Training Module L1_English 1

8/2/2019 Training Module L1_English 1

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Childhood Diarrhea Management

Training for Medical Of cers

Participants Manual


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ContentsAgenda for One day Training of Medical Ofcers 6

Pre Assessment Form for Medical Ofcers 7

Session 1:

Welcome, Introduction and Objectives 9

Session 2:

Diarrhea Management

Session 3:

Diarrhea Management Program: Design and Delivery 38

Session 4:

Understanding Communication 44

Session 5:

Learning IPC Skills 51

Session 6:

Using IEC/IPC Materials 55

Session 7:

Learning Monitoring, Evaluation, Supervision and Reporting 58

Session 8:

Closing and Thanks 64

Annexures 65

References 73


4/43Childhood Diarrhea Management

Training for Medical Ofcers

4

Abbreviations

ANM Auxiliary Nurse Midwife

ASHA Accredited Social Health Activist

AWC AnganwadiCenter

AWW AnganwadiWorker

BCC Behavior Change Communication

CDPO Child Development Project Ofcer

CHC Community Health Center

CMO Chief Medical Ofcer

DIO District Immunization Ofcer

DPO District Project Ofcer

DH District Hospital

DWCDO District Woman and Child Development Ofcer

FRU First Referral Unit

GOI Government of India

GMP Good Manufacturing Practices

HMIS Health Management Information Systems

IAP Indian Academy of Paediatrics

ICDS Integrated Child Development Scheme

IDSP Integrated Disease Surveillance Project

IEC Information, Education and Communication

IMNCI Integrated Management of Neonatal and Childhood Illnesses

IPC Inter Personal Communication

LHV Lady Health Visitor

LS Lady Supervisor

M&E Monitoring and Evaluation

MI Micronutrient Initiative

MCH Maternal and Child Health


5/43Childhood Diarrhea Management 5

MOHFW Ministry of Health and Family Welfare

MSS Mahila Swasthya Sangh

NGO Non-Governmental Organization

NRHM National Rural Health Mission

ORS Oral Rehydration Salt/Solution

ORT Oral Rehydration Therapy

PIP Project Implementation Plan

PRI Panchayati RajInstitution

PHC Primary Health Center

RCHO Reproductive and Child Health Ofcer

SHG Self-Help Group

SIHFW State Institute of Health and Family Welfare

SMO Social Marketing Organization

SUZY Scaling up Zinc for Young Children with Diarrhea

VHND Village Health and Nutrition Day

VHWSC Village Health and Water Sanitation Committee




6

Agenda for One day Training of Medical Ofcers

Session Topic Time

1 Welcome, Introduction and Objectives 30 min

2 Diarrhea Management 90 min

3 Diarrhea Control Program: Design and Delivery 30 min

4 Understanding Communication 30 min

5 Learning IPC Skills 30 min

6 Using IEC/IPC Materials 30 min

7 Learning Monitoring, Evaluation, Supervision and Reporting 45 min

8 Closing and Thanks 15 min



Pre Assessment Form for Medical Ofcers

Instructions:

1. Please mark () for correct answers in the box.

2. Please write the answers in questions which ask for a specic detail

1. What percent of children under 5 die because of diarrhea according toWHO, 2004 update?

a) 4b) 11c) 17d) 20

2. What is the current rate of IMR in Uttar Pradesh as per SRS Jan 2011?

a) 71

b) 40c) 63d) 99

3. Another name for Dysentery is

a) Acute Diarrheab) Bloody Diarrheac) Watery Diarrhead) Persistent Diarrhea

4. Children are more vulnerable to Diarrhea than adults because of all thefollowing except

a) Poor nutritional statusb) Water constitutes a greater proportion of childrens body weightc) Lower immunity levelsd) All of the above

5. The four rules of treatment plan A: home therapy to prevent dehydration andmalnutrition include all of the following guidelines except

a) Give the child more uids than usual to prevent dehydrationb) Give supplemental zinc (10 - 20 mg) to the child, every 14 daysc) Give diluted milk-free foods to the child

d) Take the child to a health worker if there are signs of dehydration or otherProblems

6. What is the difference between new and old ORS?

a) The new ORS has less glucose and sodium as compared to the traditionalWHO-ORS.

b) The new ORS has more glucose and sodium as compared to the tradi-tional WHO-ORS.

c) The new ORS has more glucose and less sodium as compared to the tra-ditional WHO-ORS.

d) The new ORS has less glucose and more sodium as compared to the tra-

ditional WHO-ORS.




8

7. Which of the following behavior is not useful for effective Inter-Personal Com-munication?

a) Appropriate gestures like nodding, smiling during interaction to encour-age the Target Group

b) Establishing and maintaining eye contactc) Asking close-ended questions which can be answered in short

d) Trying to understand the concerns of Target Group and address them

8. The daily dose of Zinc for children of below mentioned age groups for 14days should be-

a) 2-6 month. mgb) >6 months.mg

9. All are signs of completion of rehydration except,

a) The skin pinch is normal.b) The child feels thirsty and drinks vigorouslyc) Urine is passed.d) The child becomes quiet, is no longer irritable and often falls asleep.

10. Zinc deciency in children results in

a) Increased risk of diarrhea and pneumoniab) Increased severity of diarrheac) Impaired growthd) All of the above

11. Classify dehydration status of a child who has sunken eyes and whose skinpinch goes back very slowly

a) No dehydrationb) Some dehydrationc) Severe dehydration

12. The amount of ORS needed for rehydration in Treatment Plan B is estimatedasml/Kg of body weight

a) 30b) 50c) 75d) 100

13. Ideal Intravenous uid for intravenous rehydration in a child with severe de-hydration is-

a) Normal salineb) Dextrose 5%c) Ringers Lactated) Any of the above



After the session, the participants will be able to:

Understand the training objectives.

Understand the context of training.

The training on revised childhood diarrhea control and management is a very

important knowledge and skills building initiative. You as a key functionary of

the health and ICDS system are in a pivotal position to facilitate the control and

management of this easily preventable as well as treatable condition.

The Reproductive and Child Health program (RCH) II under the National Rural Health

Mission (NRHM) comprehensively integrates interventions that improve child health

and addresses factors contributing to infant and under-ve mortality. Reduction

of infant and child mortality has been an important tenet of the health policy of the

Government of India and it has tried to address the issue right from the early stages of

planned development. The National Population Policy (NPP) 2000, the National Health

Policy 2002 and the Eleventh Five Year Plan (2007-12) and National Rural Health

Mission (NRHM 2005 2012) have laid down the goals for child health.

In the eight Millennium Developmental Goals (MDGs) with a deadline of 2015, Goal

No. 4 is dedicated to reduce child mortality.

MDG Goal 4: Reduce Child Mortality

Target 4: Reduce by two-thirds the mortality rate among children under ve between

1990 and 2015.

This training is designed to improve the use of Zinc and ORS as a treatment regime

of childhood diarrhea and structured to improve technical and program management

skills to all functionaries in health and ICDS. Besides the technical component of

the training sessions, an important component of the training is enhancing the

communication and IPC skills of the functionary. It is expected that knowledge and

skills of the providers will improve the administration and counseling which will resultin improved coverage and compliance by the caregivers.

Session 1

Welcome, Introduction and Objectives

Time: 30 minutes

Learning Objectives




10

The medical ofcers have a key leadership and project management role in guiding

the other eld functionaries to undertake initiatives and intervention for childhood

diarrhea management. This would go a long way in accelerating the good beginning

of positive behaviour change increase awareness of the mother, children, families

and communities in proactively participation and responsibility towards successful

implementation of the revised diarrhea management guidelines.

The key aspects covered in this training module include:

1. Technical information on the revised childhood diarrhea management

2. Program management

3. Roles and responsibilities

4. Communication, IPC and use of communication materials

5. Monitoring and reporting

It is a highly participative, interactive training program that will enhance yourknowledge, skills, experiences and provide you tools and methods that will help

improve the overall implementation and performance of the revised diarrhea

management program in Uttar Pradesh.




