Module 4, Lesson 1 - Fever _ Diarrhea UPDATED 2021.pptx

Objectives
1. Learn how to manage fever in children and differentiate
causes of fever
2. Learn about the types of diarrhea, the causes, and how to
treat it
3. Understand diarrhea transmission and be able to explain it
to patients
4. Understand key prevention measures of diarrhea
Module 4 Lesson 1 :(Fever & Diarrhea)

Module 4 Lesson 1 :(Fever & Diarrhea)
LESSON
0 Pre-Test Hand out pre-tests
2
Role
Play
Willy, a 3 year old male patient is brought to the clinic and the mother says he has had high
fevers, chills, headache, and vomiting. What do you do?
Have one of the learners play the clinician, and have them go through subjective questions,
physical assessment, diagnosis, and treatment.
Assess the performance of the clinician and ask the group for feedback regarding what was
done properly and what was missed. This will give a good baseline assessment of the
knowledge of the group.
***It is important for the child patient to be calm if possible during the physical exam, so always
allow the caregiver to hold and comfort the patient, and do not wake a sleeping child.

LESS
ON
3
First action - Check Temperature: Take temperature in infants <3 months
rectally; Axillary temperature is preferred as an alternative in young infants;
Oral temperature is recommended for children >5 years16
-Always prevent the spread of infection by washing hands between every
consultation and using clean instruments
-Normal body temperature is 37 degrees C (98.6 degrees F)
-Generally, an axillary or oral temperature ≥37.5 degrees C is considered a
fever.1,10,29
- A rectal temperature of ≥38 degrees C (100.4 degrees F) is considered a
fever11,14,29
- All vital signs tell you how severe the fever is, but pay significant attention to
the temperature, especially in children.
Particularly in neonates and infants up to 3 months, hypothermia (<35
degrees C (95 degrees F)) can be just as indicative of sepsis as a high fever
response.2,13
Vital signs & Assessment

Normal Vital Signs12
Approximate Age Range Heart Rate Respiratory Rate
Newborn 100-160 30-50
0-5 months 90-150 25-40
6-12 months 80-140 20-30
1-3 years 80-130 20-30
3-5 years 80-120 20-30
6-10 years 70-110 15-30
11-14 years 60-105 12-20
Blood Pressure12
Approximate Age Range Systolic Range Diastolic Range
1-12 months 75-100 50-70
1-4 years 80-110 50-80
3-5 years 80-110 50-80
6-13 years 85-120 55-80
13-18 years 95-140 60-90
15-20 years 60-100 12-30

LESSON
How to convert between Fahrenheit and Celsius:8
-Converting 0C to 0F: Multiply by 9, divide by 5, then add 32
-Converting 0F to 0C: Subtract 32, multiply by 5, then divide by 9
Treat Fever:
-Treat fever over 40 degrees Celsius quickly with anti-pyretics
-Treat any fever over 41 degrees Celsius IMMEDIATELY with anti-pyretics and potentially
cooling mechanisms (wiping with lukewarm water) to induce evaporative cooling.8
-***Check the patient’s weight so that the proper dose can be given8
History of the signs & symptoms that accompany the fever:
-Establish the history of the fever (talk to the guardian):
-When did the fever start?2
-What have you done at home to decrease the fever?
-Did it help? By how much did the fever reduce?
-Have you taken any medications to reduce the fever? When was the last dose?9
-Is there a pattern to the fevers? Only in the mornings? etc.9
-Are there any past or current abnormalities or complaints?2,9
-What is the medical history?2
-What is the immunization history?2
-History of exposure to sick contacts2,9
Page 5
History of the signs & symptoms that accompany the
fever:

LESSON
-Factors that increase risk of sepsis: age under 2 months, an
immunocompromised state (neutropenic, malignancy, HIV), unvaccinated or
under- vaccinated.2,16
-Consider the source of the infection: Has the child been around others who
have similar symptoms of illness? Where has the child been playing? What has
the child been eating? Is the child up to date on immunizations?
Physical exam to assess the cause (head to toe):
-“Fever is frequently due to infection. In a febrile patient, first look for signs of
serious illness then, try to establish a diagnosis”1
-Signs of severe illness:
-Tachycardia, tachypnea, respiratory distress, SpO2 ≤90%1
-Altered mental status, petechial or purpuric rash, seizures, heart murmur,
meningeal signs, severe abdominal pain, critically ill appearance, bulging
fontanel in young children1
-Dehydration
- Dry mucous membranes, sunken fontanelles, absence of tears when
crying, and/or lack of urine output2 - IV fluid boluses can be dangerous
in African children - follow WHO rehydration plans, if dehydration is
present
Page 6

