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close this bookGuidelines for Training Community Health Workers in Nutrition (WHO, 1986, 128 p.)
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After studying this chapter, taking part in the discussions, and doing the exercises, a community health worker should be able to:

· Explain the causes and dangers of diarrhoea to mothers.

· Detect children who have lost much water and salts through their stools (dehydration) and advise the mothers about what is to be done.

· Advise mothers about feeding during and after diarrhoea.

· Explain to a mother how the common infections in children make them malnourished, and again how infection is worse and more frequent in malnourished children.

· Advise mothers about feeding during common infections of children.

· Help to control infectious disease by taking part in local immunization programmes.


What is diarrhoea?

Diarrhoea is a condition in which stools are passed more frequently and are looser or more watery than is usual for the person. People vary in the type of stools they pass, and in how often they pass them, but as a general guide, three or more loose or watery stools in a day can be considered as diarrhoea. Frequent passing of normal stools is not diarrhoea. Breast-fed babies often have stools that are very soft, but this too is not diarrhoea.

A mother usually knows when her child has diarrhoea. When diarrhoea occurs, mothers may say that their children's stools smell strongly or pass noisily, as well as being loose or watery. By talking to mothers, a useful local definition of diarrhoea can often be found.

Diarrhoea is most common between 6 months and 3 years of age. It is also common in babies less than 6 months old who are drinking cow's (or another animal's) milk or infant feeding formulas.

Diarrhoea is an illness that requires immediate care. It should never be neglected.

Why is diarrhoea dangerous?

The two main dangers of diarrhoea are death and malnutrition.

Death from diarrhoea is usually caused by the loss of large amounts of water and salts from the body in the frequent watery stools. This is called dehydration (see the section on dehydration below). Small children with severe diarrhoea lose water and salts rapidly and can die quickly, sometimes within a few hours. Many children with diarrhoea recover by themselves, but they become weak.

Malnutrition can be caused by diarrhoea because food passes too quickly through the body and therefore cannot be absorbed properly. Moreover, a person with diarrhoea usually feels too ill to be hungry and so does not eat. Adults suffering from diarrhoea are often afraid to eat because they think that eating will make their diarrhoea worse. Diarrhoea is more severe and more common in people who are already suffering from malnutrition.

In many communities it is a common practice to starve children when they have diarrhoea. Sometimes, even breast-feeding is stopped. This is wrong because it causes malnutrition, which will make the child have diarrhoea more frequently. To prevent malnutrition in children with diarrhoea it is important to give them correct treatment and proper nutrition.

What causes diarrhoea?

Diarrhoea is caused by an infection of the bowel by very small germs or organisms that cannot be seen by the naked eye. They enter the mouth and then the bowel through dirty hands, dirty food, dirty milk, dirty water, dirty feeding bottles, dirty cooking pots and feeding vessels, and so on. Some of them are also passed out in the stools. When other people come into contact with these germs, because of lack of cleanliness, the infection spreads.

What causes dehydration?

The body takes in water and salts from drinks and food. When the bowel is healthy, the water and salts pass from the bowel into the blood and are then carried to all parts of the body to be used. The water and salts that the body does not need are passed out through stools, urine, and sweat. Water and salts may also be lost by vomiting.

When there is diarrhoea, the intestines do not work normally and the water and salts pass into the blood very slowly or not at all. As a result, the body does not take up as much salt and water as it needs to replace what it is losing, and more than the normal amounts are passed in the stools. Thus, the body is drained of water, salts, and nutrients; this is dehydration. Diarrhoea may sometimes be accompanied by vomiting, which increases the rate of dehydration.

The worse the diarrhoea, the more water and salts a person loses and the more he is dehydrated. A lot of vomiting and sweating can also cause dehydration. Dehydration occurs faster in hot climates and when there is fever.

