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Diarrhoea Management

Home > Programmes > Diarrhoea Management



Call to Action on diarrhoeal disease

With more resources and effective implementation of available health, water and sanitation solutions, we can save millions of children right now. That diarrhoea remains a leading cause of death among children around the world exemplifies the urgency of reinvigorating efforts to improve child health and human development. more >>


image: Countries with the greatest number of rotavirus-related deaths

25 October 2011 - 2008 estimate of worldwide rotavirus-associated mortality in children younger than 5 years before the introduction of universal rotavirus vaccination programmes: a systematic review and meta-analysis

The Lancet Infectious Diseases, Early Online Publication - download pdf

Rotavirus remains a major killer of children under five years of age worldwide, taking the lives of 453,000 children in 2008 according to the latest estimates, published today in the Lancet Infectious Diseases journal. This translates into the staggering fact that more than 1,200 young children will die from rotavirus diarrhea each day. Rotavirus-related deaths accounted for 37% of all diarrheal deaths and 5% of all deaths in children under five years of age. One of every 260 children born each year will die from rotavirus diarrhea by their fifth birthday.

Tragically, approximately 95% of rotavirus deaths occurred in countries that are eligible to receive GAVI-support to introduce rotavirus vaccines. Five countries–India, Nigeria, Pakistan, Democratic Republic of Congo, and Ethiopia–all GAVI-eligible, accounted for more than half of all rotavirus deaths globally.

Introduction of effective and available rotavirus vaccines could substantially affect worldwide deaths attributable to diarrhoea. Our new estimates can be used to advocate for rotavirus vaccine introduction and to monitor the effect of vaccination on mortality once introduced.

Diarrhoea Management

Diarrhoea Management

Intended to target mothers’ confusion and lack of understanding about how to recognize, assess the degree of, and treat diarrhoeal dehydration. Mothers will be taught the importance of ORT, the crucial need for immediate fluid replacement, increased fluids and food, how to correctly prepare home-made and packaged ORS, cereal-based ORS, when and why to use it,  continuous feeding, including breastfeeding and discourage the use of drugs to treat childhood diarrhoea.


Name: Diarrhoea Management
Theme: Health Education to Mothers Region and Country: Maharashtra, India
Partners: Beneficiaries:
Funding Need: Budget:
Duration: Contact:

Programme Activities:
After 37 years of ORT knowledge and more than 15 years of promotion of a variety of ORS Programmes, 42% of mothers in Maharashtra still believe that a child with diarrhoea should receive less fluid and less food than normal. This programme serves the need for a comprehensive programme approach for successful prevention and treatment of dehydration from acute diarrhoea which includes efforts on three fronts:

  1. improving the outreach and effectiveness of diarrhoea management throughout the health system;

  2. using all available channels to disseminate knowledge, impart skills, and encourage the practice of better management of diarrhoea; and

  3. producing and distributing appropriate supplies and equipment for the management of diarrhoea.

a. Use of health system for delivery of ORT

Efforts need to be directed at three levels: the household, the community, and the clinic or hospital. Early home therapy is important to prevent dehydration, ORS is needed to treat most cases of dehydration, and intravenous therapy is required to treat severely dehydrated cases. Efforts must be directed at strengthening health delivery services and enlisting community participation to support activities at all three levels. More specifically:

  1. In the home, mothers and other members of the family should be informed and trained (i) to recognize diarrhoea in infants and children as an illness requiring early treatment; (ii) to prepare and give a "home remedy" by mouth; and (iii) to recognize when they should seek additional medical care, including ORS. The type of household solution to be used and its method of preparation will vary according to what mothers have available, cultural practices, the food normally used in the home, the price and availability of salt and sugar, the ability of mothers to prepare a solution accurately, the presence of standard measuring utensils, and the extent of outreach of the health delivery system. Any of the approaches indicated above for the preparation and use of home remedies can be adopted, though in most areas some operation research may be needed to determine which of the approaches is most feasible, safe, and effective. It is recommended that, if possible, the home remedy should have sodium and glucose concentrations that are between 50-100 mmol/1. The presence of even a small amount of potassium (e.g. that provided by fruit juice) can be beneficial. Making ORS packets routinely available for home use is probably feasible and desirable if deemed necessary in the community. In the majority of communities, the goal should be to have ORS packets readily accessible in the community for those who need them and who have had instruction in their use, which means distribution to the most peripheral level of the health services as possible.

  2. The first-level health worker, a community health worker who has a crucial role to play in disseminating knowledge and skills for the management of diarrhoea, as regards the use of both home remedies and ORS. ORS packets should be available in adequate supply at this level and throughout the entire health system. If this is not possible, maximum efforts should continue towards this end and, in the meantime, as complete a formulation as possibly should be used, recognizing its limitations. When potassium is a missing ingredient, patients should be encouraged to drink fluids that are rich in potassium (fruit juices). For the preparation of ORS solution the safest water should be used.

  3. In clinics and hospitals having the appropriate equipment and trained staff, intravenous fluids should be used to re-hydrate severely dehydrated cases and the few other diarrhoea patients (for example, those with vomiting that are not responding to treatment) for whom it is required. Mothers should be knowledgeable about different effective home rehydration solutions.