LESSON
- Shock
- Cool & clammy skin, pale skin, greyish colour to lips or fingernails, rapid pulse,
rapid breathing, nausea or vomiting, enlarged pupils, weakness or fatigue,
dizziness or fainting, changes in mental status or behaviour15
-Look for headaches, weakness, back pain, urinary pain, pain with deep breathing,
shortness of breath, rashes, sore throat, vomiting, diarrhea, signs of dehydration, ear or
nose pain, nasal discharge, etc.
-Determining what lab work should be collected will be guided by the history and physical
examination of the patient
-It is important to do a malaria test for all children with fever1,10
Treat the cause when found
-***Both the fever and the cause must be treated. Based on the age of the child, can
give paracetamol or ibuprofen to reduce fevers and relieve pain in conjunction with
curative treatment plan.
Page 7

LESSON
Causes of fever ***Is fever itself a disease? No, it is a sign of a disease
(examples) Some common causes of fever:
- Typhoid1,10
- TB1,10
- Pneumonia1,10
- Urinary Tract Infection (Bladder and/or Kidneys)1,10
- Ear Infection1,10
- Sinus Infection
- Dengue1
4
- Hemorrhagic fever1
- Streptococcal Pharyngitis1
- Measles1,10
- Meningitis1
- Malaria (transmitted through mosquitos)1,10
- Schistosomiasis (transmitted through contact with infested water)
- Filariasis (transmitted through mosquitos)
- Gastroenteritis1,10
- Acute HIV1
- Hepatitis1
- COVID-19
Page 8
Causes of fever
(examples)

LESSON
5
Treatment of fever
Medications to use for children to reduce fever:
-***Fever may be the only sign of serious infection in a young infant, and such infections should
be excluded before symptomatic treatment of fever is initiated - however, this must be
assessed on a case by case basis8
-Paracetamol1,4,8,16
-Infants <3 months can safely be given Paracetamol at the health centre when
undergoing care by medical staff - 10-15 mg/kg/dose every 6-8 hours as needed - max
dose Is 60 mg/kg daily in neonates16
-Infants, children & adolescents: 10 mg/kg/dose every 4 hours or 15 mg/kg/dose every 6
hours as needed (max 75 mg/kg daily)
- ***The window between a therapeutic dose and a toxic dose is so narrow with
Paracetamol, that the dosing is written this way to avoid accidental overdosing (ex. If
you gave 15 mg/kg/dose every 4 hours (6 times a day), it would equal to 90
mg/kg/day and that exceeds the max daily dose)
-Ibuprofen1,3,8
-Not recommended in infants <6 months8 (kidneys are not developed enough)
-Infants ≥6 months - children <12 years:10 mg/kg/dose every 6-8 hours (max 40 mg/kg
daily)
-Children ≥12 years & adolescents: 200-400 mg by mouth every 4-6 hours as needed (max
1200 mg daily)
-Use the lowest effective dose for the shortest effective therapy duration. Give with food if
stomach upset occurs.
Do not use aspirin in children and teens under 16 years old, as the risk for Reyes Syndrome
increases.
Page 9
Treatment of fever

LESSON
5
Treatment of fever
-Review each medication and know how quickly they work and how long they influence so that
you know how often to give the medication.
-If you give Paracetamol at 9AM, you must not wait until 2pm to check again. Check after 30
minutes to see if it has any influence. If the medication has not had the desired affect after 1
hour, consider adding another anti-pyretic. It is also important to search for the underlying
cause of the fever and treat that which will eventually hopefully also cause the fever to
decrease. IF it works, you may continue to give it as directed.
-Take the temperature of the patient every 4-6 hours if possible (or as needed if the mother
notes the child is feverish) to ensure fever is reducing; if no change, switch the anti-pyretic
medication and continue to look for and treat the cause of the fever.
-It is important to monitor the child's general appearance (for signs of serious illness such as
lethargy, stiff neck, altered mental status, purpuric rash, etc.), activity level, and fluid intake
-Give lots of fluids to drink in small sips if the patient is able; intravenous if patient unable to
tolerate oral fluids to maintain fluid status. Monitor urine output. Continue to feed, even if the
child has little appetite. The mother must be taught the importance of feeding/breastfeeding1
-Whatever the cause may be for the fever, it needs to be treated. Do NOT automatically
assume malaria without also ruling out other causes of fever like meningitis. Also,
consider that a patient that has malaria may also have another infection - thorough
and continuous assessment is necessary. Careful history taking, physical exam, and lab
work is needed to work up all differentials. This lesson focuses on the role of the nurse caring
for the patient with fever. See other lessons for appropriate treatment plans for individual
causes of fever.
Page
10
Treatment of fever