Understand diarrhea assessment, classication (mild/moderate/severe) and

treatment

Understand the new low osmolarityORS and its advantages as a life saving drug

Understand the introduction of Zinc as a micronutrient for diarrhea management

program

Understand the Jodi Strategy oflow osmolarityORS and Zinc supplementation

for diarrhea control

Learn the steps for prevention of diarrhea: Personal hygiene/Food and water

hygiene/sanitation

2.1 Introduction and Situation Status

Session 2

Diarrhea Management

Time: 90 minutes

Learning Objectives

Uttar Pradesh is the largest Indian state population-wise. The situation of

Diarrhoea and its management is given below:

Children suffered from Diarrhoea 16.2%

Women aware of diarrhoea management 62.8%

Proportion of children with diarrhoea given

ORS

35.1%

Proportion of children with diarrhoea givensalt and sugar solution

66.9%

Proportion of children with diarrhoea

continued on normal food

7.6%

Proportion of children with diarrhoea

continued on breastfeeding

3%

Proportion of children with diarrhoea given

plenty of uids

8.5%

Source: DLHS-3 (2007-08)




12

It is estimated that around 25,000 children die due to diarrhea in a month in India

(~800 in a day). In children 0-4 years of age, diarrhea is the third leading cause of

death, contributing to 13.8% of all deaths in this age group. In children 1-4 years of

age, diarrhea is the leading cause of death, responsible for 23.8% of all deaths in this

age group. (NCMH report)

According to the NCMH Background Papers, the total diarrheal deaths among

0-6 years was 1,58,209; these are based on previous data (SRS, 1998-2001). According

to recent estimates from the Million Death Study, diarrheal diseases account for

0.30 million deaths in children aged 1-59 months; and 50% of all deaths at 1-59 months

occur due to pneumonia and diarrhea.

National Rural Health Mission (NRHM)The Phase II of RCH program under the NRHM comprehensively integrates

interventions that improve child health and addresses factors contributing to

infant and under-ve mortality. Reduction of infant and child mortality has been an

important tenet of the health policy of the Government of India and it has tried to

address the issue right from the early stages of planned development. The National

Population Policy (NPP) 2000, the National Health Policy 2002 and the Eleventh Five

Year Plan (2007-12) and National Rural Health Mission (NRHM 2005 2012) have laid

down the goals for child health.

NRHM Goals: IMR and MMR

India/Current Uttar Pradesh/

Current

NRHM Goals (2012)

IMR* 50 63 36

MMR** 254 440 258

Source: NRHM Mission Document, Uttar Pradesh State Plan Report, 2010

* SRS (2011)

** SRS (2004-06)

Need to accelerate IMR reduction

Year

IMR

90

80

70

60

50

40

30

20

10

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

0

NRHMGoalmdG

Expectation

80

8079

74 74

74 72

71

72 70

68 64

6058

5857

55

53

39

Source: MDG India Report, 2009



2.2 What is Diarrhea?Let us begin by understanding what is diarrhea.

Diarrhea is the passage of three or more liquid or watery stools in a

day. However, it is the recent change in consistency and character of

the stools rather than the number of stools that is more important.

Infants, particularly those who are on breastfeeds, during the

initial 2 to 3 months of life, may pass many pasty or

semi-formed stools. Mothers usually know when their

children have diarrhea and often have a local word for diarrhea.

Diarrhea is more prevalent in the developing world, in large part

due to the lack of safe drinking water, sanitation & hygiene, as well as poorer

overall health and nutritional status. All of these components in combination

with unsanitary environments allow diarrhea to become the third leading killer of

children under ve.

As mentioned above, diarrhea is a serious disease and wherever it doesn't kill, it

wreaks havoc on young bodies and lives, leading to millions of hospitalizations,weakening immune systems, holding children back from school and play, and

contributing to long-term nutritional consequences.

MadhyaPradesh

Orissa

Up

Assam

Rajasthan

meghalaya

Chhattisgarh

Bihar

Haryana

India

AndhraPradesh

Gujarat

Jammu&Kashmir

HimachalPradesh

Jharkhand

Karnataka

Uttarakhand

Punjab

Mizoram

Sikkim

delhi

WestBengal

ArunachalPradesh

Maharashtra

Tripura

TamilNadu

Nagalan

Manipur

Kerala

Goa

Infant Mortality Rate - State-wise(2009)100

90

80

70

60

50

40

30

20

10

0

67 6563 61 59 59

5452 51 50 49 48

45 45 4441 41

3836 34 33 33 32 31 31

28 26

1612 11

UttarPradesh

India

Source: SRS (2011)




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Source: Diarrhea: Why are Children Still Dying and What can be done?, UNICEF, WHO, 2009

Proportional distribution of cause-specic deaths among

children under ve years of age, 2004

Diarrhea is the second most common cause of child deaths worldwide.

More than 80% of child deaths due to diarrhea

occur in Africa and South Asia

Nearly three quarters of child deaths due to

diarrhea occur in just 15 countries

Source: World Health Organization, Global Burden of Disease estimates, 2004 update. Note:Neonatal causes do not add up to 100% due 10 rounding.

Source: World Health Organization, Global Burden of Disease

estimates, 2004 update, with additional analyses to calculate

UNICEF regions.

Source: World Health Organization, Global Burden of Disease

estimates, 2004 update, the total were calculated by applying theWHO cause of death estimates to the most recent estimates for

the total number of under ve deaths (2007)

Pneumonia

diarrhea

Other

malaria

Measles

Injuries

Neonatal causes

AIDS

17%

16%

13%

7%

4%

4%

17%

2%

31% Prematurity and

low birth weight

25% Neonatal

infections (mostly

sepsis/pneumonia)

23% Birth asphyxia

and birth trauma

9% Other

7% Congenital anomalies

3% Neonatal tetanus

3% Diarrheal Diseases

17% and 16% of deaths among children under ve are due to pneumonia and diarrhea, respectively. But these gures do notinclude deaths during the neonatal period (the rst four weeks of life). Diarrhea causes 3% of neonatal deaths (or an additional1% of total under ve deaths), while 25% of neonatal deaths are due to severe infections (of which one-third are caused bypneumonia, adding another 3% to under ve deaths). Therefore, pneumonia and diarrhea actually cause about 20% and 17%,respectively, of total under ve deaths when estimates from the post neonatal and neonatal are combined.

Bank Country Total number of annual

child deaths due to diarrhea

1. India 386,600

2. Nigeria 151,700

3. Democratic Republic of the Congo 89,900

4. Afghanistan 82,100

5. Ethiopia 73,700

6. Pakistan 53,300

7. Bangladesh 50,800

8. China 40,000

9. Uganda 29,300

10. Kenya 27,400

11. Niger 26,400

12. Burkina Faso 24,300

13. United Republic of Tanzania 23,900

14. Mali 20,900

15. Angola 19,700

Propositional distribution of deaths due to diarrhea

diseases among children under ve years of age,

by region, 2004

Africa

Rest of the

world

46%

7%

South Asia

East Asia

& Pacic

38%

9%

ASIA



What causes diarrhea?Diarrhea is a common symptom of gastrointestinal infections caused by a wide range

of pathogens, including bacteria, viruses and protozoa. However, just a handful of

organisms are responsible for most acute cases of childhood diarrhea. Rotavirus is the

leading cause of acute diarrhea, and is responsible for about 40 per cent of all hospital

admissions due to diarrhea among children under ve worldwide. Other major bacterial

pathogens include E. coli, Shigella, Campylobacter and Salmonella, along with

V. cholera during epidemics. Cryptosporidium has been the most frequently isolated

protozoan pathogen among children seen at health facilities and is frequently found

among HIV-positive patients. Though cholera is often thought of as a major cause of

child deaths due to diarrhea, most cases occur among adults and older children.

What are the main forms of acute childhood diarrhea?There are three main forms of acute childhood diarrhea, all of which are potentially

life-threatening and require different treatment courses:

w Acute watery diarrhea includes cholera and is associated with signicant uid loss

and rapid dehydration in an infected individual. It usually lasts for several hours or

days. The pathogens that generally cause acute watery diarrhea include V. cholera

or E. coli bacteria, as well as rotavirus.

w Bloody diarrhea, often referred to as dysentery, is marked by visible blood in the

stools. It is associated with intestinal damage and nutrient losses in an infected

individual. The most common cause of bloody diarrhea is Shigella, a bacterial

agent that is also the most common cause of severe cases.

w Persistent diarrhea is an episode of diarrhea, with or without blood that lasts at

least 14 days. Undernourished children and those with other illnesses, such as

AIDS, are more likely to develop persistent diarrhea. Diarrhea, in turn, tends to

worsen their condition.

