Childhood Diarrhoea and its management

Childhood diarrhoeal diseases continue to be a major killer among under - five children in many states of India, contributing to 10% of under five deaths in the country. Around 1.2 lakhs children die due to diarrhoea annually in the country. Diarrhoeal deaths are usually clustered in summer and monsoon months and the worst affected are children from poor socio - economic situations.

Reduction of childhood mortality from 43 / 1000 live births in 2015 1 to 25 by 2025 is one of the prime goals of National Health Policy 2017.

What is Diarrhoea

Diarrhoea is considered when the stools have changed from usual pattern and are many and watery (more water than fecal matter). It is more common in settings of poor sanitation and hygiene, including a lack of safe drinking water. Most diarrhoea that causes dehydration is loose or watery.

The normally frequent or loose stools of a breastfed baby are not diarrhea.

Types of diarrhoea

Types of diarrhoea in young infants (0-2 months age)

A young infant has diarrhoea if the stools have changed from the usual pattern, and are many and watery. This means more water than faecal matter. The normally frequent or semi - solid stools of a breastfed baby are not diarrhoea.

Type of Diarrhoea in children

1. ACUTE DIARRHOEA - Is an episode of diarrhoea that lasts less than 14 days.Acute watery diarrhoea causes dehydration and contributes to malnutrition. The death of a child with acute diarrhoea is usually due to dehydration.
2. PERSISTENT DIARRHOEA -  If an episode of diarrhoea that lasts for 14 days or more. (Up to 20% of episodes of diarrhoea become persistent, and this often causes nutritional problems and contributes to death in children)
3. DYSENTERY - Diarrhoea with blood in the stool, with or without mucus. The most common cause of dysentery is Shigella bacteria. Amoebic dysentery is not common in young children. A child may have both watery diarrhoea and dysentery.

What is dehydration?

Diarrhoea can be a serious problem – and even lead to death – if child becomes dehydrated. Dehydration is when the child loses too much water and salt from the body. This causes a disturbance of electrolytes, which can affect vital organs.

A child who is dehydrated must be treated to help restore the balance of water and salt. Many cases of diarrhoea can be treated with Oral Rehydrat ion Salts (ORS), a mixture of glucose and several salts. ORS and extra fluids can be used as home treatment to prevent dehydration. Low osmolarity ORS should be used to treat dehydration.

How to assess dehydration?

There are several signs that help to decide the severity of dehydration. When a child becomes dehydrated, he is at first restless or irritable. As the body loses fluids, the eyes may look sunken, and skin loses elasticity. If dehydration continues, the child becomes lethargic or unconscious.

LOOK : AT THE CHILD’S GENERAL CONDITION

If the child is lethargic or unconscious, s/ he has a general danger sign. A child is classified as restless and irritable if s/he is restless and irritable all the time or every time s/he is touched and handled. If an infant or child is calm when breastfeeding but again restless and irritable when he stops breastfeeding, s/he has the sign restless and irritable. Many children are upset just because they are in the health facility. Usually these children can be consoled and calmed, and do not have this sign.

For the young infant : watch the infant’s movement. Does he move on his own? Does the infant only move when stimulated, but then stops? Is the infant restless and irritable?

LOOK FOR SUNKEN EYES

The eyes of a child who is dehyadrated may look sunken.

NOTE: In a severely malnourished child who is wasted, the eyes may always look sunken, even if the child is not dehydrated. Still use the sign to classify dehydration.

LOOK: TO SEE HOW THE CHILD DRINKS (only in children 2 months to 5 years age)

• A child is not able to drink if he is not able to suck or swallow when offered a drink. A child may not be able to drink because he is lethargic or unconscious.
• A child is drinking poorly if the child is weak and cannot drink without help. He may be able to swallow only if fluid is put in his mouth.
• A child has the sign drinking eagerly and acts thirsty if it is clear that the child wants to drink. If the child takes a drink only with encouragement and does not want to drink more, he does not have the sign drinking eagerly, thirsty.

FEEL: BY PINCHING THE SKIN OF THE ABDOMEN

This skin pinch tests is an important tool for testing dehydration. When a child is dehydrated, the skin loses elasticity. To assess dehydration using the skin pinch:

• Place the child on the examining table so that the child is flat on his back with his arms at his sides (not over his head) and his legs straight. Or, the mother can hold the child so he is lying flat on her lap.
• Use thumb and first finger to locate the area on the child’s abdomen halfway between the umbilicus and the side of the abdomen. Do not use your fingertips because this will cause pain. The fold of the skin should be in a line up and down the child’s body.
• PICK UP all the layers of skin and the tissue underneath them
• HOLD the pinch for one second. Then release it.
• LOOK to see if the skin pinch goes back very slowly (more than 2 seconds), slowly, (less than 2 seconds, but not immediately), or immediately. If the skin stays up for even a brief time after you release it, decide that the skin pinch goes back slowly. The photographs below show you how to do the skin pinch test and what the skin looks like when the pinch does not go back immediately. Skin pinch Skin pinch going back very slowly.

