Guidelines for New Diarrhea

Treatment Protocols
for Community-Based Healthcare Workers
Not yet field-tested
Table of Contents

Introduction 1

Overview of Diarrhea 1

The Role of the Community-Based Health Care Worker

in Diarrhea Management 3

Assessment of the child with diarrhea 3

Ask, look and feel for signs of dehydration or other problems 3

Decide how to treat 4

Home Treatment for Diarrhea 6

1. Prevention of dehydration 6

2. Treatment guidelines 7

4. Special notes 9

Teaching Parents About Home-Based Treatment 10

ORS Therapy 10

Zinc supplementation 10

Encouraging Eating and Drinking 11

Annex 1: Assessing and Treating Diarrhea Chart 13

Annex 2: Frequently Asked Questions 14

Annex 3: Potential Local Adaptations 19

Introduction

T here are two new exciting changes to current guidelines for

treating diarrhea in children:
New and improved Oral Rehydration Solution (ORS) to
prevent dehydration and the need for intravenous therapy
Zinc Supplementation to decrease the duration and
severity of diarrhea and the likelihood of future diarrhea
episodes in the 2-3 months following supplementation
As a community-based health care worker YOU are a vital part
of improved diarrhea management. With the new tools described
in this guide you will be well prepared to help mothers treat
a child with diarrhea. In addition this guide will help you
know when to refer children with more severe diarrhea and
dehydration.

Overview of Diarrhea
1. Diarrhea

In many societies, diarrhea is 3 or more loose or watery
stools (stools containing more water than normal) in a day

Mothers usually know when their children have diarrhea.
The mother knows how many stools per day the child
usually has. If a child has diarrhea, the mother will notice
that the child will have more stools than usual throughout
the day.

Stools may also contain blood, in which case the diarrhea
is called dysentery.

Diarrhea is common in children, especially those between
6 months and 2 years of age. It is also common in babies
under 6 months who are drinking cow’s milk or infant
feeding formula.

When diarrhea occurs stools may smell strong or pass
noisily, as well as being loose and watery.

1

Frequent passing of normal stools is not diarrhea. Babies
who are breastfed often have stools that are soft; this is
not diarrhea. The mother of a breastfed baby can recognize
diarrhea because the consistency or frequency of the stools
is different than normal.

2. Why is diarrhea dangerous?

Loss of body fluids: The loss of a more than usual amount
of water and salts from the body results in dehydration. It
occurs when the output of water and salts is greater than
the input. The more diarrhea stools a child passes, the
more water and salts he /she loses. Dehydration can also
be caused by a lot of vomiting, which often accompanies
diarrhea. Dehydration during diarrhea is very serious and is
a leading cause of child death around the world.

Loss of nutrients: Nutrients are lost from the body during
diarrhea. Diarrhea can cause malnutrition which becomes
worse if a mother does not feed her child while he/she has
diarrhea.

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The Role of the Community-Based Health Care
Worker in Diarrhea Management

C hildren with diarrhea are often sick with simple acute

diarrhea. Simple cases of diarrhea (those with some
dehydration) can be treated at home (see below).
As you read this section, look at the chart in Annex 1.

Assessment of the child with diarrhea

Assessment of the child with diarrhea can be done by looking
for key clinical signs to determine the level of dehydration of the
child and the appropriate treatment to begin. Recognizing the
clinical signs of severe dehydration is extremely important.

Ask, look and feel for signs of dehydration or other

problems
ASK:
Does the child have more stools than usual?
Does the child have three or more stools per day?
If yes to either, continue with the following —
ASK:
How long has the child had diarrhea?
Is there blood in the stool?
Is there vomiting?
LOOK:
What is the child’s general condition?
Is he/she well and alert?
Is he/she restless or irritable?
When offered a drink, is the child able to drink? If so,
does he/she drink eagerly, thirstily?
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 Is he/she very sleepy or unconscious?
Is he/she severely malnourished?
Are his/her eyes normal or sunken?
Pinch the skin of the abdomen or thigh. Does it go back
slowly?

