MANAGEMENT OF ACUTE DIARRHOEA
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- MANAGEMENT OF ACUTE DIARRHOEA
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NATIONAL DIARRHOEAL DISEASES CONTROL PROGRAMME, INDIA
MANAGEMENT OF ACUTE DIARRHOEA
NATIONAL INSTITUTE OF CHOLERA & ENTERIC DISEASES
(INDIAN COUNCIL OF MEDICAL RESEARCH)
NATIONAL DIARRHOEAL DISEASES
CONTROL PROGRAMME
INDIA
MANAGEMENT
OF
ACUTE DIARRHOEA
NATIONAL INSTITUTE OF CHOLERA & ENTERIC DISEASES
(INDIAN COUNCIL OF MEDICAL RESEARCH)
Introduction
Acute diarrhoeal disease is one of the major causes of morbidity and
mortality in India, especially among infants and children below 5 years of
age. However, no reliable data on diarrhoea-related morbidity and mortality
are available as diarrhoeal diseases (except cholera) are not notifiable. Results
of a few longitudinal studies conducted in different parts of the country
revealed that the children below 5 years may suffer from about 2 episodes
of diarrhoea per year. Accordingly, the total episodes of diarrhoea may be
estimated to be around 500 million per year in all age groups. Recent studies
have also indicated that most of the diarrhoea cases in the community are
mild and about 10 per cent of them may have dehydration and only one in
100 patients may require to be treated in health centres and hospitals. There
fore, it may be estimated that about 50-100 million diarrhoea patients may
be requiring rehydration therapy of which 5 million may require treatment
at the health facilities per year.
The problems of diarrhoeal diseases are further complicated by the fact
that over 25 different pathogens may be responsible for the causation of the
disease and not much informations are available regarding the ecology and
epidemiology of the diseases caused by them.
However, significant new knowledge acquired in the last decade on the
etiology, epidemiology, pathogenesis, immunology and treatment of acute
diarrhoeas provided a solid basis for an immediate attack on the problem.
The most important of the new developments is Oral Rehydration Therapy
(ORT)—a simple method of treatment by the oral route—which is safe,
economical and effective in all but the most severe cases of diarrhoea. This
type of therapy can be delivered by village health workers and can be practised
in the house by mothers with some guidance and thus is technologically
highly suited for the primary health care approach.
Recognizing the significance of these new developments, the Thirty-first
World Health Assembly in May, 1978 called for a concerted attack on
diarrhoeal diseases as part of the global commitment to primary health care
and to Health for All by the year 2000 A.D. The WHO Diarrhoeal Diseases
Control (CDD) Programme was launched shortly thereafter, with the imme
diate objective of reducing childhood mortality and the long-term objective
of reducing morbidity—caused by diarrhoeal diseases.
In view of the recommendations of World Health Assembly, the National
Diarrhoeal Diseases Control Programme in India was launched in 1981 with
main emphasis on the implementation of short-term objective of reduction
of mortality through effective introduction of Oral Rehydration Therapy
(ORT) at the most peripheral level. The components of ORT Implementation
Programme include (i) production and distribution of ORS packets, (//) train
ing of medical and para-medical health personnel as well as education of
mothers and other members of the community, and (Hi) operational/health
services research for identification of suitable strategy for Implementation.
The following progress in the implementation of the programme has been
made so far:
(/) Production and distribution of ORS packets: Implementation of ORT at
the community level will primarily depend on the availability of the required
number of packets of Oral Rehydratlon Salt (ORS) of the complete WHO
formula. The basic ingredients are readily available in the country and a
number of firms in the Public and Private sectors have started producing
the ORS packets in bulk quantities. The Indian Drugs and Pharmaceuticals
Limited (IDPL) has been entrusted with the production of ORS packets in
a large scale. IDPL has been producing about 5 million packets annually and
the production can be stepped up gradually to 100 million packets per year
as required for the Programme. Besides IDPL, the Government Medical Stores,
Madras, the Institute of Preventive Medicine, Hyderabad and a number of
private firms are also producing packets of ORS, as per WHO recommended
formula.
To make an effective impact on reduction of diarrhoea-related mortality,
ORT should be made available as close to the house of the patients as possible.
