Cover Image
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*

Unit 5: Preventing diarrhea

SESSION 1: Preventing Diarrhea

SESSION 2: Diarrhea Home Management

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.

Purpose:

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

Time: 2 1/2 hours

Materials:

- Handout - "How to Prevent Diarrhea"

- Flipchart and marking pens

Steps:

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:

Breastfeeding

Improved weaning practices

Use of plenty of clean water

Handwashing

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.

HANDOUT - HOW TO PREVENT DIARRHEA*

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

BREASTFEEDING

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.

IMPROVED WEANING PRACTICES

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.

How?

- 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).

MEASLES IMMUNIZATION

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.

USE OF PLENTY OF CLEAN WATER

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.)

HANDWASHING

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.

USE OF LATRINES

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

PROPER DISPOSAL OF BABIES' STOOLS

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.

Session 2: Diarrhea home management

Purpose:

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

Materials:

- 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

Steps:

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

January 1979

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.

Example:


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.

14. Summary

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.

HANDOUT

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

HANDOUT

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:

Glucose

20 grams

This is added

Sodium Chloride

3.5 grams

to 1 liter of

Trisodium Citrate

2.9 grams

clean water

Potassium Chloride

1.5 grams

 

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)

Sugar**

40 grams

10 grams

Salt

3.5 grams

1 gram

Water

1 liter

250 mls

* 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
of water

put

2 level
teaspoons and
sugar

a 3-finger
pinch of
salt (1 gr.)


One glass of ORS

Or. where people traditionally measure with their fingers:

In one glass
of water

put

enough sugar
to fill the hollow
of the hand

a 3-finger
pinch of
salt (1 gr.)


Traditionally measure

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.


Measuring spoon


How to use 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.

HANDOUT

Practical advice series

Reference: AHRTAG

Issue No. 2

Diarrhoea Dialogue

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


Signs of dehydration

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.

Conclusion


Seriously dehydrated child

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

Session 3: Community activities to prevent diarrhea*

Purpose:

In this session trainees will learn how to assess a community's current practices with regard to diarrhea, how to use assessment information to, prioritize specific preventive practices to emphasize in their particular area using the WHO recommended step-by-step approach and discuss ways that health workers can support selected preventive practices at the community level.

Time: 3 hours

Materials:

- Handout - "About Prevention of Diarrhea"

- Flipchart and marking pens

Steps:

1. Write on the flipchart:

* The best ways to prevent diarrhea are:

Breastfeeding

Improved Weaning Practices

Use of Plenty of Clean Water

Handwashing

Use of Latrines Proper Disposal of Babies' Stools

Measles Immunization

* Much of the format and material used to compile this session were adapted from the WHO Programme for Control of Diarrhoeal Diseases Supervisory Skills Course: Module on Prevention of Diarrhoea, and Community Involvement, revised ed.

Briefly review the methods for preventing diarrhea which have already been treated in some detail in Session 1 of the module. Make the point that each one of these methods represents an area which can be addressed through community action in a comprehensive program to control diarrhea! diseases.

2. Assessing Community Practices

The first step in designing community interventions to address diarrhea! diseases is to learn about the community's current practices regarding diarrhea and the reasons for them. This information will provide guidance to further actions by helping you to select which interventions are most needed and which are most likely to be successful in a particular setting.

Trainer: Take a few minutes to solicit suggestions from the group about various ways that this type of information can be obtained and write them on newsprint. The finished list should include:

Observation

Home Visits

Interviews

Key Informants

Five types of information on community practices should be obtained about each of the seven ways to prevent diarrhea listed above.

Write on newsprint:

- The extent to which the community engages in the preventive practice

- What community members do instead of or in addition to the preventive practices

- Reasons community members continue their current practices, as well as barriers and constraints to change

- Latrines: their number, type and cleanliness

- Water sources: their quality, convenience and quantity of supply

3. Selecting Preventive Emphasis

Once information has been obtained regarding the community's current practices, the next step is to select one or more preventive practices to emphasize in your particular area. The WHO recommends a step-by-step approach to selecting preventive emphasis.

Write on each newsprint:

Step 1: List the practices that need to be improved in your area

Point out that this includes:

- People who are not doing the preventive practices

- People doing other practices that are harmful

Step 2: Select the more important practices to improve

Trainer: Brainstorm with the large group a list of ways to prioritize practices as feasible. The list should include:

- Whether or not the government already considers the practice a priority

- What the expected effect of the change will be on the diarrhea rates

- How many people, particularly young children, will be affected

Make the point that overall, the most important practices are those which, if changed, would result in the greatest health improvement for the community.

Step 3: From the more important practices, identify some that will be more feasible to change

Trainer: Brainstorm with the large group a list of ways to prioritize practices as feasible. This list should include:

- Will community members understand and believe the benefits of the new practice or the harm in continuing the current practices?

- Do community members have the necessary resources, or can they be obtained?

- Will community members be willing to do the practice, and not feel that it is against tradition, too difficult, too expensive, or too time consuming?

- Can health workers correctly teach the new practice with little or no training themselves?

Point out that if the answer to all of these questions is yes, the change is more likely to be feasible. If the answer to any questions is no, it is unlikely that an effort to change the practice or introduce a new one will be successful, especially without a large commitment of resources.

