Diarrhoea is the passage of loose or watery stools, usually at least three times in a 24-hour period. However, it is the consistency of the stools rather than the number that is most important.
Four clinical types of diarrhoea can be recognized:
* Acute watery diarrhoea (including cholera): This lasts several hours or days, the main danger is dehydration, weight loss also occurs if feeding is not continued.
* Acute bloody diarrhoea: This is also called dysentery, the main dangers are intestinal damage, sepsis and malnutrition; other complications, including dehydration, may also occur.
* Persistent diarrhoea: This lasts 14 days or longer, the main danger is malnutrition and serious non-intestinal infection; dehydration may also occur.
* Diarrhoea with severe malnutrition: the main dangers are severe systemic infection, dehydration, heart failure and vitamin and mineral deficiency.
During diarrhoea there is an increased loss of water and electrolytes (sodium, chloride, potassium, and bicarbonate) in the liquid 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 diarrhoea 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 diarrhoea of any aetiology.
Two main dangers of diarrhoea are death and malnutrition. Death from acute diarrhoea is most often caused by loss of a large amount of water and salt from the body. This loss is called dehydration. Dysentery is another important cause of death related to diarrhoea. Diarrhoea is worse in children with malnutrition. Diarrhoea can cause malnutrition and can make it worse because:
- Nutrients are lost from the body in diarrhoea,
- It may develop loss of appetite
- Mothers may not feed children during diarrhoea, or even for some days after the diarrhoea is better.
To reduce this malnutrition, additional foods should be given to children as soon as dehydration has been corrected.
The body normally takes in the water and salts it needs (input) through drinks and food. It normally loses water and salts (output) through stool, urine and sweat.
When the bowel is healthy, water and salts pass from the bowel into the blood. When there is diarrhoea, the bowel does not work normally. Less water and salts pass into the blood, and more pass from the blood into the bowel. Thus, more than the normal amount of water and salts are passed to the stool.
This larger than normal loss of water and salts from the body results in dehydration. It occurs when the output of water and salts is greater than the input. The more diarrhoea stools a child passes, the more water and salts he/she loses. Dehydration can also be caused by a lot of vomiting, which often accompanies diarrhoea.
The most important parts of treatment of diarrhoea are:
- Prevent dehydration from occurring if possible
- Treat dehydration quickly if it does occur
- Give zinc supplements for 10/14 days, depending on the availability of supplies and national policy to reduce the severity of the episode and to reduce the incidence of diarrhoea episodes in the following 2 to 3 months, and
- Feed the child.
Prevention of dehydration:
In the home, dehydration can usually be prevented by drinking more fluids as soon as the diarrhoea starts. To do this, give the recommended home fluids or give available food-based fluids, such as gruel, soup or rice-water. Also increase the frequency of breastfeeding, or give milk feeds prepared with twice the usual amount of water. The types of fluid or solutions used in your area for preventing dehydration in the home will depend on:
- local traditions for treatment of diarrhoea,
- availability of a suitable food-based solution,
- availability of salt and sugar,
- access of people to health services, and
- availability of oral rehydration salts (ORS)
Treatment of dehydration:
If dehydration occurs, the child should be brought to a community health worker or health centre for treatment. The best treatment for dehydration is oral therapy with a solution made with ORS. This treatment for children is also good for adults with diarrhoea. For treating dehydration, ORS should always be used, if possible.
Zinc supplementation:
It has been shown that zinc supplements given during an episode of diarrhoea reduce the duration and severity of the episode, and lower the incidence of diarrhoea in the following 2–3 months. For these reasons, all patients with diarrhoea should be given zinc supplements as soon as possible after the diarrhoea has started.
Feeding:
The child should be offered small amounts of nutritious, easily digestible food frequently. If the child is breastfed, try to increase the frequency and duration of feeds. Feeding during the diarrhoea episode provides nutrients the child needs to be strong and grow, and prevents weight loss during diarrhoea. Fluids given to the child do not replace the need for food. After the diarrhoea has stopped, an extra meal each day for a week will help the child regain weight loss during the illness.
