Who Dehidrasi PG 17 PDF

IMCI
INTEGRATED MANAGEMENT
OF CHILDHOOD ILLNESS
DISTANCE LEARNING COURSE
Module 4
Diarrhoea
WHO Library Cataloguing-in-Publication Data:
Integrated Management of Childhood Illness: distance learning course.
15 booklets
Contents: – Introduction, self-study modules – Module 1: general danger signs for the
sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing
– Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia
– Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child –
Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation:
introduction and roll out – Logbook – Chart book
1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control.
4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance.
7.Teaching Material. I.World Health Organization.
ISBN 978 92 4 150682 3 (NLM classification: WS 200)
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IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA
n CONTENTS
Acknowledgements 4
4.1 Module overview 5
4.2 Introduction to diarrhoea 8
4.3 Assess a sick young infant & child for diarrhoea 10
4.4 Classify diarrhoea & dehydration 17
4.5 Treat the child with diarrhoea 23
4.6 Counsel the caregiver 37
4.7 Provide follow-up care for diarrhoea 42
4.8 Using this module in your clinic 45
4.9 Review questions 46
4.10 Answer key 47
3
Acknowledgements
The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated
the development of these distance learning materials on the Integrated Management
of Childhood illness (IMCI), in an effort to increase access to essential health services
and meet demands of countries for materials to train primary health workers in
IMCI at scale. These materials are intended to serve as an additional tool to increase
coverage of trained health workers in countries to support the provision of basic
health services for children. The technical content of the modules are based on new
WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/
AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as
care for development.
Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent
Health (MCA) led the development of the materials with contributions to the content
from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg,
José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim,
Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well
as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African
Region of WHO.
A particular debt of gratitude is owed to the principal developer, Ms Megan Towle.
Megan helped in the design and content of the materials based on the field-test
experiences of the materials in South Africa. A special word of thanks is also due to
Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam
Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix
Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic
of Tanzania
WHO is grateful for the contribution of all external experts to develop the distance
learning approaches for IMCI including professor Kevin Forsyth, Professor David
Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open
University (UK), Aisha Yousafzai who reviewed the care for development section
of the well child care module, Amha Mekasha from Addis Ababa University and
Eva Kudlova, who have contributed to different sections of the distance learning
modules.
We acknowledge the help from Ms Sue Hobbs in the design of the materials.
Financial and other support to finish this work was obtained from both the MCA
and HIV departments of WHO.
4
4.1 MODULE OVERVIEW

Diarrhoea is likely a very common problem in the children you see at your clinic.
Diarrhoea can be serious – and even lead to death.
For ALL sick children – ask the caregiver about the child’s problems,
check for general danger signs, assess for cough or difficult breathing, then ASK:
DOES THE CHILD HAVE DIARRHOEA?
NO YES
ASSESS & CLASSIFY the child using

the colour-coded classification charts
for dehydration & diarrhoea.
CONTINUE ASSESSMENT: assess for main symptoms (next is fever), check for
malnutrition & anaemia, check immunization status, HIV status, other problems
NOTE ON DIARHOEA IN SICK YOUNG INFANT: In Module 2, you were told to

refer to this module to assess and classify diarrhoea in sick young infants. The
IMCI process is similar for the two. There are some important distinctions, which
you will learn about in the module.
MODULE LEARNING OBJECTIVES

After you study this module, you will be able to:
✔✔ Define the types of diarrhoea and levels of dehydration
✔✔ Recognize clinical signs of dehydration
✔✔ Assess diarrhoea in sick children
✔✔ Assess dehydration in young infants and sick children
✔✔ Classify diarrhoea and severity of dehydration using IMCI charts
✔✔ Provide Plans A, B, and C for dehydration
✔✔ Counsel the caregiver about home treatment for diarrhoea and dehydration
5
MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
Name: Age: Weight (kg): Temperature (°C):
Ask: What are the child's problems? Initial Visit? Follow-up Visit?
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS General danger sign
NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present?
VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___
CONVULSIONS Remember to use
Danger sign when
YOUR RECORDING FORM selecting
classifications
Look at your IMCI recording form for the sick child. This section deals with thisYes __
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? No __
module:
For how long? ___ Days Count the breaths in one minute
___ breaths per minute. Fast breathing?
Look for chest indrawing
Look and listen for stridor
Look and listen for wheezing
DOES THE CHILD HAVE DIARRHOEA? Yes __ No __
For how long? ___ Days Look at the childs general condition. Is the child:
Is there blood in the stool? Lethargic or unconscious?
Restless and irritable?
Look for sunken eyes.
Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
Pinch the skin of the abdomen. Does it go back:
Very slowsly (longer then 2 seconds)?
Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above) Yes __ No __
Decide malaria risk: High ___ Low ___ No___ Look or feel for stiff neck
For how long? ___ Days Look for runny nose
MODULE ORGANIZATION
If more than 7 days, has fever been present every Look for signs of MEASLES:
day? Generalized rash and
Has child hadThis module
measels follows
within the the major stepsOne
last 3 months? of the IMCI
of these: process:
cough, runny nose, or red eyes
Look for any other cause of fever.
Do malaria test if NO general danger sign
✔ ASSESS DIARRHOEA and DEHYDRATION IN SICK CHILD
✔cases
High risk: all fever
Low risk: if NO obvious cause of fever
Test POSITIVE?✔ P.✔falciparum
ASSESSP.DEHYDRATION
vivaxNEGATIVE? IN SICK YOUNG INFANT
If the child has measles now or within the Look for mouth ulcers.
last 3 months: If yes, are they deep and extensive?
✔✔ CLASSIFY DIARRHOEA and DEHYDRATION
Look for pus draining from the eye.
Look for clouding of the cornea.
✔✔ CLASSIFY DEHYDRATION IN SICK YOUNG INFANT
DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __
Is there ear pain? Look for pus draining from the ear
✔✔ TREAT DIARRHOEA
Is there ear discharge? Feel for tender swelling behind the ear
If Yes, for how long? ___ Days
✔ COUNSEL
✔FOR
THEN CHECK CAREGIVER ONLook
ACUTE MALNUTRITION 4 RULES OF
for oedema HOME
of both feet. TREATMENT
AND ANAEMIA Determine WFH/L _____ Z score.
For children 6 months or older measure MUAC ____ mm.
✔✔ FOLLOW-UP CARE FOR DIARRHOEA
Look for palmar pallor.
Severe palmar pallor? Some palmar pallor?
If child has MUAC less than 115 mm or Is there any medical complication?
BEFORE
WFH/L less than YOUorBEGIN
-3 Z scores oedema of General danger sign?
Any severe classification?
both feet:
What do you know now about managingPneumonia withdiarrhoea?
chest indrawing?
For a child 6 months or older offer RUTF to eat. Is the child:
Before you begin studying this module, quickly
Not able to practice
finish or able to finish? your knowledge with these
For a child less than 6 months is there a breastfeeding problem?
CHECK FORmultiple-choice
HIV INFECTION questions.
Note mother's and/or child's HIV status
Circle
Mother's HIV test: theNEGATIVE
best answer POSITIVEfor each question.
NOT DONE/KNOWN
Child's virological test: NEGATIVE POSITIVE NOT DONE
Child's serological test: NEGATIVE POSITIVE NOT DONE
1. How can diarrhoea kill children?
If mother is HIV-positive and NO positive virological test in child:
Is the child breastfeeding now?
Was the child a. Children
breastfeeding lose
at the timevaluable fluids,
of test or 6 weeks salts,
before it? and sugars, which can cause shock to vital
If breastfeeding: Is the mother and child on ARV prophylaxis?
organs
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next
BCG b. ChildrenDPT+HIB-2
DPT+HIB-1 lose valuableDPT+HIB-3
nutrients because
Measles1 they cannot
Measles 2 eat Vitamin A immunization on:
OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole ________________
Hep B0
c. B1Diarrhoea
Hep Hepcauses
B2 liverHepfailure
B3 (Date)
RTV-1 RTV-2 RTV-3
2. Pneumo-1
What are critical treatments
Pneumo-2 for children with diarrhoea and dehydration?
Pneumo-3
a. Oral antibiotics
b. Oral rehydration therapy and zinc
c. Paracetamol for discomfort
Page 65 of 75
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3. What is persistent diarrhoea?

a. When a child frequently has diarrhoea over a period of 1 month, and is ill as
a result
b. When a child has several episodes of diarrhoea a day
c. When a child has an episode of diarrhoea lasting 14 days or more, which is
particularly dangerous for dehydration and malnutrition
4. Critical messages for caregivers about diarrhoea and dehydration include:
a. The child must receive increased fluids, ORS, zinc, and regular feeding
b. The child requires ORS, but should receive less food in order to reduce the
diarrhoea
c. The child should immediately receive antibiotics to stop the diarrhoea
5. Nidhi arrives at your clinic and is very lethargic. Her eyes are very sunken. She
has diarrhoea. You observe a significant loss of skin elasticity. How will you
manage Nidhi?
a. Nidhi requires ORS immediately, as she is dehydrated.
b. These are common signs of diarrhoea, as the child’s body is exhausted.
c. Nidhi is severely dehydrated. She requires urgent rehydration therapy by IV
or nasogastric tube.
After you finish the module, you will answer the same questions. This will
demonstrate to you what you have learned during the course of the module!
7
4.2 INTRODUCTION TO DIARRHOEA
n OPENING CASE STUDY – MARY

It is a busy afternoon in your clinic. A young mother comes into your clinic room, carrying a small girl. She
says her daughter, Mary, has diarrhoea. You ask the mother’s name, and she says Ana. Ana says that Mary
usually eats porridge and milk, but that she has had bad diarrhoea in the past few days. Ana tried giving
more porridge but Mary is still sick. Ana thought it was a bad stomach from spoiled milk, and that it would
pass.
However, the diarrhoea has remained for several days now, and now Mary looks unwell. Ana fears that Mary
is getting worse, and is feeling guilty that she did not come to the clinic sooner. Ana works in the mornings,
and lives some distance from the clinic. By the time she commutes into the city for her work duties, she does
not have very much time in the day to bring Mary in. She says she is worried that her family will blame her for
working at the job and letting Mary get more and more sick.
WHAT IS DIARRHOEA?
Diarrhoea occurs when stools contain more water than normal, and are loose or
watery. In many regions diarrhoea is defined as three or more loose or watery stools
in a 24-hour period. Children between the ages of 6 months and 2 years often have
diarrhoea. It is more common in settings of poor sanitation and hygiene, including
a lack of safe drinking water.
WHAT ARE THE TYPES OF DIARRHOEA IN CHILDREN?

Most diarrhoea that causes dehydration is loose or watery. Cholera is one example,
though only a small proportion of all loose or watery diarrhoeas are due to cholera.
n ACUTE DIARRHOEA is an episode of diarrhoea that lasts less than 14 days.
Acute watery diarrhoea causes dehydration and contributes to malnutrition.
The death of a child with acute diarrhoea is usually due to dehydration.
n PERSISTENT DIARRHOEA lasts 14 days or more. Up to 20% of episodes of
diarrhoea become persistent, and this often causes nutritional problems and
contributes to death in children.
n DYSENTERY is diarrhoea with blood in the stool, with or without mucus. The
most common cause of dysentery is Shigella bacteria. Amoebic dysentery is
not common in young children. A child may have both watery diarrhoea and
dysentery.
WHAT ARE THE TYPES OF DIARRHOEA IN YOUNG INFANTS?

A young infant has diarrhoea if the stools have changed from the usual pattern, and
are many and watery. This means more water than faecal matter. The normally
frequent or semi-solid stools of a breastfed baby are not diarrhoea.
8
n How do you greet Ana and begin the assessment?

You praise Ana for bringing in her daughter. You tell her that diarrhoea can be a serious problem for young
children, but that there are ways to help her daughter get better. You explain that you will check her
condition and decide the best treatment. Ana seems relieved.
You ask Mary’s age. Ana tells you that she is 9 months old. You ask Ana if there are other problems besides
the diarrhoea. She says no. This is their first time coming to the clinic for this diarrhoea. You take Mary’s
weight, 8.2 kg, and temperature, 37 degrees Celsius.
n You will check Mary for general danger signs.

First, you check Mary for general danger signs. Ana tells you that Mary is able to drink milk and take porridge.
She does not vomit. She has not had convulsions. You watch Mary. She looks very tired in Ana’s arms, but she
watches you as you speak. When you reach out to her to take her hand, she grabs your finger. Does Mary
have any general danger signs?
n Next, you will assess Mary for cough or difficult breathing.