Detecting children who have lost much water and salt from diarrhoea (cases of dehydration )

All children with diarrhoea are in danger. Many children recover, but some become seriously ill. How can the community health worker identify the children who need urgent care? Four things they should do are: ask, look, feel, and weigh. The signs of mild or severe dehydration and ways of detecting them are summarized in Table 4.

It is important to know if a child is only mildly ill or seriously ill because this affects the action you should take. A child who has mild diarrhoea can be treated at home, but a child who has severe diarrhoea, dehydration, and complications should be sent to the nearest health centre for special treatment.

Deciding which children need special treatment

Special treatment is required by children with diarrhoea if they:

· Have severe dehydration
· Have other diseases and complications of diarrhoea
· Do not improve with the treatment described in the section below.

The community health worker should be able to recognize such children, and should send them as soon as possible to a supervisor, health centre, or hospital.

· Dehydration is dangerous in diarrhoea.
· Dehydration is caused by loss of water and salts from the body
· Save a child with diarrhoea by rehydration.

What is rehydration?

The easiest way to save the life of a child with diarrhoea and dehydration is to replace the lost water and salts by giving him a solution of water and salts by mouth. This is called rehydration. This can be done by adding clean water to a specially prepared mixture of salts available as a powder in sealed packets. Salt and glucose are the two main ingredients of this mixture. This salt mixture is known as Oral Rehydration Salts (ORS). Mix the contents of one standard packet of oral rebydration salts in one litre of clean drinking-water and stir to make a solution. This is commonly known as oral rehydration solution.

When packets of oral rehydration salts are not available, a rehydration solution can be made at home. The community health workers should be taught how to make such a solution. This is not always simple because it is important that the amounts of sugar, salt, and water are correct. As a general rule, 40 g of ordinary sugar and 4-5 g of common salt should be mixed in 1 litre of clean drinking-water. It is extremely important to mix the sugar, salt, and water in the correct proportions.

How to give the solution to the child

The prepared solution should be kept in a cool place and kept covered to protect it from flies and dust. Use the fluid on the day it is prepared. Throw away any fluid that was prepared the day before.

Small amounts of the fluid should be given to the child every few minutes. The best way is to give 2-3 small spoonfuls from a cup, wait 2-3 minutes, then give some more, ln this way, the child is less likely to vomit. If he does vomit, wait 5 10 minutes, then give some more. Vomiting is not a reason to stop giving the solution, unless it is severe and frequent. In that case' the child should be taken to the nearest health centre.

For detailed instructions about how to make the solution, how much to give and how to give it, the trainer should consult the guidelines prepared by WHO.:

Table 4: Feeding during and after diarrhoea

Many people think that all foods should be avoided during diarrhoea, because foods will make the diarrhoea worse. This is wrong. Foods are needed to replace what is lost during diarrhoea.

If a child with diarrhoea is on breast milk, the mother should continue to breast-feed him. Breast milk is safe, clean, and nourishing. Breast milk should be given between drinks of oral rehydration solution.

Never stop breast-feeding during diarrhoea.

If the child is on cow's milk or artificial formula, the feeds should be diluted to half-strength with clean water. Such feeds should be given between drinks of oral rehydration solution. Full-strength milk should be started again when diarrhoea stops.

If the child normally takes solid food, he should be given soft, easily digestible foods (porridge, etc.) during diarrhoea. Small frequent meals should be given between drinks of oral rehydration solution. Feeding a child who is ill requires extra patience, time, and care.

After recovery from diarrhoea, extra food should be given. Try to give a little more than the child normally eats. Small feeds in between the main meals is also a good approach.

How to involve parents and other members of the family in the treatment of a child with diarrhoea

Explain to the parents and other members of the family in simple words what diarrhoea is and how it can be treated. Tell them how you are examining the child and what are the signs of dehydration. Show them how to prepare the rehydration fluid and ask for their help in its preparation. Once the solution is ready, taste it yourself and ask the parents to taste it also. They should notice that it is not as salty as tears.

