Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin conditions difficulties in the home and society.

1. 5
Diarrhoea
5-2 Is diarrhoea common?
Objectives Yes, it is one of the commonest problems in
childhood throughout the world.
When you have completed this unit you
should be able to: 5-3 Can diarrhoea be dangerous?
• Define and diagnose diarrhoea.
• Understand the importance and Yes. Diarrhoea can be life threatening if it is
danger of diarrhoea. severe. Diarrhoea causes a loss of fluid and
• List the causes and complications of electrolytes in the stool, which can result in
diarrhoea. dehydration and electrolyte imbalance. The
• Diagnose and grade the severity of correct management of diarrhoea is important
dehydration. as diarrhoea is one of the leading causes of
• Manage diarrhoea. death in children, especially in poor countries.
• Treat dehydration. Each year about 4 million children worldwide
• Prevent diarrhoea. die of diarrhoea.
Diarrhoea is a leading cause of infant death
DIAGNOSIS AND CAUSES worldwide.
OF DIARRHOEA
5-4 What are the common causes of
diarrhoea?
5-1 What is diarrhoea?
The 2 commonest causes of diarrhoea are:
Diarrhoea (or diarrhoeal disease) is defined
as the passage of frequent, loose, watery stools 1. Gastroentestinal infections
at least 3 times a day. Diarrhoea is not a single 2. Food allergy or intolerance
condition but simply a clinical sign, which NOTE Less common causes of diarrhoea include
has many different causes. With diarrhoea food poisoning (bacterial toxins), a side effect of
excessive amounts of water and electrolytes antibiotics (bacterial overgrowth), some drugs
(salts such as sodium and potassium) are lost which increase gut motility, coeliac disease and
into the stool. cystic fibrosis (malabsorption).

2. DIARRHOEA 95
5-5 What infections cause diarrhoea? electrolytes into the stool. It is the commonest
form of diarrhoea in childhood. Vomiting
1. Infections of the bowel:
and abdominal cramps in older children are
• Viruses, such as Rota virus and
common with gastroenteritis but pyrexia is
measles. Rota virus is the commonest
absent or only mild.
cause of diarrhoea in children.
• Bacteria, such as E. coli (Eschericia coli), Gastroenteritis is usually caused by Rota virus
Shigella, Salmonella, Campylobacter or E. coli. Rota virus is highly infectious and
and Cholera. seen in both poor and wealthy communities
• Protozoa (small one-celled organisms), especially in children less than 1 year old. The
such as Giardia, Amoeba and infection is usually spread from the stool of
Cryptosporidium. the infected person by unwashed hands or
2. Infections outside the bowel: contaminated water or food (the faecal–oral
• Children with bacterial infections, such route). Poor hygiene or sanitation may result
as otitis media, septicaemia and urinary in outbreaks of gastroenteritis. Gastroenteritis
tract infection may also have diarrhoea. usually presents as acute diarrhoea. However,
• In some children who present with if the bowel mucosa is damaged by the
diarrhoea, the infection is not in infection, gastroenteritis may also result in
the bowel but elsewhere (parenteral persistent diarrhoea.
diarrhoea).
Gastroenteritis is an acute infection of the bowel,
Rota virus infection of the bowel is the causing diarrhoea.
commonest cause of diarrhoea in children.
NOTE Rota virus causes direct bowel mucosal
damage while most types of E. coli produce
5-6 What food intolerances cause
toxins which interfere with the normal function
diarrhoea? of the bowel wall leading to excess water and
1. Carbohydrate intolerance especially lactose electrolyte loss.
intolerance.
2. Protein intolerance especially cow’s milk 5-8 What is acute diarrhoea?
protein intolerance.
Acute diarrhoea is watery diarrhoea which
Both lactose intolerance and cow’s milk lasts less than 2 weeks (14 days). Acute
protein intolerance usually cause persistent diarrhoea is usually due to gastroenteritis (an
diarrhoea following earlier damage to the acute infection of the bowel).
bowel caused by gastroenteritis. NOTE Often the term gastroenteritis and acute
NOTE Diarrhoea due to carbohydrate induced diarrhoea are used interchangeably. However,
intolerance may be caused by the excessive acute diarrhoea is not always caused by an
intake of fruit juice especially apple juice (fructose infection of the bowel but can also result from
intolerance). an infection elsewhere in the body or food
intolerance.
5-7 What is gastroenteritis?
5-9 What is persistent diarrhoea?
Gastroenteritis (or acute diarrhoeal disease)
is an acute infection of the bowel resulting Diarrhoea usually recovers within 7 days.
in watery diarrhoea without visible blood However, if diarrhoea does not recover by
or mucus in the stool. It is caused by a wide 2 weeks (14 days), it is called persistent
range of organisms which interfere with the (prolonged or chronic) diarrhoea. Persistent
normal functioning of the cells that line the diarrhoea is common in malnourished
bowel wall, resulting in loss of water and children and children with HIV infection.

