Childhood Diarrhea Management

Training for Medical Officers

Participants Manual

Contents
Agenda for One day Training of Medical Officers Pre Assessment Form for Medical Officers Session 1: Welcome, Introduction and Objectives Session 2: Diarrhea Management Session 3: Diarrhea Management Program: Design and Delivery Session 4: Understanding Communication Session 5: Learning IPC Skills Session 6: Using IEC/IPC Materials Session 7: Learning Monitoring, Evaluation, Supervision and Reporting Session 8: Closing and Thanks Annexures References 6 7

11

38

44

51

55

58

64 65 73

Training for Medical Officers

Abbreviations
ANM ASHA AWC AWW BCC CDPO CHC CMO DIO DPO DH DWCDO FRU GOI GMP HMIS IAP ICDS IDSP IEC IMNCI IPC LHV LS M&E MI MCH Auxiliary Nurse Midwife Accredited Social Health Activist Anganwadi Center Anganwadi Worker Behavior Change Communication Child Development Project Officer Community Health Center Chief Medical Officer District Immunization Officer District Project Officer District Hospital District Woman and Child Development Officer First Referral Unit Government of India Good Manufacturing Practices Health Management Information Systems Indian Academy of Paediatrics Integrated Child Development Scheme Integrated Disease Surveillance Project Information, Education and Communication Integrated Management of Neonatal and Childhood Illnesses Inter Personal Communication Lady Health Visitor Lady Supervisor Monitoring and Evaluation Micronutrient Initiative Maternal and Child Health

4 Childhood Diarrhea Management

MOHFW MSS NGO NRHM ORS ORT PIP PRI PHC RCHO SHG SIHFW SMO SUZY VHND VHWSC

Ministry of Health and Family Welfare Mahila Swasthya Sangh Non-Governmental Organization National Rural Health Mission Oral Rehydration Salt/Solution Oral Rehydration Therapy Project Implementation Plan Panchayati Raj Institution Primary Health Center Reproductive and Child Health Officer Self-Help Group State Institute of Health and Family Welfare Social Marketing Organization Scaling up Zinc for Young Children with Diarrhea Village Health and Nutrition Day Village Health and Water Sanitation Committee

Childhood Diarrhea Management 5

Training for Medical Officers

Agenda for One day Training of Medical Officers

Session 1 2 3 4 5 6 7 8 Topic Welcome, Introduction and Objectives Diarrhea Management Diarrhea Control Program: Design and Delivery Understanding Communication Learning IPC Skills Using IEC/IPC Materials Learning Monitoring, Evaluation, Supervision and Reporting Closing and Thanks Time 30 min 90 min 30 min 30 min 30 min 30 min 45 min 15 min

6 Childhood Diarrhea Management

Pre Assessment Form for Medical Officers

Instructions: 1. Please mark () for correct answers in the box. 2. Please write the answers in questions which ask for a specific detail
1. What percent of children under 5 die because of diarrhea according to WHO, 2004 update? a) 4 b) 11 c) 17 d) 20 2. What is the current rate of IMR in Uttar Pradesh as per SRS Jan 2011? a) 71 b) 40 c) 63 d) 99 3. Another name for Dysentery is a) Acute Diarrhea b) Bloody Diarrhea c) Watery Diarrhea d) Persistent Diarrhea 4. Children are more vulnerable to Diarrhea than adults because of all the following except a) Poor nutritional status b) Water constitutes a greater proportion of childrens body weight c) Lower immunity levels d) All of the above 5. The four rules of treatment plan A: home therapy to prevent dehydration and malnutrition include all of the following guidelines except a) Give the child more fluids than usual to prevent dehydration b) Give supplemental zinc (10 - 20 mg) to the child, every 14 days c) Give diluted milk-free foods to the child d) Take the child to a health worker if there are signs of dehydration or other Problems 6. What is the difference between new and old ORS? a) The new ORS has less glucose and sodium as compared to the traditional WHO-ORS. b) The new ORS has more glucose and sodium as compared to the traditional WHO-ORS. c) The new ORS has more glucose and less sodium as compared to the traditional WHO-ORS. d) The new ORS has less glucose and more sodium as compared to the traditional WHO-ORS.

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Training for Medical Officers

7.

Which of the following behavior is not useful for effective Inter-Personal Communication? a) Appropriate gestures like nodding, smiling during interaction to encourage the Target Group b) Establishing and maintaining eye contact c) Asking close-ended questions which can be answered in short d) Trying to understand the concerns of Target Group and address them

8.

The daily dose of Zinc for children of below mentioned age groups for 14 days should bea) 2-6 month. mg b) >6 months.mg

9.

All are signs of completion of rehydration except, a) The skin pinch is normal. b) The child feels thirsty and drinks vigorously c) Urine is passed. d) The child becomes quiet, is no longer irritable and often falls asleep.

10.

Zinc deficiency in children results in a) Increased risk of diarrhea and pneumonia b) Increased severity of diarrhea c) Impaired growth d) All of the above

11.

Classify dehydration status of a child who has sunken eyes and whose skin pinch goes back very slowly a) No dehydration b) Some dehydration c) Severe dehydration

12.

The amount of ORS needed for rehydration in Treatment Plan B is estimated asml/Kg of body weight a) 30 b) 50 c) 75 d) 100

13.

Ideal Intravenous fluid for intravenous rehydration in a child with severe dehydration isa) Normal saline b) Dextrose 5% c) Ringers Lactate d) Any of the above

8 Childhood Diarrhea Management

Session 1

Welcome, Introduction and Objectives

Time: 30 minutes Learning Objectives

After the session, the participants will be able to:

Understand the training objectives. Understand the context of training.

The training on revised childhood diarrhea control and management is a very important knowledge and skills building initiative. You as a key functionary of the health and ICDS system are in a pivotal position to facilitate the control and management of this easily preventable as well as treatable condition. The Reproductive and Child Health program (RCH) II under the National Rural Health Mission (NRHM) comprehensively integrates interventions that improve child health and addresses factors contributing to infant and under-five mortality. Reduction of infant and child mortality has been an important tenet of the health policy of the Government of India and it has tried to address the issue right from the early stages of planned development. The National Population Policy (NPP) 2000, the National Health Policy 2002 and the Eleventh Five Year Plan (2007-12) and National Rural Health Mission (NRHM 2005 2012) have laid down the goals for child health. In the eight Millennium Developmental Goals (MDGs) with a deadline of 2015, Goal No. 4 is dedicated to reduce child mortality. MDG Goal 4: Reduce Child Mortality Target 4: Reduce by two-thirds the mortality rate among children under five between 1990 and 2015. This training is designed to improve the use of Zinc and ORS as a treatment regime of childhood diarrhea and structured to improve technical and program management skills to all functionaries in health and ICDS. Besides the technical component of the training sessions, an important component of the training is enhancing the communication and IPC skills of the functionary. It is expected that knowledge and skills of the providers will improve the administration and counseling which will result in improved coverage and compliance by the caregivers.

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Training for Medical Officers

The medical officers have a key leadership and project management role in guiding the other field functionaries to undertake initiatives and intervention for childhood diarrhea management. This would go a long way in accelerating the good beginning of positive behaviour change increase awareness of the mother, children, families and communities in proactively participation and responsibility towards successful implementation of the revised diarrhea management guidelines. The key aspects covered in this training module include: 1. 2. 3. 4. 5. Technical information on the revised childhood diarrhea management Program management Roles and responsibilities Communication, IPC and use of communication materials Monitoring and reporting

It is a highly participative, interactive training program that will enhance your knowledge, skills, experiences and provide you tools and methods that will help improve the overall implementation and performance of the revised diarrhea management program in Uttar Pradesh.