Some mothers may fear that giving fluids may make the diarrhoea worse. Reassure them and explain that the water lost from the body should be replaced. If this is not done the child's life may be in danger.

Encourage the mother to use a cup and a spoon to feed the solution to her child. Teach the parents everything they need to do to care for a child with diarrhoea; a flip-chart may be useful for this.

Provide the mother with packets of Oral Rehydration Salts. If the diarrhoea is severe and the home is far away, give the mother more than one packet. She should use these until her child is completely well or until he is seen by you again. Advise the mother to bring the child back if his condition gets worse, if vomiting becomes severe, or if he cannot drink. If possible, the mother should always bring the child back the next day. This is to make sure that the child is getting better and to repeat the teaching about rehydration, feeding and prevention of diarrhoea.

Explain to the parents the importance of feeding during diarrhoea. Only when they see that giving properly selected foods does not worsen diarrhoea, they will be convinced.

How to prevent diarrhoea

Breast-feeding protects against diarrhoea and other infections. It also provides excellent nutrition. Do not bottle-feed. Bottles are difficult to clean and germs grow easily in the artificial milk formulas. Diarrhoea is common in bottle-fed children.

Breast-feeding is the best way to prevent diarrhoea in infants.

Diarrhoea germs come from stools. If stools are passed where people cannot come into contact with them, the germs will not spread to others. Latrines should be built, used, and kept clean.

Dirty hands cause diarrhoea. Wash hands with soap and water before feeding a child, preparing and serving food, and after passing stools. Fingernails should be kept clean.

Stale food can cause diarrhoea. Freshly cooked food is clean. Preserve food by covering it completely and keeping it cool. Food prepared early in the day or the day before may be contaminated by germs. It should be cooked again before being given to children.

Dirty water can cause diarrhoea. Water for drinking must be clean and should be kept in a special pot with a cover. Never put hands in drinking-water. Drinking-water for small children should be boiled.

Flies can carry the germs of diarrhoea. Flies settle on stools, pick up germs and then settle on food. Cover food to protect it from flies. If children pass stools near the house, the stools should be removed and covered with earth.

Keep the house and surroundings clean and there will be few flies.

Infectious diseases and the body's defence against them

Many diseases are spread by germs which can cause infection. Germs are very small creatures that cannot be seen with the naked eye. Germs are around us everywhere-in the air, in water, and on nearly everything we touch, even on our skin. Some germs are harmless, but others are harmful and cause disease.

Dangerous germs can pass from one person to another in different ways. If someone has a disease in his chest or throat, he coughs. When he coughs, germs go into the air. If someone else breathes them in, he may also develop the same disease. Tuberculosis and measles are passed on in this way. If someone has diarrhoea he may pass many germs or parasites in his stools. If the stool comes into contact with water, the water becomes dirty, and when someone drinks this dirty water he may also get diarrhoea. The diseases that are passed from person to person are called "infectious diseases" (they are sometimes called "communicable diseases").

The body can fight infections in many ways. The skin keeps out many germs, and fluids from the nose and throat catch and kill many others. The digestive juices kill many germs that are swallowed. There are also very special mechanisms that work against specific germs. For example, if a child suffers from measles and recovers, he will never get measles again. During the illness the body has made a substance that kills measles germs; this remains in the body and if, later in life, measles germs attack again, the special substance will kill them. This person is protected and is said to be "immune to" or "immunized against" measles. In childhood everyone has many infections. While overcoming the infection we become immunized and protected against attack by the same germs in the future. Unfortunately, in the case of colds and diarrhoea, for example, one attack does not give a life-time protection. People, and especially children, can have repeated attacks of diarrhoea.