Now you check Mary for cough or difficult breathing. You ask Ana if Mary has had a cough, or any fast or
noisy breathing. Ana says that Mary had a cough about 2 months ago, but it has cleared up.
This is how you will complete Mary’s recording form thus far:

Name: Mary Age: 9 mo Weight (kg): 8.2 kg Temperature (°C): 37 °C
Ask: What are the child's problems? Diarrhoea for several days Initial Visit? X Follow-up Visit?
ASSESS (Circle all signs present)
CLASSIFY
VOMITS EVERYTHING CONVULSING NOW X
Yes ___ No ___
Danger sign when
selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? X
Yes __ No __
NowIs you willinassess
there blood the stool?Mary
for the next main Lethargic
symptom, diarrhoea. This is
or unconscious? also the problem that her
mother brought her to the clinic for. Look for sunken eyes.
Slowly?
Has child had measels within the last 3 months? One of these: cough, runny nose, or red eyes
High risk: all fever cases
Test POSITIVE? P. falciparum P. vivaxNEGATIVE?
THEN CHECK FOR ACUTE MALNUTRITION 9
Look for oedema of both feet.
WFH/L less than -3 Z scores or oedema of General danger sign?
4.3 ASSESS A SICK YOUNG INFANT & CHILD

FOR DIARRHOEA
You have a very important job to do in helping a child with diarrhoea. This module
will guide you through the process of assessing, classifying, and treating by the
type of diarrhoea and the severity of dehydration.
HOW WILL YOU ASSESS?

First, you will ASK all caregivers if the child has diarrhoea. You might need to explain
diarrhoea as loose, watery stools if the caregiver needs clarification. Be sure to use
words for diarrhoea that the mother understands.
NO diarrhoea, ask about the next main symptom, fever. You do not need to further
assess.
YES or reported earlier that diarrhoea was the reason for coming to the clinic,
record her answer. You will then assess in two parts:
1. Type of diarrhoea: especially if it is persistent, or dysentery
2. Signs of dehydration
Open to your ASSESS chart for diarrhoea, which includes the assessment for both
diarrhoea and dehydration. It contains the following instructions, which you will
now learn about.
Does the child have diarrhoea?
Two of the
If yes, ask: Look and feel:
Letharg
For how long? Look at the child's general
for DEHYDRATION Sunken
Is there blood in the stool? condition. Is the child:
Not able
Lethargic or
Classify DIARRHOEA drinking
unconscious?
Skin pin
very slo
Offer the child fluid. Is the
child:
Not able to drink or
drinking poorly?
Drinking eagerly,
thirsty?
Two of the
Pinch the skin of the
Restless
abdomen. Does it go back:
Sunken
Very slowly (longer
Drinks e
than 2 seconds)?
Skin pin
Slowly?
slowly.
The ASSESS chart for the sick young infant is slightly different. There is some
additional detail to examine about the infant’s movements. It also does not test how Not enough
well the child drinks. Review the ASSESS chart for the sick young infant as well. as some or
dehydration
Dehydra
and if diarrhoea 14
days or more
10 No dehy
DIARRHOEA: SICK CHILD

ASK: FOR HOW LONG?
Diarrhoea which lasts 14 days or more is persistent diarrhoea. Give the mother
time to answer the question. She may need time to recall the exact number of days.
ASK: IS THERE BLOOD IN THE STOOL?

Ask the mother if she has seen blood in the stools at any time during this episode of
diarrhoea. As we previously reviewed, dysentery is diarrhoea with blood in the stool,
with or without mucus. The most common cause of dysentery is Shigella bacteria.
Dysentery will require specific treatments.
DEHYDRATION: SICK CHILD & YOUNG INFANT

WHAT IS DEHYDRATION?
Diarrhoea can be a serious problem – and even lead to death – if child
becomes dehydrated. Dehydration is when the child loses too much water and salt
from the body. This causes a disturbance of electrolytes, which can affect vital organs.
A child who is dehydrated must be treated to help restore the balance of water and
salt. Many cases of diarrhoea can be treated with Oral Rehydration Salts (ORS),
a mixture of glucose and several salts. ORS and extra fluids can be used as home
treatment to prevent dehydration. Low osmolarity ORS should be used to treat
dehydration.
HOW WILL YOU ASSESS DEHYDRATION?

There are several signs that help you decide the severity of dehydration. When a
child becomes dehydrated, he is at first restless or irritable. As the body loses fluids,
the eyes may look sunken, and skin loses elasticity. If dehydration continues, the
child becomes lethargic or unconscious.
LOOK: AT THE CHILD’S GENERAL CONDITION

When you checked for general danger signs, you checked to see if the child was
lethargic or unconscious. If the child is lethargic or unconscious, he has a general
danger sign. Remember to use this general danger sign when you classify the child’s
diarrhoea.
A child is classified as restless and irritable if s/he is restless and irritable all the
time or every time s/he is touched and handled. If an infant or child is calm when
breastfeeding but again restless and irritable when he stops breastfeeding, s/he has
the sign restless and irritable. Many children are upset just because they are in the
clinic. Usually these children can be consoled and calmed, and do not have this sign.
FOR THE YOUNG INFANT: watch the infant’s movement. Does he move on his own? Does the infant only
move when stimulated, but then stops? Is the infant restless and irritable?
11
LOOK FOR SUNKEN EYES

The eyes of a child who is dehydrated may look sunken. Decide
if you think the eyes are sunken. Then ask the mother if she
thinks her child’s eyes look unusual. Her opinion can help
you confirm.
NOTE: In a severely malnourished child (see Module 6) who
is wasted, the eyes may always look sunken, even if the child
is not dehydrated. Still use the sign to classify dehydration.
DVD EXERCISE – SUNKEN EYES

Watch “Assess sunken eyes” (disc 1). It is very useful to practice with a video. Record
your answers as you watch, and the video will review them. Do these children
have sunken eyes?
CHILD 1  YES  NO CHILD 3  YES  NO CHILD 5  YES  NO
CHILD 2  YES  NO CHILD 4  YES  NO CHILD 6  YES  NO
LOOK: TO SEE HOW THE CHILD DRINKS

Ask the mother to offer the child some water in a cup or spoon. Watch the child drink.
A child is not able to drink if he is not able to suck or swallow when offered a drink.
A child may not be able to drink because he is lethargic or unconscious.
A child is drinking poorly if the child is weak and cannot drink without help. He
may be able to swallow only if fluid is put in his mouth.
A child has the sign drinking eagerly and acts thirsty if it is clear that the child
wants to drink. Look to see if the child reaches out for the cup or spoon when you
offer him water. When the water is taken away, see if the child is unhappy because
he wants to drink more. If the child takes a drink only with encouragement and
does not want to drink more, he does not have the sign drinking eagerly, thirsty.
FEEL: BY PINCHING THE SKIN OF THE ABDOMEN

This skin pinch tests is an important tool for testing dehydration. When a child is
dehydrated, the skin loses elasticity. To assess dehydration using the skin pinch:
1. ASK the mother to place the child on the examining table so that the child is flat
on his back with his arms at his sides (not over his head) and his legs straight.
Or, ask the mother to hold the child so he is lying flat on her lap.
2. USE YOUR THUMB AND FIRST FINGER to locate the area on the child’s
abdomen halfway between the umbilicus and the side of the abdomen. Do not
use your fingertips because this will cause pain. The fold of the skin should be
in a line up and down the child’s body.
3. PICK UP all the layers of skin and the tissue underneath them.
4. HOLD the pinch for one second. Then release it.
12
5. LOOK to see if the skin pinch goes back very slowly (more than 2 seconds),
slowly, (less than 2 seconds, but not immediately), or immediately. If the skin
stays up for even a brief time after you release it, decide that the skin pinch goes
back slowly. The photographs below show you how to do the skin pinch test and
what the skin looks like when the pinch does not go back immediately.
Skin pinch Skin pinch going back very slowly
NOTE: The skin pinch test is not always an accurate sign. In a child with severe
malnutrition, the skin may go back slowly even if the child is not dehydrated. In a
child is overweight or has oedema, the skin may go back immediately even if the child
is dehydrated. However you should still use it to classify the child’s dehydration.
13
DVD EXERCISE – SKIN PINCH

Watch “Assess skin pinch” (disc 1) to see how skin pinches look. How do you assess
the 5 children in the video? Record your answers, and the video will review
answers with you.
1 2 3 4 5
VERY SLOWLY
SLOWLY
IMMEDIATELY

Watch “Demonstration: assess and classify diarrhoea” (disc 1)

This video reviews all steps in assessing diarrhoea.
It is useful to see in a clinical setting.

n How will you assess Mary’s diarrhoea?
Ana has already
Ask: What reported
are the child's problems?that Mary has diarrhoea. You ask Ana how many days she
Initial has had diarrhoea,
Visit? and
Follow-up Visit?
she tells you 3 days. You ask Ana if there is blood in her daughter’s stool, and she tells you no.
CHECK
Now youFOR
willGENERAL DANGER
examine Mary’s SIGNS She seems restless and irritable, especially when you touch
condition. Generalher.
danger
Yousign
begin to examine
VOMITS Mary for signs of dehydration.
EVERYTHING You check
CONVULSING NOW to see if she has sunken eyes, and it appears
Yes ___ Nothat
___
sheCONVULSIONS
does. Ana agrees that her daughter’s eyes look unusual. You offer her some water to drink and noticeto use
Remember
how she responds. She drinks the water eagerly. Danger sign when
selecting
Next, you give Mary a pinch test to determine how dehydrated she is. You ask Ana to place Mary classifications
on the
DOES THE table
examining CHILDso HAVE
thatCOUGH ORon
she is flat DIFFICULT
her backBREATHING?
with her arms at her sides, and her legs straight. You
Yesdo
__ pinch
No __
theFor
skinhow long? ___ Days
of Mary’s abdomen, and it goes backCount in 1the breaths in one minute
second.
How will you record these signs on Mary’s
Look andrecording
listen for stridor form?
DOES THE CHILD HAVE DIARRHOEA? X No __
Yes __
For how long? ___3 Days Look at the childs general condition. Is the child:
Slowly?
Decidein
malaria Look or feel for stiff neck
Then the risk:
nextHigh ___ Low you
section, ___ No___
will learn how to assess Mary’s diarrhoea using the signs you have assessed.
Look for runny nose
For how long? ___ Days
Look for signs of MEASLES:
On Ifthe
morenext
than 7page
days, has
youfever been
will present
have theevery
opportunity to practice assessing signs in two case studies.
Generalized rash and
day?
Is there ear discharge? 14
Feel for tender swelling behind the ear
THEN CHECK FOR ACUTE MALNUTRITION Look for oedema of both feet.
SELF-ASSESSMENT EXERCISE A
Read the case study below. Assess and classify the child’s diarrhoea and
dehydration.
Maya is at the clinic today because she has had diarrhoea for 4 days. She is 25 months
old. She weighs 9 kg. Her temperature is 37.0 °C. Maya has no general danger signs.
She does not have cough or difficult breathing. The health worker said to the mother,
“When Maya has diarrhoea, is there any blood in the stool?” The mother said,
“No.” The health worker checked for signs of dehydration. Maya is not lethargic or
unconscious. She is not restless or irritable. Her eyes are not sunken. Maya drinks
eagerly when offered some water. Her skin pinch goes back immediately. Record
Maya’s signs and classify them.

Danger sign when
selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __
Slowly?
both feet: 15
Pneumonia with chest indrawing?
Not able to finish or able to finish?
CHECK FOR HIV INFECTION
SELF-ASSESSMENT EXERCISE B
Read the case study below. Assess and classify the child’s diarrhoea and
dehydration.
Rana is 14 months old. She weighs 12 kg. Her temperature is 37.5 °C. Rana’s mother
said the child has had diarrhoea for 3 weeks. Rana does not have any general danger
signs. She does not have cough or difficult breathing. The health worker assessed
her diarrhoea. He noted she has had diarrhoea for 21 days. He asked if there has
been blood in the child’s stool. The mother said, “No.” The health worker checked
Rana for signs of dehydration. The child is irritable throughout the visit. Her eyes
are not sunken. She drinks eagerly. The skin pinch goes back immediately. Record
Rana’s signs and classify.

Danger sign when
selecting
classifications
Slowly?
both feet: 16
Pneumonia with chest indrawing?
CHECK FOR HIV INFECTION
4.4 CLASSIFY DIARRHOEA & DEHYDRATION

HOW WILL YOU CLASSIFY FOR MAIN SYMPTOM DIARRHOEA?
This main symptom has more than one classification table in the ASSESS AND
CLASSIFY charts. You will now classify both diarrhoea and dehydration. When
classifying:
✔✔ All children with diarrhoea are classified for dehydration
✔✔ If the child has had diarrhoea for 14 days or more, classify for persistent
diarrhoea
✔✔ If the child has blood in the stool, classify the child for dysentery

HOW DO YOU CLASSIFY DEHYDRATION?
There are three possible classifications for the type of diarrhoea. These are:
1. SEVERE DEHYDRATION
2. SOME DEHYDRATION
3. NO DEHYDRATION
Open your Chart Booklet to the dehydration classification table. What do you
observe? You will now read about these classifications and identified treatments.
Two of the following signs: Pink: If child has no other severe classification:
Lethargic or unconscious SEVERE Give fluid for severe dehydration (Plan C)
for DEHYDRATION Sunken eyes DEHYDRATION OR
Not able to drink or If child also has another severe
drinking poorly classification:
sify DIARRHOEA
Skin pinch goes back Refer URGENTLY to hospital with
very slowly. mother giving frequent sips of ORS
on the way
Advise the mother to continue
breastfeeding
If child is 2 years or older and there is
cholera in your area, give antibiotic for
cholera
Two of the following signs: Yellow: Give fluid, zinc supplements, and food for
Restless, irritable SOME some dehydration (Plan B)
Sunken eyes DEHYDRATION If child also has a severe classification:
Drinks eagerly, thirsty Refer URGENTLY to hospital with
Skin pinch goes back mother giving frequent sips of ORS
slowly. on the way
breastfeeding
Advise mother when to return immediately
Follow-up in 5 days if not improving
Not enough signs to classify Green: Give fluid, zinc supplements, and food to treat
as some or severe NO diarrhoea at home (Plan A)
dehydration. DEHYDRATION Advise mother when to return immediately
Dehydration present. Pink: Treat dehydration before referral unless the

and if diarrhoea 14 SEVERE child has another severe classification
days or more PERSISTENT Refer to hospital
DIARRHOEA
No dehydration. Yellow: Advise the mother on feeding a child who has
PERSISTENT PERSISTENT DIARRHOEA
DIARRHOEA 17 Give multivitamins and
minerals (including zinc) for 14 days
Follow-up in 5 days
SEVERE DEHYDRATION (RED)

Classify as SEVERE DEHYDRATION if the child has two or more of the following
signs: lethargic or unconscious, not able to drink or drinking poorly, sunken eyes,
or very slow skin pinch.
What are your actions?