3. 96 DIARRHOEA
Diarrhoea for more than 14 days is persistent 5-13 What is cholera?
diarrhoea. Cholera is a severe, highly infectious form
of watery diarrhoea which is common in
undeveloped countries. Cholera occurs in
5-10 What is the relationship between
epidemics as has happened in some areas of
diarrhoea and malnutrition?
South Africa in recent years. It is caused by
Diarrhoea is commoner and more severe in a bowel infection with Vibrio cholerae. The
children with malnutrition (i.e. undernutrition). stools in cholera as typically watery with small
Therefore malnourished children often have pieces (flecks) of mucus (‘rice water stools’).
persistent or repeated diarrhoea. In addition, Cholera can rapidly lead to dehydration and
malnourished children are more likely to death, even in adults. Always think of cholera
develop severe diarrhoea and die from it. if there is a local epidemic, especially with
There is therefore a close relationship between severe dehydration in an older child.
diarrhoea and malnutrition.
5-14 What is dysentery?
Diarrhoea is both common and more severe in Dysentery is a form of diarrhoea where the
children with malnutrition. stool is not simply watery, but also contains
visible blood and mucus. Dysentery is usually
Persistent or repeated diarrhoea may result caused by organisms which invade and
in weight loss and malnutrition in children damage the bowel wall. These children usually
who were previously well nourished. look ill (toxic) and have a high temperature.
Diarrhoea, especially persistent diarrhoea, Dysentery is usually caused by Shigella,
often precipitates marasmus or kwashiorkor in Salmonella, Campylobacter, Amoeba and
children who already are mildly malnourished. some types of E. coli. The commonest cause
Therefore, both malnutrition and diarrhoea of dysentery is Shigella. Dysentery is severe if
often occur in the same children. The one con- there are signs of dehydration.
dition often makes the other condition worse.
Dysentery is diarrhoea containing blood and
Diarrhoea may precipitate or aggravate mucus.
malnutrition.
NOTE With dysentery, the organisms invade and
damage the bowel wall, causing bleeding and
5-11 Is diarrhoea common in children with the secretion of mucus.
HIV infection?
Yes, diarrhoea is common and may be the 5-15 What is typhoid?
presenting sign in children with HIV infection.
Some bacteria which cause diarrhoea, can
In children with HIV infection, diarrhoea is invade the bowel wall and spread into the
not only more frequent but also more severe blood stream resulting in septicaemia.
and takes longer to recover. Diarrhoea is often Septicaemia usually complicates diarrhoea
persistent in children with HIV infection and with infections caused by Salmonella, Shigella
is a common cause of death. and Campylobacter. Septicaemia is commoner
in dysentery than in watery diarrhoea.
5-12 Which infants are at greatest risk of Typhoid is a septicaemia caused by a bowel
dying from diarrhoea? infection with Salmonella typhi. These children
• Infants under 6 months of age are very ill and may die if not treated early
• Malnourished infants with antibiotics.
• Children with AIDS

4. DIARRHOEA 97
NOTE Children with typhoid may appear severely NOTE In an attempt to keep the intravascular
ill and toxic with only mild diarrhoea or no volume as normal as possible, interstitial and
diarrhoea at all. intracellular fluid is moved into the intravascular
compartment (serum). This dehydrates the tissues
resulting in loss of skin turgor, sunken eyes and a
THE COMPLICATIONS OF sunken fontanelle.
ACUTE DIARRHOEA 5-18 How can you recognise loss of skin
turgor?
5-16 What are the complications of acute The normal skin turgor is the elasticity
diarrhoea? (stretch) which enables skin to rapidly return
to its previous position after it is gently pinched
• Dehydration into a tent shape for 2 seconds. Normally skin
• Shock returns to its position immediately after being
• Acidosis pinched and then released. With decreased
• Electrolyte loss skin turgor, the skin takes longer than normal
• Ileus to return to its previous position. Decreased
• Hypoglycaemia skin turgor is caused by a loss of fluid from the
• Septicaemia skin. The greater the loss of skin turgor, the
• Malnutrition longer it takes for the skin to go back to the
Severe dehydration is the commonest cause of normal position.
death in infants with diarrhoea and by far the Skin turgor is best tested over the abdomen.
most important complication. Using the thumb and first finger, a fold of
skin on one side of the umbilicus is lifted
Dehydration is the most important complication and gently squeezed for 2 seconds and then
and the commonest cause of death in infants released. Observe how quickly or slowly the
skin returns to its normal position.
with diarrhoea.
NOTE Wasted newborn infants and marasmic
children may have decreased skin turgor without
5-17 How can you recognise dehydration? being dehydrated (lack of subcutaneous fat)
Dehydration develops when excessive amounts while decreased skin turgor can be difficult to
of fluid are lost from the body. Diarrhoea detect in fat children who are dehydrated.
can rapidly lead to dehydration, especially
if vomiting is also present. Both the history 5-19 How can the degree of dehydration be
and the clinical examination are important in assessed?
assessing whether a child is dehydrated. All children with diarrhoea must be
In all children with diarrhoea the following examined for signs of dehydration. The
signs must be looked for: degree of dehydration can be roughly assessed
clinically into ‘no visible’ dehydration, ‘some’
• Offer the child a drink. Is the child able dehydration or ‘severe’ dehydration. This is
to drink? Is there increased thirst or a important as it is essential to identify children
refusal to drink? Does the child vomit after with severe dehydration.
drinking?
• Is the child restless and irritable or 1. ‘No visible’ dehydration: The child has no
lethargic or unconscious? signs of dehydration or not enough signs to
• Are the eyes sunken? be classified as ‘some dehydration’. However,
• Is the skin turgor (elasticity) decreased? many children with ‘no visible dehydration’
• Is the infant’s fontanelle sunken? have still lost more fluid than normal. They
• Has there been a sudden weight loss? often are thirsty and pass little urine.