LESSON
6
Case study Subjective: A 3 year old male patient is brought to the clinic with a 1 day history of high fevers, chills,
headache, and vomiting. Mother reports he has not been eating well and has been irritable, preferring to lie
about rather than play with siblings for the few days prior to the vomiting. He has vomited three times in
the last 12 hours, and his urine output has decreased; however, he has had no diarrhea. Mother denies
seizures, trauma, or patient complaints of pain – specifically no sore throat, ear/nose pain, or pain with
urination. She does not have a thermometer at home; she has been keeping him cool with wet washcloths.
None of the other siblings have signs or symptoms of an illness at this time.
Objective:
First step: Take the patient’s temperature and give the
patient medication if necessary. Temp = 40.0 C. Give an
antipyretic then continue with the rest of the exam.
Vitals: Temp: 40.0C; HR: 120 beats per minute, strong and regular; RR 34 breaths per minute, even and
unlabored; Oxygen saturation 98% on room air; weight is 14kg.
Physical exam reveals: Patient lethargic in mother’s arms, Pupils are equal, round, and reactive to light.
Tympanic membranes are opaque bilaterally. Clear nasal discharge. Pharynx without infection or tonsillar
enlargement. Heart, Lungs, and Abdominal exams are all normal. Capillary refill <2 seconds with good
colour overall. He moves all extremities weakly when asked.
What is your differential at this time?
- Most Likely – Meningitis, Malaria
- Less Likely – Gastroenteritis (no diarrhea or abdominal pain), Strep Pharyngitis (no throat findings,
pain or rash), Ear Infection (no ear pain, and does have opacity of the tympanic membrane
bilaterally), Urinary Tract Infection (no urinary changes, no supra-pubic tenderness)
Page
11

LESSON
What are the critical signs/symptoms for the top two differentials?
Meningitis (Bacterial or Viral) - Do not assume malaria instantly without also ruling out meningitis- the symptoms are
similar!!
- Symptoms specific to meningitis:
- Nuchal rigidity (neck stiffness)5,6
- Signs of increased intracranial pressure: bulging fontanelle; headache; vomiting; drowsiness; Cushing triad
(hypertension, bradycardia, & respiratory depression)5
- Photophobia (intolerance to light)5,6
- Headache5,6
- Non-blanching rash6 (less visible with darker skin - check soles, palms, and conjunctivae)
- Brudzinski’s sign: when passive flexion of the neck is performed, meningeal irritation will result in flexion of the hips
& knees5
- Kerning’s sign: Meningeal inflammation causes the person to resist leg extension5,6
- Symptoms that are nonspecific:
- Fever6
- Vomiting5,6
- Diarrhea5,6
- Irritability5,6
- Poor Feeding5,6
- Lethargy5
- Seizures5
- Hypoglycemia6
- Hypotonia5
Malaria
- “Signs and symptoms that are nonspecific. There is no combination of signs or symptoms that reliably
distinguishes malaria from other causes of fever. Diagnosis based only on clinical features has a very low
specificity and results in over-treatment. Other possible causes of fever and whether alternative or additional
treatment is required must always be carefully considered.”7
- Headache
- Weakness/fatigue
- Abdominal discomfort
- Muscle and joint aches
- Fever
- Chills
Page
12

