INTERVENTIONS FOR THE CONTROL OF DIARRHOEAL DISEASES AMONG YOUNG CHILDREN; IMPROVING LACTATION
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- Title
- INTERVENTIONS FOR THE CONTROL OF DIARRHOEAL DISEASES AMONG YOUNG CHILDREN; IMPROVING LACTATION
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Ch 3.10
SDA-RF-CH-3.2
WORLD HEALTH ORGANIZATION
CDD/85.2
ORGANISATION MONDIALE DE LA SANTE
ORIGINAL: ENGLISH
DIARRHOEAL DISEASES CONTROL PROGRAMME
INTERVENTIONS FOR THE CONTROL OF DIARRHOEAL DISEASES AMONG YOUNG CHILDREN;
IMPROVING LACTATION
by
Ann Ashworth^
and
Richard G. Feachem^
SUMMARY
The effect of improving lactation on <’*
*
' "
diarrhoea
morbidity
and mortality is analysed and
interventions to Increase the quantity or quality of breast milk
are _________
reviewed, It is not
___ ___
known whether the breast-fed children of mothers with enhanced lactation (defined in terms
of quantity and/or quality) have lower diarrhoea morbidity or mortality rates than
breast-fed children of similar mothers with inferior lactation. Although poor maternal
nutrition may lead to a deterioration in milk output and quality, attempts to improve
lactation by maternal supplementation have not achieved any sizeable increase in milk
output, though some improvement in milk quality has been observed. Interventions that
facilitate early post—partum contact and feeding on demand, or increase maternal confidencej
are likely to Increase milk output. On the basis of currently available information, the
improvement of lactation by maternal dietary supplementation is not a promising primary
intervention for national diarrhoeal diseases control programmes. The improvement of
lactation by feeding on demand and allaying maternal anxiety may be a useful supporting
intervention in combination with the promotion of breast-feeding. More prospective studies
are required into breast-milk intake, growth, and diarrhoea in exclusively breast-fed
Infants under 6 months of age.
(r
^Lecturer, Department of Human Nutrition, London School of Hygiene and Tropical Medicine,
Keppel Street, London WC1E 7HT.
^Head, Department of Tropical Hygiene, London School of Hygiene and Tropical Medicine,
Keppel Street, London WC1E 7HT.
The issue of this document does not constitute
formal publication.
It should not be reviewed,
abstracted or quoted without the agreement of
the World Health Organization.
Authors alone
are responsible for views expressed in signed
articles.
Ce document ne constitue pas une publication.
II ne doit faire I'objet d'aucun compte rendu ou
rdsum^ ni d'aucune citation sans I'autorisation de
I'Organisation mondiale de la Sant6. Les opinions
exprimdes dans les articles signes n'engagent que
leurs auteurs.
CDD/85.2
page 2
INTRODUCTION
This paper is the sixth in a series of reviews of potential interventions for the
control of diarrhoeal diseases among young children in developing countries (1^, 16—20). In
the second review in the series, data were presented showing that infants with a poor
nutritional status are predisposed to more severe and longer-lasting diarrhoea and to higher
case-fatality rates (16). In the third review, exclusively breast-fed infants were shown to
be better protected against diarrhoea than partially breast-fed or non-breast-fed infants,
and it was concluded that the promotion of breast-feeding can be expected to decrease
diarrhoea morbidity and mortality rates substantially in the first 6 months of life (19).
In this review, we examine whether improving the quantity or quality of breast milk, as
distinct from the promotion of breast-feeding, could be an effective intervention for
reducing diarrhoeal diseases among young children. If milk output could be improved in
certain situations, infants might be adequately fed for a longer period on breast milk
alone. Improving milk output or milk quality in certain situations might also improve the
nutritional status of breast-fed infants. The possible relationships are schematically
represented below:
Fed adequately for longer on breast milk alone
Reduced diarrhoea mortality
and/or morbidity
Increased milk yield
and/or improved milk quality
Improved nutritional status of infants
The separation of interventions directed towards increasing breast-feeding prevalence
and those directed towards improving lactation is desirable since the former are concerned
with maternal behaviour and the decision to breast-feed or not, whereas the latter are
concerned with physiological performance and the capacity of mothers to produce breast milk.
EFFECTIVENESS
If improving lactation is to be effective as a diarrhoeal disease control strategy, it
must be true that:
either
a considerable proportion of diarrhoea morbidity or
mortality in young children in developing countries is
due to inadequate breast-milk quantity or quality
hypothesis
1
and
programmes aimed at improving maternal nutritional
status or breast-feeding practice can improve breast-milk
quantity or quality
hypothesis
2
or
programmes aimed at improving maternal nutritional status
or breast-feeding practice can reduce diarrhoea morbidity
or mortality in young children
hypothesis
3
CDD/85.2
page 3
There is a considerable amount of literature bearing on hypothesis 2, but little is
known of hypothesis 1, and almost nothing of hypothesis 3. The effectiveness of improving
lactation as an intervention to reduce diarrhoea morbidity or mortality would be suggested
by a demonstration either of the correctness of hypotheses 1 and 2 or of the correctness of
hypothesis 3. This is schematically represented in the following diagram:
INTERVENTION
MOTHER
Improved maternal nutrition
or breast-feeding practice
Improved breast-milk
quantity and/or quality
CHILD
► Reduced diarrhoea morbidity
and/or mortality
Hypothesis 1
Hypothesis 2
Hypothesis 3
The evidence for and against these hypotheses is examined below.
‘
Hypothesis
1: A considerable proportion of diarrhoea morbidity or mortality in young
children in developing countries is due to inadequate breast-milk quantity or quality
The adequacy of lactation is assessed by determining the quantity and quality of breast
milk produced in 24 hours, or by measuring the growth of the recipient infant. Both methods
present problems because there are technical difficulties in measuring milk yields and milk
composition, and factors other than milk supply may affect infant growth. Both methods
necessitate a reference standard, and appropriate standards for developing countries have
not yet been agreed upon (65).
Adequacy of lactation in developing countries:
breast-milk quantity
Average milk yields are generally reported to be lower in developing countries than in
developed countries. In well-nourished women the average daily production of breast milk is
commonly stated to be 850 ml. This figure originated in 1950 as an estimate based on
studies in New Zealand and the USA in which 68 measurements were made in 19 mothers at
different stages of lactation (22). Milk yields in these 19 mothers ranged from 250 to
1500 ml/day, and it was tentatively assumed that 850 ml represented the average daily output
during the first 6 months of lactation. Thus, although this figure is sometimes used as a
reference for the adequacy of lactation, it was never intended as such. Since 1950, further
lactation studies have been undertaken in developed countries, the results of which indicate
that when milk output is at its peak, around the 3rd or 4th month, the average daily volume
is usually 750-800 ml (73). Volumes within this range may therefore be considered to
represent the average peak yield of well-nourished, healthy mothers. In communities with
poor living conditions and a lower plane of maternal nutrition, average peak yields are
usually below this range. In 20 studies in developing countries, average peak milk yields
in the first 6 months of lactation ranged from 400-730 ml/day (15, 73, 76).
In most studies breast-milk consumption has been measured by test-weighing the infant
before and after each feed. This is extremely difficult in traditional societies because of
the high frequency of feeding. In some studies, in order to facilitate the measurements,
infants who usually were fed on demand have been changed to scheduled feeds, with possible
CDD/85.2
page 4
adverse effects on milk output. Furthermore, the measurements themselves, or their
location, may cause the mother anxiety and adversely affect milk output. In Senegal and
Sweden, for example, daily milk output was reduced by 160 ml and 210 ml respectively when
measurements were made in unfamiliar surroundings (61, 5). It is therefore possible that
the volumes reported in some studies could be underestimates. Furthermore, the infant may
not consume all that is produced, and therefore measurements based on test-weighing may
underestimate milk production.
Notwithstanding the methodological difficulties, it is generally agreed that the average
breast-milk output is usually somewhat less in poorly nourished communities (35, 59, 73).
This view is strengthened by data from Egypt, where a difference in mean output of
195 ml/day was found between healthy and malnourished mothers (30), and by data from
The Gambia (48), Kenya (67), and Zaire (69) where a 35-40% decrease in milk yield
(200-300 ml) occurred when food stocks were low. Within-study comparisons such as these are
more likely to identify true differences, whereas between-study comparisons may be
unreliable if differing methodologies have been used.
Adequacy of lactation in developing countries:
breast-milk quality
Comparisons of breast-milk quality present methodological problems since the composition
of breast milk changes considerably during a single feed. For example, hind-milk may
contain 4-5 times as much fat as fore-milk. Breast-milk composition also varies with the
time from parturition, the time of day, the feeding frequency, and the sampling method
(manual expression or breast pump). Cross-cultural comparisons of breast-milk quality are
therefore difficult to interpret, especially with regard to fat and energy contents.
Lactose is regarded as the most stable constituent of breast milk and the protein
concentration is also generally regarded as being constant among communities (35, 59, 73).
The fat content of breast milk appears less stable and investigators in Botswana (74),
East Africa (10), India (12, 25), Pakistan (66) and Papua New Guinea (2) have reported
substantially lower fat concentrations compared with developed countries, while in
The Gambia significant seasonal differences in fat content have been observed (73). In
Brazil, however, fat concentrations were unaffected by maternal malnutrition (41). The
vitamin content of breast milk is known to be affected by maternal diet, and there have been
reports of lower concentrations of vitamin A (23), several of the B vitamins (4^, 35), and
vitamin C (74) in the milk of under-privileged mothers. Very little is known about the
mineral content of breast milk in developing countries but low concentrations of zinc and
copper have been found in milk from poor Indian women, 1—3 months post—partum (54).
Whether maternal nutrition affects the anti-infective properties of breast milk has
received little attention. In The Gambia in the rainy season, substantial decreases in the
concentrations of IgA, IgG, 04 component of complement, and lysozyme were found in addition
to a decrease in milk volume (50). During this period the prevalence of diarrhoea
increased, but this could have been due to factors other than changes in breast-milk
composition. In Colombia, significant reductions in the concentrations of colostral IgA,
IgG, and 04 component of complement were observed in malnourished mothers (45).