5. 98 DIARRHOEA
2. ‘Some’ dehydration: They have 2 or more of assessing the degree of dehydration is only
the following signs: of limited use. With ‘some’ dehydration, less
• Very thirsty and drinks eagerly than 10% of body weight is lost while 10%
• Restless and irritable or more of body weight is lost with ‘severe’
• Sunken eyes dehydration. A child may lose up to 5% of
• Moderate degree of decreased skin body weight (and body fluid) before the signs
turgor. When pinched, the skin takes of dehydration can be recognized.
longer than usual, but less than 2 NOTE If a child is 10% dehydrated, 10% of the
seconds, to return to normal. body weight will have been lost as fluid in the
3. ‘Severe’ dehydration: They have 2 or more stool or vomitus (i.e. 100 ml/kg as 1 ml of body
of the following signs: fluid weighs 1 g).
• Not able to drink or drinks very poorly
• Lethargic or unconscious 5-21 What is shock?
• Eyes very sunken.
• Severe decrease in skin turgor. When Shock (hypovolaemic shock in dehydration)
pinched, the skin takes 2 seconds or is the failure of the heart to maintain adequate
more to return to normal. circulation due to the loss of fluid. With
• Shock with delayed capillary filling time excessive fluid loss in the stools, the volume
of fluid in the circulation falls and there is not
Severe dehydration leads to shock, acidosis, enough fluid to allow normal blood flow to the
electrolyte loss, an ileus and hypoglycaemia. small capillaries of the body. As a result, blood
Always start by first looking for signs of severe flow slows down or stops in the capillaries and
dehydration. If the child has 2 or more signs of the body cells do not receive enough oxygen
severe dehydration, then the child is classified and food. Shock presents with:
as severe dehydration. If the child does not • A delayed capillary filling time
have 2 or more signs of severe dehydration, • Tachycardia (a fast heart rate)
then look for signs of some dehydration. If • A weak radial pulse which is difficult to feel
there are 2 or more signs of some dehydration, • Hypothermia (low body temperature)
the child is classified as some dehydration. especially cold hands and feet (cold
If there are no signs or only 1 sign of some peripheries)
dehydration present the child is classified as • A depressed level of consciousness
no visible dehydration. (lethargy and drowsiness)
• Hypotension (low blood pressure) with
The degree of dehydration must always be weak or impalpable peripheral pulses
assessed in children with diarrhoea. The blood pressure may still be normal in the
early stages of shock. Shock is a very serious
NOTE Children with ‘some’ dehydration often also sign and indicates that the child will probably
have a dry mouth, poor urine output and do die unless immediate treatment is started.
not look well. Children with ‘severe’ dehydration
appear severely ill and are hypotensive, with a
rapid, weak pulse, cold peripheries, and have Shock is the failure of the peripheral circulation
acidotic breathing. due to the loss of fluid.
5-20 How can weight loss help to decide 5-22 How is a delayed capillary filling time
the degree of dehydration? measured?
Weight loss is the best measure of the degree The most important sign of shock is a delayed
of dehydration. Unfortunately the child’s capillary filling time of more than 3 seconds.
weight at the onset of the diarrhoea is The capillary filling time is measured by
often not known. Therefore, this method of

6. DIARRHOEA 99
pressing on the sole of the child’s foot or palm calcium, magnesium, chloride, phosphate,and
of the hand, then releasing the pressure and bicarbonate. Electrolytes are also lost with
counting how many seconds it takes for the excessive vomiting.
pale area to regain its pink colour. Pressing on
the nail of the middle finger can also be used
to measure the capillary filling time. In order
Children with diarrhoea lose excessive amounts
to count in seconds, and not too fast or too of fluid and electrolytes in the stool.
slow, it is useful to count ‘one crocodile, two
crocodiles, three crocodiles, etc’. The return of An electrolyte imbalance (too much or too
colour to the pale area is due to the capillaries little of one or more of the electrolytes) may be
filling once more with blood. Therefore, this is a caused by dehydration or using an incorrect re-
good way of assessing the state of the peripheral hydration fluid. Electrolyte imbalance presents
circulation (the blood flow through the as floppiness (hypotonia), drowsiness or fits.
capillaries). Slow filling of the capillaries shows NOTE Children who lose more water than sodium
that the blood is not circulating properly. develop hypertonic (hypernatraemic) dehydration.
These children are very irritable and may have
convulsions. The diagnosis may be missed as the
A delay in the capillary filling time is the best way signs of dehydration are less obvious.
of diagnosing shock.
5-25 What is ileus?
5-23 What causes acidosis in children with Ileus is distension of the abdomen due to a
diarrhoea? decrease or absence of the bowel movements
With poor peripheral perfusion due to shock, (peristalsis). No bowel sounds can be heard.
many cells in the body no longer receive This lack of peristalsis is due to infection and
enough oxygen and, therefore, are no longer loss of potassium. Ileus usually does not cause
able to produce energy by fully breaking abdominal pain or bile stained vomiting.
down carbohydrates and fats. This failure
of metabolism results in the formation and 5-26 What is the danger of hypoglycaemia?
accumulation of lactic acid, which causes
Hypoglycaemia in children is defined as a blood
metabolic acidosis. Metabolic acidosis is made
glucose concentration of less than 3 mmol/l.
worse in diarrhoea by the loss of bicarbonate
Severe diarrhoea, especially in malnourished
in the stool. The use of aspirin (salicylates)
children who refuse feeds or have severe
may also make the acidosis worse.
vomiting, may cause hypoglycaemia. This can
Children with a metabolic acidosis develop result in loss of consciousness or convulsions.
rapid sighing (deep) breathing. The clinical Hypoglycaemia must always be suspected in
diagnosis of acidosis can be confirmed by children with diarrhoea who have fits or a
blood gas analysis. decreased level of consciousness.
NOTE The blood gas analysis in an infant with a Hypoglycaemia is a very serious complication
metabolic acidosis shows a low pH and low stan- that requires urgent diagnosis and immediate
dard bicarbonate together with an increased base
treatment with intravenous glucose. Hypo-
deficit. In an attempt to correct the acidosis, the
child often hyperventilates which lowers the pCO2.
glycaemia can be confirmed by measuring the
blood glucose concentration with a reagent
strip.
5-24 Why do children with diarrhoea lose
electrolytes?
5-27 How is septicaemia recognised?
Children with diarrhoea lose both fluid and
electrolytes in the stool. Important electrolytes Some infants with diarrhoea appear very ill
which are lost include sodium, potassium, and have bacteria circulating in their blood.