LESSON
- Perspiration
- Poor feeding
- Vomiting
Physical exam continued to differentiate between malaria and meningitis: Reveals no nuchal rigidity, no hyperactive reflexes,
and no photophobia. If ANY of these signs were positive, the patient should be immediately transferred to a hospital for a
lumbar puncture and lab work to rule out meningitis. Give an injection of ceftriaxone 100 mg/kg before transfer - should be
given immediately upon suspicion of meningitis.
You send the patient to the lab:
Malaria test + Assessment/Plan:
Diagnosis is Malaria
- Begin treatment for malaria following the MOH protocols for treatment of a child of this age and size, with the
appropriate scheduled follow up and patient teaching
- Because this child is vomiting and dehydrated, start an IV – This patient will need fluids and parenteral therapies
- Treat fever with either paracetamol or ibuprofen by weight
- Continue to monitor the child very carefully with vital signs 30 minutes after giving the antipyretic to assure it has taken
effect against the fever, and then vital signs every 4-6 hours
- The nurse should also continue to monitor the child for signs of meningitis; even though the initial diagnosis was
malaria and the patient did not have signs of meningitis at that time, the patient could develop signs and therefore
should be monitored and treated appropriately
- If you have the capability at the clinic site, you may consider drawing labs – Get a CBC, blood culture, and chemistry
panel—otherwise wait for these if the patient ends up needing to be transferred, and it can be done at the hospital
level
- If this patient stabilizes and is sent home, make sure to teach the mother about warning/danger signs and explain to the
mother when she should bring the child back to the health centre versus the hospital
Page
13

LESSON
7
Introduction to
Diarrhea
- Globally, there are nearly 1.7 billion cases of diarrheal disease every year…it is the 2nd leading cause of death in children under five years old. It is
both preventable and treatable.19,24
- Diarrhea is a leading cause of malnutrition in children under five years old19
- Diarrhea kills more young children than AIDS, malaria, & measles combined17
- Many people who die from diarrhea actually die from severe dehydration and fluid loss19
- For children with HIV, diarrhea is even more deadly; the death rate is 11 times higher17
- “A significant proportion of diarrheal disease can be prevented through safe drinking water and adequate sanitation and hygiene”19
Ask the participants, what is the definition of diarrhea?
- Diarrhea is the passage of 3 or more loose or liquid stools per day (or more frequent passage than is normal for the individual)18,19,24
- “Frequent passing of formed stools is not diarrhea, nor is the passing of loose, "pasty" stools by breastfed babies”19
- Diarrhea is often a symptom of an infection in the intestinal tract - can be caused by several bacterial, viral and parasitic organisms19,22
- There are three clinical types of diarrhea:18,19,24
1. Acute watery diarrhea – lasts several hours or days
2. Acute bloody diarrhea – also called dysentery (requires antibiotic treatment)
3. Persistent/chronic diarrhea – lasts ≥14 days
8
Causes
of
Diarrhea
Ask the participants, what are the causes of Infectious diarrhea?
The fecal oral route is the main cause of infectious diarrhea; transmitting the disease from the fecal matter to the mouth19
- Microorganisms - Shigella, Giardia, Vibrio cholerae, E. coli, and Rotavirus are the most common
- These pathogens can cause rapid and fatal dehydration17 that is most dangerous in the very young
- This cycle is fuelled by the “Five ‘F’s”:21 (Have the participants repeat the 5 “F’s” back)
1. Fluid (drinking contaminated water)
2. Fields (the contamination of soil and crops with human fecal matter)
3. Fingers (unwashed hands preparing food or going into the mouth)
4. Food (eating contaminated food)
5. Flies (spreading disease from feces to food and water or directly to people – particularly problematic where open air defecation is the
norm)
9
Acute
Watery
Diarrhea
Acute watery diarrhea:
- WHO defines diarrhea as the passage of 3+ loose or watery stools in a 24 hour period.19,24 Furthermore, these symptoms must last < 2 weeks to be
considered acute.18,24
- Most acute diarrheas are caused by VIRUSES, such as rotavirus17,18,19,23,24
- Rotavirus is a vaccine-preventable disease17
Page
14
Copyright LifeNet International Corporation 2015. All rights reserved. Written by Ana Barz FNP; Edited by Nadine Guenther RN.
Expert Reviewers Alyssa Pfister MD, Kibuye Hope Hospital Peediatrics and Internal Medicine & Hope Africa University Professor, Burundi;
Dr. Jennifer Harling, MD, Pediatrician at Kibuye Hope Hospital, Burundi
Last Updated October 2021