Decide how to treat

Refer urgently to the clinic/health center if the child has 2 or
more of the following signs of SEVERE dehydration:

Very sleepy or unconscious

Has sunken eyes

Not able to drink or drinking very poorly

When pinched, skin goes back to normal very slowly
(longer than 2 seconds)

Refer to the clinic/health center if the child has 2 or more of

the following signs of SOME dehydration:

Restless/irritable

Sunken eyes

Drinks eagerly/thirsty

When pinched, skin goes back slowly (1 second)

Refer to the clinic/health center if the child has had

Diarrhea for more than 14 days.

Blood in the stool

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When the child is referred to the Health Center, you can help
by:

Telling the mother to keep the child warm during the trip

Advising the mother to continue and increase breastfeeding

Providing the mother with Oral Rehydration Solution and
counseling to give the child sips on the way

When the child is brought home, you can help by:

Guiding the mother in administering the home treatment
described below

Monitoring the child

Instructing the mother to take the child back to the clinic/
health center, if the child does not improve in three days

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 Home Treatment for Diarrhea
If the child has diarrhea but NONE of the danger signs of
dehydration listed above, the child can be treated at home, as
follows:
1. Prevention of dehydration

ORS continues to be the best way to prevent and manage
dehydration. Give the recommended home fluids or ORS
(see below), or give available food-based fluids, such as
gruel, soup or rice-water.

Increase the frequency of breastfeeding, or give milk feeds
prepared with twice the usual amount of water.

Continue to feed the child. Give an additional small meal
per day for several days.

Zinc supplementation is now recognized as the best way
to reduce the length and severity of diarrhea. Because fluid
replacement is critical, zinc should NEVER take the place of
ORS. Zinc supplementation should be for 10/14 days * (see
below) in the recommended dose for the child’s age. Give
the first tablet to the child, demonstrating to the mother
how to dissolve it in water or breastmilk. These tablets can
also be chewed if the child is old enough.
Things to remember during home treatment of diarrhea

Different types of fluids or solutions may be used to prevent
dehydration. They are dependant on:
» local traditions for treatment of diarrhea
» availability of suitable food-based fluids (rice water,
soups gruels, etc.)
» availability of salt and sugar for making home recipe
» availability of oral re-hydration salts (ORS)

If the child does not seem to improve within three days, tell
the mother to go to the health clinic immediately.

* Some manufacturers produce 10-day packs while others produce 14-day packs.
See Annex 3 for more information and suggestions.
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2. Treatment guidelines
Oral Rehydration Solution is still the most important part of
diarrhea management. Both new and old versions of ORS are
prepared the same way.
Preparation: One packet mixed in 1 L clean water
Dose: Liberally given to the child to replace fluid
loss up to 20ml/kg body weight per hour
Administration: Infants — by clean dropper or syringe (no
needle); Children under 2 — by spoon
every 12 minutes; Older children — by
cup, frequent small sips. Avoid bottles and
nipples.
Side Effects: Vomiting may occur if given too quickly.
If vomiting occurs, wait 5-10 minutes and
begin ORS again.

Zinc Supplementation is now recommended for all children

with diarrhea.
Dose: 20mg/day for children 6 months of age or
older (1 tablet); 10mg/day for infants less
than 6 months of age (1/2 tablet)
Duration: 10/14 days even if diarrhea has stopped.
Supplement: Dispersible (dissolvable) tablets and syrups
(in some countries)
Administration: Tablets can be chewed or dissolved in clean
water, ORS, or breastmilk.
Side Effects: Vomiting is common in diarrhea and
sometimes children vomit after taking a zinc
supplement. Unless vomiting is severe this
should not prevent administration of the
zinc supplement.

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 Homemade sugar-salt solution. If the policy in your country
permits community-based workers to suggest a homemade
alternative to oral rehydration solution, the procedure below
is an example of an easy, general recipe.
Preparation: Wash hands and a container with soap and
clean water. To a half-liter of clean water,
add a “pinch” of salt (using 3 fingers to
make a “pinch”) and a “fistful” of sugar.
Stir the water with a clean spoon. Taste
the prepared solution. Correctly prepared
solution tastes like tears.
Dose: Liberally given to the child to replace fluid
loss up to 20ml/kg body weight per hour
Administration: Infants — by clean dropper or syringe (no
needle); Children under 2 — by spoon
every 12 minutes; Older children — by
cup, frequent small sips. Avoid bottles and
nipples.
Storage: Solution can be left at room temperature for
up to 6 hours, in a covered container. If left
at room temperature for longer than this,
it should be discarded and a new solution
should be prepared.