We therefore conclude that, although breast-milk output in developing countries is
usually good despite low levels of maternal dietary intake, reductions in daily output of
200-300 ml may occur during periods of acute or chronic maternal undernutrition.
Furthermore, poor maternal nutrition may lead to a deterioration in milk quality, primarily
in relation to the concentrations of fat and vitamins, and possibly of trace elements,
immunoglobulins, and other protective factors. Lipid components in breast milk are believed
to have anti-infective properties (36). Deficiencies of certain vitamins and trace elements
are known to impair the immune response. It is possible, therefore, that reduced
concentrations of specific nutrients and protective factors in the milk of undernourished
mothers, compounded by a lower total volume, may adversely affect the nutritional status and
immune response of their infants, especially if poor maternal nutrition also resulted in
lowered foetal storage of nutrients.
CDD/85.2
page 5
Adequacy of lactation in developing countries:
infant growth
In the majority of longitudinal or semilongitudinal surveys of infant growth in
developing countries, weight velocity begins to decelerate between 3 and 4 months of age
(14, 70) compared with United Kingdom standards (44). In several of these surveys, however,
sample sizes were small, birthweight and gestational age are not specified, and it is not
usually clear whether the infants were exclusively breast-fed throughout the entire 6-month
period. In an effort to provide more reliable data, longitudinal surveys of infant growth
have been undertaken recently in Canada (6), Manipur, India (N.C. Luwang, personal
communication, 1983), and Jordan (S. Hijazi, personal communication, 1984) of infants who
were known to be exclusively breast-fed (that is, no other fluids or foods were consumed,
except water in some instances although this was rare among the Indian infants studied).
Weight velocity and morbidity were monitored monthly in Canada and fortnightly in India and
Jordan, and growth faltering was rigidly defined. Table 1 shows that, in marked contrast to
Canadian infants, growth had faltered in 38Z of Indian infants before the age of 4 months.
In Jordan the prevalence of growth faltering was less than in India, but 15Z had faltered
before the age of 4 months. In all 3 studies, low birthweight infants were excluded. In
the Indian and Jordanian studies the definition of faltering was more severe than in the
Canadian study, namely successive fortnightly increments -2SD below the mean Increment of
North American infants (21). The Indian mothers mostly belonged to the middle
socio-economic class, were free from disease, and of parity 3 or less. Infant morbidity
data have not yet been reported from India and Jordan, but the preliminary Impression is
that in both countries faltering was the result of Inadequate lactation, rather than
infection. In the Canadian study (6) it was found that, among exclusively breast-fed
infants, those whose growth faltered had a significantly higher infection-related morbidity
rate than those with no faltering. In the majority of these infants, growth failure was
detected before clinical infections were observed, and it is therefore reasonable to
conclude that an inadequate breast-milk intake caused the growth faltering. These findings
are in keeping with the statement issued in 1980 by a United Nations Consultative Group on
Maternal and Young Child Nutrition that "In conditions where undernutrition and social
deprivation are common, the growth of exclusively breast-fed infants may show signs of
faltering before 4 months." (65).
Table 1:
Age
(months)
Growth faltering among exclusively breast-fed infants.!
Cumulative prevalence of growth faltering
m___________
___
IndiaS
n = 84
Canada^,
n = 36
JordanS
n = 87
0-1
0
0
1
1-2
0
1
8
2-3
0
11
13
3-4
0
15
38
4-5
8
29
61
5-6
14
46
85
^Canadian data from Chandra (£), Jordanian data from S. Hijazi (personal
communication), and Indian data from N.C. Luwang (personal communication).
^Faltering taken as body weight <10th centile of NCHS standard (47^).
Sfaltering taken as two successive weight increments -2SD below the mean
increment according to Fomon (21) if ^.4 months of age, or -2SD below the NCHS
standard (47) if >4 months of age.
CDD/85.2
page 6
Consequences of inadequate lactation
Poor lactation can be expected to have one of two consequences: either the infant s
growth will falter or his mother, perceiving his plight, will provide him with additional
food, as for example in The Gambia where mothers whose breast-milk output was below the
group mean were observed to introduce supplements earlier than mothers with higher
breast-milk yields (71). This second outcome is equally problematic in poor communities
since traditional supplementary foods are often of low nutritional value and highly
contaminated with diarrhoeal pathogens (3^, 58). In these circumstances, inadequate
lactation may lead to diarrhoea whether the mother chooses to supplement or not, as shown in
the diagram below (broken lines denote a degree of uncertainty).
Poor nutritional status
I
Inadequate lactation
Increased diarrhoea
morbidity or mortality
Earlier weaning with
contaminated supplementary
foods of low nutritional value
Direct evidence for this sequence of events is limited. We have located only one
prospective study of breast-milk output and diarrhoea. In this study, in The Gambia (71), a
significant linear correlation was found between breast-milk output and the age of first
diarrhoea-induced weight loss, lower milk yields being associated with earlier diarrhoea.
No incidence rates are reported in this study. Lower milk yields were also significantly
correlated with earlier weaning and this may be the cause of the earlier onset of severe
diarrhoea.
Conclusions concerning hypothesis 1
We can conclude very little about hypothesis 1 from the data reviewed above, Poor
maternal nutrition may reduce milk yields and possibly lower milk quality, but we lack
information on the prevalence of inadequate breast-milk quantity or quality. We even lack
internationally-accepted definitions of adequacy. We know little of the frequency of
undernutrition among exclusively breast-fed infants or of the proportion of this
undernutrition that may be attributed to inadequate lactation rather than to infection.
These gaps in our knowledge are not minor - they represent fundamental questions which
require urgent answers. Although inadequate lactation may predispose to diarrhoea, we have
no evidence of this except for a single report from The Gambia (71), and this relates to the
age of onset of severe diarrhoea, rather than its frequency.
CDD/85.2
page 7
Hypothesis 2: Programmes
aimed at improving maternal nutritional status or breast-feeding
liiitil
practice can improve breast-milk quantity or quality
Etiology of inadequate lactation
Breast-milk insufficiency may arise either from inadequate milk synthesis and/or
inadequate milk ejection (let-down). Both are under hormonal control, the former by
prolactin and the latter by oxytocin. Prolactin and oxytocin are released by separate
pathways in response to suckling. Conditioned release of oxytocin may also occur in
response to stimuli such as an infant’s cry. The milk—ejection reflex can be inhibited by
anxiety or physical stress, either by inhibiting oxytocin release or more often by the
release of catecholamines which constrict the mammary blood vessels, thus preventing access
of oxytocin to the myoepithelial cells. Inhibition is more likely to occur during the early
weeks of lactation than later on. Factors which may affect milk synthesis or its ejection,
and which may be amenable to short-term intervention, are maternal nutritional status,
galactogogues, breast-feeding practices, and the use of contraceptives.
Improving maternal nutritional status
In considering hypothesis 1 we concluded that poor maternal nutrition may reduce milk
yields and possibly lower milk quality. Energy and nutrient requirements are increased
during pregnancy, and more so during lactation, Dietary intakes, however, may be
constrained by poverty, unavailability of food, or intrafamilial food sharing in favour of
male members. In some communities, poor maternal nutrition may be longstanding, or may
develop during pregnancy and/or lactation. Short birth intervals may exacerbate the problem
and a reduction in body weight with increasing parity has been observed in Papua New Guinea
(68). Maternal nutrition may also be impaired by infection and an arduous work load.
Although better primary health care, family planning, and changes in cultural attitudes
towards women may lead to an improvement in their nutritional status, considerable emphasis
is currently being given to increasing the dietary intakes of lactating women either by
advising them to eat more of the locally available foods or by providing food supplements.
"Feed the nursing mother, thereby the infant" is becoming an increasingly popular maxim
although the efficacy of this advice has not been adequately tested. Indeed this quotation
is derived from an investigation in which only one mother was studied (63). In view of the
emphasis being given to the provision of food supplements to lactating women, it is
appropriate to consider the effects of such programmes on breast-milk quantity and quality.
Only a few evaluations have been undertaken and nearly all are unsatisfactory. Most have
not measured consumption of the supplement or the intake of the regular diet. Some are of
limited duration or small-scale. The results are conflicting, as shown by the following
6 studies.
In Zaire, 27 lactating mothers received dried skimmed milk (60 kcal (251 kJ) and
6 g protein/day) for one year (13).
(33). During the first 3 months of lactation, breast-milk
yields of supplemented and unsupplemented mothers averaged 480 ml and 310 ml respectively.
However, by the fourth month of lactation, the breast-milk yields of the supplemented
mothers had decreased to about 400 ml and were similar to those of unsupplemented mothers.
Breast-milk protein concentrations were similar in the first 6 months in both groups but
thereafter declined in the unsupplemented group. No decline in protein concentration was
observed in the breast milk of supplemented mothers. Consumption of the supplement and
regular diet were not measured.
In India, 15 low-income mothers with habitual protein intakes of about 60 g/day received
an additional 280 kcal (1171 kJ) and 30 g protein as skimmed milk daily for the first
6 months of lactation, and 15 similar mothers received a placebo (24). Consumption of the
supplement was supervised. Mothers were instructed to continue their usual diets, but
despite repeated exhortations it was not possible to prevent some supplemented mothers from
eating less of their regular diet. During the six-month period when their infants were
exclusively breast-fed, the infants of supplemented mothers gained only 130 g more on
CDD/85.2
page 8
average than control infants. When 6 mothers were hospitalized to facilitate dietary
compliance and measurement of breast-milk output, increasing the maternal protein intake
from 61 to 99 g/day was accompanied by an increase in average milk yield from 402 to
515 ml/day, and by a decrease in average protein concentration from 1.21 to 1.02 g/100 ml.
