| Community Nutrition Action for Child Survival |
|Part I - Community nutrition problems and interventions|
|Unit 5: Preventing diarrhea|
Trainees discuss the treatment of diarrhea following the WHO rules for treating diarrhea at home. They practice making two common types of oral rehydration fluids, a prepackaged mixture and a salt-sugar solution, the latrine using local measurements and common household utensils. Trainees are taught to recognize the signs and symptoms of dehydration and encouraged to refer dehydrated children to trained health workers for treatment.
Time: 2 hours
- Handouts - "Three Rules for Treating Diarrhea at Home"
- "How to Make ORS and SSS Oral Rehydration Fluids"
- "How to Recognize Dehydration" Prepackaged ORS (available from UNICEF)
- ORT measuring spoons (available from TALC, P.O. Box 49, St. Albany, AL14AX, London, England)
- Slides or pictures showing signs of dehydration
- Sugar, salt, boiled water, cups, spoons and liter containers
- Flipcharts and marking pens
1. Read the story below to the group.
"The mother notices that her child has had watery stool, not an uncommon occurrence for children in any part of the world. A touch of diarrhea. It will go away, she thinks. Likely it is something bad passing out of his system. The day goes on and the diarrhea continues. The child becomes restless. His skin loses elasticity. His mouth becomes dry and red. The mother is afraid to feed him and give him liquids, thinking that she will only encourage the diarrhea.
Hours pass and the child's condition worsens. He is now semiconscious and has cold skin, a weak pulse and little urine flow. Terrified, the mother calls for help from the village health worker. She is told that the child is severely dehydrated and in danger of death. He must have intravenous therapy immediately, but there is no apparatus available in the village. The child will probably die."
Salubritas, Volume 3, Number 1
2. To start the discussion, ask trainees. "What happened in this story? How could the child's life have been saved?"
3. Make the following points:
- A young child can die from severe diarrhea in as few as six hours.
- Dehydration is the cause of death from diarrhea. Dehydration is caused by the loss of water and important salts from the body in stool.
- Until a few years ago, the only way to treat dehydration was to inject rehydration fluid into the body through a vein. This requires special, sterile apparatus and a health worker trained to administer the I.V. solution.
- In the late 1950's, a health technology was developed whereby rehydration fluids could be administered orally for the prevention or treatment of dehydration due to diarrhea. This Oral Rehydration Therapy (ORT) has made it possible for families and health workers to prevent dehydration from diarrhea in the home. In a hospital or clinic, it provides the trained health worker with a low cost alternative for the treatment of dehydration.
- Most diarrheas are self limiting, i.e., if dehydration can be prevented or controlled, the diarrhea itself will disappear in a few days.
4. Definitions - Before attempting to discuss the more technical aspects of Oral Rehydration Therapy in depth, present the following definitions to the group to avoid confusion during the discussion to follow:
* Oral Rehydration Therapy (ORT)
The giving of fluids by the mouth to prevent or treat dehydration.
* Oral Rehydration Salts (ORS)
Although formerly used to abbreviate Oral Rehydration Solution, for the purpose of containing sodium chloride, potassium chloride, trisodium citrate (or in older preparations, sodium bicarbonate) and glucose. ORS is only one type of oral rehydration fluid and is the treatment of choice for dehydration due to diarrhea. It may also be used at home to prevent dehydration.
* Salt-Sugar Solution (SSS)
Again, only one type of home available oral rehydration fluid. This fluid is a simple mixture containing only sugar, salt and water.
* Home-available solutions
Refers to a variety of oral rehydration fluids, including sugar-salt and other food-based solutions that can be mixed with common household ingredients.
* Oral Therapy for Diarrhea ORT plus feeding.
5. Review the handout "Three Rules for Treating Diarrhea at Home". Point out that the purpose of this training is to learn how to manage diarrhea at home and that dehydrated children should be referred to a trained health provider for treatment. Mention that more detail on how to recognize dehydration will be given later in the session.