How infectious diseases affect nutrition

Measles, for example, is an infectious disease that attacks children mainly when they are between 9 months and 5 years of age. In some countries it is an important cause of death among young children. Measles germs travel through the air from a child who has the disease to another child who is not protected against measles. Some children become very ill with fever, rash, sore mouths, bad cough, fast and difficult breathing, diarrhoea, and sometimes unconsciousness. Usually the fever becomes less some days after the rash appears, and the child gradually recovers. During recovery the rash disappears. Sometimes the top layer of the skin peels off in small flakes. Measles is a common cause of malnutrition. The fever and illness make the child lose his appetite, and he also refuses food because his mouth is sore. During fever the child uses more energy than normal, but because little food is being taken in, the body has to use up its own tissue (food stores) for energy. A number of children with measles also develop diarrhoea. In some countries people believe that it is harmful and wrong to feed a child who has measles and so children may be starved for days or weeks. It is not surprising, therefore, that many children with measles lose a lot of weight and become malnourished. This can be clearly seen on the growth charts of children who have had measles. Many children die because of the combined effects of measles and malnutrition.

The body needs more energy in fever.

Fig. 36 illustrates how infection increases malnutrition at the same time as the malnutrition makes the infection worse. To this circle of illness, it is necessary both conditions; treating only one gives poor results.

There are many infectious diseases break to treat of them where a good diet is as important as medicine. Malaria, tuberculosis and whooping cough are some examples.

Malnourished children get more infections which are more severe and last longer.

Dietary management in infectious diseases

As in diarrhoea and measles, a good diet is essential for restoring the health of the child. Most often, a sick child is starved, because the parents think that foods will make the condition worse.

Fig. 36. The circle of infection and malnutrition

Proper diet is the best general measure in all infectious diseases

In most infectious diseases, proper diet is the best treatment. It may not be easy to feed the child at first, because the child may have a sore mouth and no appetite. The parents and other relatives taking care of the child will also need to be gently persuaded to help feed the child. Cooked cereals of soft consistency, peas and beans cooked well, potatoes, carrots and non-fibrous vegetables well cooked, oils or butter, and milk if possible, are suitable foods. As a rule a small quantity of food should be given often. Firm persuasion and much patience may be needed to feed the child. However, this is very worthwhile, because correct feeding is the best way to help him overcome the disease.

Give plenty to drink. Apart from food, an adequate fluid intake is important. This is particularly necessary for a child with fever who sweats a lot. The importance of fluids in diarrhoea has been described earlier. Other general treatments attempt to relieve discomfort and bring down fever. Half a tablet of aspirin or paracetamol given with food and fluid four times a day is helpful in bringing down fever in small children. Appetite returns with the lowering of body temperature.

The treatment of any infection is not complete until the patient begins to eat normally. The best measure of nutrition during and after an illness is the weight of the child. Nutritional improvement is shown in two ways:

· The child's weight should be more than it was before illness, and
· The growth line on the chart should be going upwards.

Until there are these signs of nutritional recovery, the child should receive extra food. This food can be an extra meal each day or an extra helping at each meal or small feeds in between meals. This is an essential part of the treatment. Proper feeding is as important as gilding any medicine, and it is more important than giving any health tonic.

Prevention of infectious diseases

Most common and serious infectious diseases can be prevented. There are two main ways of doing so:

· By decreasing the chances of individuals or the community coming into contact with the germs or parasites

· By improving the defences of individuals so that, if they are infected, the germs cannot cause disease.

The first method is really improving the environment, or the area in which people live. For example, if everyone uses latrines, has plenty of water to wash with, and throws rubbish away in a protected pit, the environment will be clean, then there will be little chance of getting germs from someone with diarrhoea, for instance.

The defences of an individual against infections can be improved in a general way or in specific ways. A better state of nutrition means that a child's defences can function fully against any infections. This is a general improvement.

Good nutrition means good defence against infections.

An improvement of the defences against specific infections can be achieved by immunization. It was explained on page 105 how a child who has had measles once becomes protected against the disease by a special substance that his body makes. This is called "natural immunization". It is also possible to produce "artificial immunization". This is done by injecting "weakened" germs into the body. These germs attack the body but are not strong enough to produce the signs of the disease. However, they do cause the body to produce the special substance that kills the disease germs and thus protects the body from future attacks. A substance which can produce specific artificial immunization is called a "vaccine". There are a number of valuable vaccines which can immunize and protect against infections.

