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close this bookCommunicable Disease Control in Emergencies - A Field Manual (WHO - OMS, 2003, 223 p.)
View the document(introduction...)
View the documentACKNOWLEDGEMENTS
View the documentINTRODUCTION
Open this folder and view contentsCHAPTER 1: RAPID ASSESSMENT
Open this folder and view contentsCHAPTER 2: PREVENTION
Open this folder and view contentsCHAPTER 3: SURVEILLANCE
Open this folder and view contentsCHAPTER 4: OUTBREAK CONTROL
Open this folder and view contentsCHAPTER 5: DISEASE PREVENTION AND CONTROL
View the documentANNEX 1: WHO REFERENCE VALUES FOR EMERGENCIES
View the documentANNEX 2: SAMPLE HEALTH SURVEY FORMS
View the documentANNEX 3: NCHS/WHO NORMALIZED REFERENCE VALUES FOR WEIGHT FOR HEIGHT BY SEX
View the documentANNEX 4: SAMPLE WEEKLY SURVEILLANCE FORMS
View the documentANNEX 5: RECOMMENDED CASE DEFINITIONS
View the documentANNEX 6: OUTBREAK INVESTIGATION FORMS
View the documentANNEX 7: ORGANIZATION OF AN ISOLATION CENTRE
View the documentANNEX 8: BASIC LABORATORY SERVICES
View the documentANNEX 9: LABORATORY INVESTIGATION KIT
View the documentANNEX 10: TREATMENT GUIDELINES
View the documentANNEX 11: MANAGEMENT OF THE CHILD WITH COUGH OR DIFFICULTY IN BREATHING6
View the documentANNEX 12: ASSESSMENT AND TREATMENT OF DIARRHOEA
View the documentANNEX 13: FLOW CHARTS FOR SYNDROMIC MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS
View the documentANNEX 14: SAMPLE HEALTH CARD
View the documentANNEX 15: LIST OF WHO GUIDELINES ON COMMUNICABLE DISEASES
View the documentANNEX 16: LIST OF PUBLISHERS
View the documentANNEX 17: GENERAL REFERENCES

ANNEX 12: ASSESSMENT AND TREATMENT OF DIARRHOEA

Table A12.1. Assessment of diarrhoeal patients for dehydration

First assess your patient for dehydration


A

B

C

1. Look at:
General condition

Well, alert

*Restless, irritable*

*Lethargic or unconscious; floppy*

Eyes a

Normal

Sunken

Very sunken and dry

Tears

Present

Absent

Absent

Mouth and tongue b

Moist

Dry

Very dry

Thirst

Drinks normally, not thirsty

*Thirsty, drinks eagerly*

*Drinks poorly or not able to drink*

2. Feel:
Skin pinch c

Goes back quickly

*Goes back slowly*

*Goes back very slowly*

3. Decide:

The patient has no signs of dehydration

If the patient has two or more signs, including at least one *sign* there is some dehydration

If the patient has two or more signs, including at least one *sign* there is severe dehydration

4. Treat:

Use Treatment Plan A

Weigh the patient if possible and use Treatment Plan B

Weigh the patient and use Treatment Plan C URGENTLY

a In some infants and children the eyes normally appear somewhat sunken. It is helpful to ask the mother if the child's eyes are normal or more sunken than usual.

b Dryness of the mouth and tongue can also be palpated with a clean finger. The mouth may always be dry in a child who habitually breathes through the mouth. The mouth may be wet in a dehydrated patient owing to recent vomiting or drinking.

c The skin pinch is less useful in infants or children with marasmus (severe wasting) or kwashiorkor (severe undernutrition with oedema) or in obese children.

Source: The treatment of diarrhoea, a manual for physicians and other senior health workers. Geneva, World Health Organization, 1995 (document WHO/CDR/95.3).

TREATMENT PLAN A: TO TREAT DIARRHOEA AT HOME

Use this plan to teach the mother to:

· continue to treat at home her child's current episode of diarrhoea; and
· give early treatment for future episodes of diarrhoea.

Explain the three rules for treating diarrhoea at home

1. Give the child more fluids than usual to prevent dehydration

· Use recommended home fluids. These include: ORS solution, food-based fluids (such as soup, rice water and yoghurt drinks) and plain water. Use ORS solution as described in the box below.

(Note: if the child is under 6 months of age and not yet taking solid food, give ORS solution or water rather than food-based fluid.)