In Mexico, 17 mothers received a supplement of partially skimmed milk, vitamins, and
minerals throughout pregnancy and lactation (7^, 8). Habitual daily intakes in lactation
were approximately 2000 kcal (8368 kJ) and 53 g protein and the supplement provided an
additional 300 kcal (1255 kJ) and 20 g protein per day. Peak breast-milk output averaged
720 ml in supplemented mothers, compared with 650 ml in control mothers who were matched for
physical and socioeconomic characteristics. These higher volumes were also maintained for a
longer period, although they were largely offset by a 15-20% decrease in energy and nutrient
concentration. Unfortunately, precise information regarding the impact of these changes on
infant growth is not available since the infants were themselves supplemented. However,
4 additional cases were studied in which the mother was supplemented but not the infant
(7_). The mean weight of these 4 infants at 8 months of age was approximately 600 g greater
than that of the infants of the 17 unsupplemented mothers. Their heavier weight, however,
is probably partly attributable to a heavier birthweight as a result of the pre-natal
supplement, and one cannot assume that the weight differential arose as a result of improved
lactation.
In Nigeria, the mean breast-milk output of 7 mothers increased from 740 g to 870 g
(pX.0.05) when they were given an additional 50 g protein per day. There was no significant
decrease in the concentration of milk solids (15). During the 2-week supplementation period
their infants grew significantly faster and gained on average 200 g more than during the
pre-supplementation period when the women ate cassava-based diets containing 50 g protein
per day. However, this was a short-term study, the duration of supplementation being only
2 weeks.
In Colombia, generous supplements of enriched bread, dried skimmed milk, and vegetable
oil were provided (32). Women were supplemented during the third trimester of pregnancy and
during lactation, and a daily supplement of 623 kcal (2607 kJ) and 30 g protein was provided
for each family member over one year of age. Pregnant women were allotted 856 kcal
(3581 kJ) and 38 g of protein. Consumption of the supplement during lactation was not
assessed, but during pregnancy the net increase in energy intake was only 18% of that
offered. Breast-milk output was not measured but, during the first 2 months of life, the
infants of supplemented mothers gained on average only 45 g more than the infants of
unsupplemented mothers.
The effects of pre-natal and post-natal supplementation are currently being investigated
in The Gambia (51_, 52). The investigation is in two stages. During the first phase of the
study the supplement was given during lactation. In the second phase, now under way,
supplementation was initiated at the beginning of pregnancy and is continuing during
lactation. In the first phase, 130 lactating women were offered groundnut-based biscuits
and a vitamin-fortified tea drink, 6 days each week for 12 months. Consumption was
supervised and measured. The daily allocation was 950 kcal (3975 kJ) and 35 g protein in
the dry season and 1100 kcal (4602 kJ) and 41 g protein in the wet season (52). Over the
whole year, the intake of the supplement amounted to 830 kcal (3473 kJ) per day, of which
107 kcal (448 kJ) replaced some of the regular diet. The mean daily energy intake was
2291 kcal (9585 kJ) compared with 1568 kcal (6560 kJ) for 120 unsupplemented lactating
mothers. Supplementation had no effect on breast-milk output at any stage of lactation or
in any season of the year. The population standard deviation remained the same after
supplementation, demonstrating that the supplement had not benefited even the lowest milk
producers (51). Supplementation increased the protein concentration of breast milk by
approximately 7% at all stages of lactation, but decreased the lactose concentration
(p<0.01 in each case). Supplementation did not significantly affect the energy content
(51).
(51). There was a significant increase in the milk content of thiamin (+40%), riboflavin
(+33%), niacin (+43%), and vitamin C (+33%). Maternal supplementation did not prevent the
seasonal decrease in IgA, IgG, 04 component of complement, and lysozyme (50).
CDD/85.2
page 9
Although there appears to be evidence that some improvement in lactation was achieved as
a result of maternal supplementation in 4 of these studies (India, Mexico, Nigeria, and
Zaire), we have been strongly influenced by the Gambian investigation because it has the
largest sample size, the most rigorous experimental design, and is the longest in duration.
The fact that no increase in milk volume was observed despite a very substantial increase in
maternal intake suggests that post-natal supplementation may not be effective in populations
where the primary dietary deficit is an inadequate energy intake. Particularly
disappointing is the lack of any significant effect on milk output during the wet season
when milk yields are known to diminish. One must also consider, however, that during this
period women are extremely busy with agricultural activities. It is therefore possible that
in the wet season lactating women do not spend as much time nursing their infants as they do
at other times of the year. An interesting hypothesis for the lack of effect is that the
increased energy intake was utilized by increasing the amount of physical labour undertaken
during the busy planting season, although it is possible that at least some of the energy
may have been dissipated by a decrease in metabolic efficiency (49). Alternatively, it is
possible that the post-partum period is too late to improve milk output and that pregnancy
is the more appropriate time when mammary growth is occurring. In rats, pre-natal
malnutrition impairs mammary growth and milk production (46).
In the second phase of the Gambian study, preliminary observations indicate that infants
of mothers who were supplemented pre- and post-natally are thriving better, although no
increase in milk yield has been observed (A.M. Prentice, personal communication, 1983).
Morbidity and birthweight data are being analysed which may help to explain this seemingly
paradoxical outcome. In this context it is relevant to note that (a) in Guatemala, weight
gain during the last trimester of pregnancy was related to the duration of lactation (29);
(b) in 5 Chilean studies, a significant association has been demonstrated between
birthweight and the prevalence and duration of lactation (40); and (c) there is a positive
correlation between birthweight and subsequent milk intake (72). These findings suggest
that pre-natal maternal nutrition may affect lactation as well as foetal growth.
The evidence that post-natal food supplementation improves breast-milk quantity is
weak. It is possible, however, that the lack of any notable impact may be due to
methodological problems, or to a failure to achieve substantial increases in maternal net
dietary intake, or to onerous lifestyles which limit the amount of time mothers can spend
breast-feeding. It is also possible that the mothers who have been studied were not
sufficiently malnourished. This does not mean that lactating women should be excluded from
supplementary feeding programmes since the additional food may improve maternal nutrition
and be beneficial for any subsequent pregnancy or may increase their feeling of well-being
and enable them to take better care of their children. Improving the maternal diet without
concurrently introducing some artificial form of contraception may, however, cause a
shortening of birth intervals and a rise in birth rate (39). Whether pre-natal
supplementation improves lactation remains to be elucidated.
Galactogogues
Many communities regard certain foods or drugs as having galactogogic properties.
Precise proof of their pharmacological effects is not available. In an Indian study, 4
substances claimed to promote lactation were Investigated but none was found to have any
appreciable effect, They were tamarind, cotton-seed, garlic, and 'Leptaden* - an indigenous
preparation (24).
Metoclopramide (38) and sulpiride (77) are dopamine antagonists which increase prolactin
release and improve milk yields. Let-down of milk can be induced by giving synthetic
oxytocin as a nasal or throat spray (60). However, galactagogues such as these are unlikely
to be of any practical use in developing countries.
Improving breast-feeding practices
Suckling stimulates prolactin and oxytocin release, thus frequent suckling facilitates
the early establishment and maintenance of a good milk flow. Demand feeding is therefore
preferable to scheduled feeding. Feeding on demand requires that the mother and infant
CDD/85.2
page 10
should be in close physical proximity. In transitional and Westernized societies, hospital
routines which separate the mother from her newborn infant, which delay breast-feeding,
which offer water or supplementary milk feeds, or which sedate the mother are not conducive
to feeding on demand and can adversely affect the initiation of lactation; they may also
give rise to anxiety, which inhibits milk-ejection. In Sweden, skin-to-skin contact and
suckling immediately after delivery was associated with a two-fold increase in the
proportion of mothers who were breast-feeding at 3 months (13). Rooming-in (allowing mother
and newborn infant to be in the same room) has been suggested to increase the feeling of
motherhood, resulting in a more positive attitude to breast-feeding (53) as well as
facilitating feeding on demand. The use of pacifiers is contrary to the concept of feeding
on demand. Changes in breast-feeding practice that increase the number of feedings are
likely to increase the quantity of milk produced. In traditional societies, feeding on
demand in the early post-parturn period is the norm and the young infant spends most of the
day and night in close bodily contact with his mother. For older infants, however, feeding
on demand may be less frequently honoured since the infant may be left with a caretaker
whilst the mother works. In India and Kenya, physical separation starts at about 6 months
of age (9_t 67). Interventions that enable mothers to spend more time with their infants (by
easing their work burdens, for example) may help to maintain a high frequency of feeding and
improve breast-milk output. Maternal attitudes are important and can affect the adequacy of
lactation. This is illustrated by data from India, where exclusively breast-fed male
infants were better nourished than exclusively breast-fed female infants (11). The
difference in lactation performance was attributed to greater motivation when mothers had
male infants.
In traditional societies, the birth attendant plays an important role, imparting the
skills of breast-feeding and providing physical help and emotional support (55). Urbanized
mothers often lack this form of traditional assistance. Support and guidance is further
reduced by the shift from ’extended’ to ’nuclear’ families. Abandonment of traditional
practices may interfere with the almost continuous nursing of the infant and may provoke
actual or perceived milk insufficiency as depicted below:
Abandonment of
traditional practices
l
Less frequent
feedings
Fussy, crying
infant
Breast distension
sore nipples
▼
INTERPRETED AS
INADEQUATE""
LACTATION
>
Maternal
anxiety
Maternal
anxiety
—> Less milk <—
Impaired
milk ejection
Insufficient
suckling
*
l
1
B
t ,
▼
WHO 85219
Adapted from reference (28).
Fatigued
agitated
infant
Sucking
difficulties
CDD/85.2
page 11
The formation of breast-feeding mothers’ support groups may assist in dispelling ’crises
of confidence’, and the guidance provided by such groups may Improve lactation, as has been
observed in slum-dwelling mothers in Brazil (D.B. Jelliffe, personal communication, 1983).
Use of contraceptives
The use of oral contraceptives to space pregnancies may lower maternal blood
concentrations of folic acid, pyridoxine, riboflavin, and vitamin C. Breast-milk levels of
pyridoxine have been found to be significantly lower in long-term users of oral
contraceptives (56). Combined oral contraceptives that contain as little as 30 /ig of
oestrogen can decrease milk volume by as much as 40% if introduced early in lactation (27_,
34, 57, 64, 75). Conversely, 17c<.- progestogen derivatives given alone (mini pills or
intramuscular Depo-Provera) may increase milk volume (26, 37, 78). Intrauterine devices
also appear to stimulate lactation, possibly by mechanical action provoking a neuroendocrine
reflex that increases prolactin output (26, 43) but the evidence is not very strong and
recent research suggests an increased risk of uterine perforation when Intrauterine devices
are used in the post-partum period (31). Where oestrogen-containing
oestrogen—containing oral contraceptives are
used, changing the type of contraceptive may improve breast-milk output.