7. 100 DIARRHOEA
This is called septicaemia. Septicaemia Treatment must be started early and every
should be suspected if the child has a high effort must be made to prevent dehydration
temperature (pyrexia) or appears a lot sicker by replacing the fluid losses. It is important
that you would expect for the degree of to teach mothers that acute diarrhoea is
dehydration or does not improve after the treated with oral rehydration solution and not
dehydration is corrected. Septicaemia is with medicines. Thirst is often a good guide
commoner in infants below 3 months, in to the need for oral rehydration solution.
malnourished children and in children with The management of most children with
dysentery. Associated HIV infection makes acute diarrhoea is both simple and cheap.
septicaemia more likely, more serious and Intravenous fluid (‘a drip’) is usually not
more dangerous. necessary. There is no need for routine stool
cultures in acute diarrhoea.
5-28 What signs suggest that the diarrhoea
may have a surgical cause? The early use of oral rehydration solution can
• Repeated, severe vomiting usually prevent dehydration.
• A markedly distended abdomen
• Bile stained vomiting
5-30 Will milk feeds make acute diarrhoea
• Passing a lot of blood and mucus with little
worse?
stool
• Severe, continuing abdominal pain (not Although continuing milk feeds in infants
just intermittent cramping pains) may appear to make the diarrhoea worse, it
is important to continue feeds as it helps to
These children must be referred to hospital
provide energy and replace fluid and electrolyte
urgently for further investigation.
losses. Infants recover from diarrhoea faster if
milk feeds are continued. Breastfeeding or full-
strength formula should be used. There is no
TREATMENT OF need to dilute feeds. The aim of feeding during
DIARRHOEA diarrhoea is to maintain nutrition. Rehydration
solution should be given in addition and not be
used to replace feeds.
5-29 What is the management of a child
with acute diarrhoea?
Milk feeds must not be stopped in infants with
1. The most important aspect of management acute diarrhoea.
is to start oral rehydration therapy as
early as possible to prevent dehydration
5-31 Can children with acute diarrhoea
from occurring. Oral rehydration solution
continue to be fed solid food?
should be used. With frequent, small
drinks most children with mild diarrhoea If the child is already receiving solid food,
can be adequately managed without this should be continued unless the child is
developing dehydration. vomiting a lot. Small feeds should be given
2. Breastfeeding, formula or solid feeds frequently (at least every 4 hours). This is
should be continued unless the child has particularly important in children who are
severe vomiting. malnourished as diarrhoea can make the
3. The clinical condition of the child must malnutrition rapidly worse. Extra feeds should
be continually assessed for signs of be given while the child is recovering from
complications, especially dehydration. the diarrhoea to improve weight gain. Feeding
4. Treat the complications if they occur. during diarrhoea does not increase the
number of stools.

8. DIARRHOEA 101
5-32 Should anti-diarrhoeal medication be rehydration solution is vomited, a smaller
used to treat acute diarrhoea? amount should be given slowly about 10
minutes later. The best way to avoid vomiting
Medicine is usually not necessary and may
is to give small sips of fluid frequently by cup.
even be dangerous in small children. Anti-
If severe vomiting continues, a serious cause
diarrhoeal medication such as codeine,
of the diarrhoea should be looked for, and
Imodium (loperamide) and Lomotil
continuous nasograstric or intravenous fluid
(diphenoxylate) decrease peristalsis and may
must be started.
cause ileus. They improve cramps in older
children but do not prevent the loss of fluid There is no role for antiemetics (drugs which
and electrolytes from the gut. Medications stop vomiting) in the management of vomiting
which absorb water like pectin and kaolin have in children with acute diarrhoea. They can
no role in the management of children with have serious side effects.
diarrhoea. Antiemetics (to reduce vomiting)
are also not used. Traditional medicine, 5-35 Can a child with acute diarrhoea be
especially enemas, must not be given. treated at home?
Children with mild diarrhoea and no visible
5-33 Should antibiotics be routinely given
signs of dehydration can be treated at home
to children with acute diarrhoea?
with continuing feeds and oral rehydration
Most cases of acute diarrhoea are caused by solution. If the diarrhoea becomes worse or
a virus and do not respond to antibiotics. does not recover in 2 days the child must be
Indication for antibiotics are: seen at a clinic. Children who refuse to drink
or who vomit repeatedly must be taken to a
• Suspected septicaemia (very ill with a high
clinic immediately as they are at great risk of
fever)
dehydration. Counsel the mother to seek help
• Small infants (under 1 month)
if the infant’s eyes or fontanelle appear sunken.
• Severely malnourished children
Most children with diarrhoea can be managed
• Dysentery (blood in the stools)
at home. The mother must know how to give
• Suspected cholera
rehydration solution correctly and when to
Infants who are sick enough to receive bring the child back to clinic.
antibiotics should be referred to hospital for
management.
Children with mild diarrhoea can be treated at
home with feeds and oral rehydration solution.
Routine antibiotics should not be used to treat
acute diarrhoea. The guidelines for managing acute diarrhoea
at home are:
NOTE Ill infants with suspected septicaemia must
receive systemic antibiotics. Dysentery (often due 1. Give extra fluids.
to Shigella) is usually treated with oral nalidixic 2. Continue feeding.
acid (12.5 mg/kg/dose 6 hourly for 5 days) while 3. Know when to take the child to the clinic
persistent diarrhoea (often due to Amoebae or or hospital.
Giardia) is treated with metronidazole (Flagyl).
5-36 What is oral rehydration therapy?
5-34 What should you do if the child vomits Oral rehydration therapy (ORT) is the most
a lot? important part of managing acute diarrhoea
Infants with acute diarrhoea may vomit. and saves the lives of millions of children
However, the vomiting usually stops once worldwide each year. ORT consists of giving
the dehydration is corrected. If the oral oral rehydration solution by mouth early in

9. 102 DIARRHOEA
acute diarrhoea to prevent or treat dehydration. 1. 1 litre of clean water.
Give frequent small sips from a cup. 2. 8 level teaspoons of sugar.
3. ½ of a level teaspoon of table salt.
Oral rehydration therapy saves million of lives One litre of water can be measured with a
every year. measuring jug or a one litre cool drink bottle.
The sugar and salt must be added to the litre of
clean water and mixed well. It is very important
5-37 What is oral rehydration solution? not to add too much salt. If possible, the sugar
Oral rehydration solution (ORS) is a mixture and salt solution should be given by cup or
of water, electrolytes (salts) and glucose which by spoon as this avoids using dirty bottles. It
is given by mouth to provide energy and is dangerous to add a sachet of rehydration
replace the fluid and electrolytes which have powder to the sugar and salt solution as this will
been lost. Oral rehydration solution can be: make the solution too concentrated.
• Bought commercially.
• Made up in the home as a sugar and salt A sugar and salt solution for oral rehydration can
solution. be easily made up at home.
5-38 What is commercial oral rehydration 5-40 Who should know how to make up
solution? sugar and salt solution for oral rehydration?
There are a number of different brands of Every mother or caretaker should know how
commercially available oral rehydration to make up a sugar and salt solution and have
solution (e.g. Sorol). They all contain a the necessary ingredients at home. The recipe
balanced mixture of electrolytes and water for making sugar and salt solution is given in
together with glucose. They are usually sold some Road-to-Health Cards.
in the form of a powder which is packaged in
a sachet (small packet). One sachet of powder
5-41 When should oral rehydration therapy
should be mixed in one litre of water. The
be started?
cleanest available water must be used. Sterile
or boiled water (which has been allowed to As soon as the diarrhoea is noticed. It is very
cool) is best. Commercial oral rehydration important to start oral rehydration therapy
solution powder should be kept in as many as early as possible to prevent dehydration.
homes with children as possible. The earlier it is started the quicker the child
NOTE Standard ORS contains 90 mmol/l of sodium
will get better. It is important to start oral
and 111 mmol/l of glucose. However, WHO and rehydration therapy before taking the child to
UNICEF have recently advised that a solution a doctor or nurse.
of 75 mmol/l of both sodium and glucose is
preferable as it gives an effective ORS with a
lower osmolality. Oral rehydration therapy at home should be
started as soon as possible, to prevent dehydration.
5-39 How can a sugar and salt solution be
made at home? 5-42 How much oral rehydration solution
should be given?
Home made sugar and salt solution (SSS)
is not quite as good as commercial oral It is best to give the oral rehydration solution
rehydration solution as it does not contain frequently and in small volumes. Too much
potassium. However, it is immediately fluid at one time may cause vomiting. Give
available and often lifesaving.. The commonest as much fluid as the child will take. Most
recipe for a sugar and salt solution is: children with no or only some dehydration

