6

M O D U L E 6

Diarrhea and Dehydration

Clifton Yu | Douglas Lougee | Jorge R. Murno
 6
Diarrhea and Dehydration
Clifton E. Yu, MD, FAAP
Douglas A. Lougee, MD, MPH
Dr. Jorge R. Murno

INTRODUCTION

Poor sanitary conditions in disaster-stricken areas result in higher risk for

diarrheal illness in vulnerable populations, especially children. This disease
negatively impacts the nutritional status of affected children and causes significant
morbidity and mortality. Early diagnosis and treatment are thus essential to
reduce the impact of diarrheal diseases on people affected by disasters. Early
identification of cases allows the implementation of measures needed to prevent
or lessen outbreaks that can occur in displaced populations in this context. The
use of primary care management tools, such as the Integrated Management of
Childhood Illness (IMCI) strategy is highly important.
This module will first discuss diarrheal diseases and their management, and
dehydration and its treatments.
 SECTION I /
DIARRHEAL ILLNESSES

DIARRHEAL ILLNESSES

Definition of Diarrhea
OBJECTIVES Diarrhea is the passage of loose or
watery stools at least 3 times in a 24-
l Describe the management of acute hour period. However, it is the consis-
diarrhea.
l Identify the clinical indications for
tency of the stools rather than the num-
antibiotic therapy for diarrheal illness in ber that is most important. Acute diar-
an acute emergency setting. rhea may be caused by different viruses,
l Identify the clinical features of dysentery,
bacteria, and parasites. Rotavirus and
the most frequent causative pathogens,
Norwalk-like virus are the most com-
and the antibiotics that can be used to
treat the infection. mon agents, causing up to 50% of acute
l Use the Integrated Management of diarrhea cases during the high-incidence
Childhood Illness (IMCI) guidelines in the seasons. It is most practical to base the
treatment of children with diarrhea.
treatment of diarrhea on the clinical
type of the illness, which is easy to
establish when a child is first examined.
Usually there is no need for laboratory
tests.

CASE.
In disaster situations, due to overcrowded living conditions, lack of adequate clean
water supply, and stool disposal, diarrhea is one of the most significant causes of
morbidity and mortality, particularly among children. Early detection and treatment
are therefore key elements in public health interventions, not only to manage
individual cases but also to prevent transmission of the disease to the rest of the
population. Effective hygiene measures markedly reduce the frequency of diarrheal
diseases.

1 What is the most probable etiology of this infant’s illness?

2 What treatment should be given?

3 What measures should be taken to prevent recurrences?

Continues on page 14.

 6 SECTION 1 / DIARRHEAL ILLNESSES

In disaster situations, due to over- Management of Acute

crowded living conditions, lack of ade- Watery Diarrhea
quate clean water supply, and stool dis- Dehydration is the most common compli­
posal, diarrhea is one of the most signifi­ cation of acute watery diarrhea in chil-
cant causes of morbidity and mortality, dren. Assessment and treatment of this
particularly among children. Early detec- complication are discussed in Section III.
tion and treatment are therefore key ele- Watery diarrhea caused by o ­ rganisms
ments in public health interventions, not other than Vibrio cholerae is usually self-
only to manage individual cases but also limited and requires no antibiotic ther-
to prevent transmission of the disease to apy. It is important to note that antibi­
the rest of the population. Effective otics have the potential to prolong the
hygiene measures markedly reduce the ­disruption of intestinal homeostasis and
frequency of diarrheal diseases. delay the recovery of normal bowel
flora. Therefore, the Integrated
Types of Diarrhea Management of Childhood Illness (IMCI)
In a disaster scenario a child with diarrhea recommends use of oral antimicrobi-
may present with three potentially severe als only for children with bloody diar-
or very severe clinical conditions: (1) rhea (amoebic or bacterial dysentery),
acute watery diarrhea (including cholera), cholera, and giardiasis. Treatment for
­
which lasts several hours or days, and can these infections is discussed later in this
cause dehydration, (2) acute bloody diar- section.
rhea or dysentery, which may cause intes- Antidiarrheal or antiemetic medications
tinal damage, sepsis, malnutrition and are not recommended to treat acute diar-
IMCI recommends dehydration, and (3) persistent diarrhea rhea, since they reduce intestinal ­motility,
use of oral (diarrhea that lasts more than 14 days).
antimicrobials only for
lengthen the course of the disease, pro-
children with bloody All children with diarrhea should be long the contact of the causal pathogen
diarrhea (amoebic or assessed to determine the duration of with the intestinal mucosa, and can wors-
bacterial dysentery), diarrhea, if there is blood in the stools, en systemic symptoms.
cholera, and giardasis.
and if dehydration is present. Nutrition is also an important issue in
Acute watery diarrhea is mainly caused children with diarrhea. It is widely rec­
by rotavirus, Norwalk-like virus, entero- ognized that fasting does not modify the
toxigenic Escherichia coli (ETEC), Vibrio outcome or severity of the diarrheal dis-
cholerae, Staphylococcus aureus, Clostridium ease. Therefore, in a child with diarrhea
difficile, Giardia, and cryptosporidia. Most and normal hydration status breastfeed-
frequent pathogens associated with acute ing (or bottle feeding with usual milk or
bloody diarrhea are Shigella and Entamoeba formula if the infant is not breastfed), as
histolytica. Campylobacter sp, invasive well as feeding with age-appropriate
Escherichia coli, Salmonella, Aeromonas food should be continued. A lactose-
organisms, C. difficile, and Yersinia sp can also reduced or lactose-free diet provides no
cause bloody diarrhea. benefit to children with acute diarrhea.
 SECTION 1 / DIARRHEAL ILLNESSES 7