It has been proposed to provide the packets to Health Guides/Anganwari
Workers at the village level so that ORT is available soon after the onset
of diarrhoea. It is proposed that 100 packets of ORS will be supplied to each
Health Guide per year by 1990 to tackle diarrhoea cases with mild to moderate
degrees of dehydration.
(//) Training of health personnel: Training of health services personnel at
all levels and education of mothers and the other members of the community
should form an essential and integral part of CDD Programme. Experiences
have shown that distribution of ORS at the community did not result in
its proper utilization without adequate training of health care delivery
personnel and members of the community.
The National Institute of Cholera and Enteric Diseases, Calcutta has
been entrusted to organize training courses for Teachers/Trainers in different
States. 45 Training Courses have so far been organised in collaboration with
the various State Health Departments. Over 2,000 medical personnel have
been trained so far. These trained persons are expected to act as Faculty
Members for the States for the training of Primary Health Centre doctors
as well as paramedical staff.
It Is proposed to organize 420 district-level training courses to train
18,000 PHC doctors by 1985. The PHC doctors in turn will train the para
medical staff including the Health Guides.
2
Operational research studies have clearly demonstrated that about 50
percent cases of diarrhoea in the community can be managed by the Mothers
with home-made/home-available fluids and the rest can be treated by the
Health Guides with ORS, and only a few may be required to be referred
to the health facilities. With the education of mothers for the use of homeavailable fluids and availability of ORS packets with Health Guides it is
expected that diarrhoea-related mortality in children will be reduced con
siderably.
TREATMENT OF DIARRHOEA
What is Diarrhoea ?
Diarrhoea may be defined as passing of 3 or more loose or watery stools
in a day. Frequent passing of normal stools is not diarrhoea. Breast-fed babies
often have softer stools than normal.
Diarrhoea is most common in children, especially those between 6 months
and 2 years of age.
What happens during Diarrhoea ?
There is loss of a large amount of water and salts from the body due to
diarrhoea and vomiting. This loss leads to what is called as dehydration. All
the signs and symptoms of diarrhoea result due to dehydration. When de
hydration is severe and untreated, it often leads to death.
Dehydration occurs faster in infants and young children, in hot climates
and when accompanied by fever.
How to treat Diarrhoea ?
The important components of treatment of diarrhoea are to (a) prevent
dehydration from occurring, and (b) treat dehydration quickly if it is present.
(a) Prevention of dehydration: Since most of the cases of diarrhoea in the
community are mild and have no dehydration, they may be treated by mothers
at home with home-available fluids, such as salt-sugar solution (sarbat), butter
milk (Lassi), rice water (kanji), soup (dal), green cocoanut water, diluted
milk, weak tea and/or breast feeding. Every community uses certain fluids
for their daily use; they are safe, available at home and acceptable to the
people.
(b) Treatment of dehydration: If there is dehydration, the child should
be treated with oral rehydration solution made with oral rehydration salts
(ORS) by the Health Guide or at the health centres/hospitals. The Health
Guides are provided with packets of ORS and plastic measuring containers
for measuring water. With adequate training they should be able to treat
the cases having mild dehydration.
3
The patients with moderate to severe dehydration should be treated
at the health centres/hospitals with ORS and/or Intravenous solutions.
Therefore, diarrhoea patients can be treated at three levels namely
(i) at home with home-available fluids by mothers, (ii) at the community
by Health Guides with ORS, and (Hi) at health centres/hospitals with ORS
and I.V. solutions, if required.
A. At home
B. At the Village
C. Health Centres
Mothers
with
available fluids
Health Guides
with
ORS Packets
Physicians
with
ORS and/or I.V. fluids
A. Home treatment
The success of home treatment would primarily depend on the educa
tion of the mothers and the other members of the community on the use
of home-available fluids for prevention of dehydration. She should be made
to understand that her child looses water and salts with each bout of diarr
hoea and vomiting. It may be dangerous unless some fluids and salts are given
immediately to the child.
The mother or any other family member who looks after the child
should be explained to observe the following rules for home treatment:
I.
Give more fluids to your child
— If the child is breast-fed, try to give breast milk more often. If the
child is not breast-fed, increase normal milk feed with diluted milk.