10 Childhood Diarrhea Management

Session 2

Diarrhea Management
Time: 90 minutes Learning Objectives

After the session, the participants will be able to:

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

treatment

Understand the new low osmolarity ORS and its advantages as a life saving drug Understand the introduction of Zinc as a micronutrient for diarrhea management
program

Understand the Jodi Strategy of low osmolarity ORS and Zinc supplementation
for diarrhea control

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

2.1 Introduction and Situation Status

Uttar Pradesh is the largest Indian state population-wise. The situation of Diarrhoea and its management is given below:
Children suffered from Diarrhoea Women aware of diarrhoea management Proportion of children with diarrhoea given ORS Proportion of children with diarrhoea given salt and sugar solution Proportion of children with diarrhoea continued on normal food Proportion of children with diarrhoea continued on breastfeeding Proportion of children with diarrhoea given plenty of fluids
Source: DLHS-3 (2007-08)

16.2% 62.8% 35.1% 66.9% 7.6% 3% 8.5%

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Training for Medical Officers

Need to accelerate IMR reduction

90 80 70 60 IMR 50 40 30 20 10 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 0 NRHM Goal 80 80 79 74 74 74 72 71 72 70 68 64 60 58 58 57 55 53 39

mdG Expectation

Year

Source: MDG India Report, 2009

It is estimated that around 25,000 children die due to diarrhea in a month in India (~800 in a day). In children 0-4 years of age, diarrhea is the third leading cause of death, contributing to 13.8% of all deaths in this age group. In children 1-4 years of age, diarrhea is the leading cause of death, responsible for 23.8% of all deaths in this age group. (NCMH report) According to the NCMH Background Papers, the total diarrheal deaths among 0-6 years was 1,58,209; these are based on previous data (SRS, 1998-2001). According to recent estimates from the Million Death Study, diarrheal diseases account for 0.30 million deaths in children aged 1-59 months; and 50% of all deaths at 1-59 months occur due to pneumonia and diarrhea.

National Rural Health Mission (NRHM)

The Phase II of RCH program under the NRHM comprehensively integrates interventions that improve child health and addresses factors contributing to infant and under-five mortality. Reduction of infant and child mortality has been an important tenet of the health policy of the Government of India and it has tried to address the issue right from the early stages of planned development. The National Population Policy (NPP) 2000, the National Health Policy 2002 and the Eleventh Five Year Plan (2007-12) and National Rural Health Mission (NRHM 2005 2012) have laid down the goals for child health.

NRHM Goals: IMR and MMR

India/Current IMR* MMR** 50 254 Uttar Pradesh/ Current 63 440 NRHM Goals (2012) 36 258

Source: NRHM Mission Document, Uttar Pradesh State Plan Report, 2010 * SRS (2011) ** SRS (2004-06)

12 Childhood Diarrhea Management

90 80 70 60 50 40 30 20 10
67 65

54

52 51 50 49 48

India

63 61 59 59

Uttar Pradesh

100

Infant Mortality Rate - State-wise (2009)

45 45 44

41 41

38

36 34 33 33 32 31 31

28 26 16 12 11

Jammu & Kashmir

Tamil Nadu

0 India Chhattisgarh Up Madhya Pradesh Andhra Pradesh Bihar Rajasthan Gujarat Orissa meghalaya Assam Haryana

Punjab

Sikkim

Himachal Pradesh

Mizoram

West Bengal

Arunachal Pradesh

Nagaland

Manipur

delhi

Tripura

Jharkhand

Uttarakhand

Source: SRS (2011)

2.2 What is Diarrhea?

Let us begin by understanding what is diarrhea. Diarrhea is the passage of three or more liquid or watery stools in a day. However, it is the recent change in consistency and character of the stools rather than the number of stools that is more important. Infants, particularly those who are on breastfeeds, during the initial 2 to 3 months of life, may pass many pasty or semi-formed stools. Mothers usually know when their children have diarrhea and often have a local word for diarrhea. Diarrhea is more prevalent in the developing world, in large part due to the lack of safe drinking water, sanitation & hygiene, as well as poorer overall health and nutritional status. All of these components in combination with unsanitary environments allow diarrhea to become the third leading killer of children under five. As mentioned above, diarrhea is a serious disease and wherever it doesn't kill, it wreaks havoc on young bodies and lives, leading to millions of hospitalizations, weakening immune systems, holding children back from school and play, and contributing to long-term nutritional consequences.

Childhood Diarrhea Management 13

Maharashtra

Karnataka

Kerala

Goa

Training for Medical Officers

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

17% 16% 13%

Other

Proportional distribution of cause-specific deaths among children under five years of age, 2004
31% Prematurity and low birth weight 25% Neonatal infections (mostly sepsis/pneumonia) 23% Birth asphyxia and birth trauma 9% Other 7% Congenital anomalies 3% Neonatal tetanus 3% Diarrheal Diseases

Pneumonia

diarrhea

Neonatal causes

17%

7%

malaria

Injuries

4%

Measles

4%

2%

AIDS

17% and 16% of deaths among children under five are due to pneumonia and diarrhea, respectively. But these figures do not include deaths during the neonatal period (the first four weeks of life). Diarrhea causes 3% of neonatal deaths (or an additional 1% of total under five deaths), while 25% of neonatal deaths are due to severe infections (of which one-third are caused by pneumonia, adding another 3% to under five deaths). Therefore, pneumonia and diarrhea actually cause about 20% and 17%, respectively, of total under five deaths when estimates from the post neonatal and neonatal are combined.

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

More than 80% of child deaths due to diarrhea occur in Africa and South Asia
Propositional distribution of deaths due to diarrhea diseases among children under five years of age, by region, 2004

Nearly three quarters of child deaths due to diarrhea occur in just 15 countries
Bank Country 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Total number of annual child deaths due to diarrhea 386,600 151,700 89,900 82,100 73,700 53,300 50,800 40,000 29,300 27,400 26,400 24,300 23,900 20,900 19,700

9%

East Asia & Pacific

Rest of the world

7%

ASIA

38%

South Asia

46%

Africa

India Nigeria Democratic Republic of the Congo Afghanistan Ethiopia Pakistan Bangladesh China Uganda Kenya Niger Burkina Faso United Republic of Tanzania Mali Angola

Source: World Health Organization, Global Burden of Disease estimates, 2004 update, with additional analyses to calculate UNICEF regions.

Source: World Health Organization, Global Burden of Disease estimates, 2004 update, the total were calculated by applying the WHO cause of death estimates to the most recent estimates for the total number of under five deaths (2007)

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

14 Childhood Diarrhea Management

Local Names of Diarrhea There is a wide range of local terms used for diarrhea at the community level. These are common across both sets of respondents community and service providers in both intervention and non-intervention districts. Some of the usual local terms used to refer to diarrhea are: kay (vomit), ulti (vomit), paikhana (stool), dast (loose motion), palti (vomit), Tatti (stool), pet kharab (upset stomach), haiza (cholera) as well the English term diarrhea. It is important to note the use of the term haiza or cholera for diarrhea, largely by community stakeholders (mothers, caregivers and influencers). Mothers and caregivers classify three types of diarrhea: green stool (hara paikhana), loose stool (patla paikhana), and blood in stool (paikhane mein khoon ana).

What causes diarrhea?

Diarrhea is a common symptom of gastrointestinal infections caused by a wide range of pathogens, including bacteria, viruses and protozoa. However, just a handful of organisms are responsible for most acute cases of childhood diarrhea. Rotavirus is the leading cause of acute diarrhea, and is responsible for about 40 per cent of all hospital admissions due to diarrhea among children under five worldwide. Other major bacterial pathogens include E. coli, Shigella, Campylobacter and Salmonella, along with V. cholera during epidemics. Cryptosporidium has been the most frequently isolated protozoan pathogen among children seen at health facilities and is frequently found among HIV-positive patients. Though cholera is often thought of as a major cause of child deaths due to diarrhea, most cases occur among adults and older children.

What are the main forms of acute childhood diarrhea?

There are three main forms of acute childhood diarrhea, all of which are potentially life-threatening and require different treatment courses:

w Acute watery diarrhea includes cholera and is associated with significant fluid loss
and rapid dehydration in an infected individual. It usually lasts for several hours or days. The pathogens that generally cause acute watery diarrhea include V. cholera or E. coli bacteria, as well as rotavirus.