An important development has been the discovery that dehydration from acute diarrhoea of any etiology and at any age, except when it is severe, can be safely and effectively treated by the simple method of oral rehydration using a single fluid. Glucose and several salts in a mixture known as Oral Rehydration Salts (ORS) are dissolved in water to form ORS solution. After 20 years of research, an improved ORS solution has been developed.
ORT is the giving of fluid by mouth to prevent and/or correct the dehydration that is a result of diarrhoea. As soon as diarrhoea begins, treatment using home remedies to prevent dehydration must be started with Oral Rehydration Salts (ORS).
ORT does not stop the diarrhoea, but it replaces the lost fluids and essential salts thus preventing or treating dehydration and reducing the danger. The glucose contained in ORS solution enables the intestine to absorb the fluid and the salts more efficiently
The benefits of fluid replacement in diarrhoea far outweigh the risks of using contaminated water to make oral rehydration solution. In situations where it is difficult to boil water, mothers are advised to use the cleanest water possible.
ORS is safe and can be used to treat anyone suffering from diarrhoea, without having to make a detailed diagnosis before the solution is given. Adult need rehydration treatment as much as children, although children must always be treated immediately because they become dehydrated more quickly.
Mothers must be taught to persist in giving ORS solution, even though this requires time and patience. They should give regular, small sips of fluid. Giving ORT reduces nausea and vomiting and restores the appetite through correction of acidosis and potassium losses.
Once the diarrhoea episode has passed, the child should be given more food than usual to make up for losses during diarrhoea. Breastfeeding is particularly beneficial because breast milk is easily digestible. It also contains protective substances which help to overcome the infection causing the diarrhoea.
High energy foods such as fats, yogurt and cereals are quite well absorbed during diarrhoea. Small, frequent feeds of energy-rich local foods familiar to the child should be given.
- Foods high in potassium are important to restore the body's essential stores depleted during diarrhoea. Such foods include lentils, bananas, mangoes, pineapples, pawpaw, coconut milk and citrus fruits.
-It is very important to continue feeding a person with diarrhoea. Give soft, easy-to-digest foods, like khichuri, watery dal, curd, bananas etc.
-You should also give plenty of other fluids, like lebu pani, lassi, coconut water etc. If the baby is being breast-fed, continue to give her mother's milk.
- Give an extra meal a day, after the diarrhoea stops, to help the body get strong again.
Certain foods should be avoided during diarrhoea, for example those containing a lot of fibre such as coarse fruits and vegetables, whole grain cereals and spicy foods.
In most cases, no. The diarrhoea will get all right by itself in a day or two. If there is any blood or mucous in the stools, any fever or vomiting, you must see the doctor immediately. Don't take any medicines yourself, It is important to follow the doctor's advice.
ORT on its own is usually enough to rehydrate the child. Unnecessary antibiotic therapy upsets the normal bacteriological balance of the intestine.
No. They are not the same thing at all. The complete formula ORS contains potassium and a base - either bicarbonate or citrate - which corrects acidosis which small infants in particular suffer when they are dehydrated. If a child is rehydrated with a solution containing no potassium, each successive attack of diarrhoea leaves the child more and more depleted of potassium - this results in fatigue, apathy and muscular weakness and finally such a child may die.
Fortunately to some extent yes. However, mothers need to be taught and motivated how to modify a child's normal diet to include these foods for several weeks after an attack of diarrhoea or more or less permanently in fact in order to have much of an effect.
Firstly, prevention including the following measures should be taken:
- breastfeeding
- environmental sanitation
- personal hygiene
- clean drinking water
- clean preparation and storage of food
- insect and fly control
Secondly, maintaining or increasing food and fluid intake during and after an attack of diarrhoea should be ensured.
Zinc is classified as an essential mineral. It is essential to over 180 biologic functions. Many foods rich in trace minerals contain zinc, with the highest amounts in meat products. Lesser amounts are found in milk, spinach, nuts, oats, rice and beans.
Many experts say that zinc deficiency is widespread. People living in poverty with diets low in zinc, especially children below five years of age, need zinc the most. Deficiencies result in poor wound healing because of zinc's role in cellular repair. Zinc deficiency also leads to slower growth. Most importantly, children with low levels of zinc are at increased risk for infection, severe infections and death.