Conclusions on hypothesis 2
Dietary supplementation studies have not been successful in increasing breast-milk
output except where habitual protein intakes have been about 50 g per day. All studies
present methodological problems which make evaluation difficult, and in only one study was a
substantial net increase in maternal energy Intake achieved. In this study, in The Gambia,
even substantial supplementation did not increase milk output, although milk quality was
improved. Interventions that facilitate early post-partum contact and feeding on demand, or
increase maternal confidence, are likely to increase milk output, especially in transitional
societies. Family planning programmes should consider the effects of oestrogen-containing
oral contraceptives on lactating women.
Hypothesis 3; Programmes
aimed at improving maternal nutritional status or breast-feeding .
n hi
practice can reduce diarrhoea morbidity or mortality in young children
We have located only one study in which the diarrhoea rates of exclusively breast-fed
infants whose mothers have participated in programmes to improve lactation have been
compared with diarrhoea rates in other exclusively breast-fed infants (62). In this study
in a poor urban district of Manaus, Brazil, where zinc deficiency is prevalent, 37 mothers
received 15 mg of zinc daily and 28 mothers received a placebo. Supplementation was started
in the first week post-partum and families were visited daily. During the first 5 months of
life, when all the infants were exclusively breast-fed, 30% of infants of supplemented
mothers had diarrhoea in contrast to 57% of control infants. The difference in diarrhoea
morbidity was significant for male infants (p<0.05) but not for female infants. In
Puriscal, Costa Rica, changes in hospital routine were associated with a decrease in
neonatal diarrhoea morbidity and mortality (42). The changes in hospital routine included
early post-partum contact and suckling, rooming-in, and advice on breast-feeding, These
changes were associated with an increase in the prevalence and duration of breast-feeding.
Whether this increase simply reflected a change in maternal attitudes towards breast-feeding
or resulted from improved breast-milk output is not known. There is, however, a
physiological mechanism for the latter since more frequent suckling could have enhanced milk
synthesis, and the extra attention and advice could have improved maternal confidence and
assisted milk ejection.
CDD/85.2
page 12
We have no other data to support or negate hypothesis 3. We have almost no data on
hypothesis 1, and only very inadequate data on hypothesis 2. We can therefore make no
theoretical calculations on the possible impact of improving lactation on diarrhoea rates.
CONCLUSIONS
There is evidence to suggest that poor maternal nutrition leads to a deterioration in
milk output and milk quality and, in The Gambia, lower milk yields were associated with
earlier weaning and earlier onset of severe diarrhoea. Attempts to improve lactation by
post-natal dietary supplementation, however, have not achieved any sizeable Increase in milk
output, although some improvement in milk composition has been achieved, mainly in vitamin
content. In a zinc-deficient population in Brazil, post-natal maternal zinc supplementation
reduced diarrhoea morbidity rates in early infancy. Although there is no proof that the
reduction in diarrhoea was due to improved lactation, there seems to be no alternative
mechanism since all the infants were exclusively breast-fed.
Pre-natal dietary supplementation may prove to be a more promising intervention to
increase milk output than post-natal supplementation. Pre-natal supplementation, however,
is subject to the high costs and logistic complexities of all supplementary feeding
programmes (16). In addition, its effect on diarrhoea through increasing birthweight (1^)
may be greater than its effect on diarrhoea through improving milk output or milk quality.
Interventions that change hospital routines to permit early post-partum contact and
feeding on demand may improve breast-milk output. Interventions which seek to maintain
feeding on demand in the home environment (keeping mother and infant in close proximity both
day and night, and discouraging use of pacifiers and supplementary feeds of water), or
provide support and guidance, are likely to improve breast-milk output. These interventions
may also have a positive effect on maternal attitudes towards breast-feeding, and their
effect on diarrhoea through increasing the prevalence of breast-fed infants (19) may be
greater than their effect on diarrhoea through improving breast-milk output.
In conclusion, on the basis of data currently available, the improvement of lactation by
maternal dietary supplementation is not a promising primary intervention for national
diarrhoeal diseases control programmes. The improvement of lactation by allowing feeding on
demand and allaying maternal anxiety may be considered a supporting intervention in
combination with the promotion of breast-feeding - an intervention that may have
considerable impact on diarrhoea morbidity and mortality in the first 6 months of life.
This review has highlighted several areas of ignorance that require further research.
More prospective studies of milk output, and of growth and morbidity in exclusively
breast-fed infants are required to determine the prevalence of inadequate lactation in
different countries and in different socioeconomic groups. Several factors may reduce milk
output, including maternal undernutrition, anxiety, and work burdens that limit the time
available for breast-feeding. The relative importance of these causal factors should be
examined in communities reporting low milk yields. A greater understanding of the
relationship between growth faltering and diarrhoea is required, particularly as regards any
effect that mild or moderate faltering may have on the frequency, duration, or severity of
diarrhoea. In zinc-deficient populations, further investigation is warranted of the effect
of maternal zinc supplementation on milk quality and diarrhoea.
ACKNOWLEDGMENTS
The authors are grateful for the constructive criticism of earlier drafts of this paper
provided by D. Blum, A. Chavez, I. de Zoysa, S. Esrey, M. Gurney, R.C. Hogan, S.L. Huffman,
D.B. Jelliffe, E.F.P. Jelliffe, M.H. Merson, A.M. Prentice, P.M. Shah, and D. Silimperi.
Secretarial, bibliographic, and editorial support were must ably provided by
Caprice Mahalla, Susanne O’Driscoll, and Ann Martinez.
CDD/85.2
page 13
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*
I
W.H.O. ORAL REHYDRATION CENTRE
Vani Vilas Children's Hospital
Bangalore
Dr. D.G. Benkappa
Prof. & Head, Dept, of Pediatrics
Superintendent, Vani Vilas Children's Hospital
Bangalore.
9
i
i
Dr. Shivananda
Assistant Professor of .Pediatrics
Vani Vilas Children's Hospital
Bangalore.
W.H.O. ORAL REHYDRATION CENTRE
Vanivilas Children’s Hospital
Bangalore
The
O.R.T. Center
was started
in
Vani
Vilas Children’s Hospital
in
December 1985 with aid from W.H.O.
OBJECTIVES OF THE CENTER :
1.
Service to the patients
2. Training of
medical,
prevention and management of dehydration.
para-medical,
Anganwadi,
Voluntary
Health
workers.
3. Health Education of the parents
- prevention of Castro Enteritis,
dehydration.
4.
Research programme - conducting trial
on use
different of types
of oral rehydration solution.
5. Growth monitoring of -the patients on follow-up.
6.
Health
Education
regarding
immunization and
infant
nutrition
so
that integrated services are
availableini a single visit.
—------------INFRASTRUCTURE
We have .about 30 beds for diarrhoea manned by two Post Graduates,
5 internees, 4 staff nurses and 2 helpers supervised by Lecturer, Asst. Prof.,
Professors and Superintendent.
ORS: Packets of 1
L and 5 L are
prepared by Post Graduates Salts are
being supplied in bulk by the stores of Vani Vilas Hospital.
TYPES OF O.R.S.
-
O.R.S.
-
Super O.R.S.
-
Citrate based ORS
-
Glycine based O.R.S.
-2-
Different .solutions are prepared in bulk of 5-20 liters depending upon
the
demand and distributed to the patients, according to the requirements.
Children who are admitted to the ward are assessed as mild, moderate
and severe as per the case proforma. Child with mild, moderate dehydration
are given different OPS at random.
IV
fluids are
given to the children with severe dehydration until the
correction of deficit therapy i.e., 4-6 hours, later as soon as the child starts
taking orally, ORS is given to the child.
These patients are kept for 24-72 hours and discharged as soon as they
make recovery. Stool samples are subjected to microscopic examination and
culture, routinely.
HEALTH EDUCATION
In
the
afternoon, mothers are
taught
about
the signs of dehydration
and method of prevention of diarrhoea.
Prevention of dehydration and nutritional care of the child and immunization advise are also given.
Stress is laid on breast feeding, usual food, during the attack of diar-
rhoea.
So far, we have trained nearly 500 medical students, 60 post graduates,
300 medical officers, 100 practitioners, 50 B.Sc. nursing students, and Anganwadi workers, nearly 5000 mothers and 120 voluntary health workers.
Table 1:
Diarrhoea still continues to be a major problem in developing countries,
it is taking the big share in the admission to Children's Hospital. In our Insti
tute 23.5% of the beds are taken away by diarrhoea.
Of
the
2206
admitted between 86
Jan. to 86
December 69 children
-3-
died. The mortality rate due to diarrhoea was 3.12%. The mortality was attri
butable to higher number of admissions due to cholera in the last year (51).
■>
More importantly, as our hospital being a referral hospital, many patients
will be in a serious state by the time they reach the hospital. Thirdly many
children were (156) malnourished and lastly the associated respiratory infec
tions were responsible for the high mortality.
M : F ratio was 2 : 3
As the table implies diarrhoea is more common in pre-school children
74.4%., 28.73% of the attacks seen in 6-12 months age. Only 13.5% were
in school going children.
SEVERITY OF DEHYDRATION
40.79% of the children were mildly dehydrated when they were admitted.
45.55% of the children were moderately dehydrated, only 13.65% of the child
ren were severely dehydrated indicating that
if proper care is taken in the
earlier stages this incidence of severe dehydration can be reduced.
Majority of the children were given ORS alone (73.48%) IV fluids were
given in 26.52% of the children. Prior to the institution of the ORT, all these
children used to receive IV fluids. Hence excessive spending of hospital budget
on■’’IVfluids’ and drugs is being reduced. Moreover the difficulties of IV fluids
therapy like over hydration, Thrombophlebitis, dys-electrolytemia which were
common
in the earlier days, are being cercumvented. Hence ORT is giving
relief to the hospital budget, less injurious to the children and cost-effective
with no side effects, we have not come across a single child with hypernatre
mia.