There is a wide range of local terms used for diarrhea at the community level. These are

common across both sets of respondents community and service providers in both

intervention and non-intervention districts. Some of the usual local terms used to refer to

diarrhea are: kay(vomit), ulti(vomit),paikhana (stool), dast(loose motion), palti (vomit),

Tatti (stool),pet kharab (upset stomach), haiza (cholera) as well the English term diarrhea.

It is important to note the use of the term haiza or cholera for diarrhea, largely by

community stakeholders (mothers, caregivers and inuencers).

Mothers and caregivers classify three types of diarrhea: green stool (hara paikhana), loose

stool (patla paikhana), and blood in stool (paikhane mein khoon ana).

Local Names of Diarrhea




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Why are children more vulnerable?Children with poor nutritional status and overall health, as well as those exposed

to poor environmental conditions, are more susceptible to severe diarrhea and

dehydration than healthy children. Children are also at greater risk than adults of

life-threatening dehydration since water constitutes a greater proportion of childrens

body weight. Young children use more water over the course of a day given theirhigher metabolic rates, and their kidneys are less able to conserve water compared to

older children and adults.

2.3 Management of Diarrhea

Diagnosis is based on clinical symptoms, including the extent of dehydration, the type

of diarrhea exhibited, whether blood is visible in the stool, and the duration of the

diarrhea episode. Treatment regimens differ based on the outcomes of this clinical

assessment.

AssessmentA careful history should elicit whether the child has acute watery diarrhea, dysentery

or persistent diarrhea with or without growth failure. Watery, large, frequent (one or

more stools every 3 hours) stools indicate relatively greater severity of the illness. The

following questions are important to plan the therapy.

w Did the child vomit during the preceding 6-8 hours?

w Did he pass urine during the same period?

w What is the nature of uids that the child has been taking?

w Was the child receiving optimum feeding before the illness?

w Has feeding been reduced or modied during diarrhea in a way that reduced the

quantity of total energy intake or the quality of food consumed?

The following should be assessed during examination

1. Physical signs of dehydration

All children with diarrhea are to be assessed for level of dehydration and classied.

If the child has had diarrhea for 14 days or more, classify the child as persistent

diarrhea.

If the child has blood in the stool, classify the child as dysentery.

Remember

2. Nutritional status of the child

3. Presence of pneumonia, otitis media, sepsis or other associated systemic infections



Dehydration: During diarrhea, there is an increased loss of water and electrolytes

(sodium, chloride, potassium, and bicarbonate) in the watery stool. Water and

electrolytes are also lost through vomit, sweat, urine and breathing. Dehydration

occurs when these losses are not replaced adequately and a decit of water and

electrolytes develops. The volume of uid lost through the stools in 24 hours can vary

from 5 ml/kg (near normal) to 200 ml/kg or more. The concentrations and amounts ofelectrolytes lost also vary. The total body sodium decit in young children with severe

dehydration due to diarrhea is usually about 70-110 millimoles per litre of water

decit. Potassium and chloride losses are in a similar range. Decits of this magnitude

can occur with acute diarrhea of any aetiology.

Assessment of severity

First Classify Dehydration

There are three possible classications of dehydration in a child with diarrhea:

w Severe Dehydration

w Some Dehydration

wNo Dehydration

wLethargy orunconscious

w Sunken eyes wUnable to drinkproperly ordrinking less

w Skin pinch goes backvery slowly (more than 2seconds)

Severe Dehydration: Two or more of the following signs

wRestless andIrritable

wSunken eyes wFeels thirsty anddrinks eagerly

wSkin pinch goes backslowly (less than 2 seconds)

Some dehydration: Two or more of the following signs

No dehydration: Not enough signs to classify as some or severe dehydration




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Using the chart, determine the degree of dehydration and select the appropriate

plan to treat or prevent dehydration. The signs typical of children with no signs of

dehydration are in column A, the signs of some dehydration are in column B, and

those of severe dehydration are in column C.

If two or more of the signs in column C are present, the child has "severe dehydration".If this is not the case, but two or more signs from column B (and C) are present, the

child has "some dehydration". If this also is not the case, the child is classied as

having "no signs of dehydration". Some textbooks also refer to these categories as

"no, mild, moderate or severe" dehydration.

A childs uid decit can be estimated as follows

Status Fluid decit as % of

body weight

Fluid decit in ml/kg body

weight

No signs of dehydration 100 ml/kg

For example, a child weighing 5 kg and showing signs of "some dehydration" has a uid decit of 250-500 ml.

Assessment of diarrhea patients for dehydration

Look at: A B C

Conditiona

Eyesb

Thirst

wWell, alert

wNormalwDrinks normally,

not thirsty

wRestless, irritable

wSunken eyeswThirsty, drinks

eagerly

wLethargic or unconscious

wSunken eyeswDrinks poorly, or not able to

drink

Feel: Skin Pinchc Goes back quickly Goes back slowly Goes back very slowly

decie The patient has

NO SIGNS OF

DEHYDRATION

If the patient has

two or more signs

in B, there is SOME

DEHYDRATION

If the patients has two or more

signs in C, there is SEVERE

DEHYDRATION

Treat Use Treatment Plan A Weigh the patient,

if possible, and use

Treatment Plan B

Weigh the patient, and use

Treatment Plan C

URGENTLY

a Being lethargic and sleepy are not the same. A lethargic child is not simply asleep: the childs mental state is dull and

the child cannot be fully awakened; the child may appear to be drifting into unconsciousness.b In some infants and children, the eyes normally appear somewhat sunken. It is helpful to ask the mother if the childs

eyes are normal or more sunken than usual.c The skin pinch is less useful in infants or children with marasmus or kwashiorkor, or obese children.

Source: The Treatment of Diarrhea: WHO Manual for Physicians and other senior health workers

Select a plan to prevent or treat dehydration

Choose the Treatment Plan that corresponds with the child's degree of dehydration:

w No signs of dehydration - follow Treatment Plan A at home to prevent dehydration

and malnutrition.

w Some dehydration - follow Treatment Plan B to treat dehydration.

w Severe dehydration - follow Treatment Plan C to treat severe dehydration urgently.


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Management of Acute Diarrhea (Without Blood)The objectives of treatment are to:

w prevent dehydration, if there are no signs of dehydration.

w treat dehydration, when it is present.

w prevent nutritional damage, by feeding during and after diarrhea.

w Reduce the duration and severity of diarrhea, and the occurrence of future

episodes, by giving supplemental zinc.

These objectives can be achieved by following the selected treatment plan, as

described below.

Treatment Plan A: Home therapy to prevent dehydration and malnutrition

Children with no signs of dehydration need extra uids and salt to replace their losses

of water and electrolytes due to diarrhea. If these are not given, signs of dehydration

may develop.

Mothers should be taught how to prevent dehydration at home by giving the child

more uid than usual, how to prevent malnutrition by continuing to feed the child, and

why these actions are important. They should also know what signs indicate that the

child should be taken to a health worker. These steps are summarized in the four rules

of Treatment Plan A:

Rule 1: Give the child more uids than usual, to prevent dehydration.

Rule 2: Give supplemental zinc (10 - 20 mg) to the child, every day for 14 days.

Rule 3: Continue to feed the child, to prevent malnutrition.

Rule 4: Take the child to a health worker if there are signs of dehydration or other

problems.

(For more details see Annexure 1)

Treatment Plan B: Fluid Therapy and Treatment of Diarrhoea with some

Dehydration

Treat some dehydration with ORS

Give in clinic recommended amount of ORS over 4-hour period

w Determine amount of ORS to give during rst 24 hours

ORS Solution Upto 4 months Upto 4-12 months 12 months-2 years 2-5 years

Weight




20

If the child wants more ORS than shown, give more

For infants under 6 months who are not breastfed, also give 100-200 ml clean

water during this period

w Show the mother how to give ORS solution

Give frequent small sips from a cup,

If the child vomits, wait for 10 minutes. Then continue, but more slowly; and Continue breastfeeding whenever the child wants.

w After 4 hours

Reassess the child and classify the child for dehydration;

Select the appropriate plan to continue treatment; and

Begin feeding the child in clinic.

w If the mother must leave before completing treatment

Show her how to prepare ORS solution at home; Show her how much ORS to give to nish 4-hour treatment at home;

Give her enough ORS packets to complete rehydration. Also give her 2 packets

as recommended in Plan A; and

Explain the four rules of home treatment:

1. Give extra uid

2. Continue feeding

3. Give zinc for 14 days

4. When to return to the health centre

2.4 New ORS, its composition and benets

New ORS in Management of DiarrheaYou will learn about the two recent advances in management

of diarrhea the use of low osmolarity ORS and Zinc; these

have the potential to save many more lives and bring

about signicant reduction in morbidity and mortality

due to diarrhea. The Government of Indias policy already

recommends use of Zinc and low osmolarity ORS in all cases

of childhood diarrhea.