LESSON
10
Acute
Bloody
Diarrhea
Acute bloody diarrhea:
- May experience abdominal cramping and pain with bowel movement18
- In the absence of a microscope, check blood in stool for diagnosis
- Rarely occurs with viruses and therefore requires antibiotic treatment18
- Frequently occurs with Shigellosis18,23,24
- Also may occur with Campylobacter jejuni, E. coli, Salmonella, or parasites such as intestinal amoebiasis18,24
- Similar treatment to acute watery diarrhea, however, also treat with antibiotics18
11
Persistent/Chroni
c Diarrhea
Persistent/Chronic diarrhea:
- Diarrhea that lasts ≥14 days18,19,23,24
- Most persistent diarrhea is a combination of poor sanitation, lack of clean water and malnutrition; therefore, treatment is largely dependent on
systemic change, hygiene campaigns and teaching patients and families about proper water preparation techniques19
- It is also associated with malnutrition, either preceding or resulting from the illness itself23
- Assess for the cause of the diarrhea:
- Consider antibiotic treatment for persistent diarrhea that is infectious/bloody23
- An HIV test should be done if the diarrhea is persistent, as it may be an indicator of an HIV infection23,25
- Consider assessing for tuberculosis, both pulmonary and extra-pulmonary23
- Consistent poor hygiene measures may mean that the child is being constantly re-infected
Page 15 Copyright LifeNet International Corporation 2015. All rights reserved. Written by Ana Barz FNP; Edited by Nadine Guenther RN.

LESSON
Assessment
/ Evaluation
Much of the evaluation of diarrhea is done with history taking: take your time and ask the mother the following questions, don’t just send the patient to
the lab.
12
Assessment:
History (subjective):
***Classify the diarrhea24
- When did it start?
- If the diarrhea has been occurring for <7 days, it is considered acute
- If it has been occurring for >14 days it is considered persistent
- What is the Consistency of the diarrhea?
- Liquid?
- Blood present?
- Mucous present?
- Many infants have many stools a day that vary in consistency; the parent will know what is normal for the child and what is abnormal; ask the
parent if this stool is different from the child’s normal stool pattern
- Stomach cramping?
- Is the child eating?
- ***Nutritional status?
- ***Hydration status?
- ***Co-morbid conditions?
Physical Exam (objective):24
- Vital signs are important in identifying the severity of dehydration and to assess for a fever (HR, RR, Temperature)
- Check the arm circumference - the signs/symptoms/treatment are somewhat different for a severely malnourished child with dehydration
compared to a well-nourished child with dehydration. If the arm circumference is <11.5 cm, the child is severely malnourished and the child
should be treated as such.23
- Evaluate for dehydration (abdomen, heart, lungs, skin, eyes) — however, there are almost always no signs of dehydration present when the child is
mildly dehydrated18,19,23,30
- Thirst
- Restless or Irritable
- Sunken eyes
- Sunken fontanelles
- Decreased urine output
- Dry mucous membranes

LESSON
- Tachycardia
- Slow skin pinch (≥2 seconds)
- Capillary refill (≥2 seconds)
- Change in level of consciousness (severe)
- Shock (severe)
- If the patient has chronic diarrhea or blood in the stool, a stool test may be needed to identify the cause and proper treatment

LESSON
13
Rehydration and
Zinc
First objectives with all diarrhea is rehydration and zinc supplementation!
***The most common cause of acute diarrhea is a viral infection that does not require antibiotic treatment but only supportive hydration measures with
ORS and zinc for children.18
REHYDRATION (primary goal)
- Oral Rehydrations Salts (ORS): Mixture of clean water, salt and sugar - absorbed in the small intestine & replaces the water and electrolytes lost in the
stool. It is the best option used very frequently and in small amounts19
- Ideally the low Osmolarity Rehydration Salts are preferred20,23
- The decreased amount of sodium and glucose in the low Osmolarity Rehydration Salts results in a reduction of stools and vomiting
- ORS is significantly underused
- It is crucial that it is used with consistency across health centres in order to reduce child mortality
- ***IV rehydration should be used for severe dehydration only19
Dosing of ORS by mouth (also, continue breastfeeding for infants) - May follow Plan A, B, & C in national guidelines (for a well-nourished child -
there are different guidelines for malnourished children)
- For no dehydration/early dehydration (Plan A):18 In addition to usual fluid intake, give ORS after each loose stool or emesis (Child < 2 years:
50-100 mL / Child 2 years: 100-200 mL)
- For moderate dehydration (Plan B):18 In addition to usual fluid intake, give 75 mL/kg ORS over 4 hours; additional ORS after each loose stool
- For severe dehydration (Plan C):18 The goal of rehydration with IV fluids is to stabilize the circulation immediately. WHO recommends that a bolus
of Ringers Lactate or Normal Saline 30 mL/kg be given over 30 minutes (or one hour in infants <12 months), followed by additional fluids to
correct the majority of the remaining fluid deficit, by giving 70 mL/kg of fluid over 2.5 hours (or 5 hours for infants <12 months).24 The IV line
should remain in place until it is certain there is successful transition to ORS.
- Re-assess every hour. At the end of each hour, the patient’s hydration status and continuing stool and emesis losses should be calculated and
those fluids replaced.20
- Do not automatically put in an IV for every child who has diarrhea! This is not the best care of these children. Only give in severe cases; in these
cases you may be putting in the IV before transferring the patient.
- In general, in patients with severe malnutrition, care must be taken in rehydration as there is a high risk of fluid overload.24
- If the child refuses to drink or vomits with the ORS administration, monitor closely and consider using IV rehydration