Step 4: Select preventive practices to emphasize in your area

Having discussed each practice on both the aspect of importance (i.e. government plans, expected effect on disease rate and number of people affected) and feasibility (i.e. community interest, resource availability and health manpower capability), select one or two practices to emphasize in your area.

4. Undertaking Specific Activities

Health and extension workers can play important roles in bringing about improvements in community health. In the prevention and control of diarrhea! disease the following activities are recommended:

(Write each activity on newsprint)

1. Health and extension workers can use food counseling techniques.

Point out that messages should be brief and clearly relevant to the person or group being addressed. Only a few messages should be given at a time. If too many messages are given, none are likely to be remembered, but the right message at the right time will make an impression.

2. Health and extension workers can -at good examples

What a person does always sends a more powerful message than what a person says.

3. Health and extension workers can participate in community projects to improve preventive practices.

Trainer: Brainstorm with the large group to solicit ideas for community projects that could improve preventive practices and that could be accomplished with limited community resources. Some examples are:

- Buying soap cooperatively

- Improving water sources

- Designating and supporting a tradesman to build family latrines

- Having a breastfeeding support group

- Gardening for improved weaning foods

4. Health and extension workers can support breastfeeding

Opportunities to support breastfeeding can be found particularly when the health worker attends births, prescribes drugs or when mothers are having difficulties with breastfeeding and seek out the health worker for advice.

5. Health and extension workers can build and maintain latrines where they work

A clean, functioning latrine can be an example to others in the community. It should be properly maintained so that people can see how a latrine works.

6. Health and extension workers can advise community members of the cleaner water sources and ways to improve water sources

When the assessments of community practices were done, the cleaner water sources were identified so it should be possible to advise community members about the best water sources. Probably, some water sources can be improved by taking simple measures.

Trainer: Brainstorm with the large group to develop a list of simple improvements that can be made to existing water sources. Include:

- Build a fence or wall around the water source to keep animals away

- Dig drainage ditches from an open well to prevent storm water from flowing into it

- Do not allow washing in the water source

- Do not allow children to play in or around the water source

- Do not locate the latrines uphill or within 10 meters of the water source

- Do not defecate within 10 meters of the water source

- Install a simple pulley device and bucket to make it easier to raise from a well

Summary: Distribute the Handout "About Prevention of Diarrhea". Review the Handout reinforcing the main points and answering any remaining questions.

HANDOUT

ABOUT PREVENTION OF DIARRHEA*

* From WHO Supervisory Skills Course: Module on Prevention of Diarrhea.

- The best ways to prevent diarrhea are:

Breast feeding

Improved Weaning Practices

Use of Plenty of Clean Water

Handwashing

Use of Latrines

Proper Disposal of Babies' Stools

Measles Immunization

- It is important to assess a community's current practices related to diarrhea and the reasons for them to know what preventive interventions are needed.

- Use of step-by-step approach to select the specific preventive practices to emphasize in a health area. Briefly, the steps include:

- List the practices that need to be improved in the area.

- Select the more important practices to improve.

- Identify the practices that will be more feasible to change.

- Select one or two preventive practices to emphasize.

- Health services should play an important role in bringing about improvements in a community's practices. Some activities that health workers can do to support selected preventive practices include:

- Use of good counseling techniques

- Set a good example

- Participate in community projects to improve preventive practices

- Support breastfeeding

- Build and maintain a latrine at the health facility

- Advise community members of the cleaner water sources and ways to improve water sources

REFERENCES

Chen, LC, and Scrimshaw, NS, eds. Diarrhea and Malnutrition: Interactions, Mechanisms and Interventions. The United Nations University. New York, New York, 1983.

"Dialogue on Diarrhoea". Issues 1-31, AHRTAG. 85 Maryleborne High Street, London WIM3DE.

Esrey SA, and Bently ME. Nutrition and Diarrhea: Draft Guidelines for PRITECH II Country Work Plan. Division of Human Nutrition, Department of International Health, Johns Hopkins University. Baltimore, Maryland, 1987.

Favin M, and McMurtry. Oral Rehydration Therapy. World Health Federation of Public Health Associations. Washington, D.C., 1983.

"Salubritas". Oral Rehydration in the Village. Vol. 3, No. 1, January 1979.

Werner, D. Helping Health Workers Learn: A Book of Methods, Aids and Ideas for Instructors at the Village Level. Hisperian Foundation. Palo Alto, Ca., 1983.

Werner, D. Where There Is No Doctor: A Village Health Care Handbook. Hisperian Foundation. Palo Alto, Cal, 1977.

World Health Organization. Programme for Control of Diarrhoeal Diseases Supervisory Skills Course: Modules on Prevention and Treatment of Diarrhoea, revised ed. Geneva, Switzerland, 1987.

World Health Organization. A Decision Process for Establishing Policy on Fluids for Home Therapy of Diarrhoea. WHO/CDD/SER/87.10. Geneva, Switzerland, 1987.

There are two newsletters which contain current information on diarrhea and other related topics that are available to Third World subscribers:

"Dialogue on Diarrhoea", AHRTAG, 85 Marylebone High Street, London, WIM3DE, United Kingdom.

"Mothers and Children". American Public Health Association, Clearinghouse on Infant Feeding and Maternal Nutrition, 1015 Fifteenth Street, Washington, D.C., 20005.