Any child with dehydration needs extra fluids. A child classified with SEVERE
DEHYDRATION needs fluids quickly. Treat with IV (intravenous) fluids. The box
“Plan C: Treat Severe Dehydration Quickly” on the TREAT chart describes
how to give fluids to severely dehydrated children. You will learn more about
Plan C in the next section.
SOME DEHYDRATION (YELLOW)

If the child does not have signs of SEVERE DEHYDRATION, look at the next row.
Does the child have signs of SOME DEHYDRATION? If the child has two or more
of the following signs – restless, irritable; drinks eagerly, thirsty; sunken eyes; skin
pinch goes back slowly – classify as SOME DEHYDRATION.

If a child has one sign in the red (top) row and one sign in the yellow (middle)
row, classify the child in the yellow row (SOME DEHYDRATION). A child who
has SOME DEHYDRATION needs fluid, foods, and zinc supplements. Treat the
child with ORS solution. In addition to fluid, the child with SOME DEHYDRATION
needs food. Breastfed children should continue breastfeeding. Other children should
receive their usual milk or some nutritious food after 4 hours of treatment with ORS.
The treatment is described in the box “Plan B: Treat Some Dehydration with
ORS”. You will learn more about ORS and zinc supplements in the next section.
NO DEHYDRATION (GREEN)
A child who does not have two or more signs in the red or yellow row is classified
as having NO DEHYDRATION. This child needs extra fluid and foods to prevent
dehydration.
The four rules of home treatment are:
1. Give extra fluid
2. Give zinc supplements
3. Continue feeding
4. Return immediately if the child develops danger signs, drinks poorly, or has
blood in stool

The treatment box called “Plan A: Treat Diarrhoea At Home” describes what
fluids to teach the mother to give and how much she should give. A child with NO
DEHYDRATION also needs food and zinc supplements. You will learn more about
Plan A and zinc in the next section.
18
breastfeeding
as some or severe IMCI DISTANCE LEARNING COURSE | MODULE 4. DIARRHOEA
NO diarrhoea at home (Plan A)
After you classify dehydration,

Pink:
classify the child for persistent diarrhoea if the child
Dehydration present. Treat dehydration before referral unless the
and if diarrhoea 14 has had diarrhoea for 14 daysSEVERE
or more. Then child
you has
classify
anotherfor dysentery.
severe classification
DIARRHOEA
DIARRHOEA:
TwoNo
ofdehydration.
SICK Yellow:
the following signs:
CHILD
Pink: Advise the mother
If child has no otheronsevere
feeding a child who has
classification:
Lethargic or unconscious PERSISTENT
Give fluid DIARRHOEA
for severe dehydration (Plan C)
HOW DO YOU CLASSIFYPERSISTENT
DYSENTERY
SEVERE IN A CHILD?
for DEHYDRATION Sunken eyes DIARRHOEA
DEHYDRATION Give multivitamins and OR
If the
Notchild has
able to diarrhoea
drink or and any blood in the minerals
stool,
If childyou
also will
hasclassify
(including zinc) for as
another 14 DYSENTERY.
severe
days
Follow-up in 5 days
sify DIARRHOEA Review the classification table in your Chart Booklet. Refer URGENTLY to hospital with
Skin pinch goes back
Blood in the stool. Yellow: Giveonciprofloxacin
the way for 3 days
and if blood in stool
DYSENTERY Follow-up inthe
Advise mother to continue
2 days
breastfeeding
If child is 2 years or older and there is
A child with dysentery should be treated for cholera
dehydration. You should
in your area, also give
give antibiotic foran
cholera
antibiotic recommended for Shigella in your area. Finding the actual cause of the
dysentery
Restless,requires
irritable a stool culture
SOME
for which itsome
can dehydration
take at least
(Plan2B)
days to obtain the
laboratory results. You willDEHYDRATION
Sunken eyes assume Shigella isIfthe
childcause because:
also has a severe classification:
✔ Shigella
Skin pinchcauses
✔Page 6 of 75 about 60% of dysentery casesmother
goes back seen ingiving
clinics.
frequent sips of ORS
slowly. on the way
✔✔ Shigella causes nearly all cases of life-threatening
Advisedysentery.
the mother to continue
breastfeeding
HOW DO YOU CLASSIFY PERSISTENT Follow-up
DIARRHOEA in 5 days ifIN
notA CHILD?
improving
IfNot
theenough
childsigns to classify
has had Green:
diarrhoea for 14 days orGive
more,fluid,you
zinc supplements,
will classifyand
forfood to treat
persistent
as some or severe NO diarrhoea at home (Plan A)
diarrhoea.
dehydration. Health workers often mismanage
DEHYDRATION Advisepersistent diarrhoea,
mother when to so these
return immediately
instructions are important: Follow-up in 5 days if not improving

and if diarrhoea 14 SEVERE child has another severe classification
DIARRHOEA
DIARRHOEA Give multivitamins and
Follow-up in 5 days
Blood in the stool. Yellow: Give ciprofloxacin for 3 days

and if blood in stool
SEVERE PERSISTENT DIARRHOEA
DYSENTERY (RED)
Follow-up in 2 days
If a child has had diarrhoea for 14 days or more and also has some or severe
dehydration, is classified SEVERE PERSISTENT DIARRHOEA. Children who are
classified with SEVERE PERSISTENT DIARRHOEA should be referred to hospital.

Treat the child’s dehydration before referral unless the child has another severe
Page 6 of 75
classification. Treating dehydration in children with another severe disease can be
difficult. These children should be treated in a hospital. These children need special
attention to help prevent loss of fluid. They may need a change in diet. They may
also need laboratory tests to identify the cause of the diarrhoea.
19
PERSISTENT DIARRHOEA (YELLOW)

A child who has had diarrhoea for 14 days or more and who has no signs of
dehydration is classified as having PERSISTENT DIARRHOEA.

Special feeding is the most important treatment for persistent diarrhoea.
DVD EXERCISE – JOSH CASE STUDY

Watch “Case study Josh” (disc 1). This is a great way to practice assessing and
classifying a child for general danger signs, respiratory problems, and diarrhoea.
As you watch the video, complete the recording form below as you would a normal
case. Assess and classify using this form and your Chart Booklet.
Does Josh present with any general danger signs? How do you classify Josh for
respiratory illness? How do you classify Josh’s diarrhoea?

Danger sign when
selecting
classifications
Slowly?
SELF-ASSESSMENT EXERCISE C
Has child had Answer One of these: cough, runny nose, or red eyes
the
measels within the questions
last 3 months? below about assessing and classifying diarrhoea and
dehydration.
1. How many signs are needed to classify a child with SOME DEHYDRATION?
2. Give two signs that may indicate that aofchild
Look for clouding has SEVERE
the cornea. DEHYDRATION.
20
both feet: Pneumonia with chest indrawing?
3. What type of ORS should be used to treat dehydration?
4. Which children need zinc supplements?
5. What are the 4 rules of home treatment of diarrhoea?

SELF-ASSESSMENT EXERCISE D
Ask: What are theAssess
child's problems?
and classify dehydration in these children. Be sure to Initial Visit?
circle the signs Follow-up Visit?
you
use to classify.
1. PANO has had diarrhoea forCONVULSING
VOMITS EVERYTHING five days. He
NOWhas no blood in the stool. He is irritable.
Yes ___ No ___
CONVULSIONS
His eyes are sunken. His father and mother also think that Pano’s eyes are sunken. Remember to use
Danger sign when
The health worker offers Pano some water, and the child drinks eagerly. When selecting
classifications
the health worker pinches the skin on the child’s abdomen, it goes back slowly.
Record the child’s signs and classification for dehydration on the Recording
Form. Look for chest indrawing
MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS Not able to drink or drinking poorly?
Name: Age: Weight (kg):
Very slowsly (longer then 2 seconds)? Temperature (°C):
Ask: What are the child's problems? Slowly? Initial Visit? Follow-up Visit?
CHECK FORrisk:
Decide malaria GENERAL DANGER
High ___ Low SIGNS
___ No___ Look or feel for stiff neck General danger sign
NOT ABLE
For how TO___
long? DRINK
DaysOR BREASTFEED Look for runnyOR
LETHARGIC nose
UNCONSCIOUS present?
VOMITS 2.
EVERYTHING
If more than JANE has had diarrhoea
7 days, has fever been present every for 3 days. There
Look for signs ofNOW
CONVULSING was
MEASLES: no blood in the stool. The child
Yes ___ No ___
CONVULSIONS
day? Generalized rash and Remember to use
was not lethargic or unconscious.
Has child had measels within the last 3 months? One ofShe was
these: notrunny
cough, irritable
nose, or or
red restless.
eyes Her eyes were
Danger sign when
sunken. She Lookbut
was able to drink, for any
sheother
wascause
notof fever.
thirsty. The skin pinch went back selecting
High risk: all fever cases classifications
immediately.
DOES
Low risk:THE
if NO CHILD HAVE
obvious cause of COUGH
fever OR DIFFICULT BREATHING? Yes __ No __
TestFor how long?P.___
POSITIVE? Days
falciparum Count the breaths in one minute
P. vivaxNEGATIVE?
Record the child’s signs and
___ classification forbreathing?
dehydration on the Recording
If the child has measles now or within the Lookbreaths perulcers.
for mouth minute. Fast
last 3 months: Form. If yes, are they deep and extensive?
Look
Look and listen forofwheezing
for clouding the cornea.
DOES
DOES THE
THE CHILD
CHILD HAVE
HAVE DIARRHOEA?
AN EAR PROBLEM? Yes
Yes __
__ No
No __
__
For howear
Is there long? ___ Days
pain? Look
Look at
forthe
puschilds general
draining fromcondition.
the ear Is the child:
Is
Is there
there blood in the stool?
ear discharge? FeelLethargic
for tenderorswelling
unconscious?
behind the ear
If Yes, for how long? ___ Days Restless and irritable?
Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)
Any severe classification? Yes __ No __
both
Decidefeet:
malaria risk: High ___ Low ___ No___ Look or feel for stiff
Pneumonia withneck
chest indrawing?
For how long? ___ Days Look
For for runny
a child noseor older offer RUTF to eat. Is the child:
6 months
If more than 7 days, has fever been present every Look for 21
signs of MEASLES:
day? For aGeneralized rash
child less than 6 and
months is there a breastfeeding problem?
CHECK FOR HIV INFECTION Look for any other cause of fever.
Do malaria test if NO
Note mother's general
and/or danger
child's sign
HIV status
Mother's
High risk: HIV
all fever test:
cases NEGATIVE POSITIVE NOT DONE/KNOWN
Child's
Low risk: if NOvirological
obvious causetest: ofNEGATIVE
fever POSITIVE NOT DONE
n How Any
willjaundice
you classify
if age lessMary’s
Pink:diarrhoea? Treat to prevent low blood sugar
than 24 hours or SEVERE Refer URGENTLY to hospital
Y Mary has had diarrhoea
Yellow palms and forsoles
3 days,
at which is an acute episode
JAUNDICE of diarrhoea.
Advise mother howShetodoes
keepnot
thehave persistent
infant
JAUNDICE diarrhoea,any
which
age lasts 14 days or more. She does not havewarm
dysentery,
on theasway
there
to is nohospital
the blood in the stool.
Every childJaundice appearingisafter
with diarrhoea Yellow:for dehydration.
also classified Advise the mother to give home care for the
24 hours of age and JAUNDICE young infant
Palms and soles not
will you classify Mary’s dehydration? Advise
n How yellow mother to return immediately if palms
and soles appear yellow.
If the young infant is older than 14 days, refer
When you assessed Mary, you observed the following signs:
to a hospital for assessment
— She has sunken eyes Follow-up in 1 day
— SheNois jaundice
eager to drink Green: Advise the mother to give home care for the
NO JAUNDICE young infant
— Her skin pinch goes back slowly
With these signs, you classify Mary with SOME DEHYDRATION. Look at your classification table. What do you
observe about the identified treatments for this classification?
Two of the following signs: Pink: If infant has no other severe classification:
Movement only when SEVERE Give fluid for severe dehydration (Plan C)
stimulated or no DEHYDRATION OR
EA for movement at all If infant also has another severe
DEHYDRATION Sunken eyes classification:
very slowly. mother giving frequent sips of ORS on
the way
breastfeeding
Two of the following signs: Yellow: Give fluid and breast milk for some
Restless and irritable SOME dehydration (Plan B)
Sunken eyes DEHYDRATION If infant has any severe classification:
slowly. mother giving frequent sips of ORS on
the way
breastfeeding
Not enough signs to classify Green: Give fluids to treat diarrhoea at home and
as some or severe NO continue breastfeeding (Plan A)
You tell Ana that Mary has some dehydration. It is not serious enough to send her to the hospital. You can
n and are many andbegin
watery (more water
treatment at than fecal matter).
the clinic, and she can continue treatment at home. Ana looks relieved.
rhoea.
You will now learn more about treatment in the next section.
Page 44 of 75
22
4.5 TREAT THE CHILD WITH DIARRHOEA