Oral rehydration saltsDenition. Oral rehydration salts (ORS) are dry mixtures of powders containing per

packet:

Sodium chloride 2.6 g

trisodium citrate dihydrate 2.9 g

potassium chloride 1.5 g

Anhydrous glucose 13.5 gTotal 20.5 g

Before administration the contents of each packet should be dissolved in 1 litre of water.




Composition of the old and the new ORS

Contents Old ORS Composition New ORS Composition

Sodium 90 m Osmol/L 75 m Osmol/L

Glucose 110 m Osmol/L 75 m Osmol/L

Potassium 20 m Osmol/L 20 m Osmol/L

Osmolarity 311 m Osmol/L 245 m Osmol/L

A solution of ORS is a simple, inexpensive and life-saving remedy that prevents

dehydration among children with diarrhea. How does it work?

In a healthy child, the small intestines absorb water and electrolytes from the digestive

tract so that these nutrient-rich uids may be transported to other parts of the body

through the bloodstream. In a sick child, diarrhea-causing pathogens damage theintestines causing an excessive amount of water and electrolytes to be secreted rather

than being absorbed. When the ORS solution reaches the small intestines, the sodium and

glucose in the mixture are transported together across the lining of the intestines, and the

sodium, which is now in higher concentrations, in the body from the gut. The discovery

that sodium and glucose are transported together across the small intestines through

a co-transport mechanism has been called potentially the most important medical

advance of the 20th century. 35 The development of ORS is a direct result of this discovery.

Sources: Water with sugar and salt, The Lancet, vol. 312, no. 8084, 1978, pp. 300-301; Rehydration. Org, Why is

rehydration so important and How it works to save childrens lives, http://rehydrate.org/rehydration, accessed June 2009.

Oral rehydration salts: One of the most important medical advances of the 20th century

For more than two decades, WHO and UNICEF recommended a single ORS formula

for treating all types of diarrhea among all age groups. During this time, researchers

also worked to improve the formula to provide additional clinical benets to patients.

Particularly important, in addition to preventing dehydration, was making ORS more

acceptable to caregivers who sought to reduce their childs diarrhea symptoms.

In 2004, WHO and UNICEF began recommending that countries use and manufacture a

new ORS formula (known as low osmolarity ORS) to treat all types of diarrhea among

all age groups. This improved formula was shown to be as safe and effective as the

previous version, but also had other important clinical benets. Stool output and vomiting

decreased in children by about 20% and 30%, respectively, when compared to children

using the original ORS formula. Unscheduled intravenous therapy also declined by 33%

among children with diarrhea using this new remedy.

Source: World Health Organization, The Treatment of Diarrhea: A manual for physicians and other senior health workers,

WHO, Geneva, 2005

Low osmolarity ORS: A life-saving remedy just got better


22/43Childhood Diarrhea Management22

Use of reduced osmolarity ORS in diarrheaThe new ORS developed has less glucose and sodium as compared to the traditional

WHO-ORS. The advantages of the new ORS over the standard ORS include:

w Less vomiting

w Less number of stools

w Less amount of water in stoolsw Reduced need for intravenous uids

Wash your hands

well using soap

Add 1 litre of clean

water into a clean

vessel

Empty the contents of

the ORS packet into the

vessel containing water

Mix the solution

well using a cleanspoon

The prepared ORS

solution should be

given to the child in

small amounts as per

the requirements.

Quantity of ORS to be given after every bout of diarrhea

Age

Children aged 2 months to 2 years Children aged 2 years to 5 years

Quarter to half glass ORS afterevery bout of diarrhea

Half to full glass ORS after everybout of diarrhea

ORS Solution kept beyond 24 hours of preparation should be discarded.

1

4 5

3

2

Method of preparing of ORS and quantity to be given

Preparation of ORS solution

How much ORS solution is needed?Refer to the table in the next page to estimate the amount of ORS solution needed

for rehydration. If the child's weight is known, this should be used to determine

the approximate amount of solution needed. The amount may also be estimated by

multiplying the child's weight in kg times 75 ml. If the child's weight is not known,select the approximate amount according to the child's age.




the exactamount of solution required will depend on the child's dehydration status.Children with more marked signs of dehydration, or who continue to pass frequent

watery stools, will require more solution than those with less marked signs or who are

not passing frequent stools. If a child wants more than the estimated amount of ORS

solution, and there are no signs of over-hydration, give more.

Oedematous (puffy) eyelids are a sign ofover-hydration. If this occurs, stop giving ORS

solution, but give breast milk or plain water, and food. Do not give a diuretic. When the

oedema has gone, resume giving ORS solution or home uids according to Treatment

Plan A.

How to give ORS solution?A family member should be taught to prepare and give ORS solution. The solution

should be given to infants and young children using a clean spoon or cup. Feeding

bottles should notbe used. For babies, a dropper or syringe (without the needle) can

be used to put small amounts of solution into the mouth. Children under 2 years of

age should be offered a teaspoonful every 1-2 minutes; older children (and adults)

may take frequent sips directly from the cup.

Vomiting often occurs during the rst hour or two of treatment, especially when

children drink the solution too quickly, but this rarely prevents successful oral

rehydration since most of the uid is absorbed. By this time, vomiting usually stops. If

the child vomits, wait 5-10 minutes and then start giving ORS solution again, but more

slowly (E.g. A spoonful every 2-3 minutes).

Monitoring the progress of oral rehydration therapyCheck the child from time to time during rehydration to ensure that ORS solution is

being taken satisfactorily and that signs of dehydration are not worsening. If at any

time the child develops signs of severe dehydration, shift to Treatment Plan C.

After four hours, reassess the child fully. Then decide what treatment to give next:

w If signs ofsevere dehydration have appeared, intravenous (IV) therapy should be

started following Treatment Plan C. This is very unusual, however, occurring only

in children who drink ORS solution poorly and pass large watery stools frequentlyduring the rehydration period.

w If the child still has signs indicating some dehydration, continue ORT by repeating

Treatment Plan B. At the same time, start to offer food, milk and other uids, as

described in Treatment Plan A, and continue to reassess the child frequently.

w If there are no signs of dehydration, the child should be considered fully

rehydrated. When rehydration is complete:

The skin pinch is normal;

Thirst has subsided;

Urine is passed; and



The child becomes quiet, is no longer irritable and

often falls asleep.

Teach the mother how to treat her child at home with

ORS solution and food following Treatment Plan A. Give

her enough ORS packets for two days. Also teach her thesigns that mean she should bring her child back.

Meeting normal uid needsWhile treatment to replace the existing water and

electrolyte decit is in progress, the child's normal daily

fluid requirements must also be met. This can be done as follows:

wBreastfed infants: Continue to breastfeed as often and as long as the infant wants,

even duringoral rehydration.

w Non-breastfed infants under 6 months of age: If using the old WHO ORS solutioncontaining 90 mmol/L of sodium, also give 100-200ml clean water during this

period. However, if using the new reduced (low) osmolarity ORS solution

containing 75 mmol/L of sodium, this is not necessary. After completing

rehydration, resume full strength milk (or formula) feeds. Give water and other

uids usually taken by the infant.

w Older children and adults: Throughout rehydration and maintenance therapy, offer

as much plain water to drink as they wish, in addition to ORS solution.

If oral rehydration therapy must be interruptedIf the mother and child must leave before rehydration with ORS solution is completed:

wShow the mother how much ORS solution to give to nish the four-hour treatment

at home;

w Give her enough ORS packets to complete the four-hour treatment and to continue

oral rehydration for two more days, as shown in Treatment Plan A;

wShow her how to prepare ORS solution; and

w Teach her the four rules in Treatment Plan A for treating her child at home.

When oral rehydration failsWith the previous ORS, signs of dehydration would persist or reappear during ORT

in about 5% of children. With the new reduced (low) osmolarity ORS, it is estimated

that such treatment failures will be reduced to 3%, or less. The usual causes of these

failures are:

w Continuing rapid stool loss (more than 15-20 ml/kg/hour), as occurs in some

children with cholera

w Insufcient intake of ORS solution owing to fatigue or lethargy

w Frequent, severe vomiting.