10. DIARRHOEA 103
will drink as much oral rehdration fluid as 5-45 What is the management of
they need to replace the fluid lost. Children dysentery?
with some dehydration are usually very thirsty.
These children should be referred to hospital
However, children with severe dehydration are
for investigation and treatment. Correct
very ill and may refuse to drink. Usually 25 ml
dehydration. An antibiotic is needed. Usually,
(5 teaspoons) can be given every 10 minutes.
nalidixic acid is given 6 hourly for 5 days (2.5
If the child vomits, try again in another 10
ml if 12 to 24 months; 5 ml if 2 to 5 years; 7.5
minutes. If the child refuses the fluid or
ml if older than 5 years).
continues to vomit the fluid, nasogastric or
intravenous therapy may be needed. This is NOTE Dysentry is usually due to Shigella, which
particularly important if a vomiting child has become resistant over the years to many
appears to be dehydrated. antibiotics. Ciprofloxacin may be required.
5-43 Which children with acute diarrhoea
should be referred to hospital? MANAGEMENT OF
Most children with acute diarrhoea can be DEHYDRATION
managed at home or at a primary care clinic.
However, the following children should be
5-46 What is the management of a child
referred to hospital for further management:
with diarrhoea but no visible dehydration?
• Children with signs of severe dehydration
These children are losing excessive amounts
or shock
of fluid and electrolytes in their stools and
• Children who have lost more than 10% of
therefore must still be given extra fluid and
their body weight
electrolytes to prevent signs of dehydration
• Children who continue to vomit despite
from appearing.
being given oral rehydration solution
• Children with a fever or other signs of 1. These children should be managed at
infection home or at a clinic using commercial oral
• Children who have had a convulsion (fit) rehydration solution or sugar and salt
or are very irritable solution to replace fluid losses. Give as
much fluid as the child will take. Continue
5-44 What is the management of persistent with extra fluids until the diarrhoea stops.
diarrhoea? 2. Normal feeds should be continued.
breastfeeding mothers should continue to
Children with persistent diarrhoea should give breastfeeds.
be referred to hospital for investigation and 3. The child should be closely observed for
further management. Correct dehydration if continuing loose stools or vomiting. Signs
present. Offer oral rehydration solution even of dehydration must also be looked for.
if the child is not visibly dehydrated. Consider 4. The mother should bring the child to the
HIV in any child with persistent diarrhoea. clinic immediately if the child becomes
NOTE The stool should be cultured and examined more sick, develops signs of dehydration,
under a microscope in an attempt to identify the refuses feeds or vomits a lot.
cause. Secondary lactose intolerance is common. 5. Children with diarrhoea but no visible
Often a lactose free formula (Isomil, Infasoy) is dehydration, who are managed at home,
given for a few weeks.
should return to the clinic in 5 days if the
diarrhoea has not stopped.
The aim of early home care is to prevent
dehydration and continue feeding. The mother
must know what fluids to use and how much

11. 104 DIARRHOEA
to give. She must also know when to return to plus oral rehydration solution until the
the clinic. diarrhoea stops. Oral rehydration solution
does not cause the fluid loss in the stools to
increase.
Home care with oral rehydration solution can 6. The mother must know how to make up
usually prevent dehydration. the rehydration solution correctly and how
much to give.
NOTE Children with ‘no visible’ dehydration who
do not meet the criteria needed to be classified If the infant refuses to drink fluids or vomits
as ‘some’ dehydration may still have lost about 5% repeatedly after drinking, a continuous
of their body fluid (about 5% loss in body weight nasogastric drip should be started. If there
and therefore need extra fluids). are still signs of ‘some’ dehydration after 4
hours, continue with the oral or nasogastric
5-47 What is the treatment of a child with rehydration solution and assess again after a
some dehydration? further 4 hours. If signs of severe dehydration
develop, manage the child for ‘severe’
These children with 2 or more clinical signs
dehydration.
of ‘some’ dehydration should initially be
managed in a clinic or hospital if possible as The lives of most children with diarrhoea
they can progress to ‘severe’ dehydration: can be saved by the simple, cheap use of oral
rehydration therapy at home or in a local
1. They can be treated with oral rehydration
primary care clinic.
solution with a close watch for repeated
vomiting or a refusal to drink. It is best
if the oral rehydation solution is given by Children with some dehydration are treated at a
cup and/or spoon. clinic or hospital with extra fluids in addition to
2. 80 ml/kg of oral rehydration solution continuing normal feeds.
should be given over 4 hours, i.e. about 20
ml/kg each hour. More can be given if the NOTE The WHO recommends 75 ml/kg of oral
child wants to drink more. It is best if the rehydration solution over 4 hours.
child has frequent, small sips. If the child
vomits, wait for 10 minutes and then try 5-48 What is the treatment of a child with
again more slowly. severe dehydration?
3. The degree of dehydration must be
assessed after 4 hours. The management of children with severe
4. If the child takes the oral rehydration diarrhoea leading to severe dehydration is a
solution well, is not vomiting and there are medical emergency. Look carefully for shock
no longer signs of dehydration (and the in all children with severe dehydration and
child has gained weight) after 4 hours, the treat immediately.
child can be sent home and return to be 1. Immediately start an intravenous infusion
assessed the next day. At home the child with Ringer’s lactate (or half normal saline
should be managed with oral rehydration or half strength Darrows/dextrose solution).
solution (as for diarrhoea with ‘no visible’ 2. Give 30 ml/kg over the first half hour (30
dehydration). The decision to send the minutes). Then give 70 ml/kg over 2 ½
child home will depend on the home hours (i.e. about 30 ml/kg per hour). Most
circumstances. The mother must bring the infants are therefore rehydrated with 100
child back immediately if the diarrhoea ml/kg over 3 hours.
gets worse, the child vomits everything or 3. The child must be closely observed and
signs of dehydration appear. reassessed every half hour. If the clinical
5. It is important that the child continues to signs of dehydration have not improved
receive regular feeds (especially breastfeeds) after an hour, fluid should be given faster.