3. Child Feeding during Diarrhea

The child should be offered small amounts of nutritious,
easily digestible food frequently.

Feeding during a diarrhea episode provides nutrients the
child needs to increase strength and prevent weight loss
during the illness.

Fluids given to the child do not replace the need for food.
After the diarrhea has stopped, an extra meal each day for
a week will help the child regain weight lost during the
illness.

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4. Special notes
Adult diarrhea. Although this document discusses treating
children, the same treatment is also good for adults with
diarrhea.
Antibiotics. Antibiotics are not needed for most diarrhea
cases and should be discouraged. If a child has blood in the
stool or if for any reason he/she may need an antibiotic, you
should refer tne child to a health center immediately.

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 Teaching Parents About Home-Based Treatment
Most children with diarrhea will be successfully treated at
home as long as dehydration is not present. You must teach the
mother how to use ORS, how to use zinc, and how to recognize
danger signs, and when to take the child to the clinic.

ORS Therapy
1. Explain that the child is losing a lot of fluid and it must be
replaced.
» ORS will replace lost fluid
» ORS will keep the child from becoming dehydrated
2. Demonstrate how to prepare ORS.
3. Explain that ORS should be given liberally while the child
has diarrhea and extra liquids should be given after each
stool is passed.
4. Know local ORS alternatives (local ORT recipes) and be able
to demonstrate. This is important if ORS is not available or
costs too much for the mother. ORS should be recommended
for the dehydrated child.
5. Explain not to stop ORS until the child has no more signs of
diarrhea.
6. Remind mother about the importance of continued feeding
(including breastfeeding).

Zinc supplementation
1. Explain that the child should take zinc to help stop the
diarrhea.
» Zinc will shorten the time and lessen the severity of the
diarrhea
» Zinc will help the child fight off diarrhea and
pneumonia for 2-3 months.
» Zinc will improve appetite and growth.
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2. Explain the dose to the mother
» Children less than 6 months of age receive ½ tablet 1
time per day for 10/14 days.
» Children 6 months to 5 years receive 1 tablet 1 time per
day for 10/14 days.
3. Show the mother how to give the zinc tablet to the child.
» For infants: Dissolve the tablet in a small amount of
expressed breastmilk, ORS, or clean water in a small
cup or spoon.
» Older children: Tablets can be chewed or dissolved in a
small amount of clean water in a small cup.
NOTE: If mother is scared or uncertain, and you have
enough zinc you may offer to let her taste one so
she is less scared about giving the supplement to
her baby.
4. Remind the mother that the child should get all 10/14 tablets
even if the diarrhea ends in a few days.
» Again tell the mother that zinc will improve the overall
health, growth, and appetite of the clild.
» Remind her to give only to this child for this episode
of diarrhea and not save it for other children or other
illnesses.
5. Answer any questions the mother might have.

Encouraging Eating and Drinking

1. Encourage a lot of liquids during diarrhea.
2. Explain the need to continue to provide the child with good
food based on local acceptance and availability.
3. ALWAYS encourage breastfeeding for as much and as often
as the baby wants. If the child drinks animal milk it can be
continued as normal.

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 4. The following liquids are appropriate to provide during
diarrhea.

GOOD LIQUIDS WITHOUT SALT GOOD LIQUIDS WITH SALT

Clean Water ORS
Unsalted rice water Salted Soup
Unsalted yoghurt drink Salted yogurt drink
Green coconut water Salted rice water
Weak tea
Unsweetened fresh fruit juice

5. Remind mothers what liquids NOT to give.

DO NOT GIVE
Soft drinks
Sweetened tea
Sweetened fruit drinks
Coffee
Some medicinal teas or infusions

When to take her child to the clinic. Mothers should go

immediately to the clinic if the child. . .