LESSON
- How do you give ORS if the patient is also vomiting?
- SLOWLY so that the child doesn’t vomit it back up - give one spoonful, and then wait a few minutes before giving ORS again, until the
appropriate amount of intake is achieved.
- Check for signs of fluid overload (edema, acute pulmonary edema)18
ZINC SUPPLEMENTATION:
- The World Health Organization recommends zinc supplementation for children <5 years in addition to ORS use for acute diarrhea
- Children under 6 months: 10 mg (1/2 tablet) once daily for 10 days18
- Children from 6 months to 5 years: 20mg once daily (1 tablet) for 10 days18
- Shown to reduce the severity and reduction in acute diarrheal episodes18,19
Other:
- Remind patients not to stop feeding the children with diarrhea - continue regular diet (nutrient-rich foods are best)18
- Promote and ensure adequate vitamin A supplementation24
14
When to Give
Medication
Antibiotics:
- Most acute diarrheas are caused by viruses, and therefore are not responsive to antibiotics18
- Antibiotics are only indicated in:
- Acute diarrhea with blood:18
- Shigellosis (the most common cause of bloody diarrhea)
- Amoebiasis
- Acute diarrhea from:18
- Cholera
- Giardiasis
- ***Check the Ministry of Health Guidelines for specific antibiotic & dosing
Other medication use:
- Children with acute diarrhea should not receive anti-motility medications. Non-sedating antiemetics may be considered, while sedating antiemetics
such as promethazine, should be avoided18
15
When to Transfer - A presentation of diarrhea to the health centre is time sensitive—do not wait to start hydrating the child.
- Always assess for dehydration and subsequently start rehydration!
- If the child needs to be transferred as they are not improving or have severe dehydration that can not be treated at the health centre level, continue
the rehydration and ORS administration until transfer is possible

LESSON
16
Role Play Role play: A woman comes in with her 4 year old boy with diarrhea. He has had 4 watery stools since yesterday morning. How do you evaluate this
patient? What do you teach the mother?
Have one of the health workers play the clinician, and have them go through the teaching with the patient’s mother.
Assess the performance of the clinician and ask the group for feedback regarding what was done properly and what was missed.
Review things done well as well as areas in need of improvement.
17
Prevention of
Severe
Infections
Prevention of severe infections:26
Ask the participants, what are some key measures to prevent diarrhea?
- Access to safe and sufficient drinking-water (both quality and quantity)19
- Let the water settle & remove sediment; boil for 3 minutes; water should be stored in the same container in which it has been boiled or
heated, preferably one with a lid or other protected opening, in order to reduce opportunities for recontamination; the water should be
consumed soon after it has cooled and preferably within the same day (potential for microbial recontamination during prolonged storage).
- Use of improved sanitation19
- Discourage/eliminate open defecation; proper disposal of human waste17
- Hand washing with soap after the toilet, before cooking, and before and after eating18,19
- Good personal and food hygiene19
- Clean cooking supplies with soap & water; never store raw and cooked foods together; cook food thoroughly;18 don’t leave food out for a
long time after it has been cooked;wash the outside of fruits and vegetables well with soap and water before cutting into them
- Health education about how infections spread19
- Rotavirus17,18,19 vaccination (Don’t forget to educate parents about why this vaccine is important!—severe diarrhea prevention)
- Should receive all 3 doses of vaccine before they turn 8 months of age28
- ***Check Ministry of Health Guidelines for specifics on vaccine dosing & timing
- Exclusive breastfeeding for the first six months of life is incredibly important for reducing the risk of life threatening diarrhea17,18,19,26
- Consider isolating patients admitted to a room for diarrhea (gown and gloves), then doing an extra good clean after they leave, as some infectious
causes of diarrhea can stay on surfaces for many days, and be passed from hand to mouth