— Give any available fluids at home such as sarbat, lassi, kanji, green
cocoanut water, dal, soup, puffed rice-soaked water, etc.
A child under 2 years of age should be given approximately 50-100 ml
(1/2—I cup) of fluid after each loose stool and older children should receive
twice the amount. Adults should take as much as they want to drink.
2. Continue feeding the child
All children above 6 months should be given easily digestable solid food
such as boiled rice, porridges, soups, eggs, fish and well-cooked meat during
diarrhoea. No child should be starved.
4
3. If the child does not improve within 12-24 hours, the Health Guide
in the village may be consulted and ORS treatment may be started when
necessary.
The mothers and the members of the community may be educated by
the Health Guide as well as through various mass media such as repeated
radio broadcasts, newspapers, posters, community meetings or visit to health
centres.
B. Treatment of Diarrhoea by Health Guides
Treatment of children with dehydration will involve Oral Rehydration
Salt (ORS) solution. A Health Guide with adequate training will be able
to treat diarrhoea with mild dehydration. Therefore, he should know how
to prepare the Oral Rehydration Salt (ORS) solution.
A Health Guide will be provided with packets of ORS (WHO formula)
with the following ingredients:
Amount
Ingredients
Glucose
20.0 grams
Sodium chloride
3.5 grams
Sodium bicarbonate
2.5 grams
Potassium chloride
1.5 grams
A packet with the above amount of ingredients is to be mixed in one
litre of drinking water. A Health Guide is also provided with a plastic measur
ing container to measure water correctly. This mixture is called ORS solution.
The following steps may be performed to prepare ORS solution:
• Wash the hands properly;
• Measure I litre of clean drinking water with the help of the measur
ing bottle and pour it into a clean container;
• Pour all the powder from one packet into the water and mix well
until powder is completely dissolved;
• Taste the solution so you know how it tastes.
ORS solution should be made fresh everyday and any solution remaining
from the day should be discarded.
The Health Guide should prepare the ORS solution and demonstrate its
use to the mothers along with the following instructions:
(i) Infants and younger children should be given 2-4 teaspoonful at
a time and repeated every 5-10 minutes to avoid vomiting. Older
5
children and adults may drink as much as they like from a glass
or a cup.
(ii) The mothers should also give breast milk or other home-available
fluid to the infants and children.
(Hi) The mothers should come quickly to the Health Guide or to the
Health Centre if diarrhoea does not improve within 12-24 hours.
The Health Guide should supervise the treatment by the mother and
if he detects signs of dehydration (increased thirst, dark urine, irritable
condition, sunken eyes and a pinch of skin does not go back quickly) he should
refer the child quickly to the Health Centre for further treatment.
C.
Treatment of Diarrhoea at the Health Centres/Hospitals
I.
Assessment of the Patient
History
Physical examination
Weighing the patients
Assessment of dehydration
1.1 History: Particular attention should be paid to the duration, fre
quency, amount and character of stool and vomitus.
1.2 Physical examination: A full physical examination should be performed.
Particular attention should be given to signs of dehydration as described in
Table I. A few additional points are worth noting:
— Fever Is often present in severely dehydrated babies. It Is necessary
to take rectal temperature as the skin may be cold despite high
fever.
— Rapid breathing may be a result of dehydration or a lower respira
tory tract infection. If the breathing is rapid and deep, this is pro
bably due to acidosis associated with dehydration.
— With severe dehydration hypovolaemic shock may occur. The signs
of this include cold sweaty extremities, a rapid feeble pulse, a low
or even unrecordable systolic blood pressure (less than 70 mmHg)
and peripheral cyanosis.
1.3 Weighing the patient: Weighing has two purposes. First, if the
patient is a child who has been weighed regularly, or an adult whose normal
v/eight is known, sudden weight loss during the diarrhoeal illness is a useful
indication of the presence and extent of dehydration. Secondly, weighing of
the patient at intervals during therapy is helpful in assessing the progress
of rehydration.
However, treatment should not be delayed because a weighing machine
is not readily available. If a weighing machine is available, carefully weigh
the patient unclothed or lighly clothed and record the weight.