Children with diarrhoea are treated for dehydration. They are also treated for their
diarrhoea, if they have persistent diarrhoea or dysentery.
WHAT TREATMENTS ARE IDENTIFIED FOR DIARRHOEA AND

DEHYDRATION?
Open your classification tables for dehydration, persistent diarrhoea, and
dysentery and review the “IDENTIFY TREATMENT” columns. The colour-coded
classifications also indicate where the treatment can be delivered – by urgent
referral, at the clinic, or at home.
Identified treatments are listed below. These are all new treatments, so you
will learn about all of them in this section:
✔✔ Plans A, B, and C for giving fluids and food
✔✔ Giving ORS for dehydration
✔✔ Zinc supplementation
✔✔ Ciproflaxacin for dysentery

HOW DO YOU TREAT DEHYDRATION?
When you classified the severity of dehydration, you identified the appropriate
treatment to replenish fluids or prevent dehydration.
There are three plans to provide fluid and replace water and salts lost in diarrhoea:
n PLAN A – treat diarrhoea at home
n PLAN B – treat SOME DEHYDRATION with low osmolarity oral rehydration
salts (ORS)
n PLAN C – treat SEVERE DEHYDRATION quickly with intravenous (IV) fluids
In the following pages, you will now learn how to give Plans A, B, and C.
PLAN C (SEVERE DEHYDRATION)

Urgent treatment
PLAN B (SOME DEHYDRATION)

Treat at clinic
PLAN A (NO DEHYDRATION)

Treat at home
23
PLAN C (SEVERE DEHYDRATION)

Urgent treatment
HOW IS PLAN C GIVEN?

Severely dehydrated children and young infants need to have water and salts quickly
replaced. Plan C requires rapid hydration using IV fluids or a nasogastric (NG)
tube.
It is important to note that rehydration therapy using IV fluids or using a
nasogastric (NG) tube is recommended only for children who have SEVERE
DEHYDRATION.
WHERE IS PLAN C GIVEN?

Open to Plan C in your Chart Booklet. There
is a flow chart determining where is the safest
place to treat the severely dehydrated child.
You will observe that the treatment of
the severely dehydrated child depends on:
n Type of available equipment at your clinic
or at a nearby clinic or hospital,
n Training you have received
n If the child can drink
IN YOUR CLINIC, WHERE IS THE SAFEST PLACE TO GIVE PLAN C?

This is important for you to determine based on available equipment and your
training. If you cannot give IV or NG fluid and the child cannot drink, refer
the child urgently to the nearest hospital that can give IV or NG treatment.
If IV (intravenous) treatment is available within a 30-minute drive, refer urgently
to hospital for treatment with IV fluids. On the way to hospital, have the mother
offer frequent sips of ORS to her sick child.
Are you able to provide Plan C in your clinic?

If not, where will you refer?
24
PLAN B (SOME DEHYDRATION)

Treat at clinic
A child or young infant with some dehydration needs fluid, zinc supplemen-
tation, and food. You will give zinc just as you will for Plan A.
HOW IS PLAN B GIVEN?

Plan B begins with a 4-hour treatment period at the clinic. During the 4
hours, the mother slowly gives a recommended amount of ORS solution. If a child
who has SOME DEHYDRATION needs treatment for other problems, you should
start treating the dehydration first. Then provide the other treatments.
After the 4 hours, you will reassess and classify the child’s dehydration. If the
signs are gone, put the child on Plan A for home treatment. If there is still some
dehydration, the child repeats Plan B. If the child now has SEVERE DEHYDRATION,
put the child on Plan C.
WHAT HAPPENS IF A CHILD HAS A SEVERE CLASSIFICATION AND

NEEDS PLAN B?
A child who has a severe classification and SOME DEHYDRATION needs urgent
referral to hospital.1 Do not try to rehydrate the child before he leaves. Quickly
give the mother some ORS solution. Show her how to give frequent sips to child on
the way to the hospital.
HOW WILL YOU TEACH THE CAREGIVER TO GIVE ORS

IN THE CLINIC?
Now study Plan B in your TREAT THE CHILD section. It contains the following
instructions:
1. DETERMINE AMOUNT of ORS to give during first 4 hours.
Use the chart in Plan B to determine how much ORS to give. To find the
recommended amount, look below the child’s weight (or age only if the weight
is not known). The child will usually want to drink as much as he needs. If the
child wants more or less than the estimated amount, give him what he wants.
The mother should also breastfeed whenever the baby wants to, then resume
the ORS solution.
2. SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
Find a comfortable place in the clinic for the mother to sit with her child. Tell
her how much ORS solution to give over the next 4 hours. Show her the
amount in units that are used in your area. If the child is less than 2 years,
show her how to give a spoonful frequently. If the child is older, show her how
to give frequent sips from a cup. Sit with her while she gives the child the
first few sips from a cup or spoon. Ask her if she has any questions.
The exception is a child with the severe classification, SEVERE PERSISTENT DIARRHOEA. This child should
1
be rehydrated then referred.
25
REFRESH: how do you decide amount of ORS to give?

1. Use chart in Plan B with child’s weight
2. If no chart, multiple child’s weight (kg) by 75 (Example: 8 kg child x 75 ml = 600 ml)
WHAT WILL YOU DO WHILE THE MOTHER GIVES ORS FOR 4 HOURS?
n Show the caregiver where to wash her hands, and where she can change the
child’s nappy or where the child can use a toilet.
n Check with the mother from time to time to see if she has problems. If
the child is not drinking the ORS solution well, try another method of giving
the solution. You may try using a dropper or a syringe without the needle.
n This also provides valuable time to teach the mother about care for
her child. The first concern is to rehydrate the child. When the child is
obviously improving, the mother can turn her attention to learning. Teach her
about mixing and giving ORS solution (Plan A).
n It is a good idea to have printed information that the mother can study
while she is sitting with her child. Posters on the wall can also reinforce this
information.
TIPS FOR THE YOUNG INFANT

During the first 4 hours of rehydration, encourage the mother to pause to breastfeed the infant whenever
the infant wants, then resume giving ORS. Give a young infant who does not breastfeed an additional
100–200 ml clean water during this period.
26
HOW WILL YOU REASSESS THE CHILD AFTER 4 HOURS?

After four hours you will reassess the child using the ASSESS AND CLASSIFY chart.
Classify the dehydration. Choose the appropriate plan to continue treatment. If the
child is not taking the ORS solution, or seems to be getting worse, reassess
before four hours.
Depending on your classifications, you will take further action:
n If the child has NO DEHYDRATION, move to Plan A. Counsel on home care.
n If the child has SOME DEHYDRATION, choose Plan B again. Begin feeding
the child in clinic. Offer food, milk, or juice. Continue to breastfeed frequently
if child is breastfed.
n If the child is worse and now has SEVERE DEHYDRATION, begin Plan C.
If the child’s eyes are puffy, it is a sign of overhydration. It is not a danger sign
or a sign of hypernatraemia. It is simply a sign that the child has been rehydrated
and does not need any more ORS solution at this time. The child should be given
clean water or breastmilk, and ORS according to Plan A when the puffiness is gone.
WHAT HAPPENS IF A CAREGIVER MUST LEAVE BEFORE

FINISHING 4 HOURS OF ORS?
1. Show the caregiver how to prepare ORS solution and have her practice.
2. Show her how much ORS to give to complete the 4-hour treatment at home.
3. Give her packets to complete rehydration PLUS 2 more packets as recommended
in Plan A.
4. Explain 4 rules of home treatment
27
SELF-ASSESSMENT EXERCISE E
Answer the following questions about PLAN B for dehydrated children.
1. The following children are classified SOME DEHYDRATION. Write the range
of amounts of ORS solution each child is likely to need in the first 4 hours of
treatment:
Name Age or Weight Range of Amounts of ORS Solution
a. Andras 3 years
b. Gul 10 kg
c. Nirveli 7.5 kg
d. Sami 11 months

2. Vinita is 5 months old and has diarrhoea. She is classified as SOME
DEHYDRATION. There is no scale for weighing Vinita at the small clinic. Vinita’s
mother died during childbirth, so Vinita has been taking infant formula. The
grandmother has recently started giving cooked cereal as well.
a. Vinita should be given ml of
during the first hours of treatment. She should also be given ml
of during this period.
b. What should the grandmother do if Vinita vomits during the treatment?
c. When should the health worker reassess Vinita?
d. When Vinita is reassessed, she has NO DEHYDRATION. What treatment

plan should Vinita be put on?
3. Yasmin is 9 months old and weighs 8 kg. Her mother brought her to the clinic
with diarrhoea. The health worker assesses Yasmin as SOME DEHYDRATION.
The health worker chooses Plan B. He asks if Yasmin still breastfeeds. Her mother
says that she breastfeeds several times each day. She also eats 3 meals each day
of rice along with vegetables, pulses, and sometimes bits of meat.
a. Approximately how much ORS solution should Yasmin’s mother give her
during the first 4 hours?
b. During the first 4 hours of treatment, should Yasmin eat or drink anything
in addition to the ORS solution? If so, what?
c. After 4 hours of treatment, the health worker reassesses Yasmin. She is still
classified as SOME DEHYDRATION. What is the appropriate plan to continue
her treatment?
28
PLAN A (NO DEHYDRATION)

Treat at home
A child with diarrhoea but no dehydration requires fluid, zinc, and food to prevent
dehydration. This child can be treated at home with Plan A.
WHAT IS PLAN A?
Plan A is based on the four rules of home treatment. These are critical for you
to remember. Plan A requires you to counsel the child’s mother about the 4 rules
of home treatment. As such, your teaching and advising skills are an important
part of Plan A.
Plan A is also an important treatment plan because eventually, all children
with diarrhoea will require Plan A. Children with diarrhoea who come to a
health worker with NO DEHYDRATION are put on Plan A right away. Child with
more serious dehydration will first be treated with Plan B or C, and then they will
be put on Plan A.
WHAT ARE THE 4 RULES OF HOME TREATMENT?

The four rules of home treatment are very important to remember:
1. Give extra fluid – as much as the child will take
2. Give zinc
3. Continue feeding
4. When to return (for a follow-up visit, or immediately if danger signs develop)
Now you will learn more about the four rules of home treatment. Open to Plan A
in your Chart Booklet to read along with the instructions.
RULE 1: GIVE EXTRA FLUID

Tell the caregiver to give as much fluid as the child will take. It is very
important for the child to have extra fluid – as much as the child will take. The
purpose of giving extra fluid is to replace the fluid lost in diarrhoea and thus to
prevent dehydration. The critical action is to give more fluid than usual, as soon as
the diarrhoea starts.
HOW SHOULD THE CAREGIVER GIVE EXTRA FLUID?

Tell the mother that breastfeeding should continue, with the addition of ORS and
clean water. If the child is exclusively breastfed, it is important for this child to be
breastfed more frequently than usual. Breastfed children under 4 months should
first be offered a breastfeed then given ORS.
If the child is not being breastfed, the child should receive ORS solution, food-
based fluids (soup, rice water, yoghurt drinks), and clean water. In your country,
the national programme for diarrhoeal disease control may have specified several
food-based fluids to use at home.
29
TIPS FOR THE YOUNG INFANT

n If infant is exclusively breastfed, it is important not to introduce a food-based fluid.
n If infant will be given ORS solution at home, you will show how much ORS to give the infant after each
loose stool. Mother should first offer a breastfeed, then give ORS.
HOW WILL YOU TEACH THE CAREGIVER TO MIX ORS?

Teach the caregiver how to mix and give ORS. Ask the caregiver to practice doing
it as you observe. The steps for making ORS are (follow along in drawings below):
✔✔ Wash your hands with soap and water
✔✔ Pour all the powder from one packet into a clean container. Use any available
container, such as a jar, bowl or bottle.
✔✔ Measure 1 litre of clean water (or correct amount for packet used). It
is best to boil and cool the water, but if this is not possible, use the cleanest
drinking water available.
✔✔ Pour the water into the container. Mix well until the powder is completely
dissolved.
✔✔ Taste the solution so you know how it tastes.
The caregiver should mix fresh ORS every day, in a clean container. She
should keep the container covered. She should throw away any solution remaining
from the day before.
1 litre
bottle
HOW WILL THE CAREGIVER GET ORS TO USE IN THE HOME?