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

stools. It is associated with intestinal damage and nutrient losses in an infected individual. The most common cause of bloody diarrhea is Shigella, a bacterial agent that is also the most common cause of severe cases.

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

least 14 days. Undernourished children and those with other illnesses, such as AIDS, are more likely to develop persistent diarrhea. Diarrhea, in turn, tends to worsen their condition.

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Why are children more vulnerable?

Children with poor nutritional status and overall health, as well as those exposed to poor environmental conditions, are more susceptible to severe diarrhea and dehydration than healthy children. Children are also at greater risk than adults of life-threatening dehydration since water constitutes a greater proportion of childrens body weight. Young children use more water over the course of a day given their higher metabolic rates, and their kidneys are less able to conserve water compared to older children and adults.

2.3 Management of Diarrhea

Diagnosis is based on clinical symptoms, including the extent of dehydration, the type of diarrhea exhibited, whether blood is visible in the stool, and the duration of the diarrhea episode. Treatment regimens differ based on the outcomes of this clinical assessment.

Assessment
A careful history should elicit whether the child has acute watery diarrhea, dysentery or persistent diarrhea with or without growth failure. Watery, large, frequent (one or more stools every 3 hours) stools indicate relatively greater severity of the illness. The following questions are important to plan the therapy.

w w w w w

Did the child vomit during the preceding 6-8 hours? Did he pass urine during the same period? What is the nature of fluids that the child has been taking? Was the child receiving optimum feeding before the illness? Has feeding been reduced or modified during diarrhea in a way that reduced the quantity of total energy intake or the quality of food consumed?

The following should be assessed during examination 1. Physical signs of dehydration

Remember All children with diarrhea are to be assessed for level of dehydration and classified. If the child has had diarrhea for 14 days or more, classify the child as persistent diarrhea. If the child has blood in the stool, classify the child as dysentery.

2. Nutritional status of the child 3. Presence of pneumonia, otitis media, sepsis or other associated systemic infections

16 Childhood Diarrhea Management

Dehydration: During diarrhea, there is an increased loss of water and electrolytes (sodium, chloride, potassium, and bicarbonate) in the watery stool. Water and electrolytes are also lost through vomit, sweat, urine and breathing. Dehydration occurs when these losses are not replaced adequately and a deficit of water and electrolytes develops. The volume of fluid lost through the stools in 24 hours can vary from 5 ml/kg (near normal) to 200 ml/kg or more. The concentrations and amounts of electrolytes lost also vary. The total body sodium deficit in young children with severe dehydration due to diarrhea is usually about 70-110 millimoles per litre of water deficit. Potassium and chloride losses are in a similar range. Deficits of this magnitude can occur with acute diarrhea of any aetiology.

Assessment of severity
First Classify Dehydration
There are three possible classifications of dehydration in a child with diarrhea:

w Severe Dehydration w Some Dehydration w No Dehydration

Severe Dehydration: Two or more of the following signs

w Lethargy or

unconscious

w Sunken eyes

w to drink Unable
properly or drinking less

Skin pinch goes back very slowly (more than 2 seconds)

Some dehydration: Two or more of the following signs

w Restless and w Sunken eyes

Irritable

w thirsty and Feels

drinks eagerly

w pinch goes back Skin

slowly (less than 2 seconds)

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

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Using the chart, determine the degree of dehydration and select the appropriate plan to treat or prevent dehydration. The signs typical of children with no signs of dehydration are in column A, the signs of some dehydration are in column B, and those of severe dehydration are in column C. If two or more of the signs in column C are present, the child has "severe dehydration". If this is not the case, but two or more signs from column B (and C) are present, the child has "some dehydration". If this also is not the case, the child is classified as having "no signs of dehydration". Some textbooks also refer to these categories as "no, mild, moderate or severe" dehydration.

Assessment of diarrhea patients for dehydration

Look at: Condition Eyesb Thirst
a

w Well, alert w Normal w normally, Drinks

not thirsty Goes back quickly The patient has NO SIGNS OF DEHYDRATION

w estless, irritable w ethargic or unconscious R L w unken eyes S w unken eyes S w hirsty, drinks T w rinks poorly, or not able to D
eagerly Goes back slowly If the patient has two or more signs in B, there is SOME DEHYDRATION drink Goes back very slowly If the patients has two or more signs in C, there is SEVERE DEHYDRATION Weigh the patient, and use Treatment Plan C URGENTLY

Feel: Skin Pinchc decide

Treat

Use Treatment Plan A Weigh the patient, if possible, and use Treatment Plan B

Being lethargic and sleepy are not the same. A lethargic child is not simply asleep: the childs mental state is dull and the child cannot be fully awakened; the child may appear to be drifting into unconsciousness. b In some infants and children, the eyes normally appear somewhat sunken. It is helpful to ask the mother if the childs eyes are normal or more sunken than usual. c The skin pinch is less useful in infants or children with marasmus or kwashiorkor, or obese children.
a

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

Select a plan to prevent or treat dehydration

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

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

and malnutrition.

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

A childs fluid deficit can be estimated as follows

Status No signs of dehydration Some dehydration Severe dehydration Fluid deficit as % of body weight <5% 5-10% >10% Fluid deficit in ml/kg body weight <50 ml/kg 50-100 ml/kg >100 ml/kg

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

18 Childhood Diarrhea Management

Management of Acute Diarrhea (Without Blood)

The objectives of treatment are to:

w w w w

prevent dehydration, if there are no signs of dehydration. treat dehydration, when it is present. prevent nutritional damage, by feeding during and after diarrhea. Reduce the duration and severity of diarrhea, and the occurrence of future episodes, by giving supplemental zinc.

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

Treatment Plan A: Home therapy to prevent dehydration and malnutrition

Children with no signs of dehydration need extra fluids and salt to replace their losses of water and electrolytes due to diarrhea. If these are not given, signs of dehydration may develop. Mothers should be taught how to prevent dehydration at home by giving the child more fluid than usual, how to prevent malnutrition by continuing to feed the child, and why these actions are important. They should also know what signs indicate that the child should be taken to a health worker. These steps are summarized in the four rules of Treatment Plan A: Rule 1: Give the child more fluids than usual, to prevent dehydration. Rule 2: Give supplemental zinc (10 - 20 mg) to the child, every day for 14 days. Rule 3: Continue to feed the child, to prevent malnutrition. Rule 4: Take the child to a health worker if there are signs of dehydration or other problems. (For more details see Annexure 1)

Treatment Plan B: Fluid Therapy and Treatment of Diarrhoea with some Dehydration
Treat some dehydration with ORS Give in clinic recommended amount of ORS over 4-hour period

w Determine amount of ORS to give during first 24 hours

ORS Solution Weight Glasses Amount Upto 4 months Upto 4-12 months 12 months-2 years <6 kg 1-2 200-400 ml 6-<10 kg 2-3.5 400-700 ml 10-<12 kg 3.5-4.5 700-900 ml 2-5 years 12-<19 kg 4.5-7 900 ml-1.4 litre

*Use the child's age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the child's weight (in kg) times 75.

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Training for Medical Officers

If the child wants more ORS than shown, give more For infants under 6 months who are not breastfed, also give 100-200 ml clean water during this period Give frequent small sips from a cup, If the child vomits, wait for 10 minutes. Then continue, but more slowly; and Continue breastfeeding whenever the child wants.

w Show the mother how to give ORS solution

w After 4 hours
Reassess the child and classify the child for dehydration; Select the appropriate plan to continue treatment; and Begin feeding the child in clinic.

w If the mother must leave before completing treatment

Show her how to prepare ORS solution at home; Show her how much ORS to give to finish 4-hour treatment at home; Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended in Plan A; and Explain the four rules of home treatment: 1. Give extra fluid 2. Continue feeding 3. Give zinc for 14 days 4. When to return to the health centre

2.4 New ORS, its composition and benefits

New ORS in Management of Diarrhea
You will learn about the two recent advances in management of diarrhea the use of low osmolarity ORS and Zinc; these have the potential to save many more lives and bring about significant reduction in morbidity and mortality due to diarrhea. The Government of Indias policy already recommends use of Zinc and low osmolarity ORS in all cases of childhood diarrhea.