6
1.4 Assessment of dehydration: No exact “formula” can be given for
assessing dehydration. It requires a careful evaluation of the history and the
physical examination. In general, the greater the stool and vomit losses are,
the more severe the dehydration will be.
Patients with signs and symptoms of dehydration can usually be classified
as having mild, moderate, or severe dehydration. As a guide, If two or more
of the signs of severe dehydration (Table I) are present, the patients should
be considered to have severe dehydration. Similarly, two or more signs of
moderate dehydration should be considered as sufficient evidence for its
presence. Note that thirst may be the only Indication of mild dehydration,
but this may not be evident in infants. The signs and symptoms that
are particularly useful In assessing dehydration and monitoring rehydration
in Infants, are indicated by an asterlk (*) in Table I. As mentioned above,
weighing may be useful In the assessment of dehydration. The best tool for
assessing dehydration Is keen observation based on experience.
2.
Management of Patients
2.1 Basic principles: Following assessment of the state of dehydration,
management of the patient, has two essential parts:
— Fluid therapy, Including the treatment of dehydration if It Is present.
— Maintenance of nutrition.
2.2
Management of the dehydrated patient.
2.2.1 General considerations: The main principle of fluid therapy is that
the output of water and electrolytes from the body In stools, vomit, urine,
sweat, and Insensible losses should be matched by the input of water and
electrolytes.
It Is useful to consider the fluids administered to a dehydrated patient
during the management of acute diarrhoea as meeting the following three
essential needs:
(a) correction of the existing water and electrolyte deficit as indicated
by the presence of signs of dehydration (rehydration therapy);
(b) replacement of ongoing abnormal losses of water and electrolytes
due to continuing diarrhoea, to prevent a recurrence of dehydra
tion (maintenance therapy);
(c)
provision of normal daily fluid requirements during rehydratlon
and maintenance therapy.
In utilizing the guidelines that follow, these three essential needs should
be considered. It will be seen that rehydration therapy can usually be achieved
7
orally with ORS solution, except in cases with severe dehydration, un
controllable vomiting, or other complications that prevent successful oral
therapy. In these cases intravenous (I.V.) therapy is needed. OKS solution
is also the fluid used for maintenance therapy. However, normal daily fluid
requirements must be given as fluids of lower salt concentration: e.g., plain
water, breast milk, or diluted milk feeds. This is particularly important in
infants due to their large surface area per kg. of body weight and their high
metabolic rate; under normal conditions they require
times more water
per kg than adults.
2.2.2 Rehydration therapy: In patient with signs and symptoms of dehy
dration, the existing water and electrolyte losses must be replaced promptly
and adequately. In oral therapy a steady but comfortable rate of ingestion
is usually adequate to achieve rehydration. Patients with severe dehydration,
with or without hypovolaemic shock, generally require intravenous therapy
to achieve complete or near complete rehydration. Guidelines for the
rehydration therapy are given in Table 2. The volumes and rates of adminis
tration are averages based on usual needs. These should be increased if they
are not adequate to achieve rehydration, or decreased if hydration is achieved
earlier than expected or if the appearance of puffiness around the eyes
suggests overhydration. Once the clinician has gained some experience in
rehydration therapy he may not need to adhere to a rigid schedule.
While rehydration therapy (to replace the body’s abnormal losses) is
in progress, the patient’s normal daily fluid requirements must also be con
sidered. These can be met in the following ways:
• Breast-fed infants: After the first 4 hours of rehydration therapy,
or earlier if rehydration is complete, breast feeding should be
started and thereafter continued as often as the infant desires, in
addition to continuing ORS solution1.
@ Non-breast-fed infants: After the first 4 hours of rehydration therapy,
or earlier if rehydration is complete, a volume of plain water should
be given equal to half the volume of ORS solution already taken
by the infant2. This plain water should be given over the next
1-2 hours, before continuing ORS solution. This is an essential
aspect of rehydration therapy in these infants.
@ Older children and adults: Throughout the rehydration therapy,
plain water should be available to patients to drink as they wish,
in addition to ORS solution.