Such children should be given ORS solution by nasogastric (NG) tube or Ringer's

Lactate Solution intravenously (IV) (75 ml/kg in four hours), usually in hospital. After

conrming that the signs of dehydration have improved, it is usually possible to

resume ORT successfully.

In rare cases, ORT should not be given. This is true for children with:wAbdominal distension with paralytic ileus, which may be caused by opiate drugs

(e.g. codeine, loperamide) and hypokalaemia; and

w Glucose malabsorption, indicated by a marked increase in stool output when ORS

solution is given, failure of the signs of dehydration to improve and a large amount

of glucose in the stool when ORS solution is given.

Giving Zinc

Begin to give supplemental zinc, as in Treatment Plan A, as soon as the child is able toeat following the initial four hour rehydration period.

Giving food

Except for breast milk, food should not be given during the initial four-hour

rehydration period. However, children continued on Treatment Plan B longer than

four hours should be given some food every 3-4 hours as described in Treatment

Plan A.All children older than 6 months should be given some food before being

sent home. This helps to emphasize to mothers the importance of continued feeding

during diarrhea.

Treatment Plan C: for paents with severe dehydraon

The preferred treatment for children with severe dehydration is rapid intravenous

rehydration, following Treatment Plan C. If possible, the child should be admitted to

hospital.

Guidelines for intravenous rehydration

Children who can drink, even poorly, should be given ORS solution by mouth until the

IV drip is running. In addition, allchildren should start to receive some ORS solution

(about 5 ml/kg/h) when they can drink without difculty, which is usually within 3-4

hours (for infants) or 1-2 hours (for older patients). This provides additional base and

potassium, which may not be adequately supplied by the IV uid.


26/43

Guidance for intravenous treatment of children and adults with

severe dehydration

Start IV uids immediately. If the patient can drink, give ORS by mouth until the drip

is set up. Give 100 ml/kg Ringer's Lactate Solution* divided as follows:

Age First give 30 ml/kg in: Then give 70 ml/kg in:Infants (under 12 months) 1 hour ** 5 hours

Oler 30 minutes** 2 hours

Reassess the patient every 1-2 hours. If hydration is not improving, give the IV drip more rapidly.

After six hours (infants) or three hours (older patients), evaluate the patient using the assessment

chart. The choose the appropriate treatment plan (A, B or C) to continue treatment

* If Ringer's Lactate Solution is not available, normal saline may be used.

** Repeat once if radial pulse is still very weak or not detectable.

Monitoring the progress of intravenous rehydration

Patients should be reassessed every 15-30 minutes until a strong radial pulse is

present. Thereafter, they should be reassessed at least every hour to conrm that

hydration is improving. If it is not, the IV drip should be given more rapidly.

When the planned amount of IV uid has been given (after three hours for older

patients, or six hours for infants), the child's hydration status should be reassessed fully.

Look and feel for all the signs of dehydration:

If signs ofsevere dehydration are still present, repeat the IV uid infusion as outlinedin Treatment Plan C. This is very unusual, however, occurring only in children who

pass large watery stools frequently during the rehydration period.

If the child is improving but still shows signs ofsome dehydration, discontinue the IV

infusion and give ORS solution for four hours, as specied in Treatment Plan B.

If there are no signs of dehydration, follow Treatment Plan A. If possible, observe the

child for at least six hours before discharge while the mother gives the child ORS

solution, to conrm that she is able to maintain the child's hydration. Remember thatthe child will require therapy with ORS solution until diarrhea stops.

If the child cannot remain at the treatment center, teach the mother how to give

treatment at home following Treatment Plan A, give her enough ORS packets for two

days and teach her the signs that mean she should bring her child back.

What to do if intravenous therapy is not availableIf IV therapy is not available at the facility, but can be given nearby (i.e. Within

30 minutes), send the child immediatelyfor IV treatment. If the child can drink, give the

mother some ORS solution and show her how to give it to her child during the journey.

Childhood Diarrhea Management26



27/43

Start IV uids immediately. If the patient can drink, give ORS by mouth while

the drip is set up. Give 100 ml/kg Ringer's Lactate Solution (or, if not available,normal saline), divided as follows:

Age First give 30 ml/kg in: Then give 70 ml/kg in:

Infants (under 12months)

1 hourb 5 hours

Oler 30 minutesb 2 hours

*Repeat once if radial pulse is still very weak or not detectable Reassess the child every 1-2 hours. If hydration status is not improving, give

the IV drip more rapidly Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after

34 hours (infants) or 1-2 hours (children). Reassess an infant after 6 hours and a child after 3 hours.

Classify dehydration. Then choose the appropriate plan (A, B or C) to continuetreatment

Plan C: Treat Severe Dehydration Quickly

FOLLOW THE ARROWS. IF ANSWER IS "YES", GO ACROSS; IF "NO", GO DOWN.

START HERECan you give

intravenous (IV) uidimmediately?

Yes

Yes

No

No

No

Is IV treatmentavailable nearby

(within 30 minutes)?

Are you trained to use anasogastric (NG) tube for

rehydration?

Can the child drink?

Refer URGENTLY tohospital for IV or NG

treatment

Refer URGENTLY to hospital for IV treatment. If the child can drink, provide the mother with ORS solution and show her how

to give frequent sips during the trip

Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg for 6hours (total of 120 ml/kg).

Reassess the child every 1-2 hours:

If there is repeated vomiting or increasing abdominal distension, give the uidmore slowly.

If hydration status is not improving after 3 hours, send the child for IV therapy

After 6 hours, reassess the child. Classify dehydration. Then choose theappropriate plan (A, B or C) to continue treatment.

NOTE:

If possible, observe the child at least 6 hours after rehydration to be sure themother can maintain hydration giving ORS solution by mouth

Childhood Diarrhea Management 27




If IV therapy is not available nearby, health workers who have been trained can give

ORS solution by NG tube, at a rate of 20 ml/kg body weight per hour for six hours (total

of 120 ml/kg body weight). If the abdomen becomes swollen, ORS solution should be

given more slowly until it becomes less distended.

If NG treatment is not possible but the child can drink, ORS solution should be given

by mouth at a rate of 20 ml/kg body weight per hour for six hours (total of 120 ml/kg

body weight). If this rate is too fast, the child may vomit repeatedly. In that case, give

ORS solution more slowly until vomiting subsides.

Children receiving NG or oral therapy should be reassessed at least every hour. If

the signs of dehydration do not improve after three hours, the child must be taken

immediately to the nearest facility where IV therapy is available. Otherwise, if

rehydration is progressing satisfactorily, the child should be reassessed after six hours

and a decision on further treatment made as described above for those given IV therapy.

If neither NG nor oral therapy is possible, the child should be taken immediatelyto the

nearest facility where IV or NG therapy is available.

2.5 Management of suspected cholera

When to suspect Cholera?Cholera should be suspected when a child older than ve years or an adult develops

severe dehydration from acute watery diarrhea (usually with vomiting), or any patientolder than two years has acute watery diarrhea when cholera is known to be occurring

in the area. Younger children also develop cholera, but the illness may be difcult to

distinguish from other causes of acute watery diarrhea, especially rotavirus.

Treatment of dehydration

Initial treatment of dehydration from cholera follows the guidelines given above

for patients with some or severe dehydration. For patients with severe dehydration

and shock, the initial intravenous infusion should be given very rapidlyto restore an

adequate blood volume, as evidenced by normal blood pressure and a strong radial

pulse. Typically, an adult weighing 50 kg and with severe dehydration would have an

estimated uid decit of ve litres. Of this, two litres should be given within 30 minutes,

and the remainder within three hours. The amount of stool lost is greatest in the rst

24 hours of treatment, being largest in patients who present with severe dehydration.

During this period, the average uid requirement of such patients is 200 ml/kg of body

weight, but some need 350 ml/kg or more. After being rehydrated, patients should be

reassessed for signs of dehydration at least every 1-2 hours, and more often if there is

profuse ongoing diarrhea. If signs of dehydration reappear, ORS solution should be

given more rapidly. If patients become tired, vomit frequently or develop abdominal

distension, ORS solution should be stopped and rehydration should be given IV with

Ringer's Lactate Solution with added potassium chloride (50 ml/kg in three hours). After

this, it is usually possible to resume treatment with ORS solution.