12. DIARRHOEA 105
Careful assessment after 3 hours is needed 5-49 What is the treatment of dehydration
to decide whether further management resulting in shock?
should be for ‘no visible’, ‘some’ or ‘severe’
Give intravenous Ringer’s lactate or normal
dehydration.
saline 20 ml/kg as fast as possible. Continue to
4. If an intravenous infusion cannot be
give fluid at this fast rate until the signs of shock
started, pass a nasogastric tube and give
have disappeared. An easily felt radial pulse and
20 ml/kg/hour over 6 hours (i.e. 120 ml/
normal capillary filling time are very reassuring
kg). Nasogastric rehydration is slower than
signs of a good response to management. Once
intravenous rehydration as it takes time for
shock has been corrected, Ringer’s lactate,
the fluid to be absorbed. If there is repeated
half normal saline or half Darrows/dextrose
vomiting or abdominal distension, give
solution is then given at the standard rate for
the nasogastric fluid slower or try again to
severe dehydration (i.e. 30 ml/kg per hour).
start an intravenous infusion.
5. Only once intravenous or nasogastric
rehydration has been started, should 20 ml/kg of intravenous fluid is given as fast as
the child be moved urgently to hospital. possible if shock is present.
Always start replacing fluid before moving
the child. One of the commonest mistakes If it is not possible to start an intravenous line,
made is to rush the child to hospital before the intraosseous route can be used in young
starting intravenous or nasogastric fluid. If children if the health worker is trained in this
no equipment is available to give fluid fast, technique. A nasogastric drip can be used if
try to get the child to drink while being neither intravenous or intraosseous routes
urgently transported to hospital. are available. Haemacel, fresh frozen plasma
6. Oral rehydration solution should be started or stabilized human serum (SHS) can also be
when the child is able to drink. used to treat shock. Using the intraosseous
Never rehydrate an infant or child with 5% or route in children under six years of age can be
10% dextrose only as they need electrolytes as a life-saving procedure.
well as fluid and glucose. Rehydration fluids
must always contain some glucose (dextrose). In an emergency with ongoing shock, where
several attempts to place an intravenous line
have failed, use the intraosseous route. The
Children with severe dehydration should be most suitable site is 2 cm below the tibial
rehydrated with 100 ml/kg of fluid intravenously tuberosity on the flat surface of the tibia (shin
over 3 hours. bone). A wide-bore needle (15–18 gauge) can
be used if a needle with stylet is not available.
NOTE In infants under one year it is best to give In children under 18 months, an 18 × 1.5 or
30 ml/kg for the first hour while the remaining 20 × 1.5 lumbar puncture needle is suitable.
70 ml/kg is given slower over a further five hours. Hold the needle perpendicular to the skin and
Therefore, small infants are rehydrated slower with a twisting movement push it into the flat
with 100 ml/kg over 6 hours. part of the tibia until a ‘give’ is felt; the needle
The amount and rate of fluid needed to correct is now in the bone marrow. Do not advance it
severe dehydration has been controversial for any further. In a shocked patient, fluid must be
many years. The Red Cross Children’s Hospital introduced under pressure (use a 20 ml syringe
in Cape Town, South Africa, recommends 20 m/ as a ‘push-in’ or a sphygmomanometer cuff
kg over the first 30 minutes followed by 100 ml/ wrapped around a collapsible IV plastic fluid
kg over the next 4 hours. This regimen avoids container). The dosage and volume of drugs
the dangers of rehydrating a child too fast. and fluid are the same as for direct IV infusion.

13. 106 DIARRHOEA
5-50 What fluids should be given once • Where there is not a supply of clean water
dehydration has been corrected? to mix formula
• When feeding bottles and teats cannot be
Once dehydration has been corrected, the total
properly cleaned
amount of fluid needed is normal maintenance
• In communities without adequate toilet
requirements plus any ongoing fluid losses.
facilities
The normal fluid needs of most infants are
• When flies are common
about 100 ml/kg daily. If possible this fluid
• When personal hygiene is poor, especially
should be given orally as rehydration solution
no handwashing before eating
or milk. Thirst is usually a good guide to the
infant’s fluid needs.
Diarrhoea is usually due to contaminated food or
5-51 What is the value of zinc supplements water.
in managing a child with diarrhoea?
NOTE Faeces left on the open ground or washed
Zinc is an important trace element which can
into the water supply by rain, pit toilets that
speed up the recovery from diarrhoea and help overflow, and vegetables ‘freshened’ with
to prevent further diarrhoea. Once the child contaminated water are all common sources of
is taking feeds well, one tablet of zinc (20 mg) infection. Infected food (e.g. eggs and shellfish)
should be given daily for 10 days. Children can also result in diarrhoea.
under 6 months should have half a tablet daily.
5-54 How can the risk of diarrhoea be
reduced?
PREVENTION OF
Diarrhoea is far less common with:
DIARRHOEA
• Breastfeeding to 6 months and longer if
possible
5-52 Is acute diarrhoea preventable? • A supply of clean water
• Adequate sanitation (the safe disposal of
Yes. The viruses and bacteria that usually cause faeces)
acute diarrhoea spead easily from person • Cup-feeding rather than bottle-feeding if
to person. Acute diarrhoea is an infectious formula is used
disease. With simple interventions, most cases • Good personal hygiene, especially hand-
of acute diarrhoea can be prevented. washing before meals or handling food
• Protecting food from flies
Acute diarrhoea is usually very infectious but can Breastfeeding, a clean safe water supply,
be prevented. appropriate hand-washing and good sanitation
will prevent most cases of diarrhoea. Well
5-53 Why do children commonly get nourished children are less likely to get severe
diarrhoea? diarrhoea than malnourished children. Breast
milk contains many substances (antibodies
Because they are exposed to the viruses and and immune cells) which protect the gut from
bacteria which cause diarrhoea. Their food infection and it thereby protects the infant
and water may also be contaminated by these from diarrhoea caused by infection.
organisms. Infections which cause diarrhoea
are particularly common:
Breastfeeding is an important way of preventing
• In infants who are bottle-fed rather than diarrhoea in young infants.
breastfed