6. Selecting an Oral Rehydration Fluid.
There are a variety of oral rehydration fluids suitable for home management of diarrhea, including food-based fluids, salt-sugar solutions (SSS) and oral rehydration salts (ORS) solution. It is now understood that early administration of fluids such as rice, water, or cereal gruel at the first sign of loose stools can help prevent dehydration. This can be particularly important when prepackaged ORS solutions are not available. However while some fluids found in the home are helpful, some are potentially dangerous, such as soft drinks, highly sugared teas and very salty soup. Therefore, diarrhea! disease control programs should try to identify the particular fluid likely to be available in the home and to advocate it specifically. Generally, recommended fluids should contain some salt and sugar or starch and should meet the following criteria. (Write on flip chart)
- safe and effective in preventing dehydration
- locally available and affordable
- culturally acceptable
- easily prepared
- one that mothers are likely to use when needed
Many diarrheal disease control programs currently advocate the use of a salt-sugar (SSS) in the home. However, research has shown that serious errors in measuring both salt and sugar occur all too frequently. It is therefore extremely important to stress the necessity for accuracy in measurement when teaching this technique. Further, it is important that programs to train people in the use of this technique incorporate a follow up component to monitor the continued accuracy of fluid preparation.
In many areas, policy decisions have been made as to which fluid mixture or mixtures should be used. Trainees should be encouraged to find out what, if any, decisions have been made in their own areas, and encouraged to follow the approved policy, including instructions for measuring and mixing ingredients.
7. Distribute the Handout - "How to Make ORS and SSS Oral Rehydration Fluid." The Handout shows two different techniques for making oral rehydration fluid using: 1) a pre-packaged mix, and 2) a mix made with sugar, salt and water. Recipes for the simple sugar, salt and water mix are shown as they might be adapted using local measurements and common household utensils. Review the Handout, then demonstrate preparation of each recipe. Or distribute containers and utensils and ask work groups (5-6 persons) to practice making each of the recipes.
8. Ask trainees to list the advantages and disadvantages of prepackaged and home available fluid mixtures when they are used in the home to prevent dehydration due to diarrhea. They may include:
a) Pre-packaged mix
Advantages - Ease of preparation; standardized amounts of each ingredient; low potential for mixing errors; only need to measure water; may better fulfill desire of mothers to use medicine when their child is ill; the education message is simpler and easier to get across.
Disadvantages - Usually imported or made nationally; expensive to distribute; difficult to distribute; taste of solution may not appeal to the non-dehydrated child; mothers may not be motivated to go out and to get packages for mild cases of diarrhea; creates dependence on product which may not always be available.
b) Home available fluids with common measure and containers:
Advantages - Ingredients are available in all homes; lower cost; good for early treatment of diarrhea.
Disadvantages - Must decide which mixture to use; more difficult to get across the educational message; more difficult mixing; measurements are not standardized so amounts of ingredients may vary from solution to solution; lack of "glamour" (not really "medicine").
Make the point that for either method, availability of clean water and variability in the sizes of containers and measuring tools present problems. Emphasize the negative effects that too much salt or too much sugar can have.
9. Describe how to give oral rehydration fluid using a cup and spoon. It is important to continue giving fluid even if vomiting occurs. In cases of vomiting, wait 10 minutes, then continue giving the solution but more slowly.
Write the following general rule on the flipchart:
Rule: Begin giving oral rehydration fluid after the first loose stool.
10. Explain that young children, who usually have many short periods of diarrhea each year, must be fed during the diarrhea, or they will become malnourished and more likely to get severe diarrhea again and again. Even though the food that a child eats when he has diarrhea will not be completely digested, some of the food is absorbed and used by the body. Mothers should be encouraged to begin feeding soft foods to their children as soon as they are able (willing) to eat. Since a mother will only know if the child is willing to eat if he accepts food, the mother should continue to offer small amounts of different kinds of food. Once the child shows a willingness to eat, it is important to offer foods that are easily digestible and to encourage the child to eat foods high in calories and energy density. Good foods, depending on the age of the child, are mixes of cereals and beans or mixes of cereals and meat or fish. It is good to add oils to these foods to increase the energy content. It is also good to encourage potassium rich foods such as fresh fruit juices and bananas. CAUTION: artificially sweetened juices contain too much sugar.
11. Rule: Breastfeeding should be continued during diarrhea.
Most children will continue to breastfeed and may even suckle during diarrhea. Continued breastfeeding may be the most important step taken to prevent malnutrition. Breastfeeding should be encouraged for the sick child.