Breast milk contains protective substances against the germs that cause diarrhoea and some other infections.

Breast milk increases the body's defence against infections.

Immunization programmes and use of vaccines

There are a number of vaccines that can give immunity against diseases. These are very valuable in protecting children against dangerous diseases of childhood. The vaccines are made and given in different ways and have to be given at about the right age for the best effect. Immunization also needs to be repeated at certain intervals.

There are six important and common diseases for which there are vaccines. These diseases are: measles, tuberculosis, whooping cough, diphtheria, tetanus, and poliomyelitis. The vaccines are given in a particular order, at specific ages and are repeated at appropriate intervals of time. The vaccine schedule may differ slightly from one country to another. Not all countries are able to offer every vaccination in their programmes yet. Although immunization schedules vary from country to country, this one is typical in the developing world:

· For tuberculosis, immunize with BCG at birth

· For poliomyelitis, immunize from 6 weeks of age: 3 doses at 4-week intervals

· For DPT (diphtheria, pertusis and tetanus), immunize from 6 weeks of age: 3 doses at 4-week intervals

· For measles, immunize from 9 months of age

· For tetanus, immunize pregnant women and women of child-bearing age to protect the newborn from neonatal tetanus: 2 doses.

The trainer should first find out the dosage and time-schedule being followed in the national immunization programme.

The importance of the community health worker in the immunization programme

The community health worker has great responsibility in an immunization programme. Its success depends very much on her. She is the person who has to persuade the people that immunizations are worth while. Whenever she finds that the growth line on the growth chart of a child has come down after an infection, she should try to convince the mother regarding the advantages of immunization.

First, she has to explain the importance of the programme to the community and convince the community leaders in particular. With their help, she must identify all the children of the right age for vaccination and convince their parents of the need to have the children vaccinated. The willing participation of the parents and leaders is important, because the community health worker will need help to get the children to the vaccination centre at the right time on the right day, and to bring them back again for their second and third vaccinations at the correct intervals.

Communities benefit from immunization programmes in two ways. First, immunizations prevent both infection and malnutrition. Secondly, the programme gives an opportunity to the community to participate collectively in its own health care.

· Start the vaccinations early in the first year.
· Try and complete the series of injections.
· Make sure the malnourished children are vaccinated, they are a priority group.


1. Lecture: Training content.

2. Demonstration and practical work: Preparing oral rehydration fluid with various household measures.

3. Group discussion: Common feeding practices in the community during diarrhoea and infectious diseases.

4. Role-playing: Advising mothers about immunization and use of oral fluid in diarrhoea.


Exercise 1. Growth charts of children with diarrhoea

Ask the trainees to visit a community and bring back some growth charts of 5-10 children who have had diarrhoea, or ask them to draw such charts themselves. They should note what happened to the children's weights when they had diarrhoea and discuss the reasons why the weights dropped. They should consider what can be done to improve the situation in the families concerned.

Exercise 2. The litre and household measures

It is important that each standard packet containing 27.5 9 of Oral Rehydration Salts should be mixed into 1 litre of water-not less than a litre nor much more than a litre. But it is not easy to judge how much water makes 1 litre when it is poured into household vessels of different shapes and sizes. Also, it is difficult to know what amount of salt or sugar weighs a given number of grams. This exercise will give community health workers practice in judging quantities. They should do this exercise while they are training and repeat it often when they are working on their own in the community.

Obtain a measuring vessel on which an exact 1-litre quantity is marked. See which local vessels hold 1 litre by pouring water from them into the 1-litre measure until the level reaches the 1-litre mark. Pour a measured litre into the household vessels and place a mark on them at the level the water reaches. Trainees can have competitions to see who can guess which local vessels most nearly hold 1 litre. They can also guess the level at which the 1-litre mark should be placed on those vessels.