14. DIARRHOEA 107
NOTE Recent research shows that probiotics, such should be placed in the second smaller hole
as bifidobacteria, added to formula feeds can which is at one end of the slab. The top of
reduce the risk of gastroenteritis. the ventilation pipe must be covered with
a fly screen. The door of the toilet should
5-55 How can a safe water supply be face into the wind. The outhouse should be
obtained? dark inside with no cover over the seat. Air
1. Chlorinated tap water must be provided flow in the pit is down the large hole and up
where ever possible. the small hole. Smell and flies escape up the
2. Water can be sterilized by boiling or pipe where the flies are trapped.
adding chlorine tablets.
3. If none of the above is available, water can Effective, cheap sanitation can be provided with a
be made safer by putting it into a clear, pit or VIP toilet.
plastic bottle or bag and leaving it in the sun
for a few hours. The ultraviolet light will kill
Where affordable, a chemical or flush toilet
most viruses or bacteria in the water.
should be used. If no toilet is available, all
If the water is cloudy or dirty it should be stools must be buried immediately.
filtered or be allowed to stand until the clear
water at the top can be gently poured off. The 5-57 Why is cup-feeding safer than bottle-
clear water must then be sterilized. feeding?
NOTE A simple water filter can be made in a If a mother is unable to safely clean dirty bottles
container with holes in the bottom. At the base and teats, it is better to feed the infant by cup.
of the container place a few centimetres of small
Unlike a bottle, a cup can easily be cleaned with
pebbles. Cover these with a few centimetres of
sand (not clay). Place the container on top of a soap and water. The inside surfaces of a cup are
second container in order to catch the drops of smooth and easily reached by finger. Unlike a
filtered water. The dirty water can now be poured feeding bottle, there are no corners for milk and
into the top container to filter down into the bacteria to lodge in.
second container.
Cup-feeding is safer than bottle-feeding.
5-56 How can sanitation be improved?
There are a number of simple ways to improve 5-58 How can hygiene be improved?
sanitation and reduce the risk of children
getting diarrhoea. All stools must be passed or • Wash hands after going to the toilet or
deposited into a flush, chemical or pit toilet: handling a soiled nappy.
• Wash hands before preparing food or
• A simple pit toilet: The pit must be dug less eating.
than a metre wide and at least 1 to 2 metres • Wash fruit and vegetables with clean water.
deep, 20 metres or more away from houses • Cover food to keep flies away.
or water sources. The deeper the pit the • Store food in a fridge (refrigerator) or cool
better. The pit must be covered with a slab place.
or platform, having a single round hole • Bury or burn all food waste.
which must be covered with a lid to keep
out flies and keep in the smell. Throwing
in lime, ash or soil after each use will help CASE STUDY 1
control flies and smell.
• A Ventilated Improved Toilet (VIP Toilet): A mother brings her 9 month old child to a
The pit should be covered by a slab with two local clinic. The child has had loose stools for
holes. An outhouse should be built over the 2 days. The mother has stopped bottle feeds
larger, central hole while a ventilation pipe of formula and given sugar and salt solution

15. 108 DIARRHOEA
as advised by a general practitioner. Oral if the diarrhoea becomes worse or the child’s
antibiotics and an anti-diarrhoea medication general condition deteriorates. The child
were started. On examination the child has should be observed for continuing loose stools
no signs of dehydration. Other than the loose, or vomiting. The aim of early home care is to
watery stools, the child appears healthy. The prevent dehydration and continue feeding. The
older sibling had loose stools the week before. mother must know what fluids to use and how
much to give. She must also know when to
1. What is the diagnosis? return to the clinic.
The child has acute diarrhoea with no visible
dehydration. The diarrhoea is probably due
to a bowel infection with Rota virus. The
CASE STUDY 2
infection probably spread from the sibling.
An ill 9 month old child with diarrhoea and
signs of severe dehydration is brought to a
2. What could have been done to prevent
local hospital. He is shocked and breathing
the diarrhoea?
fast. The mother says he has had watery stools
Good hygiene with hand-washing after going all day and vomits all feeds. The family live in
to the toilet and before meals. Breastfeeding a poor area with no formal toilets. Drinking
rather than formula feeds also reduces the risk water is collected from a stream. When
of diarrhoea. Formula feeds are best given by compared to the weight recorded in the child’s
cup rather than bottle. Road-to-Health Card two weeks before, 15%
body weight has been lost.
3. Do you agree with the use of a sugar and
salt solution? 1. What are the signs of severe dehydation?
Yes. Oral rehydration solution or a home • The child is not able to drink or drinks
made sugar and salt solution is the correct very poorly.
management of diarrhoea. • The child is lethargic or unconscious.
• The eyes are very sunken.
4. Should feeds be stopped when children • There is decrease in skin turgor. When
have diarrhoea? pinched, the skin takes two seconds or
more to return to normal.
No. It is very important that feeds are • The child is shocked.
continued. Stopping feeds does not improve
the diarrhoea and may lead to malnutrition. If 2 or more of these signs are positive, a
diagnosis of severe dehydration is made. The
5. Would you have prescribed an antibiotic? weight loss of more than 10% also suggests
severe dehydration.
There is no need for an antibiotic in acute
diarrhoea unless the diarrhoea is caused by an 2. What are the signs of shock?
infection outside the bowel, such as an acute
otitis media (ear infection). Neither is there • A delayed capillary filling time
an indication for anti-diarrhoeal or antiemetic • Tachycardia (a fast heart rate)
medications. • Hypothermia (low body temperature)
especially cold hands and feet (cold
6. Does this child need to be kept at the peripheries)
clinic or admitted to hospital? • A depressed level of consciousness
(lethargy and drowsiness)
No. A child with no visible dehydration can • Hypotension (low blood pressure) with
be managed at home. The child should be weak or absent peripheral pulses
brought back to the clinic in 5 days, or sooner