AntimicrobialsAll cases of suspected cholera with severe dehydration should receive an oral

antimicrobial known to be effective against strains ofVibrio cholerae in the area. The

rst dose should be given as soon as vomiting stops, which is usually 4-6 hours after

starting rehydration therapy.

Antimicrobials for treatment of cholera in children

Antibiotic Dosage Duration

Tetracycline 12.5 mg/Kg 4 times a day for 3 days

Erythromycin 12.5 mg/Kg 4 times a day for 3 days

After rehydration and when vomiting has subsided, zinc should be given as a supplement for 14 days as

outlined in acute watery diarrhea.

Anti-diarrheals and Anti-motility Drugs

Anti-diarrheals and anti-motility drugs have NO practical benet and are NEVERindicated in the treatment of acute diarrhea in children. Some of them could be

dangerous and should not be used in children at all.

2.6 Management of acute bloody diarrhea (dysentery)

Initial treatment and follow-upAny child with bloody diarrhea and severe malnutrition should be referred

immediately to hospital. All other children with bloody diarrhea should be assessed,

given appropriate uids to prevent or treat dehydration, and given food.

In addition, they should be treated for three days with ciprooxacin (15 mg/kg; twice

a day), or for ve days with another oral antimicrobial to which most Shigella in the

area are sensitive. This is because Shigella cause most episodes of bloody diarrhea in

children, and nearly all episodes that are severe. Determining the sensitivity of local

strains ofShigella is essential, as antimicrobial resistance is frequent and the pattern

of resistance is unpredictable.

The child should be seen again after two days if he or she:

w was initially dehydrated;

w is less than 1 year old;

w had measles during the past six weeks; and

w is not getting better.

When to consider amoebiasisAmoebiasis is an unusualcause of bloody diarrhea in young children, usually causing

less than 3% of episodes. Young children with bloody diarrhea should not be treated

routinely for amoebiasis. Such treatment should be considered only when microscopicexamination of fresh faeces done in a reliable laboratory reveals trophozoites ofE.

histolytica containing red blood cells, or two different antimicrobials usually effective

for Shigella in the area have been given without clinical improvement.




30

2.7 Management of persistent diarrhea

This is diarrhea, with or without blood, that begins acutely and lasts at least 14

days. It is usually associated with weight loss and, often, with serious non-intestinal

infections. Many children who develop persistent diarrhea are malnourished before

the diarrhea starts. Persistent diarrhea almost never occurs in infants who areexclusively breastfed. The child's history should be carefully reviewed to be certain

there is diarrhea, rather than several soft or pasty stools each day, which is normal for

breastfed infants.

The objective of treatment is to restore weight gain and normal intestinal function.

Treatment of persistent diarrhea consists of giving:

w Appropriate uids to prevent or treat dehydration;

w Nutritious diet that does not cause diarrhea to worsen;

w Supplementary vitamins and minerals, including zinc for 14 days; and

w Antimicrobial(s) to treat diagnosedinfections.

Children who have persistent diarrhea and severe malnutrition should be treated in

hospital.

2.8 Monitor the response in persistent diarrheoa

Children treated as out-patients

Children should be re-evaluated after 3 or 7 days, if diarrhea worsens or otherproblems develop. Those who have gained weight and who have less than three loose

stools per day, may resume a normal diet for age. Those who have not gained weight

or whose diarrhea has not improved should be referred to hospital.

Children treated in hospital

The following should be measured and recorded in a standard manner, at least daily:

(i) body weight; (ii) temperature; (iii) food taken; and (iv) number of diarrhea stools.

Successful treatment with either diet is characterized by:

wAdequate food intake

w Weight gain

w Fewer diarrheal stools

w Absence of fever

Many children will lose weight for 1-2 days, and then show steady weight gain as

infections come under control and diarrhea subsides. There should be at least three

successive days of increasing weight to conclude that weight gain is occurring; for

most children, weight on day 7 will be greater than on the day of admission.



Dietary failure is manifest by:

w An increase in stool frequency (usually to more than 10 watery stools/day), often

with a return of signs of dehydration; this usually occurs shortly after a new diet is

begun; or

w A failure to establish daily weight gain within seven days, as described above.

Te Initial Diet A: (Reduced lactose diet; milk rice gruel, milk sooji gruel, rice withcurd, dalia)

Ingredients Measures Approximate quantity

Milk 1/3 cup 40 ml

Sugar level tsp 2 gm

Oil level tsp 2 gm

Puffed rice powder* 4 level tsp 12.5 gm

Water Katori to make 100 ml

* Can be substituted with cooked rice or sooji

Te Second Diet B: (Lactose free diet with reduced starch)


Example of one diet

Egg white 3 level tsp 15 gm

Puffed rice powder * 2 level tsp 7 gm

Glucose level tsp 3 gm

Oil 1 level tsp 4 gm

Water katori to make 100ml

*Can be substituted with cooked rice

Te Tird Diet C: (Monosaccharide based diet)


Chicken 2 level tsp 12 gm

Or

Egg white 5 level tsp 25 g

Glucose level tsp 3 gm

Oil 1 level tsp 4 gm

Water - katori to make 100 ml

The rst diet should be given for seven days, unless signs of dietary failure occur

earlier, in which case the rst diet should be stopped and the second diet given, also

for seven days.

Children responding satisfactorily to either diet should be given additional fresh fruit

and well cooked vegetables as soon as improvement is conrmed; after seven days'

treatment with the effective diet, they should resume an appropriate diet for age,

including milk, that provides at least 110 Kcal/kg/day. Occasionally, it is necessary torestrict milk intake for more than seven days. Children may return home, but should

be followed up regularly to ensure continued weight gain and compliance with

feeding advice.



2.9 Other problems associated with diarrhea

Fever

Fever in a child with diarrhea may be caused by another

infection (e.g. Pneumonia, bacteraemia, urinary tract

infection or otitis media). Young children may also havefever on the basis of dehydration. The presence of fever

should prompt a search for other infections. This is

especially important when fever persists after a child is fully rehydrated.

Children with fever (38C or above) or a history of fever in the past ve days, and who

live in a Plasmodium falciparum malarious area, should also be given an antimalarial

or treated according to the policy of the national malaria program.

Children with high fever (39C or greater) should be treated promptly to bring thetemperature down. This is best done by treating any infection with appropriate

antibiotics as well as an antipyretic (e.g. paracetamol). Reducing fever also improves

appetite and diminishes irritability.

Convulsions

In a child with diarrhea and a history of convulsions during the illness, the following

diagnoses and treatments should be considered:

Febrile convulsion: This usually occurs in infants, especially when their temperature

exceeds 40C or rises very rapidly. Treat fever with paracetamol. Sponging with tepid

water and fanning may also be used if the temperature exceeds 39C. Evaluate for

possible meningitis.

Hypoglycaemia: This occasionally occurs in children with diarrhea, owing to inadequate

gluconeogenesis. If hypoglycaemia is suspected in a child with seizures or coma, give

5.0 ml/kg of 10% glucose solution intravenously over ve minutes. If hypoglycaemia

is the cause, recovery of consciousness is usually rapid. In such cases, ORS solution

should be given (or 5% glucose should be added to the IV solution) until feeding starts,

to avoid recurrence of symptomatic hypoglycaemia.

Hypernatraemia or hyponatraemia: Treat dehydration with ORS solution, as described

earlier.

Vitamin A deciency

Diarrhea reduces the absorption of, and increases the need for, vitamin A. In areas

where bodily stores of vitamin A are often low, young children with acute or persistent

diarrhea can rapidly develop eye lesions of vitamin A deciency (xerophthalmia)

and even become blind. This is especially a problem when diarrhea occurs during orshortly after measles, or in children who are already malnourished.




In such areas, children with diarrhea should be examined routinely for corneal

clouding and conjunctival lesions (Bitot's spots). If either is present, oral vitamin A

should be given at once and again the next day: 200 000 units/dose for age 12 months

to 5 years, 100,000 units for age 6 months to 12 months, and 50 000 units for age less

than 6 months. Children without eye signs who have severe malnutrition or have had

measles within the past month should receive the same treatment. Mothers should

also be taught routinely to give their children foods rich in carotene; these include

yellow or orange fruits or vegetables, and dark green leafy vegetables. If possible,

eggs, liver, or full fat milk should also be given.