Give the caregiver 2 packets of ORS to use at home. Show her how much fluid should
be given in addition to the usual fluid intake:
n Up to 2 years: 50–100 ml after each loose stool
n 2 years or older: 100–200 ml after each loose stool
HOW WILL YOU TEACH THE CAREGIVER TO GIVE ORS?

Finally, give the caregiver instructions for giving ORS:
1. Give frequent small sips from a cup
2. If child vomits, wait 10 minutes. Then continue, but more slowly.
3. Continue giving extra fluid until the diarrhoea stops
30
WHEN IS ORS ESPECIALLY IMPORTANT?

It is especially important to give ORS at home when:
✔✔ Child was treated with Plan B or C during this visit – in other words, the child has
just been rehydrated and needs ORS to prevent dehydration from coming back
✔✔ Child cannot return to the clinic if the diarrhoea gets worse – for example, if the
family lives far away or the mother has a job that she cannot leave
RULE 2: GIVE ZINC SUPPLEMENTS

Zinc treatment can considerably reduce the duration and severity of a child’s
diarrhoeal episode. It is also shown to decrease stool output and decrease the
need to hospitalize a child with diarrhoea.
Zinc is only given to children 2 months up to 5 years. This box describes how
much zinc to give a child with diarrhoea. Review this information in Plan A in your
Chart Booklet.
GIVE ZINC SUPPLEMENTS (one tablet is 20 mg zinc)

Remind the caregiver to give zinc supplements for the full 14 days
Tell the caregiver how much zinc to give
Up to 6 months: ½ tablet per day, for 14 days
6 months or older: 1 tablet per day, for 14 days
Show the caregiver how to give zinc supplements
Infants: dissolve the tablet in a small amount of breast milk, ORS, or clean water in a small cup or spoon
Older children: tablets can be chewed or dissolved in small amount of clean water in a cup or spoon
RULE 3: CONTINUE FEEDING

You will learn more about special feeding recommendations if the child has
persistent diarrhoea.
31
RULE 4: WHEN TO RETURN

You have learned the signs when a caregiver should return immediately to a health
worker.
Tell the mother of any sick child that the signs to return are:
•• Not able to drink or breastfeed
•• Becomes sicker
•• Develops a fever
If the child has diarrhoea, also tell the mother to return if the child has:
•• Blood in stool
•• Drinking poorly – also includes not able to drink or breastfeed
SELF-ASSESSMENT EXERCISE F
Answer the following questions about PLAN A for children with diarrhoea.
1. At your clinic, what are the recommended fluids for children with diarrhoea with
NO DEHYDRATION?
2. Somi is a 4-year-old boy who has diarrhoea. He has no general danger signs. He
was classified as having diarrhoea with NO DEHYDRATION and NO ANAEMIA
AND NOT VERY LOW WEIGHT. He will be treated according to Plan A.
a. What are the 4 rules of home treatment of diarrhoea?
b. What fluids should the health worker tell his mother to give?
3. Kasit is a 3-month-old boy who has diarrhoea. He has no general danger signs.
He was classified as NO DEHYDRATION and NO ANAEMIA AND NOT VERY
LOW WEIGHT. He is exclusively breastfed. What should the health worker tell
his mother about giving him extra fluids?
32
4. For which children with NO DEHYDRATION is it especially important to give

ORS at home?
5. The following children came to the clinic because of diarrhoea. They were
assessed and found to have no general danger signs. They were classified as NO
DEHYDRATION. Write the amount of extra fluid that the mother should give
after each stool.
Name Age Amount of extra fluid to give after each loose stool
a. Kala 6 months
b. Sam 2 years
c. Kara 15 months
d. Lalita 4 years

DIARRHOEA: SICK CHILD

Treatment is required for children who have persistent diarrhoea or dysentery.
HOW WILL YOU TREAT SEVERE PERSISTENT DIARRHOEA?

Children with this classification have persistent diarrhoea (14 days or longer) and
signs of dehydration. These children should be referred to hospital. They need special
attention to prevent fluid loss. You should treat dehydration before referral, unless
child has another severe classification.
HOW WILL YOU TREAT PERSISTENT DIARRHOEA?

Children with this classification have persistent diarrhoea (14 days or longer)
and no signs of dehydration. Special feeding is the most important treatment
for persistent diarrhoea with no signs of dehydration. Children with persistent
diarrhoea may have difficulty digesting milk other than breastmilk. They
need to temporarily reduce the amount of other milk in their diet.
Special feeding advice for a child with PERSISTENT DIARRHOEA includes:
✔✔ If still breastfeeding, give more frequent, longer breastfeeds, day and night.
✔✔ If taking other milk:
— Replace with increased breastfeeding, OR
— Replace with fermented milk products, such as yogurt, OR
— Replace half the milk with nutrient-rich semi-solid food.
✔✔ For other foods, follow feeding recommendations for the child’s age: give small,
frequent meals (at least 6 times a day), and avoid very sweet foods or drinks.
The child also should receive zinc for 14 days. The child should follow up in 5
days.
33
HOW WILL YOU TREAT DYSENTERY?

Children with dysentery should receive ciprofloxacin for 3 days (or another oral
antibiotic recommended for Shigella in your area). The box “Give an Appropriate
Oral Antibiotic” on the TREAT THE CHILD chart tells the recommended antibiotics.
Refer to Module 3 to review counselling the caregiver on oral medicines. They
should also receive zinc supplements. Zinc should be given in the same way that
you learned previously in Plans A and B. Treat dehydration as classified. Children
should follow-up for the dysentery in 2 days.
WHEN SHOULD ANTIBIOTICS BE USED FOR DIARRHOEA?

Antibiotics are not effective in treating most diarrhoea. They rarely help
and make some children sicker. Unnecessary use of antibiotics may increase the
resistance of some pathogens. In addition, antibiotics are costly. Money is often
wasted on ineffective treatment. Therefore, do not give antibiotics routinely. The
only types of diarrhoea that should be treated with antibiotics are DYSENTERY
and diarrhoea with SEVERE DEHYDRATION with cholera in the area.
34
SELF-ASSESSMENT EXERCISE G
Answer the questions below about treatment for diarrhoea and dehydration.
1. How will you give zinc supplements to a 4 month old infant, weight 7.3 kg, with
SOME DEHYDRATION?
2. How will you give zinc supplements to a 37 month old infant, weight 12 kg, with
NO DEHYDRATION?
3. How would you treat a 9 month old, weighing 8.3 kg, with a classification of
DYSENTERY?
4. How would you treat a 36 month old, weighing 15 kg, with a classification of
DYSENTERY?
5. How would you treat a 7 month old with SEVERE PERSISTENT DIARRHOEA?
6. You are talking with the mother of a 15-month-old child who is no longer
breastfed. The child has PERSISTENT DIARRHOEA. He normally takes 2 feedings
of cow’s milk and 1 meal of family foods each day. His diet has not changed during
the diarrhoea. Which of the following are appropriate to say when counselling
this mother? Tick appropriate comments.
 a. You were right to keep feeding your child during the diarrhoea. He needs
food to stay strong.
 b. Your child needs more food each day. Try to give him 3 family meals plus
2 feedings between meals.
 c. Cow’s milk is very bad for your child.
 d. Your child may be having trouble digesting the cow’s milk, and that may
be the reason that the diarrhoea has lasted so long.
 e. Give your child yoghurt instead of milk (until follow-up visit in 5 days).
Or give only half the usual milk and increase the amount of family foods
to make up for this.
35
Two of the following signs: Pink: If child has no other severe classification:
Lethargic or unconscious SEVERE
IMCI DISTANCE Give 4.
LEARNING COURSE | MODULE fluid for severe dehydration (Plan C)
DIARRHOEA
RATION Sunken eyes DEHYDRATION OR
Not able to drink or If child also has another severe
EA
n What treatment will Mary require?
on the way
Mary has an acute episode of diarrhoea lasting for 3 days, and there is no blood in the stool, so you did not
classify her for persistent diarrhoea or dysentery.
breastfeeding
You classified Mary’s dehydration as SOME DEHYDRATION. Review If childwhat
is 2treatments
years or older and there
were identified foris
SOME
DEHYDRATION. cholera in your area, give antibiotic for
cholera
Restless, irritable SOME some dehydration (Plan B)
Sunken eyes DEHYDRATION If child also has a severe classification:
Skin pinch goes back mother giving frequent sips of ORS
slowly. on the way
breastfeeding
as some or severe NO DEHYDRATION
You will remember from this section that SOME diarrhoea at Plan
requires home (Plan
B for A) foods, and zinc. Plan
fluids,
Bdehydration. DEHYDRATION
will require Ana to give ORS to Mary Advise
for 4 hours in the clinic, mother
then you will when to return
re-assess Mary’simmediately
dehydration.
Open your Chart Booklet to review Plan B. Follow-up in 5 days if not improving
The steps of Plan B are:
1. Determine the amount of ORS to give for the first 4 hours in the clinic. Mary is 8 kg and 9 months old.
rhoea 14 SEVERE child has another severe classification
We review the chart in Plan B and decide that she should receive between 450 and 800 ml of ORS. If we
more PERSISTENT Refer to hospital
had calculated with the second method, multiplying her weight 8 kg by 75 ml, we would have calculated
DIARRHOEA
560 ml, which is within the chart range.
2. Teach Ana how to give the ORS solution. You explain to Ana that Mary has diarrhoea with some
dehydration. She needs fluids and food. You ask Ana to stay at the clinic to give Mary ORS solution. Show
DIARRHOEA Give multivitamins and
Ana how much ORS to give from a cup.
You take Ana to a corner where she can sit with Mary andFollow-up in 5 You
give the ORS. daysshow her where you can wash
her hands, and where she can change Mary or use the toilets. You make sure she is comfortable. She does
not have any questions for you, but it worried about staying too late at the clinic because her husband
Blood
will in the
worry. Youstool. Yellow:
assure her that she can give all of the ORSGive
now, ciprofloxacin forwork
and then you will 3 days
with her to decide
od in stool about treatment later tonight at home. Ana props Mary on her lap. She slowly begins to give her ORS
DYSENTERY Follow-up in 2 days
from a cup. You also encourage Ana to breastfeed if Mary wants to.
3. After 4 hours, you reassess Mary. She had NO DEHYDRATION. Her diarrhoea continued, but you think
that she is ready to go home on Plan A. Plan A will also include giving zinc and food.
Page 6 of 75
36
4.6 COUNSEL THE CAREGIVER

Good teaching and advising skills are particularly important when treating
dehydration and diarrhoea. As you read in the previous section on treatment, the
caregiver gives many of the treatments in the clinic or at home. This requires you
to teach them how to give the treatment.
WHAT ARE THE 4 RULES OF HOME TREATMENT?

It is very important to counsel caregivers on the 4 rules of home treatment.
This is required for Plan A. Child classified with NO DEHYDRATION need Plan A.
After children who required Plan B or C have completed this plan, they will also
require Plan A at home.
1. Give extra fluid – as much as the child will take
2. Give zinc
3. Continue feeding
4. When to return (for a follow-up visit, or immediately if danger signs
develop)
RULE 1. How will you counsel a caregiver to give extra fluid?

You will tell a caregiver that during illness, a child loses fluid due to fever, fast
breathing, or diarrhoea. The child will feel better and stay stronger if he drinks
extra fluid to prevent dehydration. Extra fluid is especially important for children
with diarrhoea.
FIRST, TELL THE CAREGIVER TO GIVE AS MUCH FLUID AS THE

CHILD WILL TAKE.
The purpose of giving extra fluid is to replace the fluid lost in diarrhoea and thus
to prevent dehydration. The critical action is to give more fluid than usual as
soon as the diarrhoea starts. More fluid can be given by:
•• Breastfeeding more frequently, and for longer feeds. If the child is exclusively
breastfed, also give ORS or clean water in addition.
•• If child is not breastfed, increase fluid with food-based fluids (soup, rice water,
yoghurt drinks), or ORS
•• ORS is especially important at home if the child was treated on Plan B or C, or
if the child cannot return to the clinic if the diarrhoea gets worse
SECOND, teach the caregiver how to mix and give ORS.

Review these teaching steps in the previous TREAT section. Ask the caregiver to
practice doing it as you observe. You will review these steps, which are also discussed
in Plan B in the previous section:
1. Wash hands with soap and water
2. Pour the ORS powder into a clean container
37
3. Measure 1 litre of water (or specified amount). It is best to boil and cool water.
4. Pour the water into the container with the powder. Mix and taste.
5. Give solution to the child slowly, by cup. If the child vomits, wait for 10 minutes
and then continue more slowly.
6. Always make fresh ORS solution each day. Keep the solution covered.
RULE 2. How will you counsel a caregiver to give zinc?

