The document provides guidelines for managing childhood diarrhoea, including assessing for dehydration and danger signs, treating mild to severe dehydration with oral rehydration solution or intravenous fluids, and counseling caregivers on continuing feeding and fluids and signs requiring return to care. Diarrhoea is defined and types, causes, and complications are described. Treatment plans A, B, and C are outlined for treating diarrhoea at home or in facilities.

1. DIARRHOEA
Approach To Unwell
Children Under 5 Years

2. Management
Of Unwell
Child
Age 2 months –
<5 years
Ask the caregiver about the
child's problems
Check for general danger
signs
Assess and treat main
symptoms:
Cough or difficulty
breathing
Diarrhoea
Fever
Check for malnutrition and
anaemia
Check immunization status
Treat local infection
Counsel using the mother’s
card

3. General Danger Signs
ALL SICK CHILDREN MUST CHECK FOR GENERAL DANGER SIGNS
Ask
Is the child able to
drink or
breastfeed?
Does the child
vomits everything or
greenish vomitus?
Has the child had
convulsion during
this illness?
Look
Is the child Drowsy
or Unconscious ?
Is the child
convulsing now ?

4. DIARRHOEA
Definition
• Loose or watery stools ≥ 3 x in a 24-hour period
• Common age 6 months- 2yrs old
• More common in babies aged < 6 months who are drinking
infant formulas
• Frequent passing of normal stools is not diarrhoea.
• Babies who are exclusively breast fed often have soft stools; this is
not diarrhoea.
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5. DIARRHOEA
Types of Diarrhoea :
•Diarrhoea less than 14 days is acute diarrhoea
•Diarrhoea 14 days or more is persistent
diarrhoea
•Diarrhoea with blood in stool with or without
mucus is called dysentery (Shigella bacteria)
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6. Acute vs Chronic Diarrhea
ACUTE CHRONIC
<14 DAYS ≥14 DAYS
Common causes
• VIRUSES- Rotavirus, Adenovirus, Astrovirus
• BACTERIA- E-Coli, Salmonella, Cholera, Shigella,
Clostridium Difficile
• PARASITES- Entamoeba histolytica, Giardia lamblia
Common Causes
• Post infectious diarrhea
• Celiac disease (gluten intolerance)
• Inflammatory bowel disease (ulcerative colitis and
Crohn disease)
• Lactose intolerance
• Irritable bowel syndrome
• antibiotic associated colitis
Main complication- Shock Main complication- Malnutrition

7. DIARRHOEA
Complications of Dehydration
• Seizures
• Shock with tachycardia, fast breathing
• Kidney failure (no urination)
• Brain oedema
• Coma and death
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8. History taking
Aim to:
1. Obtain history regarding duration, frequency, blood in stool
2. Estimating the degree of dehydration
• Assessing the status
• The onset, frequency, quantity, and duration of diarrhea and vomiting
• Consider oral intake, urine output, and weight loss
• Abdominal pain
• Determine the location, quality, radiation, severity, and timing of pain
• Signs of infection
• Determine the presence of fever, chills, myalgias, rash, rhinorrhea, sore throat,
cough
• Epidemiological factors
• Travel history, eating history, daycare history
• Antibiotics uses
• history of recent antibiotic use increases likelihood of Clostridium difficile infection

11. Assessment
• History
• Days, Frequency, blood in stool
Physical Examination - Signs of dehydration
• General condition
• Sunken eyes
• Offer child fluid
• Skin Pinch at Abdomen
ASSESS DIARRHOEA

12. 12
ASSESS DIARRHOEA
ASK LOOK AND FEEL
DOES THE CHILD HAVE DIARRHOEA? ( YES / NO )
● For how long? …………… days ● Look at the child's general condition. Is the child:
● Is there blood in the stool Drowsy or unconscious?
Restless or irritable?
● Look for sunken eyes.
● Offer the child fluids. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
● Pinch the skin of the abdomen. Does it go back:
very slowly (longer than 2 seconds)?
slowly?