REFERENCES
1. Medecins Sans Frontiers. Clinical guidelines: diagnosis and treatment manual for curative programmes in hospitals and dispensaries, guidance for prescribing. Medecins
Sans Frontiers Web site. https://medicalguidelines.msf.org/viewport/MG/en/guidelines-16681097.html#books. June 2021. Accessed April 26, 2021.
2. Ghory HZ. Emergent management of pediatric patients with fever. Medscape. July 2019. http://emedicine.medscape.com/article/801598-overview#aw2aab6b4.
Accessed April 26, 2021.
3. UpToDate Lexicomp. Ibuprofen: Pediatric drug information. UpToDate, Waltham, MA. (Accessed April 27, 2021.)
4. UpToDate Lexicomp. Acetaminophen (paracetamol): Pediatric drug information. UpToDate, Waltham, MA. (Accessed April 27, 2021.)
5. Kaplan SL. Bacterial meningitis in children older than one month: clinical features and diagnosis. In: UpToDate, Edwards MS, Armsby C (Eds), UpToDate, Waltham, MA.
(Accessed April 28, 2021.)
6. Pentima CD. Viral meningitis in children: clinical features and diagnosis. In: UpToDate, Kaplan SL, Armsby C (Eds), UpToDate, Waltham, MA. (Accessed April 28, 2021.)
7. World Health Organization. Guidelines for the treatment of malaria. WHO Web site. http://apps.who.int/iris/bitstream/10665/162441/1/9789241549127_eng.pdf?ua=1.
2015. Accessed April 28, 2021.
LESSON
18
How to Create
ORS
How to create Oral Rehydration Salts:27
***If the mother feels confident in how to start rehydrating the child right away when the child shows signs of diarrhea or vomiting, the child has a better
chance of getting enough fluid and surviving - Find every opportunity to teach her so she is prepared before the child is sick to prevent the child from
having severe symptoms/possible death.
If packets of ORS are available:27
- If ORS packets are available: dilute the sachet of ORS in 1 litre of SAFE drinking water (Low-Osmolality ORS should be used)
- Give the solution to the patient in small amounts at regular intervals on a continuous basis
If packets of ORS are NOT available: (make sure learners write this down, the correct measurements are very important)
- “In case ORS packets are not available, homemade solutions consisting of either half a small spoon of salt and six level small spoons of
sugar dissolved in one litre of safe water, or lightly salted rice water or even plain water may be given to PREVENT or DELAY the onset
of dehydration on the way to the health facility. However, these solutions are inadequate for TREATING dehydration caused by acute diarrhea,
particularly cholera, in which the stool loss and risk of shock are often high. To avoid dehydration, increased fluids should be given as soon as
possible. All oral fluids, including ORS solution, should be prepared with the best available drinking water and stored safely. Continuous provision
of nutritious food is essential and breastfeeding of infants and young children should continue.”27 Be careful to explain to your patients not to add
too much salt! One small spoon is all—if you give too much, this can actually be harmful to the child.
19 Post-Test Hand out post-tests