Oral rehydration salts

Definition. Oral rehydration salts (ORS) are dry mixtures of powders containing per packet: Sodium chloride 2.6 g trisodium citrate dihydrate 2.9 g potassium chloride 1.5 g Anhydrous glucose 13.5 g Total 20.5 g Before administration the contents of each packet should be dissolved in 1 litre of water.

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Composition of the old and the new ORS

Contents Sodium Glucose Potassium Osmolarity Old ORS Composition 90 m Osmol/L 110 m Osmol/L 20 m Osmol/L 311 m Osmol/L New ORS Composition 75 m Osmol/L 75 m Osmol/L 20 m Osmol/L 245 m Osmol/L

Oral rehydration salts: One of the most important medical advances of the 20th century A solution of ORS is a simple, inexpensive and life-saving remedy that prevents dehydration among children with diarrhea. How does it work? In a healthy child, the small intestines absorb water and electrolytes from the digestive tract so that these nutrient-rich fluids may be transported to other parts of the body through the bloodstream. In a sick child, diarrhea-causing pathogens damage the intestines causing an excessive amount of water and electrolytes to be secreted rather than being absorbed. When the ORS solution reaches the small intestines, the sodium and glucose in the mixture are transported together across the lining of the intestines, and the sodium, which is now in higher concentrations, in the body from the gut. The discovery that sodium and glucose are transported together across the small intestines through a co-transport mechanism has been called potentially the most important medical advance of the 20th century. 35 The development of ORS is a direct result of this discovery.
Sources: Water with sugar and salt, The Lancet, vol. 312, no. 8084, 1978, pp. 300-301; Rehydration. Org, Why is rehydration so important and How it works to save childrens lives, http://rehydrate.org/rehydration, accessed June 2009.

Low osmolarity ORS: A life-saving remedy just got better For more than two decades, WHO and UNICEF recommended a single ORS formula for treating all types of diarrhea among all age groups. During this time, researchers also worked to improve the formula to provide additional clinical benefits to patients. Particularly important, in addition to preventing dehydration, was making ORS more acceptable to caregivers who sought to reduce their childs diarrhea symptoms. In 2004, WHO and UNICEF began recommending that countries use and manufacture a new ORS formula (known as low osmolarity ORS) to treat all types of diarrhea among all age groups. This improved formula was shown to be as safe and effective as the previous version, but also had other important clinical benefits. Stool output and vomiting decreased in children by about 20% and 30%, respectively, when compared to children using the original ORS formula. Unscheduled intravenous therapy also declined by 33% among children with diarrhea using this new remedy.
Source: World Health Organization, The Treatment of Diarrhea: A manual for physicians and other senior health workers, WHO, Geneva, 2005

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Use of reduced osmolarity ORS in diarrhea

The new ORS developed has less glucose and sodium as compared to the traditional WHO-ORS. The advantages of the new ORS over the standard ORS include:

w Less vomiting w Less number of stools w Less amount of water in stools w Reduced need for intravenous fluids

Preparation of ORS solution

Method of preparing of ORS and quantity to be given

Wash your hands well using soap

Add 1 litre of clean water into a clean vessel

Empty the contents of the ORS packet into the vessel containing water

Mix the solution well using a clean spoon

5 solution should be
given to the child in small amounts as per the requirements.

The prepared ORS

Quantity of ORS to be given after every bout of diarrhea

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

Quarter to half glass ORS after every bout of diarrhea

Half to full glass ORS after every bout of diarrhea

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

How much ORS solution is needed?

Refer to the table in the next page to estimate the amount of ORS solution needed for rehydration. If the child's weight is known, this should be used to determine the approximate amount of solution needed. The amount may also be estimated by multiplying the child's weight in kg times 75 ml. If the child's weight is not known, select the approximate amount according to the child's age.

22 Childhood Diarrhea Management

the exact amount of solution required will depend on the child's dehydration status. Children with more marked signs of dehydration, or who continue to pass frequent watery stools, will require more solution than those with less marked signs or who are not passing frequent stools. If a child wants more than the estimated amount of ORS solution, and there are no signs of over-hydration, give more. Oedematous (puffy) eyelids are a sign of over-hydration. If this occurs, stop giving ORS solution, but give breast milk or plain water, and food. Do not give a diuretic. When the oedema has gone, resume giving ORS solution or home fluids according to Treatment Plan A.

How to give ORS solution?

A family member should be taught to prepare and give ORS solution. The solution should be given to infants and young children using a clean spoon or cup. Feeding bottles should not be used. For babies, a dropper or syringe (without the needle) can be used to put small amounts of solution into the mouth. Children under 2 years of age should be offered a teaspoonful every 1-2 minutes; older children (and adults) may take frequent sips directly from the cup. Vomiting often occurs during the first hour or two of treatment, especially when children drink the solution too quickly, but this rarely prevents successful oral rehydration since most of the fluid is absorbed. By this time, vomiting usually stops. If the child vomits, wait 5-10 minutes and then start giving ORS solution again, but more slowly (E.g. A spoonful every 2-3 minutes).

Monitoring the progress of oral rehydration therapy

Check the child from time to time during rehydration to ensure that ORS solution is being taken satisfactorily and that signs of dehydration are not worsening. If at any time the child develops signs of severe dehydration, shift to Treatment Plan C. After four hours, reassess the child fully. Then decide what treatment to give next:

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

started following Treatment Plan C. This is very unusual, however, occurring only in children who drink ORS solution poorly and pass large watery stools frequently during the rehydration period.

w If the child still has signs indicating some dehydration, continue ORT by repeating
Treatment Plan B. At the same time, start to offer food, milk and other fluids, as described in Treatment Plan A, and continue to reassess the child frequently.

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

rehydrated. When rehydration is complete: The skin pinch is normal; Thirst has subsided; Urine is passed; and

Childhood Diarrhea Management 23

Training for Medical Officers

The child becomes quiet, is no longer irritable and often falls asleep.

Teach the mother how to treat her child at home with ORS solution and food following Treatment Plan A. Give her enough ORS packets for two days. Also teach her the signs that mean she should bring her child back.

Meeting normal fluid needs

While treatment to replace the existing water and electrolyte deficit is in progress, the child's normal daily fluid requirements must also be met. This can be done as follows:

w Breastfed infants: Continue to breastfeed as often and as long as the infant wants,
even during oral rehydration.

w Non-breastfed infants under 6 months of age: If using the old WHO ORS solution
containing 90 mmol/L of sodium, also give 100-200ml clean water during this period. However, if using the new reduced (low) osmolarity ORS solution containing 75 mmol/L of sodium, this is not necessary. After completing rehydration, resume full strength milk (or formula) feeds. Give water and other fluids usually taken by the infant.

w Older children and adults: Throughout rehydration and maintenance therapy, offer
as much plain water to drink as they wish, in addition to ORS solution.

If oral rehydration therapy must be interrupted

If the mother and child must leave before rehydration with ORS solution is completed:

w Show the mother how much ORS solution to give to finish the four-hour treatment
at home;

w Give her enough ORS packets to complete the four-hour treatment and to continue
oral rehydration for two more days, as shown in Treatment Plan A;

w Show her how to prepare ORS solution; and w Teach her the four rules in Treatment Plan A for treating her child at home.

When oral rehydration fails

With the previous ORS, signs of dehydration would persist or reappear during ORT in about 5% of children. With the new reduced (low) osmolarity ORS, it is estimated that such treatment failures will be reduced to 3%, or less. The usual causes of these failures are:

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

w Insufficient intake of ORS solution owing to fatigue or lethargy w Frequent, severe vomiting.