13. ASSEEA
Look General Condition
1. Drowsy or unconscious
• Severe dehydration may cause the child to become drowsy or unconscious. This is
one of the general danger sign.
2. Restless or irritable.
• A child is restless or irritable all the time, or every time he or she is touched and
handled.
• If the infant or child is calm when breastfeeding but again restless or irritable
when he or she stops breastfeeding, he or she has the sign "restless or irritable“
• Many children are upset when in the clinic. If they can be consoled and calmed –
Not "restless or irritable"
ASSESS DIARRHOEA

14. Look For Sunken Eyes
• Decide if you think the eyes are sunken
• If unsure, ask the mother if she thinks her child's eyes look
unusual
• Diarrhoea sunken eyes.mpg
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15. Look For Sunken Eyes
Video19_Exercise Sunken Eyes.MPG
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16. Offer Child Fluid
1. Is the child not able to drink?
• A child is not able to drink if he or she is not able to suck or swallow when offered a
drink.
• A child may not be able to drink because he or she is drowsy or unconscious.
2. Is the child drinking poorly?
• A child is drinking poorly if he or she is weak and cannot drink without help.
• He may be able to swallow only if fluid is put in his or her mouth.
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17. DIARRHOEA
Offer Child Fluid
3. Is the child drinking eagerly, thirsty?
A child has the sign drinking eagerly, thirsty if it is clear that
the child wants to drink. Look if the child reaches out for the
cup or spoon when you offer him water. When the water is
taken away, see if the child is unhappy because he or she
wants to drink more.
If the child takes a drink only with encouragement and does
not want to drink more, he or she does not have the sign
"drinking eagerly, thirsty.“
Video - Diarrhoea Assess Drinking.wmv
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18. DIARRHOEA
Pinch The skin of the Abdomen
Method
• Lie the child flat
• Locate the area halfway between umbilicus and the side of abdomen
• Use the thumb & second finger and pick all layers of skin
• Pinch the skin for one second and then release it.
When you release the skin, see if the skin pinch goes back:
• Very slowly (> 2 seconds) or
• Slowly (skin stays up even for a brief instant)
Pinch the skin.mpg
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19. FIRST STEP
ASSESS THE PERFUSION STATE OF THE CHILD
• Signs of shock (haemodynamic instability)
• Tachycardia
• Weak peripheral pulses
• delayed capillary refill time > 2 seconds
• cold peripheries
• depressed mental state with or without hypotension.
*ANY CHILD WITH SIGNS OF SHOCK GO STRAIGHT TO
TREATMENT PLAN C
Management of diarrhoea

20. The following children are at increased risk of
dehydration:
• infants, particularly those under 6 months of age
or those born with low birthweight
• if they have passed six or more diarrhoeal stools in
the previous 24 hours
• if they have vomited three or more times in the
previous 24 hours
• if they have been unable to tolerate (or not been
offered) extra fluids
• if they have malnutrition

22. PLAN A: TREAT DIARRHOEA AT HOME
Counsel the mother on the 3 rules of home treatment:
Give Extra Fluid, Continue Feeding, When to return

23. 1. Give Extra Fluids (as much as the child will take)
• Tell the mother to breastfeed frequently and for longer at each feed.
• If exclusively breastfed, give Oral Rehydration Solution (ORS) or
cooled boiled water in addition to breastmilk.
• If the child is not exclusively breastfed, give one or more of the
following: ORS, food-based fluids (soup and rice water) or cooled
boiled
water.
• It is especially important to give ORS at home when:
• The child has been treated with Plan B or Plan C during this visit.

24. • Show mother how much ORS to give in addition to the usual fluid
intake:
Up to 2 years : 50 to 100ml after each loose stool
2 years or more : 100 to 200ml after each loose stool
(If weight is available, give 10ml/kg of ORS after each loose stool)
• Tell mother to
• Give frequent small sips from a cup or spoon.
• If child vomits, wait 10 minutes, then continue but more slowly.
• Continue giving extra fluid until diarrhoea stops.

25. 2. Continue Feeding
• Breastfed infants should continue nursing on demand.
• Formula fed infants should continue their usual formula
immediately on rehydration.
• Children receiving semi-solid or solid foods should continue
to receive their usual food during the illness.

26. 3. When to Return (to
clinic/hospital)
• When the child:
• Is not able to drink or breastfeed or drinking poorly.
• Becomes sicker.
• Develops a fever.
• Has blood in stool.

27. PLAN B: TREAT SOME DEHYDRATION WITH
ORS
Give the recommended amount of ORS over 4-hour period:

28. Show the mother how to give ORS solution
• Give frequent small sips from cup or spoon.
• If the child vomits, wait 10 minutes, then continue but more slowly
(i.e. 1 spoonful every 2 - 3 minutes).
• 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 (Plan A, B or C).
Begin feeding the child.

