Analysis of prescription practices as part of UNICEF 10 districts survey revealed, of those who sought care, only 47 per cent of the children were prescribed ORS. Tonics, anti-diarrhoeal drugs, and injections continued to be prescribed for diarrhoea. Overall, 23 per cent of the children who had diarrhoea in the two weeks prior to the survey received an injectable drug, 18 per cent were given anti-diarrhoeal drugs, and 6 per cent were treated with antibiotics. We will see later in subsequent sessions that these antidiarrheal drugs, tonics and injections have no role.
present in the body in very small quantities. increases skin, and mucosal resistance to infection. increases skin, and mucosal resistance to infection. Zinc cannot be stored in the body, and nearly 50%of zinc excretion takes place through the gastrointestinal tract and is increased during episodes of diarrhea. Breast milk not sufficient source > 6 month Inadequate intake of complementary foods
Diarrhea Management in
One in 5* children die of diarrhea or diarrhea
related complications every year in India.
Diarrheal illness is the second leading cause of
child mortality; among children younger than 5
years, it causes 1.5 to 2 million deaths annually.
In developing countries, children experience
between three to six episodes of diarrhea annually.
*Predicting the distribution of under-five deaths by cause in countries without adequate vital registration
Saul S Morris,1 Robert E Black2 and Lana Tomaskovic3(International Journal of Epidemiology
Magnitude of problem
• In India,~380,000 *children die from diarrhea and its
complications every year.
• 9.8 million child deaths each year, 2/3 of which are
preventable with low-cost interventions
• 2 million child deaths from diarrhea, 88% of Diarrhea
diseases are preventable by easily available
• Diarrheal diseases are responsible for 18%** of
deaths among children under 5 years of age.
• Despite easy and affordable treatment, most patients
do not access the recommended treatment.
• Timely use of ORS-Zinc can save over 133,000 lives
*World Health Organization, Global Burden of Disease estimates, 2004
**Causes of Child Deaths - March 26, 2005 The Lancet
***Role of zinc administration in prevention of childhood diarrhea and
pneumonia-a meta analysis,Agarwal I R,Sentz J,Miller M A,Paediatrics
Causes of Child Deaths in Low-Income
Countries: Diarrhea 18%
Source: WHO, World Health Statistics 2011
• Any Change in number or consistency of stools
in exclusively breast-fed children.
• Passage of 3 or more than 3 loose or watery
stools in 24 hours in children over 2 months of
• Diarrheal illness may be of the following typesacute watery diarrhea and chronic or persistent
diarrhea (lasting for ≥14 days).
• Blood in stools-Dysentery.
• Usually seen in children between 2 months and
5 years of age.
When is it NOT Diarrhea?
• Frequent passage of soft, semisolid stools in an exclusively
• No change in consistency or
number of stools.
Diarrhea and Dehydration
•Passage of 3 or more than
3 loose or watery stools in
•Any Change in number or
consistency of stools.
•Often associated with
and/vomiting, there is loss of
water and electrolytes.
•Dehydration occurs when
these losses are not
replaced adequately and a
deficit of water and
Consequences of Diarrhoea
The two main dangers: malnutrition and
Commonest cause of diarrhea related
Equally important causes of death are
dysentery and prolonged malnourishing
Malnutrition is associated with nearly
two-thirds of diarrhea-related deaths.
What are our challenges in
the treatment of diarrhea?
• Low ORS use rates
• Use of zinc as an adjunct to ORS
• Inappropriate management of dehydration
• Inadequate emphasis on feeding
• Irrational use of antimicrobials & other
• Hand washing
Prescription Practices10 district survey in India
Management Practices for Childhood Diarrhea in India , UNICEF 2009
Two simple rules for effective
management of Diarrhea
• Replaces water and salts lost during
• Reduces dehydration and need for
• Decrease in severity of diarrhea and
• Decrease in duration of illness.
What is Zinc?
Zinc is a micro-nutrient and promotes immunity.
It is an important antioxidant and preserves cellular membrane
Promotes the growth and development of the nervous system.