’Some clinicians feel that breast feeding should be delayed beyond 4 hours if rehydration
is not complete (i.e., if signs of dehydration are still present). In such cases plain water
should be given as described above for non-breast-fed infants until breastfeeding is resumed.
2Plain water should be clean and preferably boiled and cooled. Sugar should not be added
as this may decrease the appetite and interfere with subsequent food intake.
8
The progress of the rehydration therapy should be assessed after one hour
and then every 1-2 hours. In particular, attention should be given to:
— the number and volume of stools passed;
— the extent of vomiting;
— the presence of, and changes in, the signs of dehydration;
— whether the rehydration fluid (oral or I.V.) is being successfully
given and in adequate amounts.
If, during the time period indicated in Table 2, the calculated volume
has been given and signs of dehydration are still present, but there has been
some improvement, rehydration therapy should be continued at the same
rate as long as is necessary.
If the signs of dehydration have become worse or remain unchanged,
the rate of administration and the volume of fluid given may need to be
increased. If patients receiving ORS solution develop signs of severe dehy
dration, I.V. therapy should be started as indicated in Table 2.
As soon as the signs of dehydration have gone, but not before, maintenance
therapy should be started.
2.2.3 Maintenance therapy: After the initial fluid and electrolyte deficit
has been corrected (i.e., the signs of dehydration have gone), it is important
to replace the ongoing abnormal losses of fluid and electrolytes that are
associated with continuing diarrhoea—this is maintenance therapy. The
principle is to match the input to the output1. Some guidelines are given
in Table 3.
In addition to the replacement of ongoing abnormal losses, the body’s
normal daily fluid requirements must also be considered. These can be met
in the following ways:
0 Breast-fed infants: Breast feeding should be allowed as often as the
infant desires, in addition to the required volume of ORS solution.
Non-breast-fed infants: The milk normally consumed by the infant
can be restarted but should be diluted with an equal volume of clean
plain water until the diarrhoea stops. Other fluids normally con
sumed by the infant can also be restarted. The milk and other
fluids should be given in addition to the required amount of ORS
solution and, as a guide, should form about one-third of the total
fluid intake (i.e., 2/3 ORS solution : 1/3 milk and other fluids) until
the diarrhoea stops.
® Older children and adults: Fluids normally consumed can be taken
as desired, in addition to the required ORS solution.
Measurement of stool and vomit losses is useful for calculating fluid requirements; however,
this is usually difficult or impractical and is not essential for successful therapy. If available,
a “cholera cot” or diapers and a weighing scale may be useful for calculating stool and
urine losses.
9
Patients with continuing severe diarrhoea as defined in Table 3 should
be given maintenance therapy in a treatment facility until the diarrhoea
becomes mild. If signs of dehydration reappear, and losses cannot be replaced
adequately by increasing the volume of ORS given, I.V. therapy should be
considered.
Maintenance therapy should continue until the diarrhoea stops.
2.2.4 Role of drugs in the treatment of acute diarrhoea: As a rule anti
microbial drugs have limited role in the treatment of acute diarrhoea. Specific
indications include the following:
I. Cholera (only severe cases)
2. Severe shigella dysentery
3. Amoebic dysentery
4. Acute giardiasis
The drugs of choice for treatment of these diseases are given In Table 4.
Anti-diarrhoeal agents and other drugs like kaolin, pectin, activated charcoal,
opium and diphenoxylate with atropine, steroids,stimulants, antiemetics and
purgatives are not indicated in the routine treatment of acute diarrhoeal
diseases. Febrile convulsion and hypoglycemia should be treated according
to standard procedure. Antibiotics can never be a substitute for ORS In diarrhoea.
2.2.5 Administration of ORS solution: A family member should always be
shown how to prepare and give the ORS solution and should assist In doing
so. The solution can be given to infants using a cup and spoon, a cup alone,
or, if it is usually used, a feeding bottle. These must be clean; In the case of
a feeding bottle, the mother should be shown how to clean it properly.
For babies, a dropper or syringe can be used to put small volumes of solution
into the mouth.
Alternatively, for babies who cannot drink due to fatigue or drowsiness,
but are not in shock, a nasogastric tube can be used to administer ORS
solution (average recommended rate of 15 ml/kg body weight per hour).