Provide the trainees with an accurate weighing balance, salt and sugar in the form used locally, and a number of locally available small containers (large and small spoons, bottle caps, cups, etc.). Let them practice weighing given quantities of salt and sugar and ask them to find out what weight of each the containers will hold.

Use smaller vessels for smaller packets!

The standard packets used in some countries may contain a smaller quantity of oral rehydration salts that is meant to be diluted in less than 1 litre of water. For example, some countries use smaller packets that should be diluted ¾ in litre or ½ litre of water. In these countries, use smaller vessels for this exercise.


· It is dangerous to use a solution in which the concentration of salts is too strong.
· It is safer to use a solution which is more dilute.

Exercise 3. Role-playing

There are many suitable variations. The trainees can make up some from their own experience of difficult situations. Here are some examples of difficult situations that can be used in role-playing.

(1) A mother does not want to give her child oral rehydration solution because he has vomited.

(2) The grandmother of a child says that the mother should not breast-feed the child because he cannot digest the milk when he has diarrhoea.

(3) The parents of a child with diarrhoea come asking for an injection to make the child better.

(4) A man has built a latrine for his family. His neighbour laughs at him. The child of the family with the latrine is healthy but the child of the neighbour gets diarrhoea.

Exercise 4. Gaining experience in diagnosing and managing diarrhoea

In order to gain experience in diagnosing and managing diarrhoea it will be useful for the trainees and the supervisor to visit a clinic where many cases are seen daily.

The supervisor will demonstrate the signs of dehydration in a child with diarrhoea. The trainees should look for these signs in other children attending the clinic and practice observing children with diarrhoea.

Exercise 5. Local beliefs and practices regarding diarrhoea

During field training, each trainee should each visit 2 or 3 families and inquire about their beliefs about diarrhoea, factors which influence the condition, and how they manage it at home. The trainees should also note the families' reactions to the recommendations about treating diarrhoea by oral rehydration. All the trainees can then share their experiences and discuss how to make oral therapy acceptable in the community.

Exercise 6. Observing the feeding practices during infectious diseases

The trainees should form small groups and visit at least ten households for each group. They should observe and record the following:

1. The common diseases in these households during the last one month.

2. How the children were fed during such diseases-whether completely starved, some foods given, or fed normally.

3. Why the mothers feel that all foods should be stopped during illness.

4. If some foods were not given, what were the reasons?

5. What are reasons for the feeding practices they follow during illness?

In a group discussion, this information should be presented by each group and discussed.

Exercise 7. A quick study of the infectious diseases in a community

The trainees can divide a village or community up into streets or areas. Each trainee visits all the houses in one street or area. In each home she should quickly inquire about the infectious diseases there have been in the last month. She should ask especially about diarrhoea, measles, whooping cough, fever (malaria), and tuberculosis.

When the trainees have visited all the houses in a village they should add up all the cases of the different infectious diseases they found in their survey. This information should then be discussed by the trainees. Some important points they should consider are: Is this information accurate and complete? If not, why not? In what ways will this information help with the work of a community health worker? Is it necessary to learn more about the treatment and prevention of particular diseases that are important in the community?

A quick survey of this sort will indicate which infectious diseases are common in the community. Some people may be offended by questions about the health of their family, or they may not want to talk about certain diseases. Some communities will be very sensitive about such questions; therefore, this exercise needs to be planned carefully before it is started. It will be helpful for the trainers themselves to act in role-plays about how to approach the community in such a survey.

Exercise 8. Observing the community environment

The trainees should form small groups and make a tour of the area in which the community lives. They should observe as many things as possible that make the environment dirty and point out these things to each other. Afterwards the groups should come together and compare their observations. Finally, the trainees should discuss what can be done to make the community environment cleaner for better health.