Other aspects in the management of diarrhoea:

Two other aspects must complement ORT:

Experience shows that food should not be withheld from infants and children with acute diarrhoea. Depending on their feeding status, children should receive breast-milk or diluted milk feeds; in cases of dehydration, these should be offered as soon as initial rehydration therapy has been completed. Appropriate locally available foods (cereals) should be offered as soon as the appetite returns. After the diarrhoea ceases, more than the usual amount of food should b given for a short period. The routine use of any special infant formula (lactose-free products) for diarrhoea cases should be strongly discouraged as they are only rarely necessary and are costly.

Other drugs:
Selected antibiotics should be judiciously used for the treatment of severe dysentery and cholera; otherwise, there is no need for other pharmaceuticals in the routine treatment of acute diarrhoea.

b. Use of communication channels:

Often a contributory cause of childhood dehydration and consequent death is the objection of the mother to providing fluids to the child suffering from diarrhoea. There is an urgent need to understand her present attitudes, perceptions, and practices regarding diarrhoea as well as those of health and other community workers. Socio-cultural research, group interviews and proper pre-testing are indispensable tools for the design of messages that will motivate her to a more appropriate and timely response at the first sign of diarrhoea. To change her attitude to the management of diarrhoea, and enhance her capacity for it requires a considerable but sensitive effort in effective person-to-person and mass media communication.

Appropriate educational and training materials need to be prepared to transmit priority messages on the preparation and administration of ORT solutions, the importance of continued feeding, and the need for referral if the child's condition worsens. Lessons on the causes and treatment of diarrhoea should also be given in primary schools.

Mothers require individual instruction and often need to observe a practical demonstration and practice mixing a number of times in order to prepare ORS or "salt and sugar" solutions correctly.

Separate guidelines for the management of acute diarrhoea need to be prepared for first-line, aid-level, and senior-level health workers. These should be based on well-established practices, but adapted to meet local needs.

c. Production and distribution of appropriate supplies:

There is a need for pre-packed ORS in a suitable quantity for mixing in an appropriate, "universally" available measuring container. Such packets can be manufactured industrially on a large scale by government of private pharmaceutical companies using laminated aluminum foil to prolong their shelf-life, or produced by a "cottage industry" approach using less expensive packaging material. The seasonal character of diarrhoea in the country should b borne in mind when timing both the production and distribution of packets. The use of tri-sodium citrate in place of sodium bicarbonate allows the use of cheaper packaging materials. Any packets produced locally should bear instructions for their use in the local language, and preferably be accompanied by inexpensive pictorial and printed material.

In clinics and hospitals with even the simplest pharmacies, ORS can be prepared in bulk for administration to visiting patients, and in simply made packets for immediate use at home. In view of the need for greatly increased supplies of ORS, such cost-saving measures should be implemented whenever possible, and efforts should be made to develop appropriate small-scale production technology.

The marketing and distribution of supplies of prepackaged ORS through commercial and non-governmental channels should also be promoted. Where a large enough demand can be generated through widespread promotional efforts, it will be possible to distribute ORS on a commercial basis, as has been demonstrated in some countries.

In establishing this programme, the production and distribution of other supplies besides ORS, such as intravenous fluids, weighing scales, containers, measuring spoons, and educational materials also need to be considered.

Intended Results:
This programme will serve as an informational and training programme about diarrhoea management and prevention for mothers and health-care providers. It will emphasize the importance of ORT, increased fluid intake, and continued feeding, and discourage the use of drugs to treat childhood diarrhoea. This programme will also facilitate the use of necessary communication channels to promote necessary diarrhoea management and prevention messages, and monitor the production and distribution of appropriate supplies.

Programme Management and Implementation:
This programme will be managed and implemented by the state of Maharashtra, local distributors and manufacturers of medical and related supplies, health care workers, mothers, and training personnel.

Programme Monitoring and Evaluation:
Initially, monitoring and evaluation will oversee the programme creation and its implementation in the targeted communities. Eventually, monitoring will check recall and the understanding of the targeted audiences, and modifications will be made as necessary.

Learning and Dissemination:

Related Resources:

Diarrhoea Treatment Guidelines
Including new recommendations for the use of ORS and zinc supplementation
for Clinic-Based Healthcare Workers 


- 58 pages - Diarrhoea Treatment Guidelinespdf 398 kb
These guidelines are designed to prepare clinic-based health workers to implement the new WHO/UNICEF recommendations for the use of ORS and zinc supplementation in the clinical management of diarrhoea. The information is meant to complement, not replace, more comprehensive policy guidance available from WHO on the management of diarrhoea. The guidelines presented here are generic, that is, they will be most effective when modified to support the particular strategy being used to introduce the new recommendations in each country.

Disparities in the Treatment of Childhood Diarrhoea in India
Nisha Malhotra and Nicholas Choy
August 2010 download pdf19 pages - 246 kb

Despite the severe impact of diarrhoea on children's health and mortality in India, recent surveys show that only half of all children suffering from diarrhoea receive treatment or medical advice, and more than two-thirds receive no Oral Rehydration Therapy (ORT). An understanding of the socio-demographic determinants for appropriate treatment of the disease will be critical for improving these figures. This analysis is based on the most recent National Family Health Survey (NFHS3), which shows that children are more likely to receive ORT if they are treated in a public health facility, rather than in a private health facility. Households with mothers belonging to the youngest age group, lowest educational attainment, and poorest wealth index are the least likely groups to properly treat their children suffering from diarrhoea. A significant gender bias also exists as parents show a preferential treatment of male children and delay seeking treatment for their female children. The low usage of ORT can also be attributed to a combination of low health knowledge among the aforementioned groups, and low use of public health facilities.



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