ORS solution can be put into the nasogastric tube using a syringe or a clean,
used, intravenous infusion bottle. For babies in shock, this procedure should
be used only as emergency measure (e.g., when it is not possible to give
I.V. fluids). In such cases, ORS solution should be administered at a rate of
20 ml/kg body weight per hour.
Vomiting is not uncommon during the first hour or two after adminis
tration of ORS solution, but it usually does not prevent successful oral
rehydration. To reduce vomiting and to improve ORS solution absorption,
give it slowly, in sips, at short intervals. If the patient vomits, wait 5-10
minutes then start ORS solution again slowly. Rarely, sustained severe vomit
ing may prevent the successful administration of ORS solution; when it
occurs, I.V. therapy should be used.
10
2.2.6 Maintenance of nutrition: Dietetic management: In the management
of acute diarrhoea It is essential to repair whatever nutritional deficit arises
and to maintain nutrition during the diarrhoeal illness. This deficit results
from reduced food intake due to anorexia and with-holding of food, and from
nutrient loss due to vomiting and malabsorption. There is no physiological
basis for “resting” the bowel during or following acute diarrhoea. In fact,
fasting has been shown to reduce further the ability of the small intestine
to absorb a variety of nutrients. Even during acute diarrhoea, 60% of the
normal absorption of nutrients occurs. This is particularly true for fats and
oils, which can provide a large amount of energy for the quantity eaten.
Greater weight gain has been documented In infants given a liberal dietary
intake during diarrhoea when compared with others on a more restricted
intake.
The resumption of breast feeding and other milk feeds in infants is essential
for meeting normal daily fluid requirements and also for the maintenance of
adequate nutrition.
In addition, as soon as their appetite returns, all children older than
4-6 months, and all adults, should eat foods that provide adequate calories1
and are easily digestible2. These foods should be started during maintenance
therapy—there is no reason to delay feeding until the diarrhoea stops. Foods
which are rich In potassium (e.g., fruit juices, bananas, cocoanut milk) are
useful In view of the losses of body potassium during diarrhoea.
In Infants 4-6 months of age or older who have not previously been given
semi-solid foods, this is a good time to start feeding such foods and to em
phasize their importance In the prevention of future episodes of diarrhoea.
In these Infants, and In some of those who have lost their appetite during
the diarrhoea, considerable effort may be necessary to get them to eat. In
such cases frequent small meals should be given. Severely malnourished
children may require nutrition rehabilitation in a treatment centre. In these
children solid foods may need to be re-introduced into the diet more slowly.
In infants especially, after an episode of diarrhoea one extra meal should
be given each day for at least one week after the diarrhoea stops.
2.3
Intravenous therapy for severe dehydration
2.3.1 Technique of administration: The technique of administration of
intravenous fluids can only be taught by practical demonstration by some
one with experience. Intravenous therapy should be given only by trained
Energy-rich foods are important during and following diarrhoea. Most staple foods do
not provide sufficient calories per unit weight for Infants and young children and should be
enriched with fats and oils or sugar. Dairy products, legumes, fish and eggs are also suitable
foods.
2Foods with a high fibre content (e.g., coarse fruits and vegetables, fruit and vegetable peels,
whole-grain cereals) should be avoided.
II
COMMUNITY HEALTH a’UL
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Banpalore - EGO 001.
persons. Several general points are made here. The needles, tubing, bottles,
and fluid used for intravenous therapy must be sterile.
Intravenous therapy can be given into any convenient vein. The most
accessible veins are generally those in front of the elbow, on the back of
the hand, at the ankel, or, in infants, on the side of the scalp. Use of neck
veins or incision to locate a vein are usually not necessary and should be
avoided if possible. In some cases of severe dehydration, particularly in adults,
infusion into two veins may be necessary; one infusion can be removed once
rehydration is well in progress.
It is useful to mark intravenous fluid bottles at various levels with the
times at which the fluid should have fallen to those levels. This allows easier
monitoring of the rate of administration.
2.3.2 Solutions for intravenous infusion: A number of solutions are available
for I.V. infusion; however, some do not contain appropriate or adequate
amounts of the electrolytes required to correct the deficits found in dehy
dration associated with acute diarrhoea. The following is a brief discussion
of the relative suitability of each of these solutions.