ORT
not
only reduced the budgetary
provisions of the hospital,
also
reduced the duration of hospital stay. This is definitely helpful to the patients
as it is known that hospitalisation of the children leads to lot of inconveniences
to
the
patients
as
well
as financial
desarray
of the
low income families.
-4-
Majority of the patients (81.15%) were discharged within 72 hours after
the admission.
CL1N1CAL DIAGNOSIS:
Diarrhoea : Incidence of acute G.E. was 75.65%, 6.95% had bacillary
dysentry, cholera
was in 2.35%. Amebiasis and giardiasis was diagnosed in
0.45%, 2.53% respectively.
ASSOCIATED ILLNESS :
PEM was noted in 6.98%, of these majority ' were grade III and IV mal
nourished. 3.94% had
respiratory infection like
LRI
and
branchopneumonia.
It is of interest to note that incidence of secondary lactose was very
low. It was 0.49%.
Antibiotics were
(3%).
Drugs
like,
used in 195 cases (7.9%). Metronidazole in 66 cases
antisecretary
drugs
viz.
Loperamide
and Demulcents like
Kaolin and Pectin were not used. Usage of drugs were discouraged. Parentral
antibiotics
were
given
for
children
with
associated
respiratory
infections.
PATTERN OF SPECTRUM OF ORGANISMS:
Of the
500
specimen,
sent
for
culture and sensitivity,
263,
yielded
E.coli-52.6%, in 158 children normal commensuals were grown. Shigella was
isolated in 17(3.4%) cholera was isolated in 22 (4.4%) and 43 specimens did
not yield any growth.
ANALYSIS OF DEATHS:
Of the total deaths, 14 deaths (20.3%) took place within 24 hours and
2.75% deaths occured in 24-36 hours after the admission. This indicate, 42.05%
deaths could be preventable as the majority of deaths are due to severe de
hydration (43.5%). Associated illness like PEM & Gr. Ill, IV (40.6%), LRI (8.7%)
were other contributing factors for the mortality. 4 deaths occured due
dysentry (5.8%) 44.85% deaths occured in the age group of 1-3 years.
to
-5-
Jan. 1986 to December 1986
Total Number of admissions to G.E. ward
2206
Total number deaths
69
Percentage of deaths
3.12
Sex Ratio:
Nos.
%
Males
1309
(59.33)
F emales
897
(40.67)
2-6 months
194
(8.79%)
6-12 months
634
(28.73%)
1-3 years
814
(36.89%)
3-5 years
269
(12.19%)
more than 5 years
295
(13.37%)
Mild
900
(40.79%)
Moderate
1005
(45.55%)
Severe
301
(13.64%)
Culture sent : 500
Nos
%
E. Coli
263
52.6
' Commensals
158
31.6
No growth
43
8.6
Shigella
17
3.4
Salmonella
1
0.2
Protens
4
0.4
Paracolons
7
1.4
Klebsiella
8
1.6
Vibrio cholera
22
4.4
Staph aureus
2
0.4
Age group :
Dehydration :
Rehydration :
ORS/Super ORS alone
1621 (73.48%)
ORS + IV fluids
585 (26.52%)
-6-
Number of days of hospital stay (duration of hospital stay)
Less than 24 hours
13.60%
One day
30.8%
2-3 days
37.39%
More than 3 days
18.3%
Clinical diagnosis :
Acute G.E.
75.63%
Chr. G.E.
4.53%
Dysentry
6.93%
Amoebiasis
0.45%
Giardiasis
2.53%
Cholera
2.35%
Helminthiasis
5.57%
Sec. Lactose intolerance
0.49
Associated illness
PEM
6.98%
LRI
3.94%
Post measles
0.86%
»
Drugs used :
Antibiotics
195
Metronidozole
66
(7.93%)
1983
1984
1985
1986
No. of admissions
1934
2076
2077
2206
Mortality
171
132
102
69
Percentage
8.8%
6.3%
4.9%
3.12%
-25%
-50%
-63.5%
Change
This table shows the effect of ORT on the mortality due to G.E. After
the initiation of ORT programme in Vani Vilas Children's Hospital the morta
lity has come down by 63.5%. This clearly indicate the efficacy of ORT in
the management of acute diarrhoea in infants.
f
-J-
EFFECT OF O.R.T. AND HOSPITAL MANAGEMENT
This brief note indicates the usefulness of O.R.T. in the management
of diarrhoeal disorders in children and its cost effectiveness and how it gives
a relief to the hospital budget.
1.
Use of IV fluids
Before O.R.T. (1985)
After O.R.T. (1986)
5% Glucose
469
189
5% Glucosesaline
722
31
Normal saline
222
25
Ringer lactate
892
43
Isolate P
2922
238
5227
586 (bottles)
Total
This
i
clearly shows
reduced (90%)
with IV
that
the utilisation of IV fluids has been
fluids alone, we could save Rs.
50,000/-
grossly
per year,
in the hospital budget.
♦
2.
Drugs:
1985
1986
Garamycin
232 (vials)
Ampicilin
652
31
884
83
52 (vials)
This table implies that use of antibiotics has been minimised to large
extent. After the initiation of ORT programme we are not giving any anti-
biotics for children with watery loose motions. Nowadays antibiotics are rest tricted to children with dysentry only. This has reduced the morbidity secon-
dary to the drugs.
4
We could be able to change the attitude of the parents
on the role of drugs. Emphasis has been shifted to oral fluids and continued
feeding.
-8-
3.
r
Duration of stay
1985
1986
Less than 12 hours
2.1%
13.6%
12-24 hours
11%
30.8%
5
The duration of stay in the hospital is being reduced quite remarkably.
Two 'effects have been felt by us, firstly the load on the hospital staff is
being reduced, because of this, we could focus our attention on children with
chronic
diarrhoea.
Secondly,
mothers
are
also
feeling
happy,
because
the
routine in the house has not been affected, is not coming in the way of earning
their livelihood, and also they can manage the children at home.
4.
No. of admissions:
Though
the
number
of
admissions
to
diarrhoea ward is
not affected
almost equal. At this point, we want to emphasise the fact that nearly 1465
children who were kept under observation and also some children who have
been disposed in the out-patient to follow plan A were not included in the
admissions. This was not possible in the past because we used to admit all
*
these children who come for one or two episodes of watery motions.
♦
Ik-
_
'
r Htoi
a/ '
r© -
140
• --LL
CL V»- f!<s Read,
coi.
medico friend
circle
bulletin
MAY 1988
Return of the Liquid Lost
This is a letter to ask your assistance in gather
ing information to help evolve a more integrated,
decentralized, effective, 'people—centred' app
roach to oral rehydration therapy (ORT).
As you know, in the last five years there has
been massive international promotion of ORT.
Indeed UNICEF and USAID now consider ORT
and immunization to be the twin engines of the
"Child Survival Revolution." But
whereas im
munization has met with modest success in many
countries, there is a general consensus (by WHO,
UNICEF, and others) that the impact of large scale
ORT interventions (with a few notable exceptions)
has been disappointing.
Serious re-evaluation of ORT strategy is needed.
It is important that non-governmental groups, po
pular organisations and the ultimate users of ORT,
be key participants in this re-evaluation process.
ORT, like other health and development tech
nologies, has far reaching political implications.
Any such technology can be promoted in ways
that are either "people empowering" or "people
debilitating" in terms of helping to overcome or
perpetuate the underlying social causes of poor
health.
The "Child Survival Revolution," has often been
compared to the "Green Revolution." In re
trospect, the Green Revolution, although techno
logically sound insofar as it increased total food
production, in many countries proved to be
socio-politically impoverishing since it was imp
lemented in ways that widened the gap between
rich and poor and left more landless powerless
hungry families than ever before. It would be
tragic if the "Child Survival Revolution," for fai
lure to confront the crucial conflicts of interest
that we all know exist, were also to further en
trench the social injustices and inequities that
perpetuate poverty and poor health.
Most agree that oral rehydration is an extremely
important part of primary health care. But people
disagree about how ORT should be promoted and
implemented. While the
issues debated often
seem to be technical or logistic, they often have
serious political implications Some of the issues
in the debate are listed below, (in a highly pola
rized form) according to their main proponents.
Need for wider participation in ORT evalua
tion and decision making
Most of the formal studies, publications, highlevel promotion, and international conferences on
ORT have been conducted by large international
and national agencies, whose experience and basis
tend to favour the strategies in the "top down"
column of Chart.
However, there are many small non-govern
mental and community directed programs that
have long term experience in ORT. The expe
rience and biases of these 'grass roots' and 'people
centered' programme tends to favour the 'bottomup approach. Also, there is mounting evidence
that many 'folk remedies" and traditional forms
of diarrhea management may work as well or bet
ter (at least in certain circumstances) than the ORS
formulas most promoted by the health establish
ment.
I
CHART 1
TWO STRATEGIES FOR ORT PROGRAMS
Strategy of health ministries and big international Strategy of non-governmental
field
field programs,
agencies (TOP DOWN)
popular organizations and community-based prog
rams (BOTTOM UP)
Programming:
implemented as a separate program, or as part of
'selective primary health care'
integrated into comprehensive primary health care
(includes the social causes of poor health)
Main type of ORT promoted :
—packets of ORS salts (glucose based)
—home mix (sugar or cereal based)
—standardized formula
—formula adapted to local resources, conditions
and beliefs
Main focus and investment:
—on products, (manufacture and distribution)
—social marketing
—on education (through many channels: health
posts, schools, etc)
—awareness raising
—social mobilization (getting politicians and
celebrities to promote it)
—community
participation (mothers, popular
organizations, healers, teachers, children)
Management :
—centralized
—decentralized
—controlled by health sector
—collaboration from other sectors: health, edu
cation, communication, popular organizations
Main implementing body :
Health ministry, health posts, health workers
Multisectorial: school system, health system, wo
men's organizations
How it is presented:
as a medicine (to facilitate acceptance and use)
as a food or drink (to demystify and promote un
derstanding of concept)
Annual cost :
increases every year due to growing demand
(for packets)
fairly constant for first few years, then rapidly declines as educational investment "pays off” and
-or transferred to consumers through comcommercial sale of packets
S0Und 0RT Practices become "common knowledge”
Evaluation
—safety of ORS method based mainly on con
tent of formula and accuracy of preparing
solution
—safety of methods based more on social fac
tors: availability and constraints of supply,
peoples habits and attitudes
2
—indicators of success:
—indicators of success:
—number of packets distributed
—how many people understand concept and
process
—number of people who know how to mix
ORS correctly
—reduction in child mortality
—how many people use ORT in a way that
seems to work
—reliance on hard data, statistics, controlled
studies
—impact on children's, families' and commu
nity's well-being
—reliance of peoples impressions and observa
tions.