2.10 Zinc Program for Diarrhea Management

Zinc Deciency in Indian ChildrenZinc is an essential trace element that is required for normal intestinal

mucosal integrity, sodium and water transport and immune function.

Zinc deciency is common in India, for the following reasons:

wPoor intake: Zinc is found mainly in non-vegetarian foods. Since the

diet eaten in India is predominantly vegetarian, the intake of zinc is

poor.

wPoor absorption of Zinc from the diet because of presence of

phytates in cereals

wLoss of Zinc from the body during diarrhea.

Zinc deciency in children results in:

wIncreased risk of diarrhea and pneumonia because Zinc deciency affects the

immunity of the body.

wIncreased severity of diarrhea; Zinc deciency makes episodes of a diarrheal

illness in a child more severe, last longer and increases the risk of dehydration and

other complications.

wImpaired growth.

Since large amounts of Zinc are lost from the body in the diarrheal stools, and

30 to 40% of children in low income group in India are already Zinc decient, Zinc is

recommended in ALL cases of childhood diarrhea.

Benets of giving ZincBenets of giving Zinc in a child having diarrhea have been shown by several

large scale trials in India and Bangladesh. These trials have shown that Zinc

supplemented children:

ware more playful during the illness;

wrecover faster;

whave reduced amount of diarrheal stools;

whave lesser chances of diarrhea lasting for >7 days;

whave lesser chances of being hospitalized;




34

ware less frequently given unnecessary oral and injectable drugs, and cost of care is

reduced;

whave lesser chances of getting diarrhea and pneumonia over the next 23 months; and

whave substantially increased use of ORS when Zinc and ORS are promoted

together, as compared to ORS alone.

Benets of 14 days course for ZincZinc supplementation for 14 days has long term effects on childhood illness over the

next 2-3 months after treatment with 34% reduction in diarrhea prevalence and

26% reduction in incidence of pneumonia.

Zinc supplements should be given for a duration of 14 days, because zinc not only

treats the diarrhea episode at hand, it also helps to repair the damaged gut mucosa,

enhances overall immune function and protects the child from developing pneumonia

and diarrhea in the next three months.

Without zinc

With zincDuration

Acutediarrhea

Treatment

Failure/Death

Persistentdiarrhea

Studies have shown that

Zinc treatment results

in a 25% reduction

in duration of acute

diarrhea and a 40%

reduction in treatment

failure or death in

persistent diarrhea.

Dose of Zinc in Childhood Diarrhea

wFor children aged 2 months up to 6 months, 10 mg of elemental Zinc per day, for

14 days.

wFor children 6 months and older, 20 mg of elemental Zinc per day, for 14 days.

Successful treatment of diarrhea with ORS and Zinc within the primary health

care system requires:

wFamilies know that Zinc and ORS should be given in all episodes of diarrhea and

that these should be started as early as possible after onset of diarrheal episode.

wFamilies know where Zinc and ORS are available.

wZinc and ORS are available in health facilities and in the community at all times.

wZinc and ORS are accessible to all children especially to those belonging to the

poorest section of the population.



Compliance Card

The compliance cum information card is meant for the mother/

caregiver of the child suffering from diarrhea. This cardcontains some important information such as preparation and

administration of ORS and zinc, right dosage and importance of

zinc compliance for 14 days. It also acts as a reminder as it has

14 boxes showing zinc tablets against which mother/caregiver

should tick every day after giving zinc to the child.

Zinc is critical for overall health, growth and development. It also supports proper

functioning of the immune system. Though widely found in protein-rich and other food

sources, zinc deciency is widespread throughout the developing world and has been

associated with higher rates of infectious diseases, including diarrhea, and deaths

from these illnesses. Zinc stores are further depleted during diarrhea episodes, and

supplementation as a part of treatment programs is critical for replenishing the bodys

reserves, helping children to recover from illness and stay healthy afterwards.

Clinical studies have shown that a 10-14 day treatment course with zinc effectively

reduces the duration and severity of both persistent and acute diarrhea. Zinc has been

associated with a 25% reduction in the duration of acute diarrhea, as well as a 40%

reduction in treatment failure and death in persistent diarrhea.

The recent introduction of zinc tablets into large scale diarrhea treatment programs inIndia, Mali and Pakistan suggests that it may be even more effective than clinical trial

results indicate. Zinc appears to increase ORS intake and reduces inappropriate drug use

with antibiotics and anti-diarrheal medications. Children receiving zinc tablets appeared

to recover more quickly, had increased strength and appetites, and were less ill than other

children in their communities. In fact, a Malian mother noted that her son had gained

strength and energy unlike ever before, which echoed the sentiments of many other

caregivers.

Sources:World Health Organization, Department of Child and Adolescent Health and Development (CAH), CAH

Progress report highlights 2008, WHO, Geneva, 2009; Bhandari, N., et al., Effectiveness of zinc supplementation plus

oral rehydration salts compared with oral rehydration salts alone as a treatment for acute diarrhea in a primary caresetting: A cluster randomized trial, pediatrics, vol. 121, no. 5, 2008, pp. e1285; winch, p.l., et al., cluster-randomized

program effectiveness study of community case management with zinc for childhood diarrhea in southern Mali, bulletin

of the world health organization (in press); world health organization, department of child and adolescent health and

development, CAH Meeting report: Consultation to review the results of the large effectiveness studies examining the

addition of zinc to the current case management of diarrhea, India, Mali and Pakistan), 30-31 January 2008.

Zinc: Critical to diarrhea treatment, but largely unavailable in developing countries




36

2.11 The strategy of Jodi of new ORS and Zincsupplementation

The Jodi (Team) of ORS and Zinc works better and is more

effective.

Zinc appears to increase ORS intake and reduces inappropriate

drug use with antibiotics and anti-diarrheal medications. Children

receiving zinc tablets appeared to recover more quickly, had

increased strength and appetites, and were less ill than other children

in their communities.

2.12 Prevention of diarrhea

Proper treatment of diarrheal diseases is highly effective in preventing death, but hasno impact on the incidence of diarrhea. Health staff working in treatment facilities

are well placed to teach family members and motivate them to adopt preventive

measures. Mothers of children being treated for diarrhea are likely to be particularly

receptive to such messages. To avoid overloading mothers with information, it is best

to emphasize only one or two of the following points, selecting those

most appropriate for the particular mother and child.

Breast feeding

Exclusively breastfed babies are much less likely to get diarrhea orto die from it than are babies who are not breastfed or are partially

breastfed.

Improved feeding practicesComplementary foods should normally be started when a child

is six months old. To encourage exclusive breast feeding and

proper feeding practices, health workers should be instructed

in the regular use of growth charts to monitor the weight of

children. Before a child with diarrhea leaves a health facility, his

or her weight should be taken and recorded on the child's growth

chart.

Use of safe waterThe risk of diarrhea can be reduced by using the cleanest available

water and protecting it from contamination.

Collect and store water in clean containers; empty and rinse out the

containers every day; keep the storage container covered and not

allow children or animals to drink from it; remove water with a longhandled dipper that is kept especially for the purpose so that hands

do not touch the water.

ontentsofone sachetin 100 ml provide

o di um 4 5 mm olot ass ium 10mmolhloride 40mmolicarbonate 30mmollucose 55mmol

3.7 gms



Key Messages

w Proper assessment for dehydration and selection of appropriate treatment

Plan A, Plan B and Plan C is very essential.

w Giving ORS together with zinc makes diarrhea treatment more effective in

comparison to the single intervention of ORS alone.

w For children aged six months or above, a dosage of 1 tablet (20 mg) is to be

given daily for 14 days.

w For children between 2 and 6 months of age, a dosage of half a tablet (10 mg) is

to be given daily for 14 days.

w Fluids like watery lentin, rice water or vegetables, khichri, butter milk, fresh

fruit juice, lime water, coconut water and milk may be given to a child (above 6

months) during diarrhea.




38


Understand the Revised National Diarrheal Control Policy, program and guidelines

Understand the overall diarrhea control and management programimplementation at the eld level.

Understand roles and responsibilities of different functionaries (MO/ANM/

PHN/LHV).

Understand the importance and process of supply and logistics and storage.

Identify the need to refer and when and where to refer and follow up.