In children with dehydration, ­feeding the child’s stools. Bloody diarrhea in young
should be resumed as soon as n­ ormal children is usually a sign of invasive enteric
hydration is achieved through any rehy- infection that carries a substantial risk of
dration therapy appropriate for the serious morbidity and death. About 10%
severity of the dehydration. Remember of all diarrhea episodes in children under 5
that malnourished children are at higher ears old are dysenteric, but these
risk of diarrhea due to intestinal m
­ ucosa cause up to 15% of all diarrheal deaths.
alteration. The diarrheal illness in these Dysentery is especially severe in infants
patients can last longer because of the and children who are undernourished or
reduced enterocyte turnover. Thus, who develop clinically-evident dehydration The goal of
dysentery treatment
reduced food intake only worsens the during their illness. Diarrheal episodes that is clinical
degree of malnutrition prior to the begin with dysentery are more likely to improvement, as well
as shortening the
­episode of acute diarrhea. become persistent than those that start fecal shedding of the
Patients with diarrhea but no signs of without blood in the stools. causative pathogen
dehydration usually have a fluid d ­ eficit The goal of dysentery treatment is clini- to limit transmission.

less than 5% of their body weight. cal improvement, as well as shortening the
Although these children lack distinct fecal shedding of the causative pathogen to
signs of dehydration, they should be limit transmission. Evaluate children with
given more fluid than usual to prevent acute bloody diarrhea. Administer appro-
dehydration from developing. Table 1 priate fluids to prevent or treat dehydra-
shows the classification of diarrhea with- tion, and provide food. In addition, they
out dehydration or blood in stools, should receive for 5 days an oral antimi­
according to the IMCI strategy. crobial active against Shigella, since this is
the responsible organism in most cases (up
Management of Acute to 60%) of dysentery in children.
Bloody Diarrhea It is essential to know the sensitivity of
Bacterial Dysentery Shigella local strains, because antimicrobial
A child is classified as having dysentery if resistance is common. A number of antimi­
the mother or caregiver reports blood in crobials often used for the management of

TABLE 1. Classification of children with diarrhea without dehydration or blood in

stools

Assess signs Classify Treat

(GREEN) (GREEN) (GREEN)

Not enough signs to No dehydration • Give food and fluids for treatment at home
classify as (see Plan A on page 21).
dehydration • Tell the mother which signs require immediate
medical attention.
• If diarrhea persists, follow-up in 5 days.
8 SECTION 1 / DIARRHEAL ILLNESSES

dysentery, such as amoxicillin and site, and also presents with bloody
­trimethoprim-sulfamethoxazole (TMP/ diar­rhea. It is transmitted by fecal-oral
SMX), may be ineffective for treating shigel­ route, particularly through contaminat-
losis irrespective of the local strain sensitiv- ed water and food. The most severe
ity. If available, consider ceftriaxone, a forms occur in infants, pregnant women,
flu­oroquinolone (in patients older than 18 and malnourished children. As in
years), or azithromycin for resistant Shigella-associated dysentery, the stools
strains. Ideally a stool culture is performed often contain visible blood, and d ­ iarrhea
to identify the organism and guide treat- may be associated with fever and
ment according to antimicrobial sensitivity. abdominal pain. Hepatomegaly may be
­
Hospital referral is recommended if the present.
child is malnourished or if there is a previ- Complications include fulminant coli-
ous underlying illness that can complicate tis, toxic megacolon, bowel perforation,
the diarrheal disease. and liver abscess.
Some regions of Latin America, such as When a microscopic test reveals amoe-
Argentina, have a high incidence of bic trophozoites or cysts, or when a
­hemolytic-uremic syndrome, a very severe patient with bloody diarrhea has failed two
condition caused by Shiga toxin-producing different antibiotic series, give metronida-
strains of E. coli, and associated with acute zole (30 mg/kg/day for 5-10 days).
renal failure. Antibiotic treatment may
pre­­cipitate renal failure. In these regions,
before starting empiric antibiotic therapy, Management of Persistent
take a sample of stools for culture that will Diarrhea
provide results within 48 hours. Persistent diarrhea is an episode of diar-
Evidence of improvement in bloody rhea, with or without blood, which begins
­diarrhea include defervescence, less blood acutely and lasts at least 14 days. It
in stools, less frequent evacuations, accounts for up to 15% of all episodes of
improved appetite, and a return to normal diarrhea but is associated with 30% to
activity. If there is little or no improvement 50% of deaths. Persistent diarrhea is usu­
after 2 days, refer the child to a hospital for ally associated with weight loss and often
further evaluation and treatment. If referral with serious non-intestinal infections.
is not possible, perform a stool culture in Many children who develop persis-
order to identify the organism and adjust tent diarrhea are malnourished, greatly
antibiotic therapy. If the child is improving, ­increasing their risk of death. Persistent
the antimicrobial should be continued for diarrhea almost never occurs in infants
5 days. who are exclusively breastfed.
All children with diarrhea for 14 days or
Amoebic Dysentery more should be classified based on the
Amoebic dysentery is caused by presence or absence of any dehydration
Entamoeba histolytica, a protozoan para- (Table 2):
 SECTION 1 / DIARRHEAL ILLNESSES 9

TABLE 2. Classification of children with persistent diarrhea

Has the child had diarrhea for 14 days or more?

Assess signs Classify Treatment

With dehydration Severe persistent •T reat dehydration before and during the child’s
diarrhea transfer, unless the child has another severe
condition
• Refer to hospital

Without dehydration Persistent diarrhea •T each the mother how to feed the child with
persistent diarrhea*
•T ell the mother which signs require immediate
medical attention
•G ive multivitamin and minerals (including zinc)
for 14 days
• Follow-up in 5 days

*Recommend that the mother temporarily reduce the amount of animal milk to 50 mL/kg/day, if animal milk is already part of the
child’s usual diet, and to continue breast-feeding. If the child is older than 6 months, appropriate complementary food should be given in
small, frequent amounts, at least 6 times a day.