· Give as much of these fluids as the child will take. Use the amounts shown below for ORS as a guide.
· Continue giving these fluids until the diarrhoea stops.

2. Give the child plenty of food to prevent undernutrition

· Continue to breastfeed frequently.
· If the child is not breastfed, give the usual milk.
· If the child is 6 months or older, or already taking solid food:

- also give cereal or another starchy food mixed, if possible, with pulses, vegetables and meat or fish; add one or two teaspoonfuls of vegetable oil to each serving;

- give fresh fruit juice or mashed banana to provide potassium;

- give freshly prepared foods; cook and mash or grind food well;

- encourage the child to eat: offer food at least six times a day; and

- give the same food after diarrhoea stops, and give an extra meal each day for 2 weeks.

3. Take the child to the health worker if he/she does not get better in 3 days or develops any of the following:


· many watery stools

· eating or drinking poorly


· repeated vomiting

· fever


· marked thirst

· blood in the stool

Children should be given ORS solutions at home if:

· they have been on Treatment Plan B or C;
· they cannot return to the health worker if the diarrhoea gets worse; or

· if it is national policy to give ORS to all children who see a health worker for diarrhoea.

If the child is to be given ORS solution at home, show the mother how much ORS to give after each loose stool and give her enough packets for 2 days.

Age

Amount of ORS to be given after each loose stool

Amount of ORS to provide for use at home

Under 24 months

50-100 ml

500 ml/day

2-10 years

100-200 ml

1000 ml/day

10 years or more

as much as wanted

2000 ml/day

· Describe and show the amount to be given after each stool, using a local measure.

Show the mother how to mix and to give ORS

· Give a teaspoonful every 1-2 minutes for a child under 2 years.

· Give frequent sips from a cup for older children.

· If the child vomits, wait 10 minutes. Then give the solution more slowly (for example, a spoonful every 2-3 minutes).

· If diarrhoea continues after the ORS packets are used up, tell the mother to give other fluids as described in the first rule above or return for more ORS.

TREATMENT PLAN B: TO TREAT DEHYDRATION

Table A12.2. Approximate amount of ORS solution to give in the first 4 hours

Agea


< 4 months

4-11 months

12-23 months

2-4 years

5-14 years

15 years +

Weight

0 - < 5 kg

5-7.9 kg

8-10.9 kg

11-15.9 kg

16-29.9 kg

30 kg +

In ml

200-400

400-600

600-800

800-1200

1200-2200

2200-4000

In local measure







a Use the patient's age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the patient's weight (in grams) times 0.075.

· If the child wants more ORS than shown, give more.
· Encourage the mother to continue breastfeeding.
· For infants under 6 months who are not breastfed, also give 100-200 ml clean water during this period.

Observe the child carefully and help the mother give ORS solution.

· Show her how much solution to give the child.

· Show her how to give it - a teaspoonful every 1-2 minutes for a child under 2 years, frequent sips from a cup for an older child.

· Check from time to time to see if there are problems.

· If the child vomits, wait 10 minutes and then continue giving ORS, but more slowly, for example, a spoonful every 2-3 minutes.

· If the child's eyelids become puffy, stop the ORS and give plain water or breast-milk. Give ORS according to Plan A when the puffiness is gone.

After 4 hours, reassess the child using the assessment chart, then select Plan A, B or C to continue treatment

· If there are no signs of dehydration, shift to Plan A. When dehydration has been corrected, the child usually passes urine and may also be tired and fall asleep.

· If signs indicating some dehydration are still present, repeat Plan B but start to offer food, milk and juice as described in Plan A.

· If signs indicating severe dehydration have appeared, shift to Plan C.

If the mother must leave before completing Treatment Plan B:

· show her how much ORS to give to finish the 4-hour treatment at home;
· give her enough ORS packets to complete rehydration, and for 2 more days as shown in Plan A;
· how her how to prepare ORS solution; and
· explain to her the three rules in Plan A for treating her child at home:

- to give ORS or other fluids until diarrhoea stops
- to feed the child
- to bring the child back to the health worker, if necessary.


TREATMENT PLAN C: TO TREAT SEVERE DEHYDRATION QUICKLY

Follow the arrows. If the answer is "yes" go across. If "no" go down.


Figure

Urgent: send the patient for IV or nasogastric treatment.

If possible, observe the patient for at least 6 hours after rehydration to be sure the mother can maintain hydration giving ORS solution by mouth. If the patient is older than 2 years and there is cholera in the area, give an appropriate oral antibiotic after the patient has become alert.