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close this book Community Nutrition Action for Child Survival
close this folder Part I - Community nutrition problems and interventions
close this folder Unit 5: Preventing diarrhea
View the document Session 1: Preventing diarrhea*
View the document Session 2: Diarrhea home management
View the document Session 3: Community activities to prevent diarrhea*

Session 1: Preventing diarrhea*

* Much of the format and materials used in compiling this session was adapted from the WHO Programme for Control of Diarrhoeal Diseases Supervisory Skills Course: Module on Prevention of Diarrhoea, revised ed.

Diarrhea is the disease that kills more children in the world today than any other. While diarrhea! disease control programs often emphasize proper treatment, including Oral Rehydration Therapy (ORT), for the most reduction of deaths from diarrhea among young children individuals, families and communities can take action to prevent diarrhea and to prevent death from diarrhea through a variety of other effective and affordable preventive interventions.


Trainees review the relationship between diarrhea, nutrition and child survival. Rules for the prevention of diarrhea are developed.

Time: 2 1/2 hours


- Handout - "How to Prevent Diarrhea"

- Flipchart and marking pens


1. Diarrhea and malnutrition:

Begin by reviewing the relationship between diarrhea and malnutrition. (See Unit 1, Nutrition of Women and Children).

Emphasize the following points:

- Malnourished children have more severe and more prolonged diarrhea than well nourished children, which results in a cycle of more malnutrition, more days of diarrhea, greater risk of death due to diarrhea, etc.

- Diarrhea causes malnutrition because food is not absorbed in the intestine; nausea and vomiting may decrease the amount of food eaten. Diarrhea is often related to lack of appetite among young children resulting in decreased food intake. In some cultures, food may also be withheld from a child with diarrhea.

- To prevent malnutrition we must prevent diarrhea and treat it properly when it occurs.

2. Preventing Diarrhea:

- Review the fecal-oral transmission of diarrhea through contaminated food, water and hands.

- Use the handout "How to Prevent Diarrhea" as a guide, review the seven interventions recommended by WHO which have been shown by recent research to be particularly effective and affordable in preventing diarrhea. These are:


Improved weaning practices

Use of plenty of clean water


Use of latrines

Proper disposal of babies' stools

Measles immunization

- Emphasize the importance of breastfeeding as a means of preventing diarrhea in infants (discuss studies showing large differences in rates of diarrhea among exclusively breastfed infants compared with those not breastfed or receiving both bottle and breast).

3. Ask the group to brainstorm the socioeconomic and environmental causes of diarrhea in young children. These should include:

- Use of feeding bottles

- Lack of water for washing

- Unclean water

- Lack of latrines

- Spoiled or contaminated foods

4. Divide into work groups with 5-6 trainees in each. Ask work groups to develop a list of community action for prevention of diarrhea. When they finish, each work group should read its rules to the others.

5. Distribute the handout - "How to Prevent Diarrhea." Review and discuss any rules on the handout that were not mentioned by work groups.

6. Discuss the types of community programs that could help families understand and follow rules for prevention of diarrhea. Some examples are:

- Latrine construction

- Family education

- Water supply improvement

- Breastfeeding promotion

- Immunization programs

7. Summary

Point out that all efforts to prevent diarrhea must include strong educational activities because many of the causes of diarrhea are related to behaviors, i.e., personal habits of hygiene, food preparation, etc. In many instances, the role of the health worker is to help community members to adopt and maintain the recommended practices. In other cases, outside resources and assistance may also be necessary before people are able to practice good personal and environmental hygiene, i.e., materials for latrine construction or water projects.


*Adapted form WHO Supervisory Skills Module "Prevention of Diarrhea, revised edition 1987.


Breastfeeding is declining in most developing countries, especially among the more educated and more urbanized groups. Reasons for this decline may include a belief that bottle feeding is more modern, advertisement of infant formula, difficulty in breastfeeding while at work, fear of becoming less sexually attractive, and belief that one cannot breastfeed adequately.

During the first 4-6 months of life, infants should be exclusively breastfed. This means the baby should receive breastmilk and no other fluids such as water, juice or formula.

Exclusively breastfed babies are much less likely to get diarrhea than babies who are not breastfed or are partially breastfed. If an exclusively breastfed baby does get diarrhea, the baby is much less likely to die. During the first 6 months of life, the risk of having severe or fatal diarrhea is 30 times greater for infants who are not breastfed than for infants who are exclusively breastfed.

During age six months to two years, infants should be partially breastfed. This means that breastfeeding should continue after weaning foods are introduced. Babies who continue to get breastmilk will get less diarrhea than those who do not. This partial breastfeeding will greatly reduce the risk of severe diarrhea and diarrhea death.

Breastfeeding protects because it avoids use of contaminated bottles, teats and formula. The content of breastmilk also helps the baby's body build resistance to diseases. Therefore, even if bottles are clean and formula is properly prepared, a bottle-fed child is at increased risk of disease.

What Mothers Should Do

Breastfeed their babies exclusively for the first 4-6 months, and partially up to age two or more.