24 Childhood Diarrhea Management

Such children should be given ORS solution by nasogastric (NG) tube or Ringer's Lactate Solution intravenously (IV) (75 ml/kg in four hours), usually in hospital. After confirming that the signs of dehydration have improved, it is usually possible to resume ORT successfully. In rare cases, ORT should not be given. This is true for children with:

w Abdominal distension with paralytic ileus, which may be caused by opiate drugs
(e.g. codeine, loperamide) and hypokalaemia; and

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

solution is given, failure of the signs of dehydration to improve and a large amount of glucose in the stool when ORS solution is given.

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

Giving food
Except for breast milk, food should not be given during the initial four-hour rehydration period. However, children continued on Treatment Plan B longer than four hours should be given some food every 3-4 hours as described in Treatment Plan A. All children older than 6 months should be given some food before being sent home. This helps to emphasize to mothers the importance of continued feeding during diarrhea.

Treatment Plan C: for patients with severe dehydration

The preferred treatment for children with severe dehydration is rapid intravenous rehydration, following Treatment Plan C. If possible, the child should be admitted to hospital. Guidelines for intravenous rehydration Children who can drink, even poorly, should be given ORS solution by mouth until the IV drip is running. In addition, all children should start to receive some ORS solution (about 5 ml/kg/h) when they can drink without difficulty, which is usually within 3-4 hours (for infants) or 1-2 hours (for older patients). This provides additional base and potassium, which may not be adequately supplied by the IV fluid.

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Training for Medical Officers

Guidance for intravenous treatment of children and adults with severe dehydration
Start IV fluids immediately. If the patient can drink, give ORS by mouth until the drip is set up. Give 100 ml/kg Ringer's Lactate Solution* divided as follows: Age Infants (under 12 months) Older First give 30 ml/kg in: 1 hour** 30 minutes
**

Then give 70 ml/kg in: 5 hours 2 hours

Reassess the patient every 1-2 hours. If hydration is not improving, give the IV drip more rapidly. After six hours (infants) or three hours (older patients), evaluate the patient using the assessment chart. The choose the appropriate treatment plan (A, B or C) to continue treatment
*

If Ringer's Lactate Solution is not available, normal saline may be used. Repeat once if radial pulse is still very weak or not detectable.

**

Monitoring the progress of intravenous rehydration

Patients should be reassessed every 15-30 minutes until a strong radial pulse is present. Thereafter, they should be reassessed at least every hour to confirm that hydration is improving. If it is not, the IV drip should be given more rapidly. When the planned amount of IV fluid has been given (after three hours for older patients, or six hours for infants), the child's hydration status should be reassessed fully. Look and feel for all the signs of dehydration: If signs of severe dehydration are still present, repeat the IV fluid infusion as outlined in Treatment Plan C. This is very unusual, however, occurring only in children who pass large watery stools frequently during the rehydration period. If the child is improving but still shows signs of some dehydration, discontinue the IV infusion and give ORS solution for four hours, as specified in Treatment Plan B. If there are no signs of dehydration, follow Treatment Plan A. If possible, observe the child for at least six hours before discharge while the mother gives the child ORS solution, to confirm that she is able to maintain the child's hydration. Remember that the child will require therapy with ORS solution until diarrhea stops. If the child cannot remain at the treatment center, teach the mother how to give treatment at home following Treatment Plan A, give her enough ORS packets for two days and teach her the signs that mean she should bring her child back.

What to do if intravenous therapy is not available

If IV therapy is not available at the facility, but can be given nearby (i.e. Within 30 minutes), send the child immediately for IV treatment. If the child can drink, give the mother some ORS solution and show her how to give it to her child during the journey.

26 Childhood Diarrhea Management

Plan C: Treat Severe Dehydration Quickly

FOLLOW THE ARROWS. IF ANSWER IS "YES", GO ACROSS; IF "NO", GO DOWN. START HERE
Can you give intravenous (IV) fluid immediately? Yes Start IV fluids immediately. If the patient can drink, give ORS by mouth while the drip is set up. Give 100 ml/kg Ringer's Lactate Solution (or, if not available, normal saline), divided as follows: Age Infants (under 12 months) Older First give 30 ml/kg in: 1 hourb 30 minutesb Then give 70 ml/kg in: 5 hours 2 hours

*Repeat once if radial pulse is still very weak or not detectable Reassess the child every 1-2 hours. If hydration status is not improving, give the IV drip more rapidly Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 34 hours (infants) or 1-2 hours (children). Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriate plan (A, B or C) to continue treatment Is IV treatment available nearby (within 30 minutes)? No Are you trained to use a nasogastric (NG) tube for rehydration? No Can the child drink? No NOTE: If possible, observe the child at least 6 hours after rehydration to be sure the mother can maintain hydration giving ORS solution by mouth Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg for 6 hours (total of 120 ml/kg). Reassess the child every 1-2 hours: If there is repeated vomiting or increasing abdominal distension, give the fluid more slowly. If hydration status is not improving after 3 hours, send the child for IV therapy After 6 hours, reassess the child. Classify dehydration. Then choose the appropriate plan (A, B or C) to continue treatment. Refer URGENTLY to hospital for IV treatment. If the child can drink, provide the mother with ORS solution and show her how to give frequent sips during the trip

Yes

Refer URGENTLY to hospital for IV or NG treatment

Childhood Diarrhea Management 27

Training for Medical Officers

If IV therapy is not available nearby, health workers who have been trained can give ORS solution by NG tube, at a rate of 20 ml/kg body weight per hour for six hours (total of 120 ml/kg body weight). If the abdomen becomes swollen, ORS solution should be given more slowly until it becomes less distended. If NG treatment is not possible but the child can drink, ORS solution should be given by mouth at a rate of 20 ml/kg body weight per hour for six hours (total of 120 ml/kg body weight). If this rate is too fast, the child may vomit repeatedly. In that case, give ORS solution more slowly until vomiting subsides. Children receiving NG or oral therapy should be reassessed at least every hour. If the signs of dehydration do not improve after three hours, the child must be taken immediately to the nearest facility where IV therapy is available. Otherwise, if rehydration is progressing satisfactorily, the child should be reassessed after six hours and a decision on further treatment made as described above for those given IV therapy. If neither NG nor oral therapy is possible, the child should be taken immediately to the nearest facility where IV or NG therapy is available.

2.5 Management of suspected cholera

When to suspect Cholera?
Cholera should be suspected when a child older than five years or an adult develops severe dehydration from acute watery diarrhea (usually with vomiting), or any patient older than two years has acute watery diarrhea when cholera is known to be occurring in the area. Younger children also develop cholera, but the illness may be difficult to distinguish from other causes of acute watery diarrhea, especially rotavirus.

Treatment of dehydration
Initial treatment of dehydration from cholera follows the guidelines given above for patients with some or severe dehydration. For patients with severe dehydration and shock, the initial intravenous infusion should be given very rapidly to restore an adequate blood volume, as evidenced by normal blood pressure and a strong radial pulse. Typically, an adult weighing 50 kg and with severe dehydration would have an estimated fluid deficit of five litres. Of this, two litres should be given within 30 minutes, and the remainder within three hours. The amount of stool lost is greatest in the first 24 hours of treatment, being largest in patients who present with severe dehydration. During this period, the average fluid requirement of such patients is 200 ml/kg of body weight, but some need 350 ml/kg or more. After being rehydrated, patients should be reassessed for signs of dehydration at least every 1-2 hours, and more often if there is profuse ongoing diarrhea. If signs of dehydration reappear, ORS solution should be given more rapidly. If patients become tired, vomit frequently or develop abdominal distension, ORS solution should be stopped and rehydration should be given IV with Ringer's Lactate Solution with added potassium chloride (50 ml/kg in three hours). After this, it is usually possible to resume treatment with ORS solution.

28 Childhood Diarrhea Management

Antimicrobials
All cases of suspected cholera with severe dehydration should receive an oral antimicrobial known to be effective against strains of Vibrio cholerae in the area. The first dose should be given as soon as vomiting stops, which is usually 4-6 hours after starting rehydration therapy.