l Children with severe persistent damaged gut mucosa and improve

diarrhea who also have any degree of nutritional status; c) avoid giving foods
dehydration require special treatment or drinks that may aggravate the
and should not be managed at the diarrhea; and d) ensure adequate food Proper feeding is the
most important aspect
outpatient facility. Referral to a hospital intake during convalescence to correct of treatment for most
is required. As a rule, treatment of any malnutrition. children with
dehydration should be initiated first, persistent diarrhea
unless there is another severe Routine treatment of persistent diar-
classification. rhea with antimicrobials is not effective.
l Children with persistent diarrhea and
Some children, however, have nonintes-
no signs of dehydration can be safely tinal (or intestinal) infections that require
managed in the outpatient clinic, at specific antimicrobial therapy. The per-
least initially. Proper feeding is the most
sistent diarrhea of such children will not
important aspect of treatment for most
improve until these infections are diag-
children with persistent diarrhea. The
goals of nutritional therapy are to: a) nosed and treated.
temporarily reduce the amount of
animal milk (or lactose) in the diet; b) Management of Giardiasis
provide a sufficient intake of energy, Giardiasis, an intestinal infestation due to
protein, vitamins, and minerals to a protozoan parasite, can also cause non-
facilitate the repair process in the bloody foul-smelling diarrhea that can be
 10 SECTION 1 / DIARRHEAL ILLNESSES

associated with chronic malabsorption. The ceptibility. Once cholera is confirmed in an

infection may be asymptomatic or may area, identification of subsequent cases can
Transmission of
cause abdominal cramps, epigastric pain, and be based on clinical findings. Since ­diarrheal
cholera in disaster flatulence. Fever is uncommon. Transmission illnesses with significant dehydration are
situations most occurs by fecal-oral route, through contami- common among children, the first recogni-
frequently involves
contaminated water nated water (particularly surface water), tion of cholera in an area is usually based
and increased fecal-oral from person to person, or fomites. Even a on the identification of an adult case.
spread related
to environmental small inoculum can result in infection. Suspect cholera in any adult presenting with
conditions. Consider treatment with metronidazole severe profuse watery diarrhea and severe
(15 mg/kg/day for 5 days) for children pre- dehydration, particularly if the patient dies
senting with chronic, malabsorptive, non- because of the illness.
bloody diarrhea without fever, as well as for Take measures to control the ­outbreak.
patients in whom a microscopic stool exam Take action to identify milder cases
identifies cysts or trophozoites. in ­ people who might not seek care.
Community efforts should involve
Epidemic Cholera improving sanitation, educating families
­
Cholera is a disease caused by the toxin about personal hygiene and food safety,
produced by Vibrio cholerae. It is an and ensuring a noncontaminated water
endemic infection in many parts of the supply. Occasionally household chlorina-
world, including tropical and subtropical tion or boiling of water will be necessary.
areas. Transmission of cholera in disaster Clinical manifestations of cholera
situations most frequently involves con- include painless diarrhea without fever.
taminated water and increased fecal-oral The volume of stools can vary consider-
spread related to environmental condi- ably. In severe cholera, stools have the
tions. Vibrio cholerae can survive in water appearance of rice water. The severe fluid
for 7 to 10 days. Contaminated food may loss can cause shock within the first 4 to
also result in outbreaks. 12 hours in untreated patients. Additional
It is important to identify outbreaks as findings include anxiety, muscle cramps,
early as possible and take preventive weakness (related to electrolyte alter-
measures. Cholera is a public health
­ ations and hypoglycemia), and altered
emergency. The first suspected case of ­mental status (Table 3).
cholera in an area needs to be confirmed
by culture, and public health authorities Management of Cholera
should be notified immediately. Treatment of patients with oral rehydration
Confirm the diagnosis with a qualified solution (ORS) by itself reduces the case
laboratory and determine antibiotic sus- fatality rate (CFR) to less than 1%. However,
 SECTION 1 / DIARRHEAL ILLNESSES 11

TABLE 3. Typical electrolyte composition of a cholera stool

Treatment of patients
Na+ K+ Cl- HCO3- with ORS alone
reduces the case
Adult 135 15 100 45 fatality rate (CFR) to
less than 1%.
Child 105 25 90 30

From: Mandell, Douglas, Bennett. Principles and Practice of Infectious Disease. 3rd ed. New York, NY: Churchill Livingstone; 1990.

antibiotic therapy with doxycycline, tetracy- is multidrug resistance. Manage mental

cline, TMP/SMX, erythromycin, chloram- sta­tus alterations with glucose to c­orrect
phenicol, or fluoroquinolones can reduce possible hypoglycemia. Once cholera is
the volume and duration of diarrhea, thus confirmed in an area, monitor CFR to
helping to limit transmission (Table 4). determine the adequacy/availability of
Fluoroquinolones are indicated when there rehydration therapy.

TABLE 4. Pediatric antibiotic doses for cholera

Doxycycline 6 mg/kg/dose (1dose)

Tetracycline 50 mg/kg every 6 hours for 3 days*
TMP/SMX 5 mg/kg (TMP) every 12 hours for 3 days

*Children >6 years

 SECTION II /
DIARRHEA IN INFANTS

DIARRHEA IN INFANTS
0 TO 2 MONTHS OF AGE
stools; these do not require treatment.
After that period, breastfed infants’ stools
OBJECTIVES continue to be loose, but usually without
l Identify the different types of
mucus or blood. The mother of an infant
­diarrhea. will normally recognize diarrhea because
l Define treatment for infants 0 to 2 either the consistency of the stools or the
months of age with diarrhea. frequency of evacuations will differ from
normal.
Nevertheless, consider diarrhea in an
infant younger than 2 months to be a
In this age group, diarrheal disease has severe infection and treat it accordingly.
some particular issues. The water c­ ontent
in the stools is higher than normal. Persistent diarrhea
Frequent evacuation of normal stools is Consider infants from 0 to 2 months of age
not diarrhea, and the number of evacua- with persistent (7 days or more) diarrhea
tions usually depends on diet and age. In a severely ill and refer them to a hospital
breastfed infant from 5 to 10 days of age whenever possible. These patients require
loose stools are normal. If the neonate is special care to prevent fluid loss. It might
in very good general status, with no signs also be necessary to make dietary changes
of illness and feeds appropriately, the and to perform laboratory tests to identify
diag­nosis will most probably be transition the cause of diarrhea (Table 5).