12. Show the growth chart of a child with diarrhea.
The chart demonstrates weight loss during diarrhea. To recover the lost weight and to remain well nourished, a child should be fed extra food (ex., one extra meal) each day for 5-7 days after the diarrhea has stopped. We call this "catch-up" feeding.
Rule: Feed extra food every day for 5-7 days after the diarrhea stops.
13. Distribute the Handout "How to Recognize Dehydration". Use the Handout plus slides or pictures to discuss the signs and severity of dehydration.
- Make the following points:
* While preventions of dehydration due to diarrhea can be accomplished in the home, treatment of children that are already dehydrated should be done by a trained health provider.
* Filed research indicated that a significant proportion of diarrhea! disease episodes and deaths due to diarrhea are the result of dysentery. Although dysentery treatment should include the administration of fluids and feeding, these therapies are not sufficient.
* Referral to a trained health provider is particularly important if there is blood in the stool, if there is a high fever (38.5 C or 101 F), if the child is undernourished or shows signs of dehydration or if the diarrhea worsens or does not get better.
Review the Handout "Three Rules for Treating Diarrhea at Home" with the trainees. Finish by discussing the "danger signs" of diarrhea. When these signs are present, it means that a health worker should be called.
THREE RULES FOR TREATING DIARRHEA AT HOME*
*From Treatment of Diarrhea Module, WHO Supervisory Skills Course, 1987 Field Test.
To treat a child with diarrhea who has no signs of dehydration, the mother should give the child FLUIDS and FOOD in normal and generous amounts and watch carefully to see if the child becomes worse.
EXPLAIN THE THREE RULES FOR TREATING DIARRHEA AT HOME
1. GIVE YOUR CHILD MORE FLUIDS THAN USUAL TO PREVENT DEHYDRATION. RECOMMENDED FLUIDS INCLUDE:
- Food based fluids, such as gruel, soup or rice water.
- Breastmilk or milk feeds prepared with twice the usual amount of water.
If you do not have a recommended food-based fluid, you can give a specially prepared salt and sugar solution.
2. GIVE YOUR CHILD FOOD
- Give freshly prepared foods. Recommended foods are mixes of cereal and beans, or cereal and meat or fish. Add a few drops of oil to the food, if possible.
- Give fresh fruit juices or bananas to provide potassium.
- Offer food every 3 or 4 hours (6 times a day) or more often for very young children.
- Encourage the child to eat as much as he wants.
- Cook or mash or grind food well so it will be easier to digest.
- After the diarrhea stops, give one extra meal each day for a week, or until the child has regained normal weight.
3. TAKE YOUR CHILD TO THE HEALTH WORKER IF THE CHILD:
- passes many stools
- has unusual thirst
- has sunken eyes
(These three signs suggest your child is dehydrated.)
- has a high fever
- does not eat or drink normally
- seems not to be getting better
How to Make ORS and SSS Oral Rehydration Fluids
A variety of oral rehydration fluids suitable for home management of diarrhea, including food-based, salt-sugar solution (SSS) and oral rehydration salts (ORS) have been developed. In countries where national policy decisions have been made, it is best to follow the approved policies, including instructions for measuring and mixing ingredients.
1. Pre-Packaged ORS Mixes
Packets or oral rehydration salts are often available through clinics, health workers and pharmacies. UNICEF is the major distributor of ORS packets; however, many governments are now packaging ORS locally for distribution in their countries.
ORS packets usually contain:
This is added
to 1 liter of
2. Village or Home-Made Sugar, Salt and Water Solution
A simple SSS can be made using ingredients found in most homes and villages. This solution contains:
For 1 liter
For 1 glass (250 ml)
* Some older ORS preparations used sodium bicarbonate 2.5 grams/liter.
** In most places household sugar is sucrose and the proper amount is 40 grams. However, in some places household sugar is glucose and the proper amount would then be 20 grams.
This basic information must be adapted to measurements and containers common to health workers and families in your region. Several examples are shown on the next page:
For one glass of ORS:
In one glass
Or. where people traditionally measure with their fingers:
In one glass
TALC - Teachings Aids at Low Cost has developed a special measuring spoon for making ORS in a cup of water. The spoon, which gives instructions for making and giving ORS, is shown below and can be ordered from TALC.
The spoon may be used by health workers to develop a local recipe for ORS. Use the TALC spoon to find local utensils (spoons, hand measures) that give the same amounts of salt and sugar as the spoon.