NOTE: The skin pinch test is not always an accurate sign. In a child with severe malnutrition, the skin may go back slowly even if the child is not dehydrated. In a child is overweight or has edema, the skin may go back immediately even if the child is dehydrated.

Classification of dehydration

There are three possible classifications for the type of diarrhea, which is based on the status of dehydration. These are:

1. SEVERE DEHYDRATION (RED)
• Classify as SEVERE DEHYDRATION if the child has two or more of the following signs: lethargic or unconscious, not able to drink or drinking poorly (not in children less than two months), sunken eyes, or very slow skin pinch.
• ACTION - Any child with dehydration needs extra fluids. A child classified with SEVERE DEHYDRATION needs fluids quickly. Treat with IV (intravenous) fluids.
2. SOME DEHYDRATION (YELLOW)
• Classify as SOME DEHYDRATION if the child has two or more of the following signs: restless and irritable, not able to drink or drinking poorly (not in children less than two months), sunken eyes, or very slow skin pinch.
• ACTION  - A child who has SOME DEHYDRATION needs ORS , foods and Zinc supplements. Treat the child with ORS solution and Zinc supplementation. In addition to ORS, the child with SOME DEHYDRATION needs food. Breastfed children should continue breastfeeding. Other children should receive their usual milk or some nutritious food after 4 hours of treatment with ORS.
3. NO DEHYDRATION (GREEN)
• A child who does not have enough signs to classify as dehydration is classified as having NO DEHYDRATION. This child needs extra fluid and foods to prevent dehydration.
• The four rules of home treatment are:
• Give extra fluid
• Give zinc supplements
• Continue feeding
• Return immediately if the child develops danger signs, drinks poorly, or has blood in stool.

Management of childhood diarrhoea

4 key interventions to manage a case of childhood diarrhoea are as follows.

1. Rehydrate the child with ORS solution. Stop rehydration once diarrhoea stops.
2. Administer Zinc dispersible tablets for 14 days, even after diarrhoea stops.
3. Continued age appropriate feeding.
4. Rational use of antibiotics

Treatment of Diarrhoea at Home

The 4 Rules of Home Treatment are

1. Give Extra Fluid as much as the child will take
• If the child is exclusively breastfed : Breast feed frequently and for longer at each feed. If passing frequent watery stools:
• For less than 6 months age give ORS and clean water in addition to breast milk
• If 6 months or older, give one or more of the home fluids in addition to breast milk.
• If the child is not exclusively breastfed : Give one or more of the following home fluids; ORS solution, yoghurt drink, milk, lemon drink, rice or pulses based drink, vegetable soup, green coconut water or plain clean water
2. Give Zinc Supplements (age 2 months up to 5 years) for 14 days
3. Continue Feeding, Handwashing and Toilet use
4. When to Return to the health facility
• Child becomes sicker
• Not able to drink or breastfeed
• Drinking poorly
• Develops fever
• Blood in stool

ORS preparation

• Give one teaspoon of ORS to the child. This should be repeated every 1 - 2 minutes (An older child who can drink it in sips should be given one sip every 1 - 2 minutes).
• If the child vomits the ORS, wait for 10 minutes and resume giving the ORS but this time more slowly than before.
• Breast fed babies should be continued to be given breast milk in between ORS.
• Any ORS which is left over after 24 hours should be thrown away.
• After about 4 hours of giving ORS, reassess the child for dehydration. If the child is no longer dehydrated, give home available fluids the same way as ORS was given.
• Begin feeding the child even if dehydration persists, continue ORS. If the child is still dehydrated, please visit the health facility. On the way, continue to give ORS to the child.
• Fluid to be given in addition to the usual fluid intake:
  • Upto 2 months: 5 spoons after each loose stool
  • >2 months to 2 years: 50 – 100 ml after each loose stool
  • 2 years or older: 100 – 200 ml after each loose stool
• If ORS packets are not available you can prepare it at home as well. Take 1 L (5 cupful; each cup about 200ml) of clean water. Add 6 level teaspoons (1 teaspoon = 5grams). Now add Salt - half level teaspoon. Stir the mixture till sugar dissolves. The home-made solution is adequate in most cases and is very effective for rehydration. Be very careful to mix the correct amounts.

When to refer child with Diarrhoea to health facility

• Age of the child - less than 2 months
• Child passing blood in stools
• Severe dehydration
• Not able to drink or breastfeed
• Vomits every thing
• Convulsions
• Lethargic or unconscious
• Cough or difficult breathing and fast breathing or ‘pneumonia’ or ‘paslichalna’
• Other associated illness
• Severe malnutrition
• If diarrhea more than 14 days

Common local misconceptions about Diarrhoea and its management

• ORS and glucose are the same
• ORS should not to be given in winter even when the child has diarrhea
• ORS should be given in summer even when the child does not have diarrhea. In such cases, if you feel that due to heat child needs extra fluid, give shikanji, lassi and other fluids at home.
• Some foods should be reduced in diarrhea
• Feeding during diarrhea will worsen the case.
• Breastfeeding should be reduced in diarrhea
• Diarrhea due to extremes of weather, evil spirits (uprihawa) or indigestion does not need any treatment

Source : IDCF toolkit