Preferred solutions
— Ringer’s Lactate solution (also called Hartmann’s solution for in
jection) is the best commercially available solution. It supplies
adequate concentration of sodium and potassium, and the lactate
yields bicarbonate for correction of the acidosis. It can be used
in all age groups for dehydration due to acute diarrhoea of all causes.
— Normal saline (also called Isotonic or Physiological saline). This
solution is often readily available. It will not correct the acidosis
and will not replace potassium losses. Sodium bicarbonate or
sodium lactate and potassium chloride can be given at the same
time, but this requires careful calculation of amounts, and monitor
ing is difficult. In the Infections Diseases Hospital, Calcutta, I.V.
normal saline was used successfully along with simultaneous admi
nistration of OR.S by mouth.
Unsuitable solutions
— Plain Glucose and Dextrose solutions should not be used as they
provide only water and sugar. They do not contain electrolytes
and thus they do not correct the electrolyte losses or the acidosis.
2.3.3 Providing I.V. therapy for severe dehydration: The purpose is to
give the patient a large quantity of fluids quickly to replace the large volume
of fluid loss which has resulted in severe dehydration.
12
• Begin intravenous therapy quickly in the amount specified in
Table 2.
If the signs of dehydration and the diarrhoea and vomiting have
become worse or remain unchanged, the rate of administration and
the amount of fluid given may need to be increased.
© While rehydration therapy (to replace the body’s abnormal losses)
is in progress, the patient’s normal daily fluid requirements must
also be considered. After 6 hours, begin Dreast-feeding, or for the
non-breast-fed infant, give 100-200 ml of clean water before con
tinuing OR. therapy. (For older children and adults, plain water
should be available to patients to drink as they wish, in addition
to ORS solution.)
After the first 6 hours (4 hours for older children and adults),
ASK, LOOK, and FEEL for the signs of dehydration. At this point
complete or near complete rehydration of the severely dehydrated
patient should have been achieved. The patient will require con
tinued therapy to prevent dehydration from recurring as long as
the diarrhoea continues.
13
TABLE I
ASSESSMENT OF DEHYDRATION AND FLUID DEFICIT
Signs and symptoms
Mild dehydration
Moderate dehydration
Severe dehydration
General appearance and condition
—Infants and young children
Thirsty; alert; restless
Thirsty; restless or lethargic
but irritable when touched
Drowsy; limp, cold, sweaty cyanotic
extremities; may be comatose
—older children and adults
Thirsty; alert; restless
Thirsty; alert; giddiness with
postural changes
Usually conscious; apprehensive; cold,
sweaty cyanotic extremities; wrinkled
skin of fingers and toes; muscle cramps
Radial pulse1
Normal rate and volume
Rapid and weak
Rapid, feeble, sometimes Impalpable
Respiration
Normal
Deep, may be rapid
Deep and rapid
♦Anterior fontanelle3
Normal
Sunken
Very Sunken
Systolic blood pressure3
Normal
Normal—low
Less than 10, 7 kPa (80 mmHg); may be
unrecordable
♦Skin elasticity4
Pinch retracts Immediately
Pinch retracts slowly
Pinch retracts very slowly (> 2 seconds)
♦Eyes
Normal
Sunken
Deeply sunken
Tears
Present
Absent
Absent
Mucous membrances8
Moist
Dry
Very dry
♦Urine flow*
Normal
Reduced amount and dark
None passed for several hours; empty
bladder
%body weight loss
4-5%
6-9%
10% or more
Estimated fluid deficit
40-50 ml per kg
60-90 ml per kg
100-110 ml per kg
♦Particularly useful in infants for assessment of dehydration and monitoring of rehydration.
Hf radial pulse cannot be felt, listen to heart with stethoscope.
2Useful in infants until fontanelle closes at 6-18 months of age. After closure there is a slight depression in some children.
’Difficult to assess in infants.
4Not useful in marasmic malnutrition or obesityl.
•Dryness of mouth can be palpated with a clean finger. Mouth may always be dry in a child who habitually breathes by mouth.
•A marasmic baby or one receiving hypotonic fluids may pass good urine volumes in the presence of dehydration.