Antimicrobials for treatment of cholera in children

Antibiotic Tetracycline Erythromycin Dosage 12.5 mg/Kg 12.5 mg/Kg Duration 4 times a day for 3 days 4 times a day for 3 days

After rehydration and when vomiting has subsided, zinc should be given as a supplement for 14 days as outlined in acute watery diarrhea.

Anti-diarrheals and Anti-motility Drugs

Anti-diarrheals and anti-motility drugs have NO practical benefit and are NEVER indicated in the treatment of acute diarrhea in children. Some of them could be dangerous and should not be used in children at all.

2.6 Management of acute bloody diarrhea (dysentery)

Initial treatment and follow-up
Any child with bloody diarrhea and severe malnutrition should be referred immediately to hospital. All other children with bloody diarrhea should be assessed, given appropriate fluids to prevent or treat dehydration, and given food. In addition, they should be treated for three days with ciprofloxacin (15 mg/kg; twice a day), or for five days with another oral antimicrobial to which most Shigella in the area are sensitive. This is because Shigella cause most episodes of bloody diarrhea in children, and nearly all episodes that are severe. Determining the sensitivity of local strains of Shigella is essential, as antimicrobial resistance is frequent and the pattern of resistance is unpredictable. The child should be seen again after two days if he or she:

w w w w

was initially dehydrated; is less than 1 year old; had measles during the past six weeks; and is not getting better.

When to consider amoebiasis

Amoebiasis is an unusual cause of bloody diarrhea in young children, usually causing less than 3% of episodes. Young children with bloody diarrhea should not be treated routinely for amoebiasis. Such treatment should be considered only when microscopic examination of fresh faeces done in a reliable laboratory reveals trophozoites of E. histolytica containing red blood cells, or two different antimicrobials usually effective for Shigella in the area have been given without clinical improvement.
Childhood Diarrhea Management 29

Training for Medical Officers

2.7 Management of persistent diarrhea

This is diarrhea, with or without blood, that begins acutely and lasts at least 14 days. It is usually associated with weight loss and, often, with serious non-intestinal infections. Many children who develop persistent diarrhea are malnourished before the diarrhea starts. Persistent diarrhea almost never occurs in infants who are exclusively breastfed. The child's history should be carefully reviewed to be certain there is diarrhea, rather than several soft or pasty stools each day, which is normal for breastfed infants. The objective of treatment is to restore weight gain and normal intestinal function. Treatment of persistent diarrhea consists of giving:

w w w w

Appropriate fluids to prevent or treat dehydration; Nutritious diet that does not cause diarrhea to worsen; Supplementary vitamins and minerals, including zinc for 14 days; and Antimicrobial(s) to treat diagnosed infections.

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

2.8 Monitor the response in persistent diarrheoa

Children treated as out-patients
Children should be re-evaluated after 3 or 7 days, if diarrhea worsens or other problems develop. Those who have gained weight and who have less than three loose stools per day, may resume a normal diet for age. Those who have not gained weight or whose diarrhea has not improved should be referred to hospital.

Children treated in hospital

The following should be measured and recorded in a standard manner, at least daily: (i) body weight; (ii) temperature; (iii) food taken; and (iv) number of diarrhea stools. Successful treatment with either diet is characterized by:

w Adequate food intake w Weight gain w Fewer diarrheal stools w Absence of fever
Many children will lose weight for 1-2 days, and then show steady weight gain as infections come under control and diarrhea subsides. There should be at least three successive days of increasing weight to conclude that weight gain is occurring; for most children, weight on day 7 will be greater than on the day of admission.

30 Childhood Diarrhea Management

Dietary failure is manifest by:

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

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

w A failure to establish daily weight gain within seven days, as described above.
The Initial Diet A: (Reduced lactose diet; milk rice gruel, milk sooji gruel, rice with curd, dalia)
Ingredients Milk Sugar Oil Puffed rice powder* Water Measures 1/3 cup level tsp level tsp 4 level tsp Katori to make 100 ml Approximate quantity 40 ml 2 gm 2 gm 12.5 gm

* Can be substituted with cooked rice or sooji

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

Ingredients Example of one diet Egg white Puffed rice powder * Glucose Oil Water
*Can be substituted with cooked rice

Measures 3 level tsp 2 level tsp level tsp 1 level tsp katori to make 100ml

Approximate quantity 15 gm 7 gm 3 gm 4 gm

The Third Diet C: (Monosaccharide based diet)

Ingredients Chicken Or Egg white Glucose Oil Water 5 level tsp level tsp 1 level tsp - katori to make 100 ml 25 g 3 gm 4 gm Measures 2 level tsp Approximate quantity 12 gm

The first diet should be given for seven days, unless signs of dietary failure occur earlier, in which case the first diet should be stopped and the second diet given, also for seven days. Children responding satisfactorily to either diet should be given additional fresh fruit and well cooked vegetables as soon as improvement is confirmed; after seven days' treatment with the effective diet, they should resume an appropriate diet for age, including milk, that provides at least 110 Kcal/kg/day. Occasionally, it is necessary to restrict milk intake for more than seven days. Children may return home, but should be followed up regularly to ensure continued weight gain and compliance with feeding advice.
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2.9 Other problems associated with diarrhea

Fever
Fever in a child with diarrhea may be caused by another infection (e.g. Pneumonia, bacteraemia, urinary tract infection or otitis media). Young children may also have fever on the basis of dehydration. The presence of fever should prompt a search for other infections. This is especially important when fever persists after a child is fully rehydrated. Children with fever (38C or above) or a history of fever in the past five days, and who live in a Plasmodium falciparum malarious area, should also be given an antimalarial or treated according to the policy of the national malaria program. Children with high fever (39C or greater) should be treated promptly to bring the temperature down. This is best done by treating any infection with appropriate antibiotics as well as an antipyretic (e.g. paracetamol). Reducing fever also improves appetite and diminishes irritability.

Convulsions
In a child with diarrhea and a history of convulsions during the illness, the following diagnoses and treatments should be considered: Febrile convulsion: This usually occurs in infants, especially when their temperature exceeds 40C or rises very rapidly. Treat fever with paracetamol. Sponging with tepid water and fanning may also be used if the temperature exceeds 39C. Evaluate for possible meningitis. Hypoglycaemia: This occasionally occurs in children with diarrhea, owing to inadequate gluconeogenesis. If hypoglycaemia is suspected in a child with seizures or coma, give 5.0 ml/kg of 10% glucose solution intravenously over five minutes. If hypoglycaemia is the cause, recovery of consciousness is usually rapid. In such cases, ORS solution should be given (or 5% glucose should be added to the IV solution) until feeding starts, to avoid recurrence of symptomatic hypoglycaemia. Hypernatraemia or hyponatraemia: Treat dehydration with ORS solution, as described earlier.

Vitamin A deficiency
Diarrhea reduces the absorption of, and increases the need for, vitamin A. In areas where bodily stores of vitamin A are often low, young children with acute or persistent diarrhea can rapidly develop eye lesions of vitamin A deficiency (xerophthalmia) and even become blind. This is especially a problem when diarrhea occurs during or shortly after measles, or in children who are already malnourished.

32 Childhood Diarrhea Management

In such areas, children with diarrhea should be examined routinely for corneal clouding and conjunctival lesions (Bitot's spots). If either is present, oral vitamin A should be given at once and again the next day: 200 000 units/dose for age 12 months to 5 years, 100,000 units for age 6 months to 12 months, and 50 000 units for age less than 6 months. Children without eye signs who have severe malnutrition or have had measles within the past month should receive the same treatment. Mothers should also be taught routinely to give their children foods rich in carotene; these include yellow or orange fruits or vegetables, and dark green leafy vegetables. If possible, eggs, liver, or full fat milk should also be given.

2.10 Zinc Program for Diarrhea Management

Zinc Deficiency in Indian Children
Zinc is an essential trace element that is required for normal intestinal mucosal integrity, sodium and water transport and immune function. Zinc deficiency is common in India, for the following reasons:

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

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

w absorption of Zinc from the diet because of presence of Poor

phytates in cereals

w Loss of Zinc from the body during diarrhea.