Zinc is prescribed to treat and prevent diarrhoea for children < 5 years of age.
Yes, zinc and ORS can be given at the same time when a child has diarrhoea. Zinc is given once a day. Give the zinc at a time of day that is easy for you to remember and repeat every day for 10-14 days. ORS needs to be given throughout the day only as long as your child has loose or watery stools, but zinc should be given for the entire 10 to 14 days.
During diarrhoea ORS should be given first and followed by zinc. If it is the first time the child has received zinc, it is best to wait 30 minutes after the ORS is given.
Usually children with severe dehydration are given intravenous fluids first. After the intravenous fluid is no longer needed and the child is not vomiting, ORS and zinc should be started.
The zinc tablet is meant to be dissolved in water, breast milk, or ORS.. Other fluids are not recommended.
No, you should continue to give plenty of ORS, as recommended, even though you are giving zinc. ORS will help to replace fluids lost during diarrhoea. Zinc will speed up recovery but does not replace fluids.
The earlier that zinc is administered, the sooner the child will benefit. However, it can be started at any time during the illness.
Zinc treatment is recommended for the complete dosing regimen of 10 to 14 days because zinc not only decreases the number of days with diarrhoea and the severity of diarrhoea, it helps the child fight off new episodes of diarrhoea and pneumonia for the next 3 months following a full treatment.
Studies have included 10 or 14 days of treatment. Both have been proven to be equally effective.
Yes, all episodes of diarrhoea should be treated with zinc. Even if a child has recently completed a full course of zinc treatment, it is still safe to give a second course. Children with persistant, repeated episodes of diarrhoea should be taken to a clinic or hospital.
It is clear that zinc is vital for a wide range of biological functions. In diarrhoea we have come to know that zinc helps in the following ways:
- It boosts the immune system
- It helps in healing the intestinal lining
- It improves absorption of fluids
The zinc treatment is given according to age, not weight. Irrespective of the child's weight, the recommended dose of zinc for children 6 months to 5 years is 20 mg zinc once daily for 10 consecutive days. Children 2 to 6 months are prescribed 10 mg/day.
Yes, it can be chewed. Chewing is not the recommended mode of delivery, but is acceptable.
Give the zinc tablet the next day and continue for the full course of 10 days.
The current recommendation is to provide zinc treatment to all children < 5 years of age. However, diarrhoea among newborns is rare and may be a sign of sepsis or severe disease so care should be sought.
Zinc can be given to anybody, but WHO/UNICEF recommendations are limited to children under five years of age.
No. Parents should be advised to only purchase zinc products that you know to be safe and of high quality.
Yes, children should continue to be fed. Allow the child to take as much as they want. If vomiting occurs, the smaller, more frequent feeds are recommended.
Yes, zinc can be given with other medications. However, if a child is receiving iron supplement, it is recommended this be stopped while on the zinc treatment because the iron will decrease the effect of zinc.
Yes, multivitamins without iron can be continued. If the multivitamin contains iron, it should be stopped until the 10-14 days of zinc is finished.
During the 10-day period of zinc treatment, the child should stop taking the iron supplements. If the child is being treated for severe anemia, he/she should be seen by a doctor (or nurse where no doctor is available) before deciding to continue or stop iron supplementation.
Zinc fortified foods contain low amounts of zinc in line with recommended daily requirements. Adding the zinc treatment is safe and highly recommended. There is no risk of overdosing.
Do not stop the zinc. The child should be taken to a local clinic or a community health worker for further assessment.
Zinc tablets are preferred over syrup for the following reasons: -
- Easier distribution and storage
- Lower cost
- Easier for caretakers to administer properly as well as count the number of days given
-Longer shelf-life
The ingredients in zinc tablet include zinc sulphate, glucose and flavoring.
At the dose being provided in the zinc tablet, there is a small increased chance of transient nausea or vomiting. If the child is vomiting, we recommend settling the child first before administering zinc.
You should keep the tablets away from all children in the home to prevent this from happening. If more than one tablet is taken, wait until the next day a resume to course of one tablet per day until the blister pack is finished.
When a child is vomiting with diarrhoea, wait for the child to settle before giving zinc. If the child vomits repeatedly withhold zinc for that day and start from the next day.