Main goal emphasized :
child survival
improved quality of life
Political Strategy : win government support
by using methods that strengthen and legitimize
government and make people dependent on its
provisions (government empowering).
win popular support using methods that organize
and empower people, and helping them to become
less dependent, more self-reliant.
It is time to recognise the credibility of the ex
perience and perspectives of these non-government, people-centered and traditional approaches
of the management of children's diarrhea. There
are many reports of dramatic reduction in child
mortality using home mix ORT sensitively adapt
ed to or building on people's traditions, local
resources and constraints. Too often these suc
cessful grass roots approaches are not seriously
considered by scientists and policy makers be
cause those most intimately involved in community
work do not have all the 'baseline data' and, scien
tifically controlled studies to validate their findings.
Yet, the cumulative findings, 'impressions' and
success of many community-based endeavors
may have greater validity (especially in terms of
long range social goals) than the expensive care
fully controlled (but no less biased and perhaps
no more accurate) studies by the experts.
Please send us any reports, information, ex
periences, anecdotes, program plans, teaching
materials and names of other people we should
write that you can that could help us document
and formulate alternative "people-centered” ap
proaches to ORT. Please also let us know of the
problems and obstacles you have encountered,
with whatever approaches to ORT you have used
or observed.
It is time that those 'on the bottom' be listened
to more carefully and that new 'people-centered'
models of research be encouraged and recogniz
ed for +heir pragmatic validity.
3. traditional forms of diarrhea control (e.g.
using traditional weaning food as supple
mentary nutrition during diarrhea episode)
how well they work, and why
The controversial and polarized issues of ORT
strategy, as they relate both to technical issues of
implementation and to societal issues of poverty
and power, seem a good place to begin.
4. obstacles, problems, conflicts of interest,
and reasons for success or failure (opposi
tion from doctors, local authorities, traditio
nal healers, etc.—and ways of overcoming
it).
Areas in which we are Especially Interested in
Learning from you about include:
1. Comparison of different approaches: ORS,
formula, home mix, cereal based ORT (in
cluding soured porridges), etc. (including
social, political, economic issues).
2. factors affecting safety
technical, chemical)
We need the help of those of you who rep
resent, work closely with, or feel accountable to
the poor majority.
(social,
logistic.
5. effect of ORT strategy on overall health and
social goals
3
6. relative advantages and disadvantages of
promoting
ORT as medicine' or as food,
ways this is done and results.
Part B The Politics of Ora! Rehydration Therapy.
This part will focus on ORT in the larger context
of primary health care, and the root causes of
poverty, poor health and death from diarrhea.
It will explore conflicts of interest and try to give
voice to those who are least heard.
7. educational methods and materials and com
parative results (including experiences in
using school teachers, children, women's
organization, political groups, nutrition wor
kers, agriculture extension workers, etc. in
promotion and implementation)
This book will be presented in clear, simple
language with many examples and illustrations so
that field workers, community health workers,
and persons with limited formal education can
understand underlying issues and the politics of
health interventions, so that they can begin to
participate in deciding about methods and stra
tegies.
8. ways to stress importance of adequate fluid
intake during and after diarrhea
9. pros and cons of new development strate
gies applied to ORT-eg. 'social marketing'
'social mobilization', technological fixes',
commercialization as compared to more
people-centered
strategies
focusing on
participation, cooperative action, awareness
raising, and popular organization.
We enclose a summary of a report on diarrhea
control in Mozambique. This was written based
on my trip in March 1986. I returned to Mozam
bique in September 1987 to participate with
Mozambique's Ministry of Health in planning the
educational component of its exitcing new 'people
centered'' plan for diarrhea control.
10. implications, successes, difficulties or hard
ships that have arisen through the com
mercialization of ORS products (specific
examples)
Timeline for your input
I would appreciate your response as soon as
possible. Please do keep sending me your ob
servations and ideas throughout the next year, as
both the development of the Mozambique prog
ram and the proposed book will be an ongoing
learning process.
11. examples of 'participatory research'
12. examples of misleading data, statistics or
reports
13. ORT as applies to other illnesses than diar
rhea (e.g. measles)
The information we are asking you to send us
need not be well organized or studiously presented. Even casual observations can be very helpful.
14. ideas and suggestions for more effective
approaches to ORT (especially in the con
text of primary health care and social
change)
Please help us in helping to formulate and edu
cate the health establishment about more truly
"people-centered" approaches to ORT and to
promote primary health care as a part of a world
wide struggle for social justice.
What we hope to do with the information
gathered.
We hope to write a booklet to be titled
something like
The Return of Liquid Lost:
putting ora! rehydration therapy in the people's
hands. The booklet will be in two parts.
We eagerly await your response. As thanks
for your help, we will be pleased to send you a
complimentary copy of 'The Return of Liquid Lost'
when it is published. Thank you.
Part A helping people learn about ORT. Em
phasis will be on non-formal education and com
munication methods that adapt to and build on
people local traditions and beliefs. Examples will
be included (with your help) from many com
munity programs in different parts of the world.
—David Werner
The Hesperian Foundation,
P.O. Box. 1692, Palo Alto
California 94302, U.S.A.
4
Summary of report Concerning "Diarrhea
Control in Mozambique," based on a visit by
David Werner (March 8-15, 1986), as a con
sultant to the Ministry of Health,
bique, a number of possibilities exist for a more
appropriate, cost-effective approach to ORT:
—Creation of a Central Committee for Diar
rhea Control, authorized to coordinate an
integrated multisectoral approach to diarrhea
control and ORT.
In Mozambique the approach to oral rehydra
tion based on manufactured packets has not signi
ficantly reduced child mortality from diarrhea. In
the city of Beira, where the ORS packet-produc
ing factory is located, 14% of children under 5
still die of diarrhea—one of the highest diarrhearelated mortalities in the world. Reasons for low
ORT effectiveness include: terrorism that hampers
factory productivity; inadequate packet supply;
the common practice of giving only one packet
per case of diarrhea; popular misconceptions; diffi
culty in supplying packets to outlying areas;
inadequate educational component; colonialteach
ing methods; insufficient consideration of people's
beliefs, traditions and home remedies- and in
adequate health infrastructure, especially in re
mote parts of the country.
A shift in focus from production to education
and from packets to home mix ORS.
Involvement of the school system as the main
promoter of home-based ORS, in collabo
ration with the local women's organization
and Party organization, and with support of
the mass media.
—A process of 'participatory research' involv
ing school teachers, school children, and mo
thers in investigating modern and traditional
diarrhea management in homes, in order to
facilitate study on how best to adapt ORT
to different parts of the country.
In one district. Inhambane, the child mortality
due to diarrhea is much lower than many other
parts of the country. On looking for an explana
tion, it was found that although oral rehydration
packets had been promoted in the area, most
mothers continued to use traditional home re
medies, which correspond very closely to cereal
based ORS solutions. Research in Bangladesh
and elsehwere has shown cereal-based solutions
are in many ways superior to sugar-based solu
tions.
—Investigation and
promotion of different
types of home mix, with emphasis on rice
powder, maize powder, and other cereal
based mixes, especially for areas where sugar
is not available (including possibilities of
cereal-based ORS without salt where salt is
not available).
—Development of 'people-centered'
educa
tional methods and clear, simple, well-illus
trated educational materials, for use in
schools, health posts, and homes.
Based on the success of the mothers in Inham
bane, and given the unique constraints in Mozam-
Goa, 403501 and Mr. John D'Souza, CED, 3
Suleman Chambers, 4 Battery Street, Bombay
400039. Anybody wishing to get a copy of the
book at the subsidized rate is welcome to contact
these organizations or Lok Paksh, P. Box 10517,
New Delhi 110067 directly.
Dear Friend,
I note from Ravi Narayan's review of Prof.
Bannerji's book "Health and Family Planning Ser
vices in India" in mfc bulletin (No. 136) that it
has been pointed out that Lok Paksh has priced
this book too high. Considering the cost of pro
duction, the price cannot be much lower. The
effort was to recover the cost by selling it to insti
tutions and then offer heavy discount to those
scholars who are interested but who are unable
to afford the price. Incidentally, this was pre
cisely the reason why this book was published
through Lok Paksh. You will be glad to know
that following the commitment of Lok Paksh,
it has already made available the book at a dis
count of 40% to such types of people through
Ms. Norma Alvares, c/o Almeido Vaddo, Parra,
Disha Banerjee, Manager,
Lok Paksh.
I do share Dr. Morley's concern that it is neces
sary to use separate standards for boys and girls
because boys are slightly heaviei than girls at all
ages (Dear Friend column, mfeb 138). I have
indeed used separate standards for the analysis
(Conte/, on p. 8)
5
Medical Research on Trial
(Contd. from issue No. 139)
Yusuf, Collins and Peto give as an example 24
trials aimed at determining the usefulness of
long-term treatment with beta-blockers during
the months or years following myocardial in
farction. Out of these 24 trials, 21 failed to pro
duce results that were statistically significant
by conventional analysis. Yet together, say Yusuf
and his colleagues, the aggregated results sug
gest a statistically significant reduction in the
death rate. The individual trials were too small
to detect this effect on their own. Such incon
clusive results may have discouraged many
doctors from using this treatment routinely.