Zinc deficiency in children results in:

w Increased risk of diarrhea and pneumonia because Zinc deficiency affects the
immunity of the body.

w Increased severity of diarrhea; Zinc deficiency makes episodes of a diarrheal

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

w Impaired growth.
Since large amounts of Zinc are lost from the body in the diarrheal stools, and 30 to 40% of children in low income group in India are already Zinc deficient, Zinc is recommended in ALL cases of childhood diarrhea.

Benefits of giving Zinc

Benefits of giving Zinc in a child having diarrhea have been shown by several large scale trials in India and Bangladesh. These trials have shown that Zinc supplemented children:

w more playful during the illness; are w recover faster; w have reduced amount of diarrheal stools; w have lesser chances of diarrhea lasting for >7 days; w have lesser chances of being hospitalized;

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Training for Medical Officers

w less frequently given unnecessary oral and injectable drugs, and cost of care is are
reduced;

w have lesser chances of getting diarrhea and pneumonia over the next 23 months; and w have substantially increased use of ORS when Zinc and ORS are promoted
together, as compared to ORS alone.

Benefits of 14 days course for Zinc

Zinc supplementation for 14 days has long term effects on childhood illness over the next 2-3 months after treatment with 34% reduction in diarrhea prevalence and 26% reduction in incidence of pneumonia. Zinc supplements should be given for a duration of 14 days, because zinc not only treats the diarrhea episode at hand, it also helps to repair the damaged gut mucosa, enhances overall immune function and protects the child from developing pneumonia and diarrhea in the next three months.

Without zinc

With zinc

Acute diarrhea

Persistent diarrhea

Studies have shown that Zinc treatment results in a 25% reduction in duration of acute diarrhea and a 40% reduction in treatment failure or death in persistent diarrhea.

Dose of Zinc in Childhood Diarrhea

w children aged 2 months up to 6 months, 10 mg of elemental Zinc per day, for For
14 days.

w children 6 months and older, 20 mg of elemental Zinc per day, for 14 days. For
Successful treatment of diarrhea with ORS and Zinc within the primary health care system requires:

w Families know that Zinc and ORS should be given in all episodes of diarrhea and
that these should be started as early as possible after onset of diarrheal episode.

w Families know where Zinc and ORS are available. w Zinc and ORS are available in health facilities and in the community at all times. w Zinc and ORS are accessible to all children especially to those belonging to the
poorest section of the population.

34 Childhood Diarrhea Management

Duration

Treatment Failure/Death

Zinc: Critical to diarrhea treatment, but largely unavailable in developing countries Zinc is critical for overall health, growth and development. It also supports proper functioning of the immune system. Though widely found in protein-rich and other food sources, zinc deficiency is widespread throughout the developing world and has been associated with higher rates of infectious diseases, including diarrhea, and deaths from these illnesses. Zinc stores are further depleted during diarrhea episodes, and supplementation as a part of treatment programs is critical for replenishing the bodys reserves, helping children to recover from illness and stay healthy afterwards. Clinical studies have shown that a 10-14 day treatment course with zinc effectively reduces the duration and severity of both persistent and acute diarrhea. Zinc has been associated with a 25% reduction in the duration of acute diarrhea, as well as a 40% reduction in treatment failure and death in persistent diarrhea. The recent introduction of zinc tablets into large scale diarrhea treatment programs in India, Mali and Pakistan suggests that it may be even more effective than clinical trial results indicate. Zinc appears to increase ORS intake and reduces inappropriate drug use with antibiotics and anti-diarrheal medications. Children receiving zinc tablets appeared to recover more quickly, had increased strength and appetites, and were less ill than other children in their communities. In fact, a Malian mother noted that her son had gained strength and energy unlike ever before, which echoed the sentiments of many other caregivers.
Sources: World Health Organization, Department of Child and Adolescent Health and Development (CAH), CAH Progress report highlights 2008, WHO, Geneva, 2009; Bhandari, N., et al., Effectiveness of zinc supplementation plus oral rehydration salts compared with oral rehydration salts alone as a treatment for acute diarrhea in a primary care setting: A cluster randomized trial, pediatrics, vol. 121, no. 5, 2008, pp. e1285; winch, p.l., et al., cluster-randomized program effectiveness study of community case management with zinc for childhood diarrhea in southern Mali, bulletin of the world health organization (in press); world health organization, department of child and adolescent health and development, CAH Meeting report: Consultation to review the results of the large effectiveness studies examining the addition of zinc to the current case management of diarrhea, India, Mali and Pakistan), 30-31 January 2008.

Compliance Card
The compliance cum information card is meant for the mother/ caregiver of the child suffering from diarrhea. This card contains some important information such as preparation and administration of ORS and zinc, right dosage and importance of zinc compliance for 14 days. It also acts as a reminder as it has 14 boxes showing zinc tablets against which mother/caregiver should tick every day after giving zinc to the child.

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2.11 The strategy of Jodi of new ORS and Zinc supplementation

The Jodi (Team) of ORS and Zinc works better and is more effective. Zinc appears to increase ORS intake and reduces inappropriate drug use with antibiotics and anti-diarrheal medications. Children receiving zinc tablets appeared to recover more quickly, had increased strength and appetites, and were less ill than other children in their communities.
3.7 gms

Oral Rehydration Salts

Contents of one sachet in 100 ml provide Sodium 45 mmol Potassium 10 mmol Chloride 40 mmol Bicarbonate 30 mmol Glucose 55 mmol

2.12 Prevention of diarrhea

Proper treatment of diarrheal diseases is highly effective in preventing death, but has no impact on the incidence of diarrhea. Health staff working in treatment facilities are well placed to teach family members and motivate them to adopt preventive measures. Mothers of children being treated for diarrhea are likely to be particularly receptive to such messages. To avoid overloading mothers with information, it is best to emphasize only one or two of the following points, selecting those most appropriate for the particular mother and child.

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

Improved feeding practices

Complementary foods should normally be started when a child is six months old. To encourage exclusive breast feeding and proper feeding practices, health workers should be instructed in the regular use of growth charts to monitor the weight of children. Before a child with diarrhea leaves a health facility, his or her weight should be taken and recorded on the child's growth chart.

Use of safe water

The risk of diarrhea can be reduced by using the cleanest available water and protecting it from contamination. Collect and store water in clean containers; empty and rinse out the containers every day; keep the storage container covered and not allow children or animals to drink from it; remove water with a long handled dipper that is kept especially for the purpose so that hands do not touch the water.

36 Childhood Diarrhea Management

Key Messages
w Proper assessment for dehydration and selection of appropriate treatment w w w w
Plan A, Plan B and Plan C is very essential. Giving ORS together with zinc makes diarrhea treatment more effective in comparison to the single intervention of ORS alone. For children aged six months or above, a dosage of 1 tablet (20 mg) is to be given daily for 14 days. For children between 2 and 6 months of age, a dosage of half a tablet (10 mg) is to be given daily for 14 days. Fluids like watery lentin, rice water or vegetables, khichri, butter milk, fresh fruit juice, lime water, coconut water and milk may be given to a child (above 6 months) during diarrhea.

Childhood Diarrhea Management 37

Training for Medical Officers

Session 3

Diarrhea Management Program: Design and Delivery

Time: 30 minutes Learning Objectives After the session, the participants will be able to: Understand the Revised National Diarrheal Control Policy, program and guidelines Understand the overall diarrhea control and management program implementation at the field level. Understand roles and responsibilities of different functionaries (MO/ANM/ PHN/LHV). Understand the importance and process of supply and logistics and storage. Identify the need to refer and when and where to refer and follow up.