- Important: Adding too much salt or sugar can be very dangerous. Be sure to measure all ingredients accurately.
- Water used in ORS solutions should be as clean as possible; however, the need for liquid in a dehydrated child is so urgent that there may not be time to boil and cool the water. Use the cleanest water available for the first fluid given, then boil some water and store it to make the next solution.
How to Give Oral Rehydration Fluid
- Begin giving oral rehydration fluid and other liquids when the diarrhea starts.
- The amount of fluid given depends on the size of the child:
- 1/4 - 1/2 large cup after each stool for children under two years.
- 1/2 - 1 large cup for older children
- Give fluid in a cup to older children, or with a cup and a spoon to infants.
- Give fluid slowly - two or three spoonfuls at a time to avoid vomiting. Continue to give fluid even if the child vomits - some of the solution will stay with him.
- Mix a new batch of oral rehydration fluid every day.
- Continue giving oral rehydration fluid and other liquids until the diarrhea stops.
Practical advice series
Issue No. 2
How to recognize dehydration
Diarrhoea kills because it causes dehydration. The stools of a healthy child contain relatively little water but a child with diarrhoea passes very watery stools which also contain vital salts (sodium, sodium chloride, potassium and bicarbonate). II the losses are great, both the water and the salts must be replaced or the child will die. To recognize the signs of dehydration it is necessary to ask. look feel and. if possible. weigh the child.
Important signs and symptoms
Stools Ask about the number and size of the diarrhoea stools. Has there also been vomiting? These answers may also give clues to the severity of dehydration.
Thirst This may be the earliest sign of dehydration. Until a child has lost more than five per cent of his body weight, dehydration causes few signs. When severely dehydrated, a child may not be fully conscious and may be unable to drink.
Urine A healthy child usually passes urine about every three hours. The body of a dehydrated child tries to save water and only produces a small amount of dark coloured urine. Mothers usually know how much urine their children have passed, so ask them if there has been less that usual.
Condition If there is no dehydration, a child will appear alert and well. At a later stage, he will be weak, irritable and may look unwell or sleepy. A severely dehydrated child may appear very sleepy or be unconscious. He may also have fits or convulsions.
Sunken eyes A child's eyes lie in soft, wet, fatty tissue. If he becomes dehydrated, this tissue shrinks and becomes drier and his eyes sink back into his skull. His eyes also lose their shining appearance and stay half open when he is asleep.
Dry mouth A dehydrated child cannot make enough saliva and so his mouth and tongue become dry. This is an important sign.
Breathing Sometimes, a severely dehydrated child breathes fast and deeply. This kind of breathing occurs when a child has been dehydrated for some days or has been rehydrated with the wrong fluids. Do not mistake this deep, fast breathing for the shallow, rapid breathing of pneumonia.
Loss of skin elasticity The skin of a healthy child is elastic. If you pinch the skin of the abdomen and then let go, the skin quickly flattens again. De. hydration makes a child's skin dry and less elastic so when pinched it sticks up for some seconds before going net again. If it child is very thin or very fat, loss of skin elasticity is not easy to detect and therefore not a helpful sign in diagnosing dehydration.
Pulse Dehydration makes a child's pulse faster and weaker. When he becomes severely dehydrated, it may not be possible to feel the puke at the west, you may have to feel at the groin or listen to the heart. (With very severe dehydration, the pulse is sometimes slow).
Sunken fontanelle The fontanelle is the soft place between the bones at the top of a baby's skull. It is large when he is born but closes over by the time he is about 18 months old. When a baby becomes dehydrated, his brain and tissues in the skull lose water and shrink. The fontanelle sinks down between the bones of the skull.
Loss of weight This may occur quickly during a few hours or over several days. A severely dehydrated child may have lost a tenth or mom of his normal body weight. If he weighed ten kilograms before the onset of diarrhoea, he may have lost at least a kilo of water and may now weigh only nine kilograms. Loss of weight due to malnutrition occurs more slowly over several weeks or months.
Dehydrated children need urgent rehydration and should be encouraged to drink even if vomiting occurs Those with severe dehydration and complications such as convulsions should be given oral rehydration fluid and taken to a centre where they can receive special care.
6 Diarrhoea Dialogue, Issue 2, August 1980. Produced quarterly by AHRTAG at 85 Marylebone High Street, London W1M 3DE