TABLE 5. Classification of persistent diarrhea in infants less than 2 months

Signs Classify as Treat

(PINK) (PINK) (PINK)

Diarrhea for 7 days Persistent diarrhea • Urgent referral to a hospital with mother
or more offering frequent sips of ORS
• Counsel the mother to continue
breast-feeding
 SECTION I1 / DIARRHEA IN INFANTS 13

Bloody Diarrhea under 2 months old with diarrhea.

Most frequent causes of bloody diarrhea Infection may occur at birth with organ-
in the neonate include hemorrhagic dis- isms present in the mother’s feces, or
Most frequent causes
ease (due to vitamin K deficiency), allergic afterwards by a great variety of o
­ rganisms of bloody diarrhea in
colitis, necrotizing enterocolitis, or other from other infected children or the moth- the neonate include
hemorrhagic disease
coagulation disorders, such as disseminat- er’s hands. Infecting agents causing diar- (due to vitamin K
ed intravascular coagulation due to sepsis. rheal diseases in infants younger than 2 deficiency), allergic
colitis, necrotizing
In infants older than 15 days of age, blood months old usually include Escherichia coli, enterocolitis, or other
in the stools may result from anal fissures, Salmonella, echovirus, and rotavirus. coagulation disorders,
such as disseminated
cow’s milk allergy, or surgical disorders, The disease may start abruptly, associ- intravascular
such as intussusception. Bacterial dysen- ated with poor feeding and/or vomiting. coagulation due to
sepsis.
tery is not common in this age group, but Stools may initially be yellow and loose,
when it is suspected, consider Shigella and then greenish and highly watery, and the
administer appropriate therapy. Amoebic number of evacuations may increase. The
dysentery is unusual in very young infants. most ominous feature of the disease is
Consider bloody diarrhea in this age acute fluid loss, resulting in dehydration
group as severe illness requiring urgent and electrolytic disorders. Hand washing,
referral to a hospital (Table 6). exclusive breastfeeding, and early ade-
Identification of a causal agent is possi­ quate treatment can prevent dehydration
ble in only a small proportion of infants and potential death.

TABLE 6. Classification of bloody diarrhea in infants less than 2 months

Assess signs Classify as Treat

(PINK) (PINK) (PINK)

Blood in stools Bloody diarrhea l Urgent referral to a hospital
l Counsel the mother to continue
breast-feeding if tolerated by the
infant
l Give a dose of intramuscular
vitamin K
l Give the first dose of the
recommended antibiotics
 SECTION III /
DEHYDRATION

DEHYDRATION
morbidity and mortality associated with
OBJECTIVES dehydration caused by diarrheal illness
regardless of the etiology.
l Describe and identify the different types
of dehydration. Dehydration Types
l Assess the degree of dehydration.
Dehydration is usually classified into 3
l Describe the physiologic basis of oral
types based on the amount of sodium in
rehydration therapy (ORT).
l Explain the characteristics and routes of
the blood: isotonic, hypotonic (hypona­
tremia), and hypertonic (hypernatremia).
administration of ORT solutions.
l List the advantages of ORT. In clinical practice, the first 2 can be
l Define when ORT has failed and when grouped into a single isohypotonic categ­
ORT is contraindicated. ory since they share similar p­hysiologic
l Describe how to give ORT to children characteristics, clinical presentations, and
with severe dehydration. treatments. In this case, net water and
l Outline a strategy for setting up an ORT
electrolyte loss is either hypertonic
Dehydration resulting unit at the site of a disaster.
from acute diarrheal (resulting in hypotonic dehydration) or
illness is one of the isotonic (resulting in isotonic dehydration)
most significant causes ­compared to normal plasma osmolarity. As
of morbidity and
Dehydration resulting from acute diarrheal a result of these losses, extracellular fluid
mortality in
populations displaced illness is one of the most significant causes volume (EFV) is significantly reduced, with
by disaster. of morbidity and mortality in populations no or little decrease in intracellular fluid
displaced by disaster. In some cases, it volume (IFV). Reduced EFV is responsible
accounts for more than 50% of the deaths for most of the clinical signs of dehydra-
during the initial stages of a humanitarian tion, which are therefore very evident.
emergency. The use of oral rehydration Hypertonic dehydration occurs when
therapy (ORT) has markedly reduced the net fluid losses are hypotonic in compari-

CASE. (cont.)
The child presents again 24 hours later. He has continued to have loose stools that
have now turned watery. He has also continued to vomit all fluids he has been offe-
red. The mother says he is drowsy and much weakened. There has been no urine
output for more than 8 hours. Physical examination shows marked sunken eyes,
reduced skin turgor (>4 seconds), capillary refill >5 seconds, and pale and cold skin.
4 What is the appropriate course of action at this moment?
 SECTION I1I / DEHYDRATION 15

son to normal plasma osmolarity. In this dynamic disturbance) dehydration can be

case, the osmolar balance between the made through the clinical signs that become
intracellular and extracellular compart- visible in each condition.
Severe dehydration
ment leads to the shift of water from the Remember that decreased skin turgor (fluid loss 10% of body
intracellular to the extracellular space. (skin pinch) may be misleading, since it can weight) is usually
Because EFV is thus compensated and be present in malnourished children without accompanied with
significant
less affected, clinical signs of dehydration dehydration. The Integrated Management of hemodynamic
are less obvious. The loss of intracellular Childhood Illness (IMCI) strategy classifies disturbance.
fluid results in intracellular dehydration dehydration and determines its treatment
evidenced by specific clinical features. according to clinical findings (Table 7).

Dehydration Degrees Hypertonic Dehydration

The most accurate way to assess the degree Hypertonic dehydration usually presents
of dehydration is by calculating the percent- with specific features associated with the
age of weight loss. However, a child’s weight underlying physiologic process that causes
The IMCI strategy
prior to the episode is rarely known, and it it. Risk factors include previous exposure classifies dehydration
is usually necessary to rely on clinical signs. to very hot weather or to heated rooms and determines its
Table 7 describes the clinical signs accord- while wearing too much clothing, r­ esulting treatment according to
ing to different degrees of dehydration. in significant sweating with low sodium clinical findings.