Your TREAT chart and the previous section describe how much zinc to give a child
with diarrhoea. Zinc is only given to children 2 months up to 5 years.
Show the mother how to give the zinc to her baby with diarrhoea. For
example, infants can be given the tablet dissolved in a small amount of expressed
breast milk ORS, or clean water in a cup. Older children can chew the tablet or take
it in a small amount of clean water.
The mother should give her child the first zinc supplement. If a child is 2
months up to 6 months, he can have half a 20 mg tablet daily for 14 days. A child
6 months or older can take a whole 20 mg tablet. Explain how she will continue
to give this treatment for 14 days. Check her understanding with checking
questions, and answer any problems she has.
RULE 3. How will you counsel a caregiver to continue feeding?

The caregiver should continue feeding, as explained in the previous TREAT section.
You will also remember that children with persistent diarrhoea have
special feeding needs. If may be difficult for these children to digest milk other
than breast milk. Caregivers need to temporarily reduce the amount of other milk
in the child’s diet. To make up for this reduction, the child must take more breast
milk or other foods. Continue other foods appropriate for the child’s age. The child
with persistent diarrhoea should be seen again in 5 days for follow-up, and will be
given further feeding instructions during this visit.
RULE 4. How will you counsel a caregiver to return to clinic?

You will advise on follow-up care as you would with all other conditions.
Remember that if the child is required to follow up for more than one
illness, they should return for follow-up at the earliest definite date. The child
should follow up:
Immediately if  The child is not able to breastfeed or drink
 Becomes sicker
 Develops a fever
 Has blood in the stool
In 3 days if The child has dysentery
In 5 days if The child has persistent diarrhoea
38
SELF-ASSESSMENT EXERCISE H
Complete this case study.
CASE STUDY: Health worker Basaka must teach a mother to prepare ORS solution
for her child with diarrhoea. First he explains how to mix the ORS, then he shows
her how to do it. He asks the mother, “Do you understand?” The mother answers
“yes”. So Basaka gives her 2 ORS packets and says good-bye.
1. What are the four rules of home treatment that must be explained to the mother?
2. What information did Basaka give the mother about the task?
3. Did he show her an example?
4. Did he ask her to practice?
5. How did Basaka check the mother’s understanding?
6. Did Basaka check the mother’s understanding correctly?
7. How would you have checked the mother’s understanding?
39
SELF-ASSESSMENT EXERCISE I
Answer these questions about counselling a caregiver.
1. A 4-year-old boy has diarrhoea. He has no general danger signs. He was classified
with NO DEHYDRATION and NO ANAEMIA AND NOT VERY LOW WEIGHT.
The health worker has taught his mother Plan A and given her 2 packets of ORS
to use at home. Tick all the fluids that the mother should encourage her son to drink
as long as the diarrhoea continues.
 Tea that the child usually drinks with meals
 Fruit juice that the child usually drinks each day
 Water from the water jug. The child can get water whenever he is thirsty.
 ORS after each loose stool
 Yoghurt drink when the mother makes some for the family
2. A mother brought her 11-month-old daughter, Aviva, to the clinic because she
has diarrhoea. Aviva usually eats cereal and bits of meat, vegetables and fruit.
Her mother has continued to breastfeed her as well. The mother says she lives
far from the clinic and might not be able to come back for several days, even if
the child gets worse.
The health worker assesses Aviva and finds she has no general danger signs and
no other disease classifications. He classifies her as NO DEHYDRATION. He
decides Aviva needs treatment according to Plan A.
a. Should the health worker give this mother ORS packets to take home? If so,
how many one-litre packets should he give?
b. What should the mother do if the child vomits while being fed the solution?
c. How long should Aviva’s mother continue giving extra fluid?
d. The health worker will tell the mother to continue feeding Aviva. He will
also teach her the signs to return immediately. What signs should the health
worker teach Aviva’s mother?
3. Which of the following is the best checking question after advice about increasing
fluids during diarrhoea? (Tick one.)
a.  Do you remember some good fluids to give your child?
b.  Will you be sure to give your child extra fluid?
c.  How much fluid will you give your child
40
n What do you advise Ana about home treatment?

You classified Mary with SOME DEHYDRATION and gave her Plan B in the clinic. You re-assessed after Ana
had been giving her ORS for 4 hours, and Mary showed signs of NO DEHYDRATION.
You will now counsel Ana on home treatment of diarrhoea with Plan A. You give Ana a Mothers’ Card to
take home. This card reminds her of important information like what fluids and food to give her child.
n What are the 4 rules of home treatment you will teach Ana?
1. You tell Ana to give extra fluid, as much as Mary will take.
This will include breast milk, clean water, ORS, or food-based fluids such as soup, rice water, yogurt drinks.
You ask Ana which of these options she will use to give Mary more fluid. Ana says that Mary takes rice
water well, and she will still breastfeed. She will also try to get some yogurt from a neighbour who makes
some. You remind Ana to breastfeed as often as Mary will.
You previously taught Ana how to make the ORS when you were preparing it in the clinic. You ask her
checking questions to make sure she remembers how to make it.
— You ask, “How much clean water do you need for 1 packet of ORS?” Ana says, “1 litre.”
— You ask, “How will you give the ORS?” Ana says, “With a cup, as she sits in my lap.”
— You also ask Ana, “How often will you give ORS?” “What will you do if Mary vomits?”
You remind Ana that if Mary vomits, she should wait 10 minutes, then continue again, but more slowly.
You give Ana 2 packets of ORS to take home.
2. You advise Ana how to give Mary zinc tablets.
Mary is 9 months old, so she will take 1 full tablet a day for 14 days. You show Ana how to dissolve the
tablet in a spoon with breast milk or clean water. You explain why you are giving zinc to Ana, that it is a
good nutrient for the body that will help with Mary’s diarrhoea.
3. You advise Ana to continue feeding, and that Mary should get between 50–100 ml of solution after
each loose bowel movement.
4. You advise Ana to return to the clinic immediately if Mary develops the following: she is not able
to breastfeed or drink, she becomes sicker, she develops a fever, she has blood in the stool. You use Ana’s
Mother’s Card to demonstrate these signs. Mary does not have other illnesses that require specific follow-
up, or else you would have given them a specific date to return.
Your conversation with Ana also gives her a chance to ask questions. Your checking questions gave you an
idea of how much she understands home treatment. After you talk with Ana, you feel confident that she
understands home treatment, and you say goodbye to her and Mary.
41
4.7 PROVIDE FOLLOW-UP CARE FOR DIARRHOEA

DO YOU REMEMBER THE STEPS FOR PROVIDING FOLLOW-UP CARE?
First, you will re-assess your earlier classifications. Is the child:
 Improving?
 The same?
 Worsening?
Second, you will reassess the child using IMCI to see if there are any new issues.
You will use a second recording form for this visit.
DIARRHOEA IN SICK YOUNG INFANT (FOLLOW-UP 2 DAYS)

When an infant with diarrhoea follows-up in 2 DAYS, you will:
✔✔ ASK – Has the diarrhoea stopped?
 DIARRHOEA HAS STOPPED

Tell the mother to continue exclusive breastfeeding. If the infant’s signs are
improving, tell the mother to continue giving the infant the fluids and breastfeeding
according to plan A.
  DIARRHOEA HAS NOT STOPPED

If the diarrhoea has not stopped, reassess the young infant for diarrhoea. Classify
the dehydration and select a fluid plan.
If the signs are the same or worse, refer the infant to hospital. If the young
infant has developed fever, give intramuscular antibiotics before referral, as for
VERY SEVERE DISEASE.
PERSISTENT DIARRHOEA (FOLLOW-UP 5 DAYS)

First you will ASK:
✔✔ Has the diarrhoea stopped?
✔✔ How many loose stools is the child having per day?
 DIARRHOEA HAS STOPPED (less than 3 stools/day)

Tell the mother to follow the usual feeding recommendations for the child’s age.
If the child is not normally fed in this way, you need to teach her the feeding
recommendations on the COUNSEL chart.
 DIARRHOEA HAS NOT STOPPED (more than 3 stools/day)

Do a full reassessment of the child. Identify and manage any problems that require
immediate attention such as dehydration. Then refer the child to hospital.
42
DYSENTERY (FOLLOW-UP 3 DAYS)

First you will ASK:
✔✔ Are there fewer stools?
✔✔ Is there less blood in the stool?
✔✔ Is there less fever?
✔✔ Is there less abdominal pain?
✔✔ Is the child eating better?
 FEWER STOOLS, LESS BLOOD IN STOOLS, LESS FEVER, LESS ABDOMINAL

PAIN, AND EATING BETTER
The child is improving on the antibiotic ciprofloxacin. Usually all of these signs will
diminish if the antibiotic is working. If only some signs have diminished, use your
judgment to decide if the child is improving. Tell the mother to finish the 3 days of
the ciprofloxacin prescribed. Review with the mother the importance of finishing
the antibiotic.
 CHILD IS DEHYDRATED
Use the classification table to classify the child’s dehydration. Select the appropriate
fluid plan and treat the dehydration.
 MORE STOOLS, BLOOD IN STOOLS, FEVER, ABDOMINAL PAIN, AND EATING

IS SAME OR WORSE
The child is not improving on the antibiotic. Stop the first antibiotic and give the
second-line antibiotic recommended for Shigella for 5 days. Refer to TREAT chart.
Antibiotic resistance of Shigella may be causing the lack of improvement. Advise
the caretaker to return in 2 days.
What actions will you take?
✔✔ Give the first dose of the new antibiotic in the clinic.
✔✔ Teach the caregiver how and when to give the antibiotic and help her plan how
to give it.
✔✔ Advise the caregiver to bring the child back again after two more days.
What actions will you take on the follow-up visit in 2 days?
If the child has received the second-line antibiotic for two days, and has not improved,
the child may have amoebiasis. This child may be treated with metronidazole if it
is available or can be obtained by the family, or referred for treatment. Amoebiasis
can only be diagnosed with certainty when trophozoites of E. histolytica containing
red blood cells are seen in a fresh stool sample.
REFER if the non-improving child has any of these 3 high-risk factors:

1. Less than 12 months old, or
2. Was dehydrated on the first visit, or
3. Had measles within the last 3 months,
43
n How do you provide Mary with follow-up care?

You classified Mary with SOME DEHYDRATION, and she received Plan B in the clinic. Then you re-assess her,
and classified with NO DEHYDRATION. You counselled her mother Ana on Plan A home treatment, and sent
them home.
Ana and Mary were only supposed to return for follow-up if Mary’s dehydration and diarrhoea did not
improve. You are pleased that Mary does not return to the clinic for follow-up. You hope this means that the
fluid plan worked, and Mary was no longer dehydrated and acting unwell.
SELF-ASSESSMENT EXERCISE J
Answer questions for this case about follow-up of DYSENTERY or PERSISTENT
DIARRHOEA.
Details about this clinic: This clinic refers children with severe dehydration because
health workers cannot give IV or NG therapy. A hospital nearby can give IV therapy.
Evaristo was brought for follow-up of PERSISTENT DIARRHOEA after 5 days. He
is 9 months old and weighs 6.5 kg. His temperature is 36.5 °C today. He is no longer
breastfed. His mother feeds him cereal twice a day and gives him a milk formula 4
times each day. When you saw him last week, you advised his mother to give him
only half his usual amount of milk. You also advised the mother to replace half the
milk by giving extra servings of cereal with oil and vegetables or meat or fish added.
1. What is your first step for reassessing Evaristo?
2. Evaristo’s mother says the diarrhoea has not stopped. What do you do next?
You do a complete reassessment of Evaristo, as on the ASSESS & CLASSIFY chart.