3.1 Program design and roll out

Diarrheal Disease Control Program
You must be familiar with the management of diarrhea and use of ORT therapy. ORS was introduced in 1978 when the Diarrheal Disease Control Program was launched across the world including India. ORT has saved more than 50 million childrens lives over the last 25 years. In the 1980s, nearly five million children under five died each year from diarrhea in 2000, this figure dropped to 1.8 million. In 2008, diarrhea was estimated to have caused 1.336 million deaths in children under five, contributing to 15% of all deaths in this age group.

Revised National Diarrhea Control Policy (2007) and Guidelines

The revised diarrhea management guidelines including the use of zinc during diarrhea were elucidated in the Government of India policy released in 2007. In Uttar Pradesh guideline has been issued in August, 2011. Challenges in the introduction include lack of clarity in the implementation strategy, the roles and responsibilities of the various stakeholders, the absence of resource material and issues related to procurement and availability of supplies of Zinc and ORS packets.

Micronutrient Initiative
Micronutrient Initiative (MI) in collaboration with the Government of Uttar Pradesh is implementing the US fund for UNICEF supported project: Reducing Childhood Diarrhea through Sustainable Use of Zinc and Oral Rehydration Solution (ORS) in

38 Childhood Diarrhea Management

Uttar Pradesh. The project aims to increase the coverage of Zinc and ORS for the treatment of childhood diarrhea and improve compliance to the recommended course of treatment by the caregivers through public health service delivery channels in Uttar Pradesh.

Strategy for Implementation

Implementation of Revised Diarrhea Management Guidelines will require coordinated efforts of stakeholders at the state as well as district level. Implementation of the revised guidelines will require coordinated efforts of the various stakeholders, which include:

w Department of Health w Department of Women and Child Development

Revised Diarrhea Management Guidelines are to be implemented by the Department of RCH/IDSP/others, as decided by the state. The Director (RCH/Family Welfare) is responsible for implementation, supported by the Nodal Officer for Zinc and ORS who coordinates the day-to-day implementation. Secretary (Health) provides overall guidance and support. At the district level, the District RCHO/DIO/another officer will be responsible for implementation. The following sections describe the different steps in implementation in the order in which they are to be implemented.

3.2 What is required from the Systems (Health and WCD) and the Community for the management of diarrhea in children?
The state, district, block and sector level officials of Departments of Health and WCD are responsible for introduction and implementation of the new guidelines for the management of diarrhea in children. This includes:

w Training of health functionaries in the new diarrhea treatment guidelines. w Initiate and maintain a communication
campaign to create awareness in the community.

w Ensure availability of zinc and ORS at all the DHs,

CHCs, PHCs, SCs, AWCs and with the ASHAs all throughout the year.

w Monitor implementation of the revised

guidelines.

w Ensure reporting of information from the field

to the district and from district to the state level, review reports and take corrective action.
Childhood Diarrhea Management 39

Training for Medical Officers

w Carry out periodic reviews of the implementation at the PHC, CHC/Block, district
and state levels, take corrective measures as required.

w Coordinate with concerned departments (Department of Women and Child

Development (WCD), Panchayati Raj) and sensitize the leaders regarding the use of ORS and zinc in childhood diarrhea.

3.3 Provision of ORS and Zinc through different channels at various opportunities
Availability of ORS and Zinc tablets in the village to be ensured round the clock, through the following mechanisms:

w Stock at the AWC and the sub-center. w ASHA to always keep ORS and Zinc supplies at her home
vks-vkj-,l-

so that these are available even after the AWC closes.

Village depots of ORS and Zinc should be made at the sub-centers, AWCs and with the ASHA, and availability of ORS and Zinc should be ensured round the clock.

fT+kad

3.4 Roles of the MO in Childhood Diarrhea Management

Service Delivery Role
w Counsel mothers to start giving suitable home available fluids immediately upon
onset of diarrhea in her child.

w Give zinc tablets and ORS to all children

above two months of age having diarrhea as per the dose recommended.

w Counsel mothers on need for giving

zinc for 14 days and to give it even after diarrhea has stopped.

w Explain to the mother/caregiver how

much zinc is to be given and how the tablet is to be administered, ask the mother to demonstrate dissolving zinc tablet and administer it to her child.

w Give 2 packets of ORS and explain to

the mother/caregiver how to prepare and administer. Ask her to prepare ORS solution with 1 litre of water. Teach mother how much ORS to give and to fetch more packets when these finish.

40 Childhood Diarrhea Management

w Use antibiotics only when appropriate, i.e. in the case of bloody diarrhea, and
abstain from administering anti-diarrheal drugs.

w Emphasize continued complementary feeding or increased breast feeding during,

and increased feeding after the diarrheal episode.

w Teach caregivers how to recognise danger signs for seeking care immediately.

Administrative and Supervisory Role

w Stock management of Zinc and ORS. w Logistics planning and ensuring timeliness of delivery. w Field visits to support and cross-check operations
and any problems functionaries are facing.

w Monthly meeting for stock taking and problem

solving for workforce.

w Ensuring the communication material and

activities are available and properly utilized.

w Records and reports are properly maintained and

updated.

Managerial and Leadership Role

w Proactive role with functionaries and
communities.

w Motivation, Empathy and Recognition for good

work and efforts.

w Planning and execution. w Building the image and value of the functionaries in the eyes of the families and
communities.

w Building the capacity and morale of the workers. w Building the image and reputation of the workers and the system.
The role of the Medical Officer and Senior Health functionaries is very crucial and critical for the success of the childhood diarrhea control and management.

Childhood Diarrhea Management 41

Training for Medical Officers

Roles and Responsibilities of Health and ICDS functionaries

Medical Officers ANM Pharmacist

w w w w w w w w w w

As a Service provider Assessment Treatment planning Coordination with other departments Coordination with NGOs Monitoring Training /orientation Monthly review meeting Stock and supply maintenance Morale and motivation of staff Leadership role for facility area

As a Service provider Assessment Treatment Referral Supportive supervision of ASHA and AWW Stocking ORS and Zinc and distributing to ASHA & AWW Compilation of ASHA & AWW reports Participate in review meetings

w w w w w

Counseling of caregiver Support in reporting OP/IP cases ORS and Zinc stock indenting and record keeping Supply of stock to OPD, IPD and ANMs Participate in review meetings

w w w w

CDPO

Anganwadi Supervisor

AWW

w w w w w w w w

Supportive supervision of AWW and AWS Stock and supply maintenance Coordination with other departments Coordination with NGOs planning Monitoring Training/ orientation Consolidate and analyze reports of the Anganwadis and provide feedback

w w w w

Supportive supervision of AWW Stock and supply maintenance Monitoring Training/ orientation of AWW Consolidate and analyze reports of the Anganwadis and provide feedback

w w

Community mobilization Service provision Assessment Treatment Referral Depot holder for ORS, Zinc Recording and Reporting House hold visit

w w w

BHEO

ASHA

w w w w

Supportive supervision of ANM, ASHA and AWW Planning support to MOIC Implementation support to MOIC Support MOIC in Block-level review meetings

w w

Community mobilization Service provision Assessment Treatment Referral Depot holder for ORS, Zinc Recording and Reporting House hold visit

w w w

42 Childhood Diarrhea Management

3.5 Demand and Supply Estimation

Maintaining Stock
w stock of ORS and zinc tablets must be entered into the Stock Register at the The
various levels of district, PHC, CHC, sub-centre, AWW and ASHA. The same stock should also be entered into the computer wherever the software has been made available (for instance, at the PHC and CHC levels)

Supply Chain
Supply

District Health Society/ Chief Medical Officer

Medical Officer/ Primary Health Center

Health Sub-Center/ANM

ASHA

Anganwadi Worker

Key Messages
w Medical Officers have an important role in child diarrhea management. For
this, they must perform their roles proactively. w Primary Health care Centers and sub-centers would act as depot of ORS and zinc packets. Stocks of ORS and zinc should be available 24 hours a day with them. w Medical Officer's role is not only in service provision but also in project management, supportive supervision and community engagement. w PHCs/Anganwadi Centers and sub-centers should register the receipt of ORS and zinc supplies in the Stock Register with them.

Childhood Diarrhea Management 43