To breastfeed comfortably and safely,

- to decrease risk of infection, give no extra fluids such as water, sugar water, or milk formula, especially during the first days of life

- start breastfeeding as soon as possible after delivery

- breastfeed on demand (increased sucking increases milk supply)

- if it is not possible to take the baby to work, breastfeed before leaving home, on returning, at night, and at any other time when with the baby

- express milk manually to avoid engorgement during periods of separation from the baby

Breastfeed during and after illness of their babies, especially diarrhea.


Weaning is the process by which the infant gradually becomes accustomed to the adult diet. The child's diet changes from milk alone to one based on the regular family meals. Milk, preferably breastmilk, continues to be an important part of the diet.

Weaning is a hazardous period for infants. Poor weaning practices are associated with increased risk of diarrhea and diarrhea death. Good weaning practice involves attention to the when, the what and the how.

What Families Should Do

When to begin to Wean?

When the child is about 4-6 months old, continue to breastfeed regularly and introduce a few soft, mashed foods, twice per day. When the child is about six months old, continue to breastfeed but expand the variety of foods and give them 4 times per day. From one year of age, continue to breastfeed as desired and give all foods, suitably prepared, 4 to 6 times per day.


- Wash hands before preparing weaning food and before feeding the baby.

- Prepare food in a clean place.

- Wash uncooked food well when preparing it.

- Cook or boil food when preparing it.

- If possible prepare weaning foods immediately before they will be eaten.

- Cover foods which are being kept. Keep foods in a cool place. Refrigerate if possible.

- If cooked food is prepared more than 2 hours in advance, heat it to a boil before feeding it to the baby.

- Feed the baby with a clean spoon. (Do not use a bottle).


In preventing measles, measles immunization also prevents the diarrhea that often accompanies or follows it. Diarrhea which is associated with measles is particularly severe, is often dysentery, and is more likely to lead to death than most diarrhea in children. Up to 10% of children with measles and diarrhea die.

What Families Should Do

Immunize children against measles as soon as possible following the approved national vaccination schedule.


Using plenty of clean water helps protect families from diarrhea. Families that have good access to a reliable supply of clean water have less diarrhea than less fortunate families. In general, families cannot make major changes in the availability of a good water supply. Improvements in water supply usually come about through government-assisted projects, in which families and communities may play an important role. Families may also be able to improve their facilities for collecting and storing rainwater. Families can reduce their risk of diarrhea by using the cleanest available water and protecting it from contamination, at the source and in the home.

What Families Should Do

Collect water from the cleanest available water source.

Protect water sources by keeping animals away, by locating latrines more than 10 meters away and downhill, and by digging drainage ditches uphill from the source to channel storm water away from it.

Collect and store water in clean containers. Empty and rinse out containers daily. Keep the storage container covered and do not allow children or animals to drink from it. Allow no one, especially a child, to put his hands into the storage container. Obtain water with a long-handled dipper which is kept specially for that purpose.

Boil water used from making food or drinks for young children. Boil other drinking water if sufficient fuel is available. Water needs only to be brought just to a boil. (Vigorous boiling wastes fuel and is unnecessary.)


Parents can help protect young children against diarrhea by adopting certain hygiene practices. These practices may differ from one culture to another. One very important practice is handwashing.

Good handwashing means use of soap (or a local substitute), use of plenty of water, and careful cleaning of all parts of the hands. If water is scarce, it may be used more than once to wash hands and utensils. It can then be used to wash the food or to irrigate the vegetable garden.

What Families Should Do

All family members should wash their hands well

- after cleaning a child who has defecated, and after disposing of a child's stool

- after defecation

- before preparing food

- before eating

- before feeding a child

An adult or older sibling should wash the hands of young children.


Diarrheal diseases are spread by the stools of infected persons. Disposing of stools more safely reduces the diarrhea transmission. In some countries, latrine use reduces the risk of diarrhea even more than improving water supplies.

All families should have and use a clean and functioning latrine. Families who do not have a latrine should build one, following a design recommended by the relevant government agency. (Two practical designs are in Annexes A and B). When there is no latrine, families should defecate as hygienically as possible. Consideration should be shown by not defecating uphill or upstream from other people or villages.

What Families Should Do

Have a clean functioning latrine that is used by all members of the family old enough to do so. Keep the latrine clean by regularly washing down dirty surfaces.

If there is no latrine

- defecate away from the house, paths, or anywhere that children play, and at least 10 meters from the water supply

- avoid going barefoot to defecate

- do not allow a child to visit the defecation ground alone


Hygienic disposal of the stools of young children is important everywhere. In some communities, the stools of infants and young children are considered harmless. However, these stools are dangerous because they transmit diseases to the children and parents. They should be disposed of quickly and hygienically.

What Families Should Do

Quickly collect the stool of a young child or baby, wrapping it in a leaf or newspaper and putting it into a latrine.

Help young children to defecate into an easily cleaned container, such as a potty. Immediately put the stool in a latrine and wash out the container. Alternatively, have the child defecate onto a disposable surface, such as a newspaper or a large leaf. Wrap up the stool and put it into a latrine. If there is no latrine, select a place to dispose of children's stools, such as in a hole or in one corner of the yard.

Promptly clean a child who has defecated. Then wash your hands and the child's hands.