORS PAGE -20

52. How much fluids (p 17)
0-4 m 200-400 ml 2 glasses
4-12 m 400-600ml 3 glasses
12-24 m 600-1000ml 5 glasses
2-5 yrs 1.0 -1.4 litres 7 glasses
 Small sips from glass
 If vomits wait for 10 min and give again
 Continue BF
 Revaluate after 4 hours

53. Caused by Vibero Cholera
Occur in Epidemic
Rice water stool and sever dehydration
Loss of fluid may be 200-350 ml/kg
Usually IV fluids required /IG fluids
Doxycycline 6 mg/kg single dosage
Cholera management

54.  Diarrhea with blood in stool (Shigellae ,E
Histolytica )
 Assess dehydration ,if sever refer
 Give ORS ,DIET
 AB–Ciprofloxacin -15 mg/kg orally 2 times a
day/Cotrim (ped )
 Reassess after 2 days
Dysentery management

55. Diarrhea more than 14 days
Malnutrition /multiple deficiencies
Prevent dehydration
High calorie food
Zinc ,vitamins, minerals for 14 days No iron
preparation
AB –cotrimoxazole /ciprofloxacin 5 -7 days
HIV testing
Severe Acute Malnutrition –IN HOSPITAL
Management of persistent
diarrhoea

56. Antiemetic in acute
diarrhea
 Vomitingcommonly associated symptom : Low
osmolarity ORS reduces vomiting
 Mostly managed by frequent small sips (5-10 ml) of
ORS.
Antiemetic
have no role in the
management of acute gastroenteritis

57. With the current evidence available
pro or prebiotics are not
recommended for the treatment of
diarrhea
IAP consensus statement 2003,
2007
Ind Pediatr, 2004, 2006

58. IMNCI diet A, B, C

59. Fever, fast breathing
Convulsions
◦ hypernaterima.,hyponatremia
◦ Hypogiycemia
Meningitis
Vitamin A deficiency
Other problems with diarrhea

60. WHY ZINC?

61. Zinc deficiency is widespread in low
and middle income countries like India
IZiNCG advocacy statement (http://www.izincg.org/pdf/IZiNCG_Advocacy-
PrintingFormat.pdf)

62. Why zinc deficiency is common in children from
developing countries?
• Breast milk not sufficient source >6 mo
• Intake of complementary foods low, particularly
animal foods
• Limited bioavailability;↑ phytates from cereals
• High fecal losses during diarrheal illness
• Low content of soil, of foods

63. Zinc deficiency has direct effects on mucosal
functions
 Disrupts intestinal mucosa
 Reduces brush border enzymes
 Increases mucosal permeability
 Increases intestinal secretion
Roy 1992, Hoque 2005

64. 937 children, 6-35 mo, diarrhea < 7 d
20 mg zinc daily
% reduction (95%CI)
Risk of continued diarrhea 23 (12 to 32)*
Mean no of watery stools/d 39 (6 to 70)*
Sazawal et al, N Eng J Med 1995

65. Zinc critical for immune and non immune
functions that resist or clear infection & its
consequences
The percentage of anergic children decreased from
67% to 47% (p=0.05) in the zinc supplemented
group as compared to the controls
Zinc supplemented group had:
↑ 25% CD3+ (p=0.02)
↑ 64% CD4+ (p=0.001)
↑ 73% CD4/CD8 (p=0.004)
Sazawal et al, Ind Pediatr 1997

66. Recommendations for Use of Zinc in
Acute Diarrhea
WHO/UNICEF Joint statement (2001), IAP
2003, GOI 2007
20 mg/day (10 mg/day for infants 2-6 mo) of
zinc supplementation for 14 days starting
as early as possible after onset of diarrhea

67. Zinc reduces diarrheal duration and
severity when given during a diarrheal
episode
RCT: 1995-2004 No. of subjects
Studies from Nepal, Bangladesh 4362
Sazawal, New Delhi 931
Bahl, New Delhi 805
Bhatnagar, New Delhi 266
Combined estimate (meta-analysis):
Recovery from diarrhea was faster: Relative Hazards 0.84, 95%CI
0.78 to 0.89
Episodes lasting > 7 days were less: OR 0.66, 95%CI 0.52 to 0.83
Total stool output was less; Ratio of GM 0.76 , 95%CI 0.59 to 0.98
Bahl, 2004

68. Role of Zinc in Cholera and Dysentery
In children with cholera, zinc supplemented patients
had 12% shorter duration of diarrhea and 11% less
stool output than control patients
Roy et al, BMJ,
2008
Zinc supplementation shortens duration of
acute shigellosis & reduces diarrheal
morbidity during the subsequent 6 months
Sazawal et al 1998; Rahman et al 2001; Roy et al, BMJ,
2008

69. Zinc experience in India (2007-
•
2008)
Policy decision taken for including zinc in
RCH/NRHM
• Several pharmaceutical companies manufactured
syrup & dispersible zinc tablets
• State PIPs included zinc
• GOI sanctioned funds for procurement of zinc
tablets as part of RCH kit

70. Dose of Zinc
 2- 6 months 10 mg for 14 days
6 mo-5 yrs 20 mg for 14 days

71. Exclusive
Breastfeeding
Improved dietary
Habits
Safeand clean
water
Prevention of Diarrhea

72. Zinc Preparation

73. Compliance card

74. Hand Washing

75. Key messages
Zinc along with ORS is more
effective
Zinc acts like tonic and not medicine
6mo and more children should get
20 mg/d for 14 days
2-6 mo children to get 10 mg for 14
days
Home cooked foods like rice water,
lemon water,dal soup, fresh fruit
juice without sugar should be given .

76. National Policy for treatment of Diarrhea
in children 2007
2.8.2011 NHRM office Lucknow UP
order for implementation of ORS+Zinc
Jodi by health workers up to ASHA
&Anganwari workers
Revised diarrhea management
policy and guidelines (2007)

78. Questions?