29. If the mother must leave before completing treatment
• Show her how to prepare ORS solution at home.
• Give her enough ORS packets to complete rehydration
• Explain the 3 Rules of Home Treatment (Plan A):
1. GIVE EXTRA FLUID
2. CONTINUE FEEDING
3. WHEN TO RETURN

30. PLAN C: TREAT SEVERE DEHYDRATION QUICKLY
• Airway, Breathing and Circulation (ABCs) should be assessed and
established quickly.
• Start intravenous (IV) fluid immediately.
If patient can drink, give ORS by mouth while the drip is being set up.
• Initial fluids for resuscitation of shock: 20 ml/kg of 0.9% Normal Saline (NS)
or Hartmann’s solution as a rapid IV bolus.
• Repeated if necessary until patient is out of shock or if fluid overload is
suspected.
• Review patient after each bolus and consider other causes of
shock if child is not responsive to fluid bolus, e.g. septicaemia.

31. • Once circulation restores, commence rehydration, provide
maintenance and replace ongoing losses.
• For rehydration use isotonic solution: 0.9% NS or Hartmann’s
solution
(0.45% NS in neonates).
• Fluid deficit: Percentage dehydration X body weight in grams
(to be given over 4-6 hours).

32. Example:
A 13-kg child is clinically shocked and 10% dehydrated as a result of diarrhoea
Initial therapy: To establish ABCs
• 20 ml/kg for shock = 13× 20 = 130 ml of 0.9% NS given as a rapid
intravenous bolus. Repeat if necessary.
• Fluid for Rehydration/Fluid deficit: 10/100 x 13000 = 1300 ml
• Daily maintenance fluid = 1st 10 kg 100 × 10 = 1000 ml
Subsequent 3 kg, 3 x 50 = 150 ml
Total = 1150 ml/day
• To rehydrate (1300 ml over 6 hours) 0.9%NS or Hartmann’s solution
+ maintenance (1150 ml over 24 hours) with 0.9%NS D5%.
The cornerstone of management is to reassess the hydration status
frequently (e.g. at 1-2 hourly), and adjust the infusion as necessary.

33. • Generally normal feeds be administered in addition to the
rehydration fluid
• Once a child is stable, oral rehydration according can be used and the
IV drip reduced gradually and taken off.
• If there is repeated vomiting or increasing abdominal distension, give
the fluid more slowly.
• Reassess the child after six hours, classify dehydration
• Then choose the most appropriate plan (A, B or C) to continue
treatment.

34. • Caution - more judicious fluid administration rate will be required in
certain situations:
• Children less than 6 months age.
• Children with co-morbidities.
• Children that need careful fluid balance, i.e.: heart or kidney
problems, severe malnutrition
• Children with severe hyponatraemia/ hypernatraemia
• Start giving more of the maintenance fluid as oral feeds e.g. ORS
(about 5ml/kg/hour) as soon as the child can drink, usually after 3 to
4 hours for infants, and 1 to 2 hours for older children. This fluid
should be administered frequently in small volumes.

35. Other indications for intravenous therapy
• Unconscious child.
• Failed ORS treatment due to continuing rapid stool loss ( >15-
20ml/kg/hr).
• Failed ORS treatment due to frequent, severe vomiting, drinking
poorly.
• Abdominal distension with paralytic ileus, usually caused by some
antidiarrhoeal drugs (e.g. codeine, loperamide ) and hypokalaemia
• Glucose malabsorption, indicated by marked increase in stool output
and large amount of glucose in the stool when ORS solution is given
(uncommon).

36. Indications for admission to Hospital
• Shock or severe dehydration.
• Failed ORS treatment and need for intravenous therapy.
• Concern for other possible illness or uncertainty of diagnosis.
• Patient factors, e.g. young age, unusual irritability/drowsiness,
worsening symptoms.
• Caregivers not able to provide adequate care at home.
• Social or logistical concerns that may prevent return evaluation if
necessary.

37. Other problems associated with diarrhoea
• Fever
• Seizures
• Lactose intolerance
• Usually in formula-fed babies less than 6 months old with infectious
diarrhoea.
• Clinical features:
- Persistent loose/watery stool
- Abdominal distension
- Increased flatus
• Cow’s Milk Protein Allergy

38. PHARMACOLOGICAL AGENTS
Antimicrobials
• Antibiotics should not be used routinely.
• They are reliably helpful only in children with bloody diarrhoea, probable
shigellosis, and suspected cholera with severe dehydration.