Rich sources of Zinc are foods of animal origin, such as meat and
Zinc is also present in nuts, seeds, legumes, and whole grain
cereal, but the high phytate content of these foods interferes with its
Zinc cannot be stored in the body, and zinc excretion through the
gastrointestinal tract is increased during episodes of diarrhea.
• Young children who have frequent episodes of
diarrhea and have diets low in animal products and
high in phytate-rich foods are most at risk of Zinc
• Zinc reduces the fluid and salt loss in stools by
improving mucosal permeability.
• Accelerated regeneration of mucosa
• Increased levels of brush-border enzymes
• Enhanced cellular immunity
• Higher levels of secretory antibodies
• Zinc improves absorption of ORS.
• Reduces the severity and duration of illness.
• Reduces need for antibiotics.
• Reduces the chances of complications.
• Full dose for 14 days protects against diarrhea and
pneumonia for next 3 months.
• Acts as a general tonic-improves appetite and
Research Studies on
efficacy of Zinc
• A study conducted by an international team of scientists
working in Bangladesh and led by researchers from the
Johns Hopkins Bloomberg School of Public Health.
• The researchers treated 8,070 children with diarrhea
living in areas of Bangladesh.
• Groups of children were randomized by region to receive
zinc in addition to standard treatments and compared to
children who did not receive zinc.
• The children in the zinc areas received 20 mg elemental
zinc daily for 14 days during each episode of diarrhea in
addition to ORS therapy.
• The researchers found the incidence of diarrhea was
significantly less and non-injury deaths were 50 percent
less in children who received zinc compared to those
who did not.
• In addition, it was found that
oral rehydration solution therapy (ORS) use, which is
one of the standard treatments for diarrheal disease,
increased by 20 percent among the children who
received zinc. Antibiotic use decreased by 60 percent
among the same group. These findings are published in
the November 9, 2002, of the British Medical Journal.
for Use of Zinc in
WHO/UNICEF Joint Statement
Endorsed by Indian Academy of
Endorsed by Government of India
Zinc has been included in the
WHO and India Essential
Medicines List for the treatment
Evidence of Efficacy of
• 15% faster recovery during the episode of diarrhea*.
• 16 % decrease in duration of diarrhea*.
• 24% decrease in frequency of episodes lasting more
than 7 days*.
• 9-23% decrease in frequency of stools*.
• Up to 31% reduction in stool output during the episode
• 42% reduction in treatment failure or death in persistent
*ACUTE CHILDHOOD DIARRHEA: A REVIEW OF RECENT ADVANCES IN THE STANDARD MANAGEMENT
Seema Alam, Rajeev Khanna, Uzma Firdaus
Pediatric Gastroenterology Section, Department of Pediatrics, JNMC, AMU, Aligarh
**Zinc with ORT reduces the stool output and duration of diarrhea in hospitalized children -a randomized controlled trial;S Bhatnagar et al, Dept
at AIIMS and Kasturba Hospital ,New Delhi
***Zinc Investigators’ Collaborative Group. AJCN 2000.
Long Term Effects of Zinc
• Zinc supplementation for 10-14 has
longer term effects on childhood
illnesses in the 2-3 months after
• 34% reduction in prevalence of
• 26% reduction in incidence of
Zinc Investigators’ Collaborative Group. Pediatrics. 1999.
Cost Effectiveness of ORS and
• Decreases the duration and severity of the
• Decreases the need for expensive
• Decreases the use of unnecessary
antibiotics and other drugs
• Further cost-benefit analyses are
Robberstad, Strand, Sommerfelt, and Black. Bull WHO 2004.
Baqui, Black, Arifeen. J Health Pop Nutr. 2004.
Current total costs of treating a
case of diarrhea higher than the
cost of Zinc treatment
Reported total costs of
treating a case of diarrhea,
Location for differing levels of
ORS sachets are sold for Rs 5-7 in the private sector ($0.10-$0.14). Zinc treatment for 10-14 day
regimen costs ~Rs.28-33 in the private sector ($0.56-$0.66)
Source: Formative research in preparation for promotion of zinc treatment for childhood diarrhea:
Cross-country comparison of diarrhea treatment practices and implications for programs; June
Dosage of Zinc
• Available as ZINC Tablets.