Does not improve in 3 days

Has an increase in the number of stools

Begins to have very watery or bloody stools

Has severe vomiting

Develops a high fever

Has a marked thirst or begins eating or drinking poorly

Has a decrease in alertness or consciousness

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 Annex 1
Two of the following signs:
Does the child have diarrhea?
• Lethargic or unconscious
• Is the stool more watery than usual? for Refer URGENTLY to health
DEHYDRATION • Sunken eyes clinic with mother giving
• Are there 3 or more loose or watery SEVERE
frequent sips of fluid on
stools a day? • Not able to drink or DEHYDRATION
the way. Advise the mother
drinking poorly to continue breastfeeding.
If yes
• Skin pinch goes back very
ASK: LOOK AND FEEL: slowly.

• For how • Look at the child’s

Classify Two of the following signs: Refer to health clinic with
long? general condition. Is DIARRHEA mother giving frequent sips
the child: • Restless, irritable of fluid on the way. Advise
• Is there the mother to continue
blood in the Lethargic or • Sunken eyes SOME breastfeeding.
stool? unconscious? DEHYDRATION
• Drinks eagerly, thirsty Give fluid, zinc
• Is there Restless and supplements and food.
• Skin pinch goes back
vomiting? irritable? slowly. Monitor for improvement
• Look for sunken
Not enough signs to Give fluid, zinc
eyes. NO
classify as some or severe supplements and food to
DEHYDRATION
• Offer the child fluid. dehydration. treat diarrhea at home.
Is the child:

Not able to drink or Refer URGENTLY to health

drinking poorly? AND SEVERE clinic with mother giving
PERSISTENT frequent sips of fluid on
Drinking eagerly, Dehydration present DIARRHOEA the way and continuing
thirstily? if diarrhea 14 breastfeeding.
days or more
• Pinch the skin of the
AND PERSISTENT
abdomen. Does it go Refer to health clinic.
back: No dehydration DIARRHOEA

Very slowly (longer

than 2 seconds)? if blood in Blood in the stool DYSENTERY Refer to health clinic.
Slowly? stool

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 Annex 2
Frequently Asked Questions
Zinc supplements are a new treatment for diarrhea so mothers
may have many questions. Knowing the answer to common
questions will help you calm fears and address issues.

Zinc and ORS

Q: Can I give zinc and ORS at the same time?
A: Yes, zinc and ORS can be and should be given at the same
time while your child has diarrhea. Zinc is given once a day
and can be given with ORS. Give the zinc at a time of day
that is easy for you to remember and repeat every day until
all zinc tablets are gone. ORS needs to be given throughout
the day while your child has loose stools.

Q: Should I give less ORS since I am giving zinc?

A: No, you should continue to give ORS liberally even though
you are giving zinc. Zinc helps reduce the diarrhea, but does
not help prevent your child from losing too many fluids. The
ORS is important to help your child not lose too much fluid.

Length of time to use zinc

Q: Why do I give zinc after my child is better?
A: Zinc is good for your child while he/she is sick, but it is
important to give to your child after he is better too. The
zinc will help your child grow and will improve his/her
appetite. Remember, even though your child does not have
loose stools, he/she will still need to take the zinc AND eat
and drink a lot for 2 weeks, all of this will help replace lost
nutrients. Zinc will help your child not get diarrhea again
soon.

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Vomiting
Q: If my child vomits the zinc should I give another one?
A: Yes, try to give the child one more tablet. Wait until he/she
is calm again and not vomiting. Make sure your child is not
vomiting ORS. When he/she takes ORS with no problems,
give the next zinc tablet. If he/she vomits after the second
tablet do not give anymore on that day, wait to give the next
tablet until the next day. Give zinc again the next day and
daily until there are no more tablets in the pack.

Q: If my child is vomiting other things, like ORS, should I try to

give the child zinc?
A: No, if your child is vomiting ORS and all food and other
liquids you should bring him/her to the health center.

Side effects
Q: Can zinc have any bad side effects?
A: The only side effect of zinc supplementation is sometimes
vomiting. You should not expect any other side effects. As
always, go to the health center if your child has any danger
signs with or without the zinc supplements.

Q: I think tablets are bad for babies, what do I do?