You find that Evaristo has no general danger signs. He has no cough. When you
reassess his diarrhoea, his mother says that now he has had diarrhoea for about
3 weeks. There is no blood in the stool. Evaristo is restless and irritable. His eyes
are not sunken. When you offer him some water, he takes a sip but does not seem
thirsty. A skin pinch goes back immediately. Evaristo’s mother tells you that he has
no other problems.
3. Is Evaristo dehydrated?
4. How will you treat Evaristo?
5. If your reassessment found that Evaristo had some dehydration, what would
you have done before referral?
44
4.8 USING THIS MODULE IN YOUR CLINIC

How will you begin to apply the knowledge you have gained from this module
in managing children with diarrhoea? In the coming days, you should focus on
these key clinical skills. Practicing these skills in your clinic, and using your IMCI
job aids, will allow you to observe and better understand the signs needed to assess
and classify a child with dehydration and diarrhoea.
ASSESS
✔✔ Assess children for diarrhoea – how long has the diarrhoea lasted? Is there blood
in the stool?
✔✔ Assess children for signs of dehydration, including sunken eyes, skin pinches,
the child’s condition, and the child’s willingness and ability to drink.
✔✔ Practice giving children skin pinches and assessing if it returns very slowly,
slowly, or immediately.
✔✔ Practice observing children’s conditions (restless, irritable, unconscious,
lethargic) and willingness to drink.
CLASSIFY
✔✔ Use your chart booklet to classify the signs of dehydration
✔✔ Classify if a child has persistent diarrhoea or dysentery
TREAT
✔✔ Determine if children need Plans A, B, or C.
✔✔ Determine how you will give Plan C in your facility – what equipment do you
have for intravenous fluid? Is there a facility within a 30 minute drive that can
give this fluid? Are you trained to use Naso-Gastric tubes for rehydration?
✔✔ Advise a caregiver on giving Plan B in your facility. Determine correct amount of ORS.
✔✔ Advise a caregiver about giving Plan A. Focus on the 4 rules of home treatment.
COUNSEL
✔✔ Teach a caregiver how to make and give ORS. Determine the amounts required.
✔✔ Advise a caregiver on giving extra fluid and continue breast feeding in the home.
✔✔ Advise a caregiver on giving zinc, and show them how to give tablets. Advise on
how often zinc should be given.
✔✔ Advise a caregiver on continued feeding, especially for children with persistent
diarrhoea.
✔✔ Counsel a caregiver about when to return for follow-up for diarrhoea or
dehydration.
✔✔ Counsel a caregiver about when to return immediately.
Remember to use your logbook for MODULE 4:

n Complete logbook exercises, and bring completed to the next meeting
n Record cases on IMCI recording forms, and bring to the next meeting
n Take notes if you experience anything difficult, confusing, or interesting during these cases. These will be
valuable notes to share with your study group and facilitator.
45
4.9 REVIEW QUESTIONS

AFTER THE MODULE: WHAT DO YOU KNOW NOW ABOUT
MANAGING DIARRHOEA AND DEHYDRATION?
Before you began studying this module, you practiced your knowledge on with
several questions. Now that you have finished the module, you will answer the same
questions. This will help demonstrate what you have learned.
Circle the best answer for each question.
1. How can diarrhoea kill children?
a. Children lose valuable fluids, salts, and sugars, which can cause shock to vital
organs
b. Children lose valuable nutrients because they cannot eat
c. Diarrhoea causes liver failure
2. What are critical treatments for children with diarrhoea and dehydration?
a. Oral antibiotics
b. Oral rehydration therapy and zinc
c. Paracetamol for discomfort
3. What is persistent diarrhoea?
a. When a child frequently has diarrhoea over a period of 1 month, and is ill as
a result
b. When a child has several episodes of diarrhoea a day
c. When a child has an episode of diarrhoea lasting 14 days or more, which is
particularly dangerous for dehydration and malnutrition
4. Critical messages for caregivers about diarrhoea and dehydration include:
a. The child must receive increased fluids, ORS, zinc, and regular feeding
b. The child requires ORS, but should receive less food in order to reduce the
diarrhoea
c. The child should immediately receive antibiotics to stop the diarrhoea
5. Nidhi arrives at your clinic and is very lethargic. Her eyes are very sunken. She
has diarrhoea. You observe a significant loss of skin elasticity. How will you
manage Nidhi?
a. Nidhi requires ORS immediately, as she is dehydrated.
b. These are common signs of diarrhoea, as the child’s body is exhausted.
c. Nidhi is severely dehydrated. She requires urgent rehydration therapy by IV
or nasogastric tube.
Check your answers on the next page. How did you do? ............... complete out of 5.
Did you miss questions?
Turn back to the section to re-read and practice the exercises.
46
4.10 ANSWER KEY

REVIEW QUESTIONS
Did you miss the question? Return to this section
QUESTION ANSWER
to read and practice:
1 A INTRODUCTION
2 B CLASSIFY, TREAT
3 C CLASSIFY
4 A TREAT, COUNSEL THE CAREGIVER
5 C CLASSIFY, TREAT
EXERCISE
Name:
A (MAYA)
Ask: What are the child's problems?
Age: Weight (kg):
Initial Visit?
Temperature (°C):
Follow-up Visit?
MANAGEMENT
OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS CLASSIFY
NOTMaya
Name: ABLE TO DRINK OR BREASTFEED Age: 25 mo
LETHARGIC Weight (kg): 9 kg
OR UNCONSCIOUS 37 °C
present?
Temperature (°C):
VOMITS
Ask: EVERYTHING
What are the child's problems? CONVULSING NOW
Initial Visit? X Yes ___
Follow-up No ___
Visit?
CONVULSIONS
Diarrhoea
Remember
CLASSIFY to use
Danger sign when
selecting
classifications
VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___ X
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
CONVULSIONS Yes __ Noto__
Remember use
For how long? ___ Days Count the breaths in one minute Danger sign when
___ breaths per minute. Fast breathing? selecting
Look for chest indrawing classifications
DOES THE CHILD HAVE COUGH OR DIFFICULTLook BREATHING?
and listen for wheezing X
Yes __ No __
DOES THE CHILD HAVE DIARRHOEA?
X
Yes __ No __
4
Is there blood in the stool? No Lethargic or unconscious?
No
Restless and irritable?No
DOES THE CHILD HAVE DIARRHOEA? Offer the child fluid. Is the child: Yes __ No __
For how long? ___ Days LookNotat able
the childs
to drink general condition.
or drinking Is the child:
poorly?
No visible
Drinking eagerly, Yes
thirsty? dehydration
Restless
Pinch the skin and
of theirritable?
abdomen. Does it go back:
Slowly?
Decide malaria risk: High ___ Low ___ No___
Look or feel for stiff neck
Yes __ No __
EXERCISE
Name:
Ask:If What
more are than Bthe
7(RANA)
days,
child'shas fever been present every
problems?
Age:
Look for signs of MEASLES:
Slowly?
Weight (kg):
Initial Visit?
Temperature (°C):
Follow-up Visit?
day? (Circle all signs present) Generalized rash and
ASSESS
Has child had measels within the last 3 months?
Decide malaria risk: High ___ Low ___ No___
One
Look for
Look
of
or feel
these:
anyfor
cough,
stiffcause
other
runny
neck of fever.
nose, or red eyes Yes __ No __
CLASSIFY
CHECK
Do malariaFOR test if GENERAL
NO general danger DANGERsign SIGNS General danger sign
Look for runny nose
Rana
For how
HighNOT
Name:
If
risk:ABLE
more
long?
all fever
than
TO___
14 mo
7
cases
days,
DaysOR BREASTFEED
DRINK 12 kg
has fever been
37.5 °C
present every
LETHARGIC
Age: for signsOR
Look
UNCONSCIOUS
of MEASLES: Weight (kg): present?
Temperature (°C):
Ask:VOMITS
Lowday?Whatif are
Diarrhoea
risk:
CONVULSIONS
ASSESS
EVERYTHING

NO the child's
obvious cause
(Circle all signs present)
X
problems?
of fever
CONVULSING NOW
Generalized rash and Initial Visit? Yes ___
Follow-up No ___
Visit?