TABLE 2
GUIDELINES FOR REHYDRATION THERAPY
Degree of
dehydration
Age group
Type of fluid
Volume of fluid
Mild
All
ORS Solution
50 ml/kg
Within 4 hours
Moderate
All
ORS Solution
100 ml/kg1
Within 4 hours
I.V.2
Ringer’s
Lactate
30 ml/kg
Within 1 hour
40 ml/kg
Within next 2 hours
ORS Solution
40 ml/kg
Within next 3 hours
I.V.2
Ringer’s
Lactate
110 ml/kg
Within 4 hours;
initially as fast
as possible until
radial pulse is
palpable
Time of
administration
Followed by
Severe
Infants
I.V.2
Ringer’s
Lactate
Followed by
Older
children
and adults
*During the Initial stages of therapy, adults can usually consume up to 750 ml per hour and
children up to 300 ml per hour.
2lf Ringer’s Lactate is not available, one of the other I.V. solutions listed in section 2.3.2
may be used in the same volumes as shown above (except for I/2 Strength Darrow’s Solution,
for which the volumes shown above should be increased by 50%).
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TABLE 3
GUIDELINES FOR MAINTENANCE THERAPY
Amount of diarrhoea
Kind of
fluid
Route and place of
administration
Amount of fluid
Mild diarrhoea
(not more than one
stool every 2 hours or
longer, or less than
5 ml stool per kg
per hour)
ORS
By mouth:
at treatment facility
100 ml/kg body weight per
day until diarrhoea stops1
Severe diarrhoea
(more than one stool
every 2 hours, or more
than 5 ml of stool
per kg per hour)
ORS
By mouth:
at treatment facility
Replace stool losses volume
for volume; if not
measurable give 10-15
ml/kg body weight per
hour
Severe diarrhoea
with recurrence of signs
of dehydration
Treat as for Severe Dehydration in Table 2
*ln infants, as an alternative, mothers can be advised to give 10 ml/kg body weight for each
diarrhoea stool. In older children and adults, thirst is an adequate guide for fluid needs;
they can be told to drink as much as they want to satisfy their thirst.
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TABLE 4
ANTIMICROBIALS USED IN THE TREATMENT OF SPECIFIC CASES OF
ACUTE DIARRHOEA
Clinical Diagnosis
of cause
Suspect
Cholera2* 3
Shigella
dysentery2. 4
Dose(s) of Choice1
Alternative1
Tetracycline
Children—50 mg/kg/day
in 4 divided doses x 3 days
Furazolidone
Children—5 mg/kg/day
in 4 divided doses x 3 days
Adults—500 mg 4 times a
day x 3 days
Adults—100 mg 4 times a
day x 3 days
Ampicillin—100 mg/kg/day
OR
Nalidixic Acid
55 mg/kg/day in 4 divided
doses x 5 days (all ages)
Trimethoprim (TMP)—
Sulfamethoxazole (SMX)
Children—TMP 10 mg/kg/day
and SMX 50 mg/kg/day
in 2 divided doses X 5 days
Tetracycline—50 mg/kg/day
in 4 divided doses x 5 days
(all ages)
Adults—TMP 160 mg and SMX
800 mg twice daily X 5 days
Acute
intestinal
amoebiasis
Metronidazole6
Children—30 mg/kg/day
X 5-10 days
Adults—750 mg 3 times a day
X 5-10 days
Acture
giardiasis
In very servere cases:
Dehydroemetine hydrochloride
by deep intramuscular injection,
1-1.5 mg/kg (maximum 90 mg)
for up to 5 days depending on
response (all ages)
Metronidazole6
Children—15 mg/kg/day
X 5 days
Adults—250 mg 3 times a day
X 5 days
XAII doses given are for oral administration unless otherwise indicated.
2Decision on selection of antibiotic for treatment should take into account frequency of
resistance to antibiotics in the area.
3Antibiotic therapy not essential for successful therapy but shortens duration of illness and
excretion of organisms in severe cases.
4Antibiotic therapy especially required in infants with persistent high fever.
6Tinidazole and ornidazole can also be used in accordance with the manufacturers’
recommendations.
17
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