To prevent all the research that has gone into
numerous small trials going to waste, it is pos
sible-provided that someone has the motiva
tion and resources to undertake such a mammoth
task—to obtain the results, from all the rando
mised trials of a particular treatment, and look
at them together. This is just what Yusuf, Peto
and Collins, together with John Lewis, a statis
tician with ICI Pharmaceuticals, and Peter Sleight,
Professor of Cardiovascular
Medicine in Ox
ford, did to find out about the 24 trials of beta
blockers mentioned above. They ended up with
data covering about 24,000 patients, analysis
of which allowed them to conclude that long
term treatment with beta-blockers reduced the
death rate by about 25 per cent.
Systematic overviews of this kind are cum
bersome and need careful research. It is parti
cularly important to track down all related
studies, not just published ones, for there is a
tendency for studies that appear to be unpromis
ing or that are not statistically significant-often
confusingly, called "Negative" studies, even
though the results may be in favour of treat
ment—to remain unpublished. A more logical
approach is to design and conduct large studies
from scratch. Some medical researchers have
already successfully adopted this approach the
results from the two largest trials of treatment
of overt disease ever completed were published
in The Lancet earlier this year. One trial collect
ed data from 16027 patients in 245 centres in
14 countries. It showed that treatment with
beta-blockers for just a week significantly re
duced mortality in the first seven days after a
heart attack, and that this benefit persisted for at
least a year.
The other "supertrial" investigated the effect
of a drug called streptokinase, again in the im
mediate treatment of patients who had just had
a myocardial infarction. Doctors wanted to know
if the drug's ability to
dissolve blood clots
would reduce the risk of death. This trial involved
11086 patients admited to 176 of the 200
coronary units in Italy.
The Lancet called the organisation of this
trial "an unparalleled achievement."
Doctors
managed to recruit enough patients within 17
months. The trial showed that patients treated
with streptokinase suffered 18 per cent fewer
deaths during their stay in hospital, a reduction '
that was "statistically highly significant", said
The Lancet.
Yet organisation is not the only obstacle to
setting up such trials. Doctors need to be per
suaded to take part. Richard Peto says that col
laborators derive no personal gain, such as
a published paper under their own name, by
taking part. This may be a positive disincentive
in a medical career where advancement can de
pend on amassing a string of publications. As
a means of encouragement, the organisers of such
trials simplify the administration for collabora
tors as far as they can. The easier it is for indi
vidual doctors, the more likely they are to enter
their patients. And the more collaborations there
are, the sooner results will be available.
The problems do not end here, however.
Many doctors and medical scientists involved in
organising trials have been puzzled by recent
attacks on their methods. Two news items in
The Guardian earlier this year carried the head
lines: "Doctors keep leukaemia patients in the
dark" and "Prostate cancer sufferers being cas
trated without proper consent, doctor claims."
The doctor in question was Richard Nicholson,
deputy director of an organisation called the
Institute of Medical Ethics. Nicholoson maintains
that patients entering these trials are not given
enough information to allow them to give fully
informed consent to their participation. This
argument hinges mainly on the fact that in some
trials designed to compare two similar treatments
in current use, patients are first randomised and
then asked for their consent to the treatment
they have been allocated to-and of course if
the patient is not happy with the allocated treat-
6
merit, then s/he does not receive it. But the im
portant point is that patients are eligible to enter
the trial only if their doctor is uncertain about
what is the best treatment for them.
Take the example of the MRC's trial into the
treatment of prostate cancer. This trial is com
paring early or late treatment for cancer of the
prostate that is too advanced for local treatment
to be wholly effective. The trial aims to deter
mine whether more patients survive for longer
if orchiectomy (removal of the testes) is carried
out as soon as cancer of the prostate is diag
nosed or whether it is better to wait until sym
ptoms, such as bone pain, appear as the cancer
spreads beyond the prostate. Orchiectomy is an
effective treatment because prostate cancer
thrives on the hormone testosterone produced
by the testes. There are alternatives to orchiec
tomy-drugs that interfere with the cancer's
response to the hormone-but some of these
have severe side effects. The drugs also cause
the testes to shrivel.
I
is a necessary parallel between good ethics
and good science. If you are certain that a parti
cular treatment works for a particular patient
It is only ethical and scientifically interesting to
randomise where you are uncertain."
The only difference for the patient is that the
treatment he receives is determined at random,
rather haphazardly. Yet Nicholson says: "Old
men up and down the country are being castrat
ed without their informed consent." Reto takes
a different view: "You do ask for consent for
the operation. But if you are comparing two
treatments, either of which is appropriate, then
it is acceptable to allocate the patient to either
group at random, and then ask them to join the
study." In the case of the prostate cancer trial,
he says, it is very difficult to get the idea of un
certainly over. "Post-randomisation consent al
lows you to explain much better what the pa
tient is in for and of course, they can always
refuse the allocated treatment, just as they can
in ordinary clinical practice."
Reto believes that the prostate cancer trial
will be valuable whatever its result, provided of
course that enough patients-at least 2000enter to make its results informative. For, if the
trial finds that there is no material difference in
survival between those given late and those
given early orchiectomy, then thousands of
patients
in
Britain, and tens of thousands
throughout the world, will be spared unneces
sary surgery or drugs. If there is a difference, then
thousands more men each year may benefit
from treatment that will delay the progression
of their disease.
At present, treatment is haphazard. Whether
a patient (whose symptoms are such that he
would be eligible to enter the MRC's trial) re
ceives early or late treatment either with drugs
or by orchiectomy will depend on which hos
pital he attends, and, perhaps, on which con
sultant his general practitioner refers him to.
Urologists disagree about which treatment is
best The proportions of patients who receive a
particular treatment in various parts of the country
differ, just as the rates at which different drugs
are prescribed following a heart attack vary
throughout Europe. Treatment depends not on
scientific evaluation but on a surgeon's perso
nal preference, however muchthat may be found
ed on good faith and sound, 'clinical judgment"
Nicholson maintains: "I am no enemy of
controlled trials. I think that they are the best
ways we have at the moment of increasing and
improving medical knowledge. But it is essential
that they are entered into trials." He believes
that the requirements for consent are greater
in research than in "ordinary treatment". Reto
disagrees. "I think that what is said to patients
in trials should bear a reasonable relationship
to what is said outside of trials. I do not see any
reasons for double standards." He asks why
doctors who are obviously thinking about whe
ther a treatment works should be harassed while
others, who pretend a certainty that they are
not justified in having, are left in peace. "There
is no fuss about what they say to patients in
hospitals where they do not bother to enter
The treatment of patients entering the trial
differs in the following way. By taking part in
the trial, their surgeons have admitted that they
do not know which is the best treatment in this
particular case. Instead of treatment depending
on their personal preference, the surgeons will
allow the trial'sorganisers to allocate their pa
tient at random to either early or late orchiec
tomy. The trial's protocol says. "It is the MRC's
view that there is no ethical requirement for in
formed consent when the consultation in charge
of the case is satisfied that each option used
in the trial may reasonably be believed to be in
the individual patient's best interest." Reto, who
is analysing the data for the trial, says: "There
(contd. on page 8)
7
I
R.N. 27565/76
A Decade After Hathi Committee
(contd. from p. 5)
The Hathi Committee appo.nted by the Go
vernment of India, to study the and suggest mea
sures to improve the drug industry in India, sub
mitted its report more than a decade ago. Hathi
Committee Report is still considered both within
and outside India, as the most authentic and ex
haustive study of the Indian Pharmaceutical In
dustry. Unfortunately the recommendations of
the Hathi Committee were largely neglected in
India whereas many other developing countries
have already formulated their National Drug
Policies in the line of Hathi's recommendations.
The new Drug Policy announced by GOI in 1986
gave away more concessions to the foreign sec
tor much against the spirit of the Hathi recom
mendations. Eventhough the Hathi Committee
Report was published in 1975, copies of the re
port are not available now. Kerala Sastra Sahitya
Parishad (KSSP) decided therefore to publish a
summary of this report for the benefit of all those
who are striving for a people's Drug Policy for
our country. The book "A Decade After Hathi
Committee" contains apart from the Hathi Com
mittee Report, the recommendations of Pai Com
mittee appointed by the Kerala Government on
procurement and supply of drugs and the papers
presented by eminent doctors and social scientists
at the seminar on the Indian Drug Industry orga
nised by KSSP. The book is to be released on
the 24th of May 1988, the third death anniversary
of Dr. Olle Hansson the Swedish Paediatric Neu
rologist who fought against the unethical market
ing practices of multinational drug companies.
Edited by Dr. B. Ekbal, and priced at Rs. 25/copies are available from the
presented in the mfc article and have indicated
that NCHS standards are preferred because they
are available separately for boys and girls (p 3,
mfeb 136). Regarding Dr. Morley's second point
about subtle discrimination against girls in food
availability, the possibility cannot be overlooked
or wished away. It is however, an extremely
difficult area to research, document and measure
its incremental impact on nutrition and survival
of children.
Convenor,
Publication Committee,
KSSP, Maravancheri,
Trichur, Kerala.
Editorial Committee:
Abhay Bang
Dhruv Mankad
Kamala S. Jayarao
Padma Prakash
Vimal Balasubrahmanyan
Sathyamala, Editor
Visaria,
GIAP,
Gujarat.
Ratnagln Drugs Pvt. Ltd., situated at Ratnagiri, a backward district of Maharashtra, is a well
planned pharmaceutical manufacturing Unit. A
group of like-minded persons intend to manu
facture and market essential products in generic
form. For doctors who wish to prescibe generic
products, availability of such products in pres
cribable form is not assured. Ratnagiri Drugs
Pvt. Ltd. plans to do just that—manufacture generic
products in prescribable form. The factory will
be inaugurated by Dr. Zafrullah Chowdhry, of
Gonashasthra Kendra, Bangladesh on Olle Han
sson Day, the 24th of May 1988. All drug Acti
vists are welcome. For further informa ion con
tact Dr. Rane, 2117 Sadashiv Peth, Pune 411 030.
h
(contd. from p. 7)
patients into trials. "The really unethical thing
is that thousands of patients die because treat
ments are not evaluated properly."
(concluded)
Money is to be sent by MO, DD or cheque
(add Rs. 5 - for Bank charges; postage is tree.)