A: This tablet should be dissolved in breastmilk, ORS, or clean
water. When you do that you will make a small syrup to
give to your baby. Babies like this very much, especially in
breastmilk.

Q: What if my child takes more than one tablet?

A: You should keep the tablets away from any children in the
house to prevent this from happening. If your child takes

15
 too many tablets he/she will probably vomit them up. Your
child should take 1 per day. One or two extra taken by
mistake will likely not hurt your child, but you should come
to the clinic and discuss what happened with a health care
worker, just to be safe.

Q: Are vitamins/minerals harmful for my child who has a bad

stomach?
A: No, vitamins and minerals are very important while your
child is sick and will help your child get better faster. You
should give the zinc to your child even though his stomach
is bad.

Q: I give a multivitamin to my child; can I give zinc on top of

that?
A: Yes, your child is losing a lot of zinc in his stools right now,
so giving more than usual zinc is good while he/she is sick.
After the diarrhea is over it will help replace lost nutrients.
You can continue to give the multivitamin and give the zinc
as diarrhea treatment for the full 10/14 days. This will not
harm your child.

Other Medicines
Q: Can zinc be given with other medicines?
A: Yes, zinc is OK to be given with other medicines. Only give
your child medicines that are prescribed at the clinic [or by a
community health care worker].

Q: Should I get an antibiotic for the diarrhea?

A: Only children with bloody diarrhea need antibiotics. If you
start to see blood in your child’s stool, bring him/her to a
healthcare center for further assessment and treatment.

16
Persistent Diarrhea
Q: What do I do if my child does not get better? Could this be
because of the zinc?
A: If your child does not improve continue to give the zinc. If
your child does not get better that is not because of the zinc,
but some other reason. If he/she is not improved in 3 days,
take him/her to the health center. Also, go to the health
center if at any time he/she shows any danger signs.

Blood in the stools

Q: Can I give zinc if my child has blood in the stools?
A: Yes, zinc can be given if your child has bloody stools. If
your child develops bloody stools, you should go to the
health center for more medicine. Your child will need an
antibiotic.

Feeding
Q: Should I feed my child as usual?
A: Yes, continue to feed your child and offer an extra meal per
day for several days. If your child will eat more than usual,
allow him/her to do that. Increased foods will help him/her.
Do not restrict eating.

Q: Should I give breastmilk?

A: Yes, allow your baby to breastfeed as much as he/she
wants. This might be more than usual and that is good.
Allow your child to eat as many times as he/she wants for
as long as he/she wants.

17
 Q: Does breastmilk cause diarrhea?
A: No, breastmilk is not the cause of diarrhea. Keep
breastfeeding your child. Breastfeeding can prevent diarrhea.
Babies under 6 months of age should get only breastmilk to
prevent diarrhea.

Q: Can I still give my child milk?

A: Yes, if your child already drinks cow’s milk, you can keep
giving this to him/her. Be sure to also give lots of ORS and
plain clean water as well.

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Annex 3
Potential Local Adaptations

Supplement Availability
Ten or fourteen days
The WHO recommendation found in the publication, “The
treatment of diarrhoea — a manual for physicians and other
senior health workers,” is for a 14-day dose of zinc. However,
some manufacturers may produce a 10-day tablet pack to be
promoted in a local or country-wide setting. To account for each
scenario in this document, the dose is designated as 10/14 and
should be read as one or the other, in concordance with the
local product and policy.

Tablets and/or syrup

The most convenient delivery system for zinc treatment is a
dispersible tablet. Currently, there is only one producer which
has such a tablet available, meeting international product
standards. Efforts will be made to encourage other producers.
However, there might be other zinc products locally available
in either tablet or syrup form. These products may or may not
meet minimum standards. Promotion of zinc products should be
based upon quality assurance and product safety and must be
reviewed at the national and/or local level.

Local Food and Drink

Foods and fluids during diarrhoea are very important. The
lists provided in this manual are meant to serve as a guide
and can not include all appropriate food and beverages for all
local situations around the world. Food and drink vary from
country to country and region to region. The health worker is
expected to be able to use these lists as a guide to develop his/
her local version of these suggestions, taking into consideration
availability, accessibility, and acceptability by mothers during
diarrhoea episodes.
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