According to IMCI guidelines the signs loss; fever; or the administration of fluids
suggesting severe dehydration include the containing too much salt. Typical clinical
following 4 signs: lethargy or unconscious, signs (sunken eyes, decreased skin t­urgor,
sunken eyes, skin pinch that goes back very hypotension) are less evident than in iso-
slowly, and not able to drink or drinking tonic or hypotonic dehydration of the
poorly. A child with at least 2 of these signs same severity. The tendency to develop
is classified as severe (pink). The 4 signs that shock is delayed because the i­ntravascular
indicate some dehydration (yellow) include volume is relatively protected by the water
restless or irritable, sunken eyes, thirsty and shift from the intracellular space. The
drinks eagerly, sunken eyes, and the skin patient is usually very irritable, even with
pinch goes back slowly (not very slowly). very severe degrees of dehydration, and
Again the child must have at least 2 of these drinks avidly. Seizures and intracranial hem­
signs. Children 2 months to 5 years that do orrhage may occur. For treatment, if ORT
not have at least 2 signs are considered has failed or is contraindicated, intravenous
green and do not have some or severe (IV) rehydration therapy should correct
dehydration. the electrolytic disorder within 36 to 48
Even if an accurate assessment of the hours. This situation is different in hypo-
degree of dehydration might not be possi­ tonic dehydration, where IV correction can
ble, a diagnosis of mild (fluid loss <5% of be attained within a few hours using poly-
body weight) or severe (fluid loss >10% and electrolytic solutions.
usually accompanied by significant hemo-
16 SECTION I1I / DEHYDRATION

TABLE 7. Classification of dehydration

Assess clinical signs Classify as Treat

(PINK) (PINK) (PINK)

Two of the following signs: Severe dehydration l If the child does not have another
l Lethargy/unconsciousness severe classification: give fluid for
l Sunken eyes severe dehydration (See Plan C on
l Drinks poorly or unable to page 23)
drink l If the child has another severe
l Skin turgor: skin pinch goes classification: urgently refer to a
back very slowly to normal hospital with the mother giving
frequent sips of ORS during the
trip. Advise the mother to continue
breast-feeding if the child’s state of
consciousness allows it
l If any case of cholera has been
detected in the area, administer an
antibiotic for this disease

(YELLOW) (YELLOW) (YELLOW)

Two of the following signs: Some dehydration l If there is some degree of
l Restless, irritable dehydration, administer fluids and
l Sunken eyes food (See Plan B on page 22)
l Drinks avidly, shows thirst l If the child has another severe
l Skin turgor: skin pinch goes clasification: urgently refer to a
back slowly to normal hospital with the mother giving
frequent sips of ORS during the
trip. Advise the mother to
continue breast-feeding if the
child’s state of consciousness
allows it
l Tell the mother which signs require
immediate medical attention
l If diarrhea persists: schedule a
follow-up visit in 24-48 hours

(GREEN) (GREEN) (GREEN)

Not enough signs to classify as No dehydration l Give food and fluids adequate to
dehydration treat diarrhea at home (See Plan A
on page 21)
l Tell the mother which signs require
immediate medical attention
l If diarrhea persists: schedule a
follow-up visit in 5 days
 SECTION I1I / DEHYDRATION 17

Management of in cholera. The osmotic gradient in the

Dehydration intercellular space maintains the absorp-
Oral Rehydration Therapy tion of potassium and bicarbonate. In this In the overwhelming
The efficacy and safety of ORT have been way, the metabolic acidosis usually associ- majority of patients
proven worldwide. In 1964, the identifica- ated with dehydration can be corrected with diarrheal illness
without the risk of overcorrection. in a disaster, ORT is
tion of the sodium-glucose cotransport effective in preventing
sys­tem in the intestinal mucosa led to the and treating the
development of different solutions for the Advantages of Oral Rehydration associated
oral treatment of dehydration. During the Therapy dehydration.

1971 cholera outbreak in Bangladesh, mor- Oral rehydration therapy has multiple
tality rates from diarrheal illness dropped advantages over parenteral rehydration
from 25% to 3% when ORT was introduced (Box 1). Since ORT uses the normal
instead of IV therapy. In the overwhelming physiologic mechanisms of intestinal
­
majority of patients with diarrheal illness in absorption there is no risk of complica-
a disaster, ORT is effective in preventing and tions, such as water overload or overcor-
treating the associated dehydration. rection of electrolyte and acid-base distur-
bances associated with dehydration. Thus,
Physiological Basis of ORT ORT can be used in any dehydrated child,
In normal physiologic status, water is regardless of the type of dehydration.
absorbed osmotically across the small Moreover, laboratory tests are not usually
bowel through tight junctions between necessary for the patient’s evaluation.
­epithelial cells due to a sodium gradient that Normal hydration in children ­receiving
is maintained by 2 mechanisms of sodium ORT is usually achieved in 4 to 6 hours,
absorption in the brush border membrane allowing early refeeding, resulting in
of the luminal cell: passive sodium/potassi­ decreased risk of malnutrition associated
um diffusion and active cotransport of sodi- with diarrheal disease.
um jointly with monosaccharides such as Costs of ORT are minimal compared
­glucose. The resulting intracellular sodium is with those of IV therapy. Moreover, its
then actively transported via ATPase carrier major ingredients (salt, water, and sugar
enzymes into the intercellular space, result- or starchy foods like rice) are often pres-
ing in an osmotic gradient between the ent in the community when premixed
intercellular and luminal spaces, allowing for oral rehydration solutions (ORS) are not
free diffusion of water (Figure 1). readily available. ORT is simple and can
In diarrheal illness, the passive absorp- be given by trained health assistants. In
tive mechanism of sodium and chloride is addition, it requires the participation of
impaired, but glucose absorption remains the mother, thus encouraging family
largely intact. This allows the absorption of involvement in the child’s health. Because
enough water and sodium to compensate its requirements are minimal, ORT can
for fluid losses as significant as those seen be used at the site of the disaster, reduc-
18 SECTION I1I / DEHYDRATION