Anil Patel
Leela
Reprinted from New Scientist, 18 Sep. 1986
p. 48-52.
Views and opinions expressed in the bulletin are those of the authors
and not necessarily of the organization.
Annual Subscription — Inland Rs. 20.00
Foreign: Sea Mail US $ 4 for all countries
Air Mail: Asia — US S 6; Africa & Europe Canada & USA — US $ 11
Edited by Sathyamala, B-7/88/1, Safdaijung Enclave, New Delhi 110029
Published by Sathyamala for Medico Friend Circle Bulletin Trust,
50 LIC quarter University Road, Pune 411016
Printed by Sathyamala at Kalpana Printing House, L-4, Green Park Extn., N. Delhi 16
Correspondence and subscriptions to be sent to—The Editor, F-20 (GF),
Jungpura Extn., New Delhi-110014.
CH 3-13
No.3/160/81
Extract from the TECHNICAL SERIES issued
by the Director of Ifealth & Family Welfare
Services, Bangalore .(Ref .HEE/35/80-81 dt.5/1/^1)
DJ
- FH‘-1
U
12|h Jan. ,81
DIARRHOEAL DISEASES - THEIK SIGNIFICANCE
1.
Diarrhoea is the most common cause of sickness and
death among children below three years of age.
2.
Repeated attacks of diarrhoea dutin'g early childhood
precipitate malnutrition which makes the children
susceptible to diarrhoea thus setting in a vicious
cycle.
3.
4.
b
&
O «
O
b c'?. <o
<r
It is a popular practice to withhold milk and other
This is
food from a child suffering from diarrhoea.
wrong, as a child with diarrhoea requires more fluid
and nourishment.
- -s o
i? **
” <5
Diarrhoeal diseases are caused by annumber- of patho- (
genic germs including cholera vibrio and these harmful
germs thrive in places where sanitary conditions are
poor,
WHAT HAPPENS IN DIARRHOEA?
There is an enormous loss of water (dehydration) and
salts from the body due to vomiting and diarrhoea in these
conditions. This loss of water & salts from the body causes
various symptoms like intense thirst, restlessness, cold
hands & feet* weak pulse, lowering of blood pressure.and stopy
page of urine; when severe, this condition may lead to death
of the patient*
TREATMENT OF DIARRHOEA PRIMARILY HE ANS THE TREATMENT OF
DEHYDRATION
Replacement of water and salts, which have been lost
^nomath4itoodyjfof treatment af all diarh
rhoeal diseases.. This can be done with :
1)
ORAL GLUCOSE-SALIN.E :
It has been shown that oral glucose solution increases
the absorption of water & salts in the body.
Based on this^
a glucose-salt solution has been developed by the’—Choleta
Research Centre, Calcutta. This preparation named as
’CHOROSOL1 contains the following ingredients per litre' of
water :
Sodium chloride (common salt)
Sodium bicarbonate (baking soda)
Potassium chloride
Glucose
3.5 grams
2.5
1.5
20.0
ft
it
ft
The above<salts and glucose can be dissolved in one
litre of drinking uater •& then given to patients liberally.
2)
INTRAVENOUS SALINE :
A small number of patients with severe dehydration who
do not respond to oral glocose-saline or who cannot be given
oral fluids because of unconsciousness may require intra
venous saline. Treatment with ihtraVenbus saline can only
be given in hospitals and dispensaries under the supervision
of an experienced doctor.
2
2
ANTIBIOTICS :
••
i passing blood and
Cases of severe diarrhoea and; those
treated with tetracycline, 2
mucus in the stools ms:y be I---capsules (500 mg.) 6 hourly in adults and one capsule (or
for 2
in children
2 teaspoonfuls of syrup) every 12 hours in
ch
can
also
used
be
in
days.
Furazolidone or chloramphenicol
place of tetracycline.
OF DEGREE DF DEHYDRATION
ASSESSMENT
:
< diarrhoea and vomiting may present
of dehydrolion
Uhen mildly•
I“:onSoua) oondl•PeMy.
patient
may
^
’i”2!h2"fX“
a patient may appear almost normal whereas
in comatose
dehydration may be the
degree of dehydration must be assessed
tion* Therefore, t..y -, Certain symptoms and signs
before initiation of treatment.,
help in this assessment.
HOU D EH YD R AT ED IS THE PATIENT?
Severe
Mild
1. Too weak to drink •
-j2. Drowsy or unconscious
u..
weak
or
absent
3. Radial puise
;4. Urine flow reduced or' absent
5. Skin elasticity poor
L.
5. Skin elasticity may be recfuqed
1. Thirsty
u )'
2. Alert
3. Radial pulse normal
4. Urine flow normal
ORAL FLUID THERAPY :
How to make the fluid ®
Fixed quantities of salts and glucos e as indicated
earlier are to be dissolved in one li-tre of drinking water
;;a_should be,used Uithin 24 hours. .4Th^.sqlyti9n^hJould not
be boiled.
•
•
i
Hou to administer the .Fluid : Infants,& younger children :
A small quantity of Glucose-salt solution ^-3 tea
spoonfuls) should be given by mouth ^ery five minutes to
infants and young children,., Large quantity of f,luid 9
time U result In vomiting.
Thnrefere
----- --j 4
not be given in too large a quantity#
quantity.
But as mucn
patient is willing to drink may be given.
01der Children and,Adu1ts s
fluid as
Patients may.be instructed to drink; as much
container with
A
large
. ,
Ithey like from a clean glass or cup.
bed
be
kept
at
the
side.
glucose—salt solution may
HOU MUCH FLUID TO BE GIVEN?
child may require
In a mild state of dehydration,► a 2-3 litres of oral
gbout a litre and an iadult may require
fluid per day.
however, the requirement may be much
In severe cases,
■ 'be> continued until the diarrhoea
fluid shouldis
more. The dehydration
compensated and the patients look
stops and (
normal.
3
WHAT HAPPENS WHEN THE PATIENT IS VOPiITING?
A patient may sometimes vomit out a part of the oral
fluid; however, the rest of the. fluid gets rapidly absorbed
and once the dehydration is corrected the patient stops
vomiting.
ADVANTAGES OF ORAL FLUID THERAPY :
1.
The patient need not b'b hospitalized and can be treated
at home by pari-medical staff or by the relatives.
2
Oral fluid therapy is cheap and the ingredientsj are
available locally. A jpacket of CHOROSOL costs about a
rupee o
3.
The solution can be made with ordinary drinking water.
No sterilization is required.
4.
Storage and transportation cost is minimum. A packet
of CHOROSOL can be stored at room temperature for long.
INTRAVENOUS FLUID THERAPY :
Experience at the Infectious Diseases Hospital, Calcutta,
has shown that as many as 95% of all cases of gastro
enteritis including cholera can be treated with oral fluid
alone.
Less than 5% of cases who come with severe dehydra
tion may require intravenous saline to start with, followed
by oral glucose-salt solution. However, the number of such
severely dehydrated cases can be reduced if oral fluid therapy
is given during the early stage of dehydration.
The severely dehydrated cases should be transported to
the nearest hospital or (dispensary for intravenous rehydra—
tion. Oral glucose-saline must be started, however, even
uiils, and should be continued till the patient reaches
before this
the hospital and till such time intravenous therapy could
be started.
WHAT INTRAVENOUS FLUIDS ARE TO BE. USED?
D
RINGER’S LACTATE SOLUTION is the best commercially
available solution which can be used for children and
adults. However, it is not readily available in most
places.
2)
NORMAL SALINE has been in use at the Infectious Diseases
Hospital, Calcutta, for the last few years.
Intravenous
solution
saline
oral
glucose-salt
normal
alongwith
cam
be successfully used for the treatment of all degrees^
of dehydration.
HOW FIUCH .TO BE GIVEN?
Ringer’s lactate or normal saline may be given at a
dose of 100 ml./kg. body weight initially during the first
6 hours. Oral glucose-salt solution may also be given
liberally.
It is absolutely of no use to given subcutaneous saline
and this practice must be stopped.
/
■t
--------- z.....A- i — ■ ■■■
EDUCATING THE MOTHERS
IN HOME-CmRE
Treatment of a child with diarrhoea should begin at
home and therefore, mothers should be educated on the basis
principles of home-care. ■ A -mot her---should • kp.-o-w that.; ,
n
A child who has diarrhoea, should be given as much
fluid as he/sh6 will drink.
For this purpose, the
glucose-salt solution can be prepared by dis-solving
.
J a
packet of ’CHCROSOL' in one litre (2 pints) of drinking
water. In case of infants, a teaspoonful of fluid may
be given every five minutes until the diarrhoea stops.
Large quantity of fluid, if given at a time, may cause
vomiting.
2)
A child with diorrhoea.shouId get his normal food to
maintain his nutrition. Uith-holding milk and other
food will make the child weak.
If the infant is being
breastfed, breastfeeding should be continued.
3)
A child gets infection through contaminated food or
drink and diarrhoea can be prevented by following hygie
nic practices in child care, particularly in feeding.
A child should be given freshly prepared food in clean
utensils o
4)
A child with poor health suffers more5 often from diarrhocal diseases. Therefore, 1the general health of the
child should be improved to prevent diarrhoea, The
following basic facts should be remembered 2
a) A child’s body is just like a running machine and
it needs food (fu&l) to keep the machine in, running
condition. Therefore, a child should not be allowed
to starve at any time - in health or in disease.
h) A child’s body is growing all the time. The child
needs food c-o-n-t-aining- the building materials such
as proteins ’ (egg, fish, meat, milk, dal, etc..,)
etc.,) as
well as energy-giving food (rice, wheat, p ot at 3,
sugar, etc.,) to build the body.
c) It is a common practice to keep a child on barleywater for. days when-he is sick. This is wrong since
barley water is the most inferior food and contains
no protein.
Enough quantities of simple food stuffs
like rice, chapati, and dal can support the normal
growth of a child if meat, fish or eggs are not
available.
Copy to^
Interns
2* Staff, Department of Paediatrics
3. Staff, Community Medicine
BEAN
4
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SDA-RF-CH-3.2.pdf
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