3.1 Program design and roll out

Diarrheal Disease Control ProgramYou must be familiar with the management of diarrhea and use of ORT therapy. ORS

was introduced in 1978 when the Diarrheal Disease Control Program was launched

across the world including India. ORT has saved more than 50 million childrens lives

over the last 25 years. In the 1980s, nearly ve million children under ve died each

year from diarrhea in 2000, this gure dropped to 1.8 million. In 2008, diarrhea was

estimated to have caused 1.336 million deaths in children under ve, contributing to

15% of all deaths in this age group.

Revised National Diarrhea Control Policy (2007) and GuidelinesThe revised diarrhea management guidelines including the use of zinc during

diarrhea were elucidated in the Government of India policy released in 2007. In Uttar

Pradesh guideline has been issued in August, 2011. Challenges in the introduction

include lack of clarity in the implementation strategy, the roles and responsibilities

of the various stakeholders, the absence of resource material and issues related to

procurement and availability of supplies of Zinc and ORS packets.

Micronutrient InitiativeMicronutrient Initiative (MI) in collaboration with the Government of Uttar Pradesh

is implementing the US fund for UNICEF supported project: Reducing Childhood

Diarrhea through Sustainable Use of Zinc and Oral Rehydration Solution (ORS) in

Session 3

Diarrhea Management Program:

Design and Delivery

Time: 30 minutes

Learning Objectives



Uttar Pradesh. The project aims to increase the coverage of Zinc and ORS for the

treatment of childhood diarrhea and improve compliance to the recommended course

of treatment by the caregivers through public health service delivery channels in Uttar

Pradesh.

Strategy for ImplementationImplementation of Revised Diarrhea Management Guidelines will require coordinated

efforts of stakeholders at the state as well as district level.

Implementation of the revised guidelines will require coordinated efforts of the

various stakeholders, which include:

wDepartment of Health

wDepartment of Women and Child Development

Revised Diarrhea Management Guidelines are to be implemented by the Departmentof RCH/IDSP/others, as decided by the state. The Director (RCH/Family Welfare) is

responsible for implementation, supported by the Nodal Ofcer for Zinc and ORS

who coordinates the day-to-day implementation. Secretary (Health) provides overall

guidance and support.

At the district level, the District RCHO/DIO/another ofcer will be responsible for

implementation.

The following sections describe the different steps in implementation in the order in

which they are to be implemented.

3.2 What is required from the Systems (Health andWCD) and the Community for the management ofdiarrhea in children?

The state, district, block and sector level ofcials of Departments of Health and WCD

are responsible for introduction and implementation of the new guidelines for the

management of diarrhea in children. This includes:

wTraining of health functionaries in the new diarrhea treatment guidelines.

wInitiate and maintain a communication

campaign to create awareness in the

community.

wEnsure availability of zinc and ORS at all the DHs,

CHCs, PHCs, SCs, AWCs and with the ASHAs all

throughout the year.

wMonitor implementation of the revised

guidelines.wEnsure reporting of information from the eld

to the district and from district to the state level,

review reports and take corrective action.




40

wCarry out periodic reviews of the implementation at the PHC, CHC/Block, district

and state levels, take corrective measures as required.

wCoordinate with concerned departments (Department of Women and Child

Development (WCD), Panchayati Raj) and sensitize the leaders regarding the use

of ORS and zinc in childhood diarrhea.

3.3 Provision of ORS and Zinc through differentchannels at various opportunities

Availability of ORS and Zinc tablets in the village to be ensured round the clock,

through the following mechanisms:

wStock at the AWC and the sub-center.

fT+kad

vks-vkj-,l-

wASHA to always keep ORS and Zinc supplies at her home

so that these are available even after the AWC closes.

Village depots of ORS and Zinc should be made at the sub-centers,

AWCs and with the ASHA, and availability of ORS and Zinc should

be ensured round the clock.

3.4 Roles of the MO in ChildhoodDiarrhea Management

Service Delivery Role

wCounsel mothers to start giving suitable home available uids immediately upon

onset of diarrhea in her child.

wGive zinc tablets and ORS to all children

above two months of age having diarrhea

as per the dose recommended.

wCounsel mothers on need for giving

zinc for 14 days and to give it even after

diarrhea has stopped.wExplain to the mother/caregiver how

much zinc is to be given and how the

tablet is to be administered, ask the

mother to demonstrate dissolving zinc

tablet and administer it to her child.

wGive 2 packets of ORS and explain to

the mother/caregiver how to prepare

and administer. Ask her to prepare ORS

solution with 1 litre of water. Teach mother how much ORS to give and to fetchmore packets when these nish.



wUse antibiotics only when appropriate, i.e. in the case of bloody diarrhea, and

abstain from administering anti-diarrheal drugs.

wEmphasize continued complementary feeding or increased breast feeding during,

and increased feeding after the diarrheal episode.

wTeach caregivers how to recognise danger signs for seeking care immediately.

Administrative and Supervisory Role

wStock management ofZinc and ORS.

wLogistics planning and ensuring timeliness of delivery.

wField visits to support and cross-check operations

and any problems functionaries are facing.

wMonthly meeting for stock taking and problem

solving for workforce.

wEnsuring the communication material and

activities are available and properly utilized.

wRecords and reports are properly maintained and

updated.

Managerial and Leadership Role

wProactive role with functionaries and

communities.

wMotivation, Empathy and Recognition for good

work and efforts.

wPlanning and execution.

wBuilding the image and value of the functionaries in the eyes of the families and

communities.

wBuilding the capacity and morale of the workers.

wBuilding the image and reputation of the workers and the system.

The role of the Medical Ofcer and Senior Health functionaries is very crucial and

critical for the success of the childhood diarrhea control and management.




42

Roles and Responsibilities of Health and ICDS functionaries

Medical Ofcers ANM Pharmacist

w As a Service provider

Assessment

Treatment

w planning

w Coordination with other de-partments

w Coordination with NGOs

w Monitoring

w Training /orientation

w Monthly review meeting

w Stock and supply mainte-nance

w Morale and motivation ofstaff

w Leadership role for facilityarea

w As a Service provider

Assessment

Treatment

Referral

w Supportive supervision ofASHA and AWW

w Stocking ORS and Zinc anddistributing to ASHA & AWW

w Compilation of ASHA &AWW reports

w Participate in review meet-ings

w Counseling of caregiver

w Support in reporting OP/IPcases

w ORS and Zinc stock indentingand record keeping

w Supply of stock to OPD, IPDand ANMs

w Participate in review meet-ings

CDPO Anganwadi Supervisor AWW

w Supportive supervision of

AWW and AWS

w Stock and supply

maintenance

w Coordination with other

departments

w Coordination with NGOs

w planning

w Monitoring

w Training/ orientation

w Consolidate and analyze

reports of the Anganwadis and

provide feedback

w Supportive supervision of

AWW

w Stock and supply maintenance

Monitoring

w Training/ orientation of AWW

w Consolidate and analyze reports

of the Anganwadis and provide

feedback

w Community mobilization

w Service provision

Assessment

Treatment

Referralw Depot holder for ORS, Zinc

w Recording and Reporting

w House hold visit

BHEO ASHA

w Supportive supervision ofANM, ASHA and AWW

w Planning support to MOIC

w Implementation support toMOIC

w Support MOIC in Block-levelreview meetings

w Community mobilization

w Service provision

Assessment

Treatment

Referral

w Depot holder for ORS, Zinc

w Recording and Reporting

w House hold visit


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3.5 Demand and Supply Estimation

Maintaining Stock

wThe stock of ORS and zinc tablets must be entered into the Stock Register at the

various levels of district, PHC, CHC, sub-centre, AWW and ASHA. The same stock

should also be entered into the computer wherever the software has been madeavailable (for instance, at the PHC and CHC levels)

Supply Chain

Supply

Medical Ofcer/

Primary Health Center

District Health Society/Chief Medical Ofcer

ASHA Anganwadi

Worker

Health

Sub-Center/ANM

Key Messages

w Medical Ofcers have an important role in child diarrhea management. For

this, they must perform their roles proactively.

w Primary Health care Centers and sub-centers would act as depot of ORS and

zinc packets. Stocks of ORS and zinc should be available 24 hours a day with

them.

w Medical Ofcer's role is not only in service provision but also in project

management, supportive supervision and community engagement.

w PHCs/Anganwadi Centers and sub-centers should register the receipt of ORS

and zinc supplies in the Stock Register with them

Documents

Training Module L1_English 1