8. Ward MA. Fever in infants and children: pathophysiology and management. In: UpToDate, Edwards MS, Torchia MM (Eds), UpToDate, Waltham, MA. (Accessed April 27,
2021.)
9. Palazzi DL. Fever of unknown origin in children: evaluation. In: UpToDate, Kaplan SL, Sundel R, Drutz JE, Torchia MM (Eds), UpToDate, Waltham, MA. (Accessed April 27,
2021.)
10. World Health Organization. WHO informal consultation on fever management in peripheral health care settings: a global review of evidence and practice. WHO Web site.
https://apps.who.int/iris/bitstream/handle/10665/95116/9789241506489_eng.pdf?sequence=1. 2013. Accessed April 27, 2021.
11. Smitherman HF, Macias CG. Febrile infant (younger than 90 days of age): definition of fever. In: UpToDate, Teach SJ, Edwards MS, Wiley JF (Eds), UpToDate, Waltham,
MA. (Accessed April 28, 2021.)
12. Charbek E, Christensen B. Normal vital signs. Medscape. November 2018. http://emedicine.medscape.com/article/2172054-overview. Accessed April 28, 2021.
13. Corneli HM, Kadish H. Hypothermia in children: clinical manifestations and diagnosis. In: UpToDate, Danzl DF, Wiley JF (Eds), UpToDate, Waltham, MA. (Accessed April 27,
2021.)
14. Smitherman HF, Macias CG. Febrile infant (younger than 90 days of age): outpatient evaluation. In: UpToDate, Teach SJ, Kaplan SL (Eds), UpToDate, Waltham, MA.
(Accessed April 28, 2021.)
15. Mayo Clinic. Shock: first aid. Mayo Clinic Web site. https://www.mayoclinic.org/first-aid/first-aid-shock/basics/art-20056620. September 2019. Accessed April 21, 2021.
16. Epocrates. Acetaminophen. Epocrates Web site. https://online.epocrates.com/drugs/30610/acetaminophen/Monograph. 2021. Accessed April 28, 2021.
17. Centers for Disease Control and Prevention. Global diarrhea burden. CDC Web site. http://www.cdc.gov/healthywater/global/diarrhea-burden.html. December, 2015.
Accessed April 29, 2021.
18. Medecins Sans Frontiers. Clinical guidelines: diagnosis and treatment manual for curative programmes in hospitals and dispensaries, guidance for prescribing. Medecins
Sans Frontiers Web site. https://medicalguidelines.msf.org/viewport/MG/en/guidelines-16681097.html#books. June 2021. Accessed July 22, 2021.
19. World Health Organization. Diarrheal disease: fact sheet. WHO Web site. http://www.who.int/mediacentre/factsheets/fs330/en/. May 2017. Accessed April 29, 2021.
20. Freedman S. Oral rehydration therapy. In: UpToDate, Mattoo TK, Stack AM, Kim MS (Eds), UpToDate, Waltham, MA. (Accessed April 29, 2021.)
21. Water1st. Paths of disease transmission. Water1st Web site. https://water1st.org/problem/f-diagram/. 2021. Accessed July 26, 2021.
22. Fleisher GR, O’Ryan MG. Patient education: acute diarrhea in children (beyond the basics). In: UpToDate, Sanghamitra MM, Torchia MM (Eds), UpToDate, Waltham, MA.
(Accessed July 22, 2021.)
23. Moore SR. Persistent diarrhea in children in resource-limited countries. In: UpToDate, Li BUK, Hoppin AG (Eds), UpToDate, Waltham, MA. (Accessed July 22, 2021.)
24. Harris JB, Pietroni M. Approach to the child with acute diarrhea in resource-limited countries. In: UpToDate, Calderwood SB, Edwards MS, Bloom A (Eds), UpToDate,
Waltham, MA. (Accessed April 29, 2021.)
25. Centers for Disease Control and Prevention. Hygiene-related diseases: chronic diarrhea. CDC Web site. http://www.cdc.gov/healthywater/hygiene/disease/
chronic_diarrhea.html. August 2, 2016. Accessed July 26, 2021.
26. UNICEF, WHO. Ending preventable child deaths from pneumonia and diarrhea by 2025. 2013. http://apps.who.int/iris/bitstream/
10665/79200/1/9789241505239_eng.pdf. Accessed July 26, 2021.
27. World Health Organization (WHO). Cholera: WHO position paper on oral rehydration salts to reduce mortality from cholera. http://www.who.int/cholera/technical/en/. 2008.
Accessed July 26, 2021.

28. Centers for Disease Control and Prevention. Rotavirus vaccination: what everyone should know. CDC Web site. https://www.cdc.gov/vaccines/vpd/rotavirus/public/
index.html. March 2021. Accessed October 2, 2021.
29. Alberta Health Services. Fever. AHS Web site. https://www.albertahealthservices.ca/heal/page12428.aspx. 2021. Accessed October 2, 2021.
30. Auerbach M. Assessment of systemic perfusion in children. In: UpToDate, Torrey SB, Wiley JF (Eds), UpToDate, Waltham, MA. (Accessed October 2, 2021.)

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