TestHasPOSITIVE?
child hadP. falciparum
measels withinP.the
vivaxNEGATIVE?
last 3 months? One of these: cough, runny nose, or red eyes Remember
CLASSIFY to use
Look for any other cause of fever. Danger sign when
CHECK
If
Dothe
malaria childFOR
testhas GENERAL
if NOmeasles
general dangerDANGER
nowsign SIGNS
or within the Look for mouth ulcers. General danger
selecting
sign
HighNOT risk: ABLE
all fever TOcases
DRINK OR BREASTFEED LETHARGIC
If yes, are ORtheyUNCONSCIOUS
deep and extensive? present?
last 3 months: classifications
VOMITS EVERYTHING
CONVULSING
Look NOW from the eye.
for pus draining X
Yes ___ No ___
DOES THE CHILD HAVE COUGH OR DIFFICULTLook
CONVULSIONS BREATHING?
for clouding of the cornea. Yes __ Noto__
Remember use
TestForPOSITIVE? P. falciparum P. vivaxNEGATIVE?
DOEShow THE long?CHILD___ DaysHAVE AN EAR PROBLEM? Count the breaths in one minute Danger
Yes __sign
No when
__
If the
Is therechild ear haspain?measles now or within the
Look for mouth
___ breaths perulcers.
minute. Fast breathing?
Look for pus draining from the ear selecting
lastIs 3theremonths: LookIf yes, are they
for chest deep and extensive?
indrawing classifications
ear discharge? Feel for tender swelling behind the ear
Look for
andpus draining
listen from the eye.
for stridor
DOESIf Yes,THE for how CHILDlong? HAVE
___ DaysCOUGH OR DIFFICULT BREATHING?
Look for
andclouding
listen forofwheezing
the cornea. X
Yes __ No __
THENFor how CHECK long? FOR
___ DaysACUTE MALNUTRITION Look
Count the breaths in one feet.
for oedema of both minute
DOES
AND
THE
ANAEMIA
CHILD HAVE AN EAR PROBLEM? Determine
DIARRHOEA? WFH/L _____ Z
___ breaths per minute. Fast breathing? score. X
Yes __ No __
Is
For there
howear 21
long? pain?
___ Days Look
For for puschilds
at the
Lookchildren
for chest6draining
months from
general
indrawing
the ear
condition.
or older Is the
measure child:____ mm.
MUAC
Is there ear blood discharge? No
in the stool? Feel
Look for tender
Lethargic
Look for
andpalmar
orswelling
listen for
No
unconscious?
pallor.
stridor
behind the ear
Look
Restlesspalmar
Severe Yes
and irritable?Some palmar pallor?
and listen for pallor?
wheezing
THEN CHECK FOR ACUTE MALNUTRITION Look for sunken
oedema eyes.
of complication?
both feet.
If childTHE
DOES has CHILD MUAC HAVE less than 115 mm or
DIARRHOEA? Is there
Offer
any medical
the child fluid._____
Is the Zchild: Yes __ No __
Determine WFH/L score.
AND ForANAEMIA
WFH/L howlesslong? than
___ -3DaysZ scores or oedema of Look
General
Not
For Anyat the
able
children
danger
childs
tomonths
6 drink
sign?
general
oror condition.
drinking
older Is the
poorly?
measure child:____ mm.
MUAC
Some
both feet:
Is there blood in the stool? Look
severe
Lethargic
Drinking
for palmar
Pneumonia
classification?
or pallor. Yes
unconscious?
eagerly,
with chestthirsty?
indrawing?
dehydration
Restless
Pinch the skinandof irritable?
the
Severe palmar
For a child 6 months orabdomen.
pallor? offerDoes
olderSome palmar
RUTF it go back:
pallor?
to eat. Is the child:
If child has MUAC less than 115 mm or Is Not able to finish or able to2finish?
Very
there slowsly
any medical (longer then
complication? seconds)?
Offer the
Slowly? child fluid. Is the child:
WFH/L less than -3 Z scores or oedema of For aGeneral
child lessdanger
than 6sign? months is there a breastfeeding problem?
CHECK
both feet: FOR HIV INFECTION Any severe classification? Yes __ No __
Drinking
Pneumonia eagerly, thirsty?
Decide
Notemalaria
mother's risk: High child's
and/or ___ Low HIV___ No___
status Look or feel for with chest indrawing?
stiff neck
Pinch the
For a child skin
6 monthsof the abdomen. Does it go back:
NOTLook for runny noseor older offer RUTF to eat. Is the child:
ForMother's
If more
how long?
than
Child's
HIV___ Days NEGATIVE POSITIVE
test:
7 days, has
virological test:fever been present
NEGATIVE every
POSITIVE NOTLookDONE
47
DONE/KNOWN
Veryable
Not slowsly
for signsto of (longer
finish thento2finish?
or able
MEASLES:
seconds)?
Slowly?
For aGeneralized
child less than 6 months is there a breastfeeding problem?
day? Child's serological test: NEGATIVE POSITIVE NOT DONE rash and
CHECK FOR HIV INFECTION Yes __ No __
IfHas child
mother ishad measels
HIV-positive within
and NO thepositive virological test in child:One of these: cough, runny nose, or red eyes
last 3 months?
Decide
Note malaria
mother's risk: High child's
and/or ___ Low HIV ___ No___
status Look or feel
Look for anyfor stiffcause
other neck of fever.
Is the child breastfeeding
Do malaria test if NO general danger sign now?
ForMother's
how the
Was long? HIV___
child Days NEGATIVE
test:
breastfeeding POSITIVE
at the time NOTLook
of test or 6 weeks
for runny nose
DONE/KNOWN
before it?
High risk: all fever cases Look for signs of MEASLES:
If more than
Child's 7 days,
virological has fever
test: been
NEGATIVE present every
POSITIVE
If breastfeeding: Is the mother and child on ARV prophylaxis? NOT DONE
Low risk: if NO obvious cause of fever Generalized rash and
EXERCISE C (CLASSIFY)
1. 2 SIGNS from any of the following – sunken eyes, restless/irritable, drinks eagerly/
thirsty, and slow skin pinch (faster than 2 seconds, but not immediate).
2. 2 SIGNS from any of the following – lethargic/unconscious, sunken eyes, not able
to drink/drinking poorly, very slow skin pinch (over 2 seconds)
3. Low osmolarity ORS.
MANAGEMENT
4. ChildrenOF
withTHE SICK
diarrhoea CHILD
that do AGED
not require 2 MONTHS
immediate referral – thatUP TO 5with
is, children YEARS
Name: diarrhoea and some or no dehydration.
Age: Children with persistent
Weight (kg): diarrhoea receive
Temperature (°C):
zinc for 14 days. Zinc supplements are a very important part of treating diarrhoea.
5. 4 rules DANGER
CHECK FOR GENERAL of home SIGNS
treatment of diarrhoea: General danger sign
1. Give extra fluid
VOMITS EVERYTHING – as muchCONVULSING
as the child
NOWwill take Yes ___ No ___
2. Give zinc Danger sign when
3. Continue feeding selecting
classifications
4. When to return (for a follow-up visit, or immediately if danger signs develop)
EXERCISE D
MANAGEMENT OF(CLASSIFY)
THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
3. PANO Look and listen for stridor
Name: Look
Age: and listen for wheezing Weight (kg): Temperature (°C):
Ask:
DOES What are the
THE child'sHAVE
CHILD problems?
DIARRHOEA? Initial Visit? Follow-upX
Yes __Visit?
No __
ASSESS (Circle
For how 5
long?all___
signs present)
Days Look at the childs general condition. Is the child: CLASSIFY
Is thereFOR
CHECK blood GENERAL No
in the stool? DANGER SIGNS Lethargic or unconscious? No General danger sign
NOT ABLE TO DRINK OR BREASTFEED Restless and
LETHARGIC OR irritable?
UNCONSCIOUS Yes present?
VOMITS EVERYTHING Look for sunkenNOW
CONVULSING eyes.
Yes ___ No ___
CONVULSIONS
Some
Remember to use
Drinking eagerly, thirsty? Yes dehydration
Danger sign when
Pinch the skin of the abdomen. Does it go back: selecting
Very slowsly (longer then 2 seconds)? classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Slowly? Yes Yes __ No __
For how long? ___ Days Count the breaths in one minute Yes __ No __
Decide malaria risk: High ___ Low ___ No___ ___ breaths
Look perstiff
or feel for minute.
neckFast breathing?
Look for
Look for runny
chest indrawing
nose
For how long? ___ Days
Look for
andsigns
listenoffor stridor
4. JANE
If more than 7 days, has fever been present every Look
Look and listen for
MEASLES:
wheezing
DOES THEhad
Has child CHILDmeaselsHAVE
within DIARRHOEA?
the last 3 months? One of these: cough, runny nose, or red eyes X
Yes __ No __
For howtest
Do malaria long? 3 ___general
if NO Days danger sign Look for anychilds
at the othergeneral
cause ofcondition.
fever. Is the child:
No
Is there blood in the stool?
Lethargic or unconscious? No
Restless and irritable? No
Test POSITIVE? P. falciparum P. vivaxNEGATIVE? Offer the child fluid. Is the child:
Not
No dehydration
If the child has measles now or within the Look forable
mouth to drink or drinking poorly?
ulcers.
Drinking
If yes, are eagerly,
they deepthirsty?
and extensive?
last 3 months: Pinchfor
thepus
skin of the abdomen. Does it go back:
Look draining from the eye.
LookVery slowsly (longer
for clouding then 2 seconds)?
of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM? Slowly? Yes __ No __
Is there ear pain? Look for pus draining from the ear Yes __ No __
Is there
Decide malariaear discharge?
risk: High ___ Low ___ No___ Lookfor
Feel or tender
feel forswelling
stiff neckbehind the ear
IfFor
Yes,
how forlong?
how long? ___ Days
___ Days Look for runny nose
THENIf moreCHECK EXERCISE
FORhas
than 7 days, ACUTE E (PLAN B)
MALNUTRITION
fever been present every Look for
Look for oedema
signs of MEASLES:
of both feet.
day? Generalized
Determine WFH/L rash and Z score.
_____
AND ANAEMIA 1. Answers below:
Has child had measels within the last 3 months? For One of these:
children cough,
6 months runnymeasure
or older nose, or MUAC
red eyes
____ mm.
Look for
Look for palmar
any other cause of fever.
pallor.
High risk: all fever cases Name Age or Weight Severe Rangepalmarofpallor?
Amounts
Some of ORSpallor?
palmar Solution
If
Lowchild
risk: ifhas MUACcause
NO obvious less ofthan
fever115 mm or Is there any medical complication?
a. Andras 3 years 900–1400
General ml
danger sign?
WFH/L less than
Test POSITIVE? -3 Z scores
P. falciparum or oedema of
P. vivaxNEGATIVE? Any severe classification?
both b. Gul 10 kg 750 ml or 700–900 ml
If the feet:
child has measles now or within the Look for mouth with
Pneumonia ulcers.
chest indrawing?
last 3 months: c. Nirveli 7.5 kg For aIfchild
yes, 6are
562.5 they
months
ml ordeep andoffer
or 400–700
older extensive?
RUTF
ml to eat. Is the child:
LookNotforable
pustodraining
finish orfrom
ablethe
to eye.
finish?
d. Sami 11 months Look
For for400–700
a child less thanofml
clouding 6the cornea.
months is there a breastfeeding problem?
DOES THE
CHECK FORCHILD HAVE AN EAR PROBLEM?
HIV INFECTION Yes __ No __
Is there
Note ear pain?
mother's and/or child's HIV status Look for pus draining from the ear
Is there ear discharge?
Mother's HIV test: NEGATIVE POSITIVE NOTFeel for tender swelling behind the ear
DONE/KNOWN
If Yes, for how
Child's long? ___
virological test:Days
NEGATIVE POSITIVE NOT DONE
THENChild's
CHECK FOR test:
serological ACUTE MALNUTRITION
NEGATIVE POSITIVE NOT Look
DONE for oedema of both feet.
AND If mother
ANAEMIA Determine WFH/L _____ Z score.
is HIV-positive and NO positive virological test in child:
Is the child breastfeeding now? For children 6 months or older measure MUAC ____ mm.
Was the child breastfeeding at the time of test or 6 weeks Look
before 48
for palmar
it? pallor.
If breastfeeding: Is the mother and child on ARV prophylaxis? Severe palmar pallor? Some palmar pallor?
If child has
CHECK THEMUAC CHILD'S lessIMMUNIZATION
than 115 mm orSTATUSIs(Circle there anyimmunizations needed today)
medical complication? Return for next
WFH/L
BCG less than -3 Z scores or
DPT+HIB-1 oedema of DPT+HIB-3
DPT+HIB-2 General danger sign?
Measles1 Measles 2 Vitamin A immunization on:
OPV-0feet: OPV-1 OPV-2 OPV-3 Any severe classification? Mebendazole ________________
both
Hep B0 Hep B1 Hep B2 Hep B3 Pneumonia with chest indrawing? (Date)
2. Answers below:
a. Vinita should be given 400–700ml of low osmolarity ORS solution during the
first 4 hours of treatment. She should also be given 100–200 ml of clean water
during this period.
b. She should wait 10 minutes before giving more ORS solution. Then she should
give Vinita the ORS solution more slowly.
c. After Vinita is given ORS solution for 4 hours on Plan B
d. Because Vinita has been reassessed as NO DEHYDRATION, she should be put on
Plan A.
e. 2 one-litre packets
f. To continue treatment at home, the grandmother should give Vinita 50–100 ml
of ORS solution after each loose stool.
3. Answers below:
a. 400–700 ml of ORS solution
b. Yes, Yasmin should breastfeed whenever and as much as she wants.
c. Because Yasmin is still classified as SOME DEHYDRATION, she should continue
on Plan B.
EXERCISE F (PLAN A)
1. Answers will vary
2. Somi answers:
a. Give extra fluid, Give zinc, Continue feeding, Advise when to return
b. ORS solution, food-based fluids (such as soup, rice water, yoghurt drinks), clean
water
3. The health worker should tell Kasit’s mother to breastfeed him more frequently
than usual. The health worker should also tell the mother that after breastfeeding,
she should give Kasit ORS solution or clean water.
4. Children who have been treated with Plan B or Plan C during the visit, or children
who cannot return to a clinic if the diarrhoea gets worse.
5. Answers below:
a. Kala 6 months 500–100 ml
b. Sam 2 years 100–200 ml
c. Kara 15 months 50–100 ml
d. Lalita 4 years 100–200 ml
49
EXERCISE G (TREAT)
1. 10 mg (1/2 of a 20 mg tablet) once each day for 14 days. Tablet should be crushed
and dissolved in breast milk, ORS, or clean water. It is important to give zinc for all
14 days.
2. 20 mg tablet given once each day for 14 days. Tablets can be chewed or dissolved
in fluid. It is important to give zinc for all 14 days.
3. Give 1ml ciprofloxacin (250 mg/5 ml) 2 times a day for 3 days
4. Give 3ml ciprofloxacin (250 mg/5 ml) 2 times a day for 3 days
5. Start treatment for dehydration, give Vitamin A dose, teach mother to give
frequent sips of ORS on the way, give other urgent pre-referral treatment as other
classifications require, and refer URGENTLY.
6. Correct answers are A, B, D, E
EXERCISE H (CASE STUDY COUNSEL)

1. Rules are:
a. GIVE EXTRA FLUID: Explain what extra fluids to give. Since the child is being
treated with Plan B during this visit, the mother should give ORS at home. Explain
how much ORS solution to give after each loose stool.
b. CONTINUE FEEDING: Instruct her how to continue feeding during and after
diarrhoea.
c. GIVE ZINC: explain dosing and schedule for 14 days of zinc, how to give, why it
is given
d. WHEN TO RETURN: Teach her the signs to bring a child back immediately.
2. How to mix ORS into water. He did not include what containers to use, what ratio of
packets and water, how to give the ORS to her child, or instructions for frequency
of treatment.
3. YES
4. NO
5. WITH A YES/NO QUESTION (“DO YOU UNDERSTAND?”). THIS IS NOT A CHECKING
QUESTION.
6. NO. THE QUESTION DOES NOT SHOW IF THE CAREGIVER LEARNED.
7. CHECKING QUESTION –for example “How will you prepare the ORS for your child?”
EXERCISE I (CASE STUDY COUNSEL)

1. All five answers should be checked.
2. Aviva answers:
a. YES, 2 PACKETS
b. The mother should wait 10 minutes before giving more fluid. Then she should
give the solution more slowly.
c. Aviva’s mother should continue giving extra fluid until the diarrhoea stops
d. Drinking poorly or not able to drink or breastfeed, Becomes sicker, Develops a
fever, Blood in stool
3. Only C “How much fluid will you give your child?” is a good checking question
50
EXERCISE J (EVARISTO FOLLOW-UP)

1. Ask: Has Evaristo’s diarrhoea stopped? How many loose stools is he having per day?
2. Reassess Evaristo completely as described on the ASSESS & CLASSIFY chart. Treat
any problems that require immediate attention. Then refer him to hospital.
3. NO
4. Refer him to a hospital. He does not need any treatments before he leaves.
5. Rehydrate him according to Plan B before referral.
51
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IMCI

DISTANCE LEARNING COURSE

© World Health Organization 2014

4.1 MODULE OVERVIEW

ASSESS & CLASSIFY the child using

NOTE ON DIARHOEA IN SICK YOUNG INFANT: In Module 2, you were told to

MODULE LEARNING OBJECTIVES

3. What is persistent diarrhoea?

4.2 INTRODUCTION TO DIARRHOEA

n OPENING CASE STUDY – MARY

WHAT ARE THE TYPES OF DIARRHOEA IN CHILDREN?

WHAT ARE THE TYPES OF DIARRHOEA IN YOUNG INFANTS?

n How do you greet Ana and begin the assessment?

n You will check Mary for general danger signs.

n Next, you will assess Mary for cough or difficult breathing.

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

4.3 ASSESS A SICK YOUNG INFANT & CHILD

HOW WILL YOU ASSESS?

DIARRHOEA: SICK CHILD

ASK: IS THERE BLOOD IN THE STOOL?

DEHYDRATION: SICK CHILD & YOUNG INFANT

HOW WILL YOU ASSESS DEHYDRATION?

LOOK: AT THE CHILD’S GENERAL CONDITION

LOOK FOR SUNKEN EYES

DVD EXERCISE – SUNKEN EYES

LOOK: TO SEE HOW THE CHILD DRINKS

FEEL: BY PINCHING THE SKIN OF THE ABDOMEN

Skin pinch Skin pinch going back very slowly

DVD EXERCISE – SKIN PINCH

Watch “Demonstration: assess and classify diarrhoea” (disc 1)

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

4.4 CLASSIFY DIARRHOEA & DEHYDRATION

DEHYDRATION: SICK CHILD & YOUNG INFANT

Dehydration present. Pink: Treat dehydration before referral unless the

SEVERE DEHYDRATION (RED)

What are your actions?

SOME DEHYDRATION (YELLOW)

What are your actions?

What are your actions?

After you classify dehydration,

Dehydration present. Pink: Treat dehydration before referral unless the

Blood in the stool. Yellow: Give ciprofloxacin for 3 days

What are your actions?

PERSISTENT DIARRHOEA (YELLOW)

What are your actions?

DVD EXERCISE – JOSH CASE STUDY

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

3. What type of ORS should be used to treat dehydration?

4. Which children need zinc supplements?

5. What are the 4 rules of home treatment of diarrhoea?

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

4.5 TREAT THE CHILD WITH DIARRHOEA

WHAT TREATMENTS ARE IDENTIFIED FOR DIARRHOEA AND

DEHYDRATION: SICK CHILD & YOUNG INFANT

PLAN C (SEVERE DEHYDRATION)

PLAN B (SOME DEHYDRATION)

PLAN A (NO DEHYDRATION)