• Given for 14 days for full benefits.
• 20 milligrams per day for children older
than six months.
• 10 mg per day in those younger
than six months.
Less than 2
2 months – 6
Dissolved in 1
tsp of breast
6 months- 5
Dissolved in 1
tsp of breast
Objective of Treatment
• Prevent dehydration, if no signs of
dehydration are present.
• Treat dehydration, if present.
• Reduce duration and severity of illness.
• Prevent nutritional damage.
• Reduce the occurrence of future
• Caregivers/ mothers should start treatment
with new low osmolarity ORS solution
immediately upon onset of diarrhea in a child.
• Zinc supplementation with 20 mg per day
of zinc supplementation for 14 days (10 mg
per day for infants under six months old).
• Emphasize continued feeding or increased
breastfeeding during, and increased feeding
after, the diarrheal episode.
• Emphasize handwashing.
Lessen absorption capacity
Faster Recovery of Intestine Mucosa
Increase in absorption capacity
Increase in immunity
Management of Diarrhea
Yes, but in
Well , Alert
Drinks poorly or
not able to drink
slowly bit in less
than 2 seconds
Goes back very
slowly, in more
than 2 seconds
Is the child
More than 14
Blood in stool
<5 % of body wt
or 50 ml./ kg
5-10% of body wt
or 50-100 ml / kg
>10% of body wt
or 100 ml / kg
Home therapy to prevent dehydration and malnutrition
Children with no signs of dehydration need extra fluid and salt to replace their losses of
water and electrolytes due to diarrhea.
Fluids to be given
Salted drinks e.g. salted rice water, salted yoghurt drink ,green coconut water.
Home based ORS.
Plain water should also be given.
Commercial fizzy drinks, fruit juices, sweetened tea, coffee, medicinal tea should be
How much to give?
Give as much fluid as the child wants until diarrhea stops.
Children < 2 years of age : 50-100 ml of fluid.
Children 2 years - 10 years : 100-200 ml.
Older children and adults : As much as they want.
Give 10 / 20 mg (depending on age of the child) every day for 14 days.
What feeds to give?
Breastfeeding should always be continued.
The infant's usual diet should be continued during diarrhea and increased afterwards.
washing of Hands
For children with some dehydration
Approximate amount of ORS required (in ml) can be calculated by multiplying
the patient's weight in kg by 75.
More can be given, if required.
Breast feeding should be continued.
No other foods are to be given during the initial period.
After 4 hours, the child should be given some food every 3-4 hours.
After 4 hours, reassess the child and decide what treatment to be given next as
per level of dehydration.
Referred for IV rehydration if dehydration persists.
11-15.9 kg 16-29.9 kg
30 kg or
Why are drugs prescribed in
• Lack of Knowledge
• Lack of confidence in ORS
• Families demand drugs and
• Consultation/ Dispensing fees
Irrational use of drugs
• Increases the cost of therapy
• Diverts attention from main therapy- ORS, feeding and Zinc
- antibiotic induced diarrhea
• Complications- Simple infection converted into a lifethreatening infection due to - Abdominal distension,
- Paralytic ileus
- Respiratory depression
- Pseudomembranous entero-colitis
• Drug resistance
Antibiotics, Adsorbents and Anti-motility drugs are
NOT indicated in the routine treatment of acute
Refer immediately if•
Does not improve within 3 days.
Increase in the number of stools.
Develops very watery or bloody stools.
Marked reduction in urine output.
Develops high grade fever.
Decrease in alertness or consciousness.
Prevention of diarrhea
• Exclusive breast feeding for 6
• Complementary feeding at 6
• Hand washing
• Safe drinking water
• Environmental sanitation and safe
disposal of excreta
• Measles vaccination
A substantial reduction in the diarrhea burden will require
greater emphasis on the following actions:
Reinstate diarrhea prevention and treatment as a cornerstone
of community-based primary health care.
Reach every child with effective interventions.
Ensure wide availability of low-osmolarity ORS.
Ensure wide availability and use of zinc.
THERE IS NO BETTER TIME THAN