FIGURE 1. Mechanisms of water absorption in the intestinal mucosa

Na+ CI- Na+ glucose

H2O H2O
passive active

Tight
junctions
CI-

Na+ glucose

Active via
ATPPase carrier
enzymes

H2O Na+

ing the demands on medical hospital- quantities of sodium and glucose, which
based personnel and allowing patients to enhances the intestinal absorption of
be in close contact with their families both molecules. The solution also con-
(Box 2). Lastly, complications associ- tains a source of bases (bicarbonate or
ated with invasive procedures, such as IV citrate) and potassium (Box 3).
therapy, particularly infections, are total- Despite initial concerns for hyperna­
ly avoided. tremia associated to the use of the WHO
solution, particularly in hypertonic dehy-
Composition of ORS dration, the ORS has been proven to be
The most widely used formulation for efficacious and safe, regardless the
oral rehydration is the one designed by patient’s serum sodium.
the World Health Organization (WHO). The WHO ORS does not reduce the
The most important feature of this duration or intensity of diarrhea. For this
solution is the inclusion of equimolar reason, research has focused on alterna-
 SECTION I1I / DEHYDRATION 19

tive formulations with different compo- solutions. The simplest requires rice,
nents, such as the use of amino acids as water, and salt. One hundred grams of
cotransporting molecules; solutions rice is cooked in 1 liter of boiling water Oral rehydration
derived from cooked cereals, usually rice- for 10 minutes or until the rice pops. The therapy involves no
based; and glucose-based ORS with lower water is then drained from the rice into a risk of complications,
such as water overload
osmolarity. Amino acid-based formulations container, and any remaining water is or overcorrection of
have not been proven significantly benefi- squeezed from the rice with a spoon. the electrolyte and
acid-base disturbances
cial. Rice-based formulations have demon- When all the water is squeezed from the associated with
strated improved efficacy in patients with rice, enough water is added to the solu- diarrheal dehydration.
cholera. They may be used in situations tion to bring the total volume to 1 liter
where rice is readily available. and 1 pinch of salt is added.
A number of studies have demonstrat- Use only drinking water to prepare
ed that lowering the concentrations of rehydration solutions. Any other ­beverage
­glucose and sodium to a total o ­ smolarity (such as mineral water or carbonated
of 245 mOsm/L can decrease stool o ­ utput ­beverages) will modify the concentrations
and vomiting in children with acute non- of the various components and conse-
cholera diarrhea, without significantly quently reduce its efficacy. Ideally, once
compromising efficacy in cholera patients. prepared, keep solutions refrigerated.
Based on these findings, the WHO has Discard any unused solution 24 hours
recently recommended the use of hypoos- after preparation. WHO has recently
molar solution, particularly for children recommended the use
of hypoosmolar
with acute, non-cholera diarrhea. Contraindications for ORT solution, particularly
In situations where prepackaged ORS is Contraindications for ORT are listed in for children with
acute, non-cholera
not available, rehydration can be per- (Box 4). The presence of other severe diarrhea.
formed with different extemporaneous disease, such as sepsis or meningitis, also

BOX 1. Advantages of ORT BOX 2. Requirements for ORT

l Use of normal physiologic l Oral rehydration salt packets

mechanisms l Drinking water

l Early re-feeding l Refrigerator

l 90-95% effective l Watch

l Effective for all types of l Pencil and paper

dehydration l Scale

l No need for laboratory tests l Containers (feeding bottles,

l Low economic and social cost glasses, pitchers)

l Availability l Nasogastric tube

l No infectious, metabolic, or l Trained staff

electrolytic complications
20 SECTION I1I / DEHYDRATION

BOX 3. Composition of WHO oral rehydration solution

Reduced osmolarity grams/litre Reduced osmolarity mmol/litre

ORS ORS
Sodium chloride 2.6 Sodium 75
Glucose, anhydrous 13.5 Chloride 65
Potassium chloride 1.5 Glucose, anhydrous 75
Trisodium citrate Potassium 20
Dihydrate 2.9 Citrate 10
Total Osmolarity 245

The reduced osmolarity ORS containing 75 mEq/l sodium, 75 mmol/l glucose (total osmolarity of 245 mOsm/l) is as effective as standard ORS in adults
with cholera. However, it is associated with an increased incidence of transient, asymptomatic hyponatraemia. This reduced osmolarity ORS may be used in
place of standard ORS for treating adults with cholera, but careful monitoring is advised to better assess the risk, if any, of symptomatic hyponatraemia.
Because of the improved effectiveness of reduced osmolarity ORS solution, especially for children with acute, non-cholera diarrhoea, WHO and UNICEF
now recommend that countries use and manufacture this formulation in place of the previously recommended ORS solution with a total osmolarity of
311 mOsm/l.

contraindicates the use of ORT, but vom- include 3 plans. Administer Plan A (page
iting before or during ORT is not a con- 21) to children with diarrhea but without
traindication. Only untreatable vomiting dehydration or to those who have been
will require parenteral therapy. successfully rehydrated. Plan B (page 22)
The presence of severe hemodynamic is for children with mild-moderate dehy-
disturbances prompts immediate IV fluid dration, and Plan C (page 23) is for severe
replacement. However, if no supplies are dehydration.
available, perform ORT until IV treatment
is possible.
Before starting ORT, auscultate the BOX 4. Contraindications for
abdomen to check for the presence of ORT
bowel sounds and rule out a diarrhea-
l Shock
related ileus (severe hypokalemia, anti-
l Patient younger than 1 month
spasmodic-drug toxicity).
of age
l Ileus
Dehydration Management l Significantly altered sensorium
with the IMCI Guidelines l Severe difficulty breathing
The IMCI guidelines for the management l Painful abdominal distension
of dehydration in children with diarrhea
 SECTION I1I / DEHYDRATION 21

PLAN A: TREAT DIARRHOEA AT HOME

Counsel the mother on the 4 Rules of Home Treatment:

1. Give Extra Fluid
2. Give Zinc Supplements (age 2 months up to 5 years)
3. Continue Feeding
4. When to Return.

1. GIVE EXTRA FLUID (as much as the child will take)

■ TELL THE MOTHER:
l Breastfeed frequently and for longer at each feed.
l If the child is exclusively breastfed, give ORS or clean water in addition to breast milk.

l If the child is not exclusively breastfed, give one or more of the following: ORS solution, food-

based fluids (such as soup, rice water, and yoghurt drinks), or clean water.
■ It is especially important to give ORS at home when:
l the child has been treated with Plan B or Plan C during this visit.

l the child cannot return to a clinic if the diarrhoea gets worse.

■ TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2
PACKETS OF ORS TO USE AT HOME.
■ SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE
USUAL FLUID INTAKE:

Up to 2 years 50 to 100 ml after each loose stool

2 years or more 100 to 200 ml after each loose stool

Tell the mother to:

l Give frequent small sips from a cup.
l If the child vomits, wait 10 minutes. Then continue, but more slowly.

l Continue giving extra fluid until the diarrhoea stops.

2. GIVE ZINC (age 2 months up to 5 years)

■ TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab):

2 months up to 6 months 1/2 tablet daily for 14 days

6 months or more 1 tablet daily for 14 days

■ SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS

l Infants — dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a cup.

l Older children — tablets can be chewed or dissolved in a small amount of water.

3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)

4. WHEN TO RETURN
22 SECTION I1I / DEHYDRATION

PLAN B: TREAT SOME DEHYDRATION WITH ORS

In the clinic, give recommended amount of ORS over 4-hour period

■ DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS

WEIGHT <6 kg 6 – <10 kg 10 – <12 kg 12 –19 kg

AGE* Up to 4 months 4 months up to 12 months up 2 years up to

12 months to 2 years 5 years

In ml 200 – 450 450 – 800 800 –960 960 –1600

*Use the child’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 child’s weight (in kg) times 75.

l If the child wants more ORS than shown, give more.



l For infants under 6 months who are not breastfed, also give 100 –200 ml clean water during this


period if you use standard ORS. This is not needed if you use new low osmolarity ORS.

■ SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.

l Give frequent small sips from a cup.
l If the child vomits, wait 10 minutes. Then continue, but more slowly.
l Continue breastfeeding whenever the child wants.

■ AFTER 4 HOURS:
l Reassess the child and classify the child for dehydration.
l Select the appropriate plan to continue treatment.
l Begin feeding the child in clinic.

■ IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:

l Show her how to prepare ORS solution at home.
l Show her how much ORS to give to finish 4-hour treatment at home.
l Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended in

Plan A.
l Explain the 4 Rules of Home Treatment:

1. GIVE EXTRA FLUID

2. GIVE ZINC (age 2 months up to 5 years)
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
4. WHEN TO RETURN
 SECTION I1I / DEHYDRATION 23

PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

FOLLOW THE ARROWS. IF ANSWER IS “YES”, GO ACROSS. IF “NO”, GO DOWN.

START HERE

Can you give ■ Start IV fluid immediately. If the child can drink, give ORS by
intravenous (IV) fluid YES" mouth while the drip is set up. Give 100 ml/kg Ringer’s Lactate
­immediately? Solution (or, if not available, normal saline), divided as follows

NO First give Then give

$ AGE 30 ml/kg in: 70 ml/kg in:
Infants (under 12 months) 1 hour* 5 hours
Children (12 months up to 30 minutes* 2 1/2 hours
5 years)
*Repeat once if radial pulse is still very weak or not detectable.

■ Reassess the child every 1–2 hours. If hydration status is not

improving, give the IV drip more rapidly.
■ Also give ORS (about 5 ml/kg/hour) as soon as the child can

drink: usually after 3– 4 hours (infants) or 1–2 hours (children).

■ Reassess an infant after 6 hours and a child after 3 hours. Classify

dehydration. Then choose the appropriate plan (A, B, or C) to

continue treatment.

Is IV treatment ■ Refer URGENTLY to hospital for IV t­ reatment.

■ If the child can drink, provide the mother with ORS solution and
available nearby YES"
(within 30 ­minutes)? show her how to give frequent sips during the trip or give ORS
by naso-gastric tube.

NO
$
■ Start rehydration by tube (or mouth) with ORS solution:
Are you trained give 20 ml/kg/hour for 6 hours (total of 120 ml/kg).
to use a naso-­gastric ■ Reassess the child every 1–2 hours while waiting for
(NG) tube for YES"
­transfer:
­rehydration? l If there is repeated vomiting or increasing abdominal disten-

sion, give the fluid more slowly.

NO l If hydration status is not improving after 3 hours, send the
$
child for IV therapy.
Can the child ■ After 6 hours, reassess the child. Classify dehydration. Then
YES"
drink? choose the appropriate plan (A, B or C) to continue treatment.

NO
$
NOTE:
Refer URGENTLY ■ If the child is not referred to hospital, observe the child at least
to hospital for IV or
6 hours after rehydration to be sure the mother can maintain
NG treatment
hydration giving the child ORS solution by mouth.
24 SECTION I1I / DEHYDRATION

Organization of ORT units in ORS packets, if possible, an adequate

disaster settings amount of drinking water, and the rest
Because morbidity and mortality asso- of the items previously mentioned.
ciated with diarrhea can be significantly The staff in charge of the unit must
reduced by early hydration, set up ORT keep records of the patients treated
units at the onset of almost every dis­ and should be trained to identify cases
aster relief situation. Very few supplies of severe dehydration and suspected
are needed, and it is easy to train aux- cases of cholera. Such records are
iliary personnel in the IMCI approach essential for surveillance purposes, and
to ORT. the information obtained will prove
The supplies needed to set up an useful in improving public health inter-
ORT unit include a sufficient number of ventions in disaster situations.
 SUMMARY / SUGGESTED READING 25

SUMMARY
Diarrheal disease and dehydration—its most common complication—are the main
causes of morbidity and mortality in populations exposed to a disaster. There are
different types of diarrhea caused by different pathogens. The causative agent can
be suspected from the clinical manifestations, which help in selecting the initial
treatment.
ORT and continued feeding (especially breastfeeding) have notably reduced
the morbidity and mortality classically associated with diarrhea and dehydra-
tion. The substantial advantages of ORT over IV therapy make it the ideal tool
in humanitarian emergencies involving large displaced populations.
The IMCI strategy is a fundamental tool of primary care in emergency set-
tings because it makes use of available resources to provide safe and effective
treatment.

