3Diarrhoea and dehydration

Publication Details

Assessment of the child with diarrhoea

Image ch3fu1

Assess the child with diarrhoea for signs of dehydration

  • ASK: For how long has the child had diarrhoea?
  • ASK: Is there blood in the stool?
  • LOOK at the child's general condition. Is the child lethargic or unconscious? Restless and irritable?
  • LOOK for sunken eyes.
  • OFFER the child fluid. Is the child not able to drink or drinking poorly? Drinking eagerly and thirsty?
  • PINCH the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly?

Classify the child's level of dehydration

There are three possible classifications of dehydration:

  • Severe dehydration
  • Some dehydration
  • No dehydration

Classify the child's dehydration:

  • If two or more of the following signs are present, classify the child as having SEVERE DEHYDRATION.
    • Lethargic or unconscious
    • Sunken eyes
    • Not able to drink or drinking poorly
    • Skin pinch goes back very slowly (longer than 2 seconds)
  • If two or more of these signs are present, classify the child as having SOME DEHYDRATION.
    • Restless, irritable
    • Sunken eyes
    • Drinks eagerly, thirsty
    • Skin pinch goes back slowly (less than 2 seconds but longer than normal)
  • If two or more of the above signs are not present, classify the child as having NO DEHYDRATION.

Management of dehydration

Plan ATreatment of diarrhoea at home

Counsel the mother on the 4 rules of home treatment.

  1. Give extra fluid
  2. Give zinc supplements
  3. Continue feeding
  4. When to return
  1. Give extra fluid (as much as the child will take)
    • Tell the mother:
      -

      Breastfeed frequently and for longer at each feed.

      -

      If the child is exclusively breastfed, give ORS or clean water in addition to breast milk.

      -

      If the child is not exclusively breastfed, give one or more of the following: food-based fluids (such as soup, rice water, and yoghurt drinks) or ORS.

    • It is especially important to give ORS at home when:
      -

      the child has been treated with Plan B or Plan C during this visit

      -

      the child cannot return to a clinic if the diarrhoea gets worse.

    • Teach the mother how to mix and give ORS. Give the mother 2 packets of ORS to use at home.
    • Show the mother how much fluid to give in addition to the usual fluid intake.
    • Tell the mother:
      -

      Give frequent small sips from a cup.

      -

      If the child vomits, wait 10 minutes. Then continue, but more slowly.

      -

      Continue giving extra fluid until the diarrhoea stops

  2. Give zinc supplements
    • Tell the mother how much zinc (20 mg tablets) to give
      -

      Up to 6 months: 1/2 tablet daily for 14 days

      -

      6 months or more: 1 tablet daily for 14 days

    • Show the mother how to give zinc supplements
      -

      Infants: dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a cup

      -

      Older children: tablets can be chewed or dissolved in a small amount of clean water in a cup

  3. Continue feeding
  4. When to return
    • Advise the mother to return immediately with the child if the child develops any danger sign (lethargy, unconsciousness, convulsions, inability to eat or drink)
    • Follow up in 5 days if there is no improvement.

Plan BTreatment for some dehydration with ORS

Give recommended amounts of ORS over a 4 hour period

  • Determine amount of ORS to give during first 4 hours
    -

    Use the child's age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the child's weight in kg times 75.

    -

    If the child wants more ORS than shown, give more.

    -

    For infants below 6 months who are not breastfed, also give 100–200ml clean water during this period.

  • Show the mother how to give ORS solution
    -

    Give frequent small sips from a cup.

    -

    If the child vomits, wait 10 minutes. Then continue, but more slowly.

    -

    Continue breastfeeding whenever the child wants.

  • After 4 hours
    -

    Reassess the child and classify the child for dehydration.

    -

    Select the appropriate plan to continue treatment.

    -

    Begin feeding the child in clinic.

  • If the mother must leave before completing treatment
    -

    Show her how to prepare ORS solution at home.

    -

    Show her how much ORS to give to finish 4-hour treatment.

    -

    Explain the 4 Rules of home treatment.

    1. Give extra fluid
    2. Give zinc supplements
    3. Continue feeding
    4. When to return
    -

    Advise the mother to return immediately with the child if the child develops any danger sign (lethargy, unconsciousness, convulsions, inability to eat or drink).

    -

    Follow-up in 5 days if not improving.

Plan CTreat for severe dehydration quickly

FOLLOW THE ARROW, IF ANSWER IS “YES”, GO ACROSS, If “NO”, GO DOWN

Image ch3box3fu1

Types of diarrhoea

Diarrhoea could be:

  • acute diarrhoea (including cholera)
  • persistent diarrhoea (diarrhoea for 14 days or more)
  • severe persistent diarrhoea (persistent diarrhoea with some or severe dehydration)
  • dysentery (blood in the stool)

Classify the child with PERSISTENT DIARRHOEA if the child has had diarrhoea for 14 days or more.

Classify the child with SEVERE PERSISTENT DIARRHOEA if the child had diarrhoea for 14 days or more and the child has some or severe dehydration.

Classify the child as having DYSENTERY the child has diarrhoea and blood in the stool.

Classify the child as having CHOLERA if it is known that there is an on-going cholera epidemic in the area and the child has watery diarrhoea.

Cholera should be suspected when a child older than 5 years or an adult develops severe dehydration from acute watery diarrhoea, or when any patient older than 2 years has acute watery diarrhoea when cholera is known to be occurring in the area. Younger children also can develop cholera but the illness may be difficult to distinguish from other causes of acute watery diarrhoea.

Management of the child with diarrhoea

A child with PERSISTENT or SEVERE PERSISTENT DIARRHOEA needs both fluid and nutrition.

  • Treat dehydration as per plan A, B or C depending on the level of dehydration.
  • Advise mother on how to feed her child.
  • Give multivitamin supplement every day for 2 weeks if possible.
  • Identify and treat infections (See Module 2, Chapters 4 and 5).
  • Do not give antibiotics to children with diarrhoea unless they have dysentery or severe cholera.
  • Monitor the child's feeding and treatments and the child's response (e.g. weight gain).

A child with DYSENTERY1 needs antibiotics and fluid.

  • Administer antibiotics for possible shigella infection.
    • Oral ciprofloxacin (15 mg/kg) twice a day for 3 days
      Size of tablet 2 times a day for 3 days:
      Some strains of shigella are resistant to antibiotics. Alternative drugs for multi-resistant strains of shigella are:
      • IM ceftriaxone (50–100 mg/kg) once a day for 2–5 days
      • Oral pivmecillinam (20 mg/kg; maximum 300 mg) four times a day for 5 days.
  • Treat dehydration as above.
  • Administer zinc
    • for children less than 6 months: 10 mg/day for 14 days
    • for children 6 months or older: 20 mg/day for 14 days.

A child with CHOLERA needs fluid. Fluid replacement is the mainstay of cholera management. Antibiotics can be administered in addition to fluids if the cholera is severe.

  • Treat dehydration as above.
  • A child with cholera can lose fluids very quickly and may need an IV for fluid management.
  • Administer antibiotics to children with severe cholera. It is important to perform antibiotic sensitivity testing prior to treatment. The following antibiotics may be effective:
    • doxycycline
    • oral tetracycline
    • oral cotrimoxazole
    • oral erythromycin
    • oral furazolidone.

Footnotes

1

In some countries, the major cause of dysentery might be amoebic dysentery. In this case, you need to use metronidazole.