39. LIKELY ORGANISM SEVERITY ANTIBIOTIC
PREFERRED ALTERNATIVE
Shigella, Campylobacter, E Coli Mild or uncomplicated Not required Oral Ampicillin 25mg/kg QID 5-7 days
Severe IV Ceftriaxone 50-70mg/kg QID 5 days IV Azythromycin 10mg/kg QID 3 days
Salmonella sp Mild or uncomplicated Oral Ciprofloxacin 10-20mg/kg BD 5-7
days
Oral Chloramphenicol 25mg/kg QID
minimum 14 days
Severe or suspected resistant IV Ceftriaxone 50-75mg/kg QID 7-14
days
IV Ciproflaxocin 10-15mg/kg BD 7-10
days
Cholera sp Oral Azythromycin 20mg/kg/day OD
OR
Oral EES 12.5mg/kg QID 3days

40. LIKELY ORGANISM SEVERITY ANTIBIOTIC
PREFERRED ALTERNATIVE
Entamoeba H. Oral Metronidazole 10mg/kg TDS 7-10
days
Giardia Lamblia Oral Metronidazole 5mg/kg TDS 5-7
days

41. Antidiarrhoeal medications
• Diosmectite (Smecta®) has been shown to be safe and effective in
reducing stool output and duration of diarrhoea.
• It acts by restoring integrity of damaged intestinal epithelium
• capable to bind to selected bacterial pathogens and rotavirus.
• Avoid use of Smecta in infants and children < 2 years old
• >2 yr 2-3 sachets daily

42. • Antiemetic medication- not recommended
• Zinc supplements
• benefit in children aged 6 months or more in areas where the
prevalence of zinc deficiency or the prevalence of malnutrition is
high
• has been found to reduce the duration and severity of diarrhoeal
episodes and likelihood of subsequent infections for 2–3 months
• Dosage (for 10-14 days)
• < 6 months = 10 mg/day
• >6 months = 20mg/day

43. Case study :
Video22_ Exercise G Case Study Josh.MPG
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44. Scenario 1
Mother complains her daughter Mary,9 months old has diarrhea and this is their first time coming to
the clinic for this diarrhoea.
Mary weight, 8.2 kg and temperature, 37◦C. Mary is able to drink milk and take porridge. She does not
vomit. She has not had convulsions. You watch Mary. She looks very tired in mother’s arms, but she
watches you as you speak. When you reach out to her to take her hand, she grabs your finger. No
cough.
Mother has already reported that Mary has diarrhoea. You ask mother how many days Mary has had
diarrhoea, and she tells you 3 days. You ask mother if there is blood in her daughter’s stool, and she
tells you no.
Now you will examine Mary’s condition. She seems restless and irritable, especially when you touch
her. You begin to examine Mary for signs of dehydration. You check to see if she has sunken eyes, and
it appears that she does. Mother agrees that her daughter’s eyes look unusual. You offer her some
water to drink and notice how she responds. She drinks poorly. Next, you give Mary a pinch test to
determine how dehydrated she is. You ask Mom to place Mary on the examining table so that she is
flat on her back with her arms at her sides, and her legs straight. You do pinch the skin of Mary’s
abdomen, and it goes back in 1 second.
1. Does Mary have any general danger
signs?
2. Classify the hydration status
3. How would you manage

45. Scenario 2
Mother tells you that Ahmad is 11 months old and has diarrhoea. This is their first time coming to
the clinic for this diarrhoea.
You take Adam’s weight, 10.5 kg, and temperature, 37◦C. Adam is able to drink milk and take
porridge. He does not vomit. He has not had convulsions. You watch Adam. He looks very tired in
mother’s arms, but he watches you as you speak. When you reach out to him to take his hand, he
grabs your finger. No cough.
Mother has already reported that Adam has diarrhoea. You ask mother how many days Adam has
had diarrhoea, and she tells you 3 days. You ask mother if there is blood in her son’s stool, and she
tells you no.
Now you will examine Adam’s condition. He seems alert and calm. You begin to examine Adam for
signs of dehydration. You check to see if he has sunken eyes, and it appears that he does. Mother
agrees that her son’s eyes look unusual. You offer him some water to drink and notice how he
responds. He drinks calmly. Next, you give Adam a pinch test to determine how dehydrated he is.
You ask Mom to place Adam on the examining table so that he is flat on his back with his arms at his
sides, and his legs straight. You do pinch the skin of Adam’s abdomen, and it goes back in 1 second.
1. Does Adam have any general danger signs?
2. Classify the hydration status
3. How would you manage

46. Summary
Diarrhoea in children
- Proper history
- Correct assessment
- Hydration status
- Treatment-Plan A,B,C
- Counsel mother when to return
- REFER if unsure
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47. Advise When To Return Immediately For All Children
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48. 11-13 April 2018 48
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49. THANK YOU
Questions ?
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