SUGGESTED READING

Atención integrada a las enfermedades prevalentes de la The management of bloody diarrhea in young children.
infancia en Argentina. OPS Washington DC, 2005 Document WHO/CDD/94.9 Geneva, OMS, 1994.

Black RE. Persistent diarrhea in children in developing Dell RB. Pathophysiology of dehydration. In: Winters RW (ed).
The body fluids in pediatrics. Boston, Little Brown, 1973.
countries. Pediatr Infect Dis J 1993:12:751-761.
Sordo ME, Roccatagliata GM, Dastugue MG, Murno JR.
Fontaine O. Acute Diarrhea Pediatric Decision Making. 4th edi­ Hidratación oral ambulatoria. In: Pediatría ambulatoria.
tion. Philadelphia; Mosby, 2003. Buenos Aires; Puma, 1987.
26 ANNEX

Does the child have diarrhea?

IF YES, ASK: LOOK AND FEEL: for DEHYDRATION
l For how long? l Look at the child´s
l Is there blood in the general condition. Is the
stool? child
Lethargic or uncon-
scious?
Restless and irritable?
l Look for sunken eyes

l Offer the child fluid. Is

the child
Classify
Not able to drink or DIARRHOEA
drinking poorly?
Drinking eagerly, thirsty?
l Pinch the skin of the

abdomen.
Does it go back
Very slowly (longer than
2 seconds)?
Slowly?
and if diarrhea
14 days or more

and if blood
in stool
 ANNEX 27

Two of the following signs: l Ifchild has no other severe classification

l Lethargic or unconscious – Give fluid for severe dehydration (Plan C)
l Sunken eyes O
l Not able to drink or drinking poorly SEVERE If child also has another severe classification:
l Skin pinch goes back very slowly
DEHYDRATION – Refer URGENTLY to hospital with mother giving frequent
sips of ORS on the way
Advise the mother to continue breastfeeding
l If child is 2 years or older and there is cholera in your area,

give antibiotics for cholera.

l Give fluid, zinc supplements and food for some dehydration
Two of the following signs
l Restless, irritable (Plan B).
l Sunken eyes l If child also has a severe classification:
SOME
l Drinks eagerly, thirsty DEHYDRATION – Refer URGENTLY to hospital with mother giving
l Skin pinch goes back slowly frequent sips of ORS on the way
Advise the mother to continue breastfeeding
l Advise mother when to return immediately.

l Give fluid, zinc supplements and food to treat diarrhea at home

Not enough signs to classify as severe
or some dehydration NO DEHYDRATION (Plan A).
l Advise mother when to return immediately.

l Dehydration present SEVERE l Treat dehydration before referral unless the child has another
PERSISTENT severe classification
DIARRHOEA l Refer to hospital

l Advise the mother on feeding a child who has PERSISTENT

l No dehydration
PERSISTENT DIARRHOEA
DIARRHOEA l Give multivitamin and minerals (including zinc) for 14 days
l Follow-up in 5 days

l Treat for 3 or 5 days with an oral antimicrobial recommended

l Blood in the stool BLOOD for Shigella in your area. Treat dehydration and give zinc
IN STOOL l Follow-up in 2 days
28 CASE RESOLUTION

Case resolution
1-3. Based on the frequency of the evacuations and the characteristics of the stools,
the infant has acute diarrhea. There is no blood in the stools, so the most probable
causative agent is rotavirus or E. coli. In both cases the disease is usually self-limited and
does not require antibiotic therapy. Since the child is not dehydrated, advise the mother
to give him ORS after every evacuation of loose stools, to provide more fluids than
usually, and to continue breastfeeding and giving the child the other foods he usual eats.
Determine if other household contacts are similarly affected, which might indicate an
outbreak. If adults are experiencing significant watery diarrhea with dehydration, sus-
pect V. cholerae infection.
Continued breastfeeding is an important way to reduce potential recurrences.
Intensify hygiene measures, and provide adequate water supply and stool disposal.

4. Upon his return, the child presents with more than 2 signs in the IMCI classifica­
tion for severe dehydration. There are no other signs of severe disease, but there are
findings consistent with hemodynamic disorder (shock). Begin immediate ­treatment
for severe dehydration (Plan C in the IMCI guidelines). Once rehydration has been
achieved, the child should be switched to a maintenance plan (Plan A) and reassessed
in 24 hours. Because there is no history of cholera in the population, antibiotic
therapy is not needed.
 MODULE REVIEW 29

MODULE REVIEW
SECTION I - DIARRHEAL ILLNESSES

1. What clinical features characterize the different types of diarrhea, and what
are the most frequent etiological agents for each type?
2. What are the fundamental components of the treatment of diarrhea?
3. Why is nutrition important in the treatment of diarrhea?
4. What steps do the IMCI guidelines recommend for treating diarrhea
without blood in the stools and for dysentery?
5. What treatment is indicated for the various agents responsible for bloody
diarrhea?
6. What are the causes of persistent diarrhea and what is the treatment?
7. What are the characteristics of epidemic cholera, and what is the
appropriate approach to managing an outbreak in an emergency setting?

SECTION II - DIARRHEA IN THE INFANT 0 TO 2 MONTHS

OF AGE

1. How should diarrhea be treated in the infant 0 to 2 months?

2. What is the approach to managing persistent diarrhea in this age group?
3. What is the treatment for bloody diarrhea in this age group?

SECTION III - DEHYDRATION

1. What physiological and clinical features differentiate isotonic and hypotonic

dehydration from hypertonic dehydration?
2. What is the physiological basis of oral rehydration therapy (ORT)?
3. How should ORT be administered, and what supplies are needed to
implement ORT?
4. What are the advantages and contraindications of ORT?
5. What variables do the IMCI guidelines use to classify dehydrated children
and to determine their treatment?
6. What is the appropriate approach to managing severe dehydration in
children?