16. DIARRHOEA 109
3. Why is this child breathing fast? CASE STUDY 3
He is probably acidotic. However, he may also
have pneumonia. A child of 2 years has a one-month history of
loose stools. The child has some dehydration.
4. How should shock due to dehydration be The weight falls below the third centile. It
treated? is noticed that the child has generalised
lymphadenopathy. The grandmother says that
It is very important that the child is given the child’s mother died a few months before.
intravenous fluid immediately and fast. Usually
Ringer’s lactate or half Darrows/dextrose is
1. What is your diagnosis?
used, starting with 20 ml/kg. The signs of
shock must be carefully observed. If the child This child has persistent diarrhoea as the loose
is still shocked after the first 20 ml/kg, repeat stools have been present for more than 14 days.
this amount fast. If it is not possible to start
an intravenous infusion, the fluid should be 2. How is ‘some’ dehydration recognized?
given via an intraosseous route or a nasogastric
tube if this is not possible. The child should be The child does not have severe dehydration
transferred immediately to hospital. but 2 or more of the following signs:
• Very thirsty and drinks eagerly
5. How is severe dehydration corrected? • Restless and irritable
• Sunken eyes
Once the shock is corrected, the child should
• Moderate degree of decreased skin turgor
receive Ringer’s lactate or Darrows/ dextrose
When pinched, the skin takes longer than
intravenously (or via a nasogastric tube) to
usual, but less than two seconds, to return
treat the severe dehydration. Usually 30 ml/kg
to normal.
is given over 30 minutes followed by 70 ml/kg
over 2 ½ hours. Start oral rehydration solution
once the child is fully conscious and able to 3. What is the correct treatment of ‘some’
take fluids. dehydration?
These children should be treated at a clinic or
6. Why does this child have diarrhoea? in hospital. Usually oral rehydration solution is
given with a close watch for repeated vomiting
Probably because there are no toilets or
or a refusal to drink. It is best if the oral
clean drinking water. If clean tap water is not
rehydration solution is given by cup. 80 ml/kg
available, water can be sterilized by boiling or
of oral rehydration solution should be given
adding chlorine tablets. If this cannot be done,
over 4 hours, i.e. about 20 ml/kg each hour.
water can be made safer by putting it into a
More can be given if the child wants to drink
clear, plastic bottle or bag and leaving it in the
more. Usually the fluid is given by cup or
sun for a few hours. The ultraviolet light will
spoon. It is best if the child has frequent, small
kill most viruses or bacteria in the water.
sips. If the child vomits, wait for 10 minutes
and then try again more slowly. The degree of
7. What can be done if no toilet is available? dehydration must be assessed after 4 hours.
A simple pit toilet can be made. A Ventilated
Improved Toilet (VIP Toilet) would be even 4. When can this child be sent home?
better. Some plan must always be made to get
Children with acute diarrhoea and ‘some’
rid of waste safely.
dehydration can be sent home if they take
the oral rehydration solution well, are not
vomiting and there are no signs of dehydration
after 4 hours. It is important that the child

17. 110 DIARRHOEA
continues to receive regular feeds. The decision 3. How should this child be managed?
to send the child home will depend on the
Children with dysentery should be referred
home circumstances. The child must continue
to hospital for investigation and treatment.
to be offered rehydration solution frequently
An antibiotic, usually nalidixic acid, is given 6
and return to be assessed the next day. The
hourly (7.5 ml as the child is older than 5 years).
mother must bring the child back immediately
Oral redydration solution should be given.
if the diarrhoea gets worse, the child
vomits everything or signs of dehydration
appear. However, as this child has persistent 4. What simple steps can reduce the risk of
diarrhoea, she must be admitted to hospital for diarrhoea and dysentery?
investigation and further management. Making sure that there is:
• Breastfeeding to 6 months and longer if
5. What is the relationship between
possible
diarrhoea and malnutrition?
• A supply of clean water
Diarrhoea, especially persistent diarrhoea, • Adequate sanitation (the safe disposal of
can lead to malnutrition while children with faeces)
malnutrition are at high risk of getting severe • Cup-feeding rather than bottle-feeding if
diarrhoea. Therefore, the one often leads to formula is used
the other. • Good personal hygiene, especially hand-
washing before meals or handling food
6. What illness must be suspected in this
child? 5. How can a safe water supply be
obtained?
AIDS. HIV infection often presents clinically
with persistent or recurrent diarrhoea. The • Chlorinated tap water must be provided
generalized lymphadenopathy suggests HIV wherever possible.
infection. This child’s mother may have died • Water can be sterilized by boiling or
of AIDS. adding chlorine tablets.
• If these are not available,water can be
made safer by putting it into a clear,
CASE STUDY 4 plastic bottle or bag and leaving it in the
sun for a few hours.
An 8-year-old child presents with a week’s
history of loose stools containing both blood 6. What trace element may help the
and mucus. The child has a temperature and recovery from diarrhoea?
looks ill. There are no signs of dehydration. Zinc. One dissolved tablet should be taken
daily for 10 days.
1. What is the importance of blood in this
child’s stool?
It indicates that he has dysentery.
2. What may the cause be?
As the child is ill with a temperature, typhoid
(Salmonella) or Shigella or amoebic dysentry
must be suspected. The commonest cause of
dysentery is Shigella.