This document provides guidelines from UNICEF and IAP on the management of acute watery diarrhea. It defines diarrhea and describes the clinical types. It discusses determining the degree of dehydration and selecting treatment plans. Treatment plans A, B, and C are outlined for preventing, treating some, and treating severe dehydration respectively. Details are given on oral rehydration, intravenous rehydration, continuing feeding, giving zinc and antimicrobials. Prevention of diarrhea and vitamin A deficiency are also covered.

1. UNICEF and IAP guidelines
on management of Acute
Watery Diarrhoea
Dr Muzammil Koshish
DCH, DNB Resident,
JLN Hospital and Research
Centre, Bhillai.

2. Definition of diarrhoea
• Diarrhoea is the passage of loose or watery stools,
usually at least three times in a 24 hour period
• It is the consistency of the stools rather than the
number, that is most important
• Frequent passing of formed stools is not diarrhoea
• Babies fed only breast milk often pass loose, "pasty"
stools ; this also is not diarrhoea

3. Clinical types of diarrhoeal diseases
Four clinical types of diarrhoea can be recognized, each reflecting the basic
underlying pathology and altered physiology:
· acute watery diarrhoea (including cholera), which lasts several hours or days:
the main danger is dehydration; weight loss also occurs if feeding is not continued;
· acute bloody diarrhoea, which is also called dysentery: the main dangers are
intestinal damage, sepsis and malnutrition; other complications, including
dehydration, may also occur;
· persistent diarrhoea, which lasts 14 days or longer: the main danger is
malnutrition and serious non-intestinal infection; dehydration may also occur;
· diarrhoea with severe malnutrition (marasmus or kwashiorkor): the main
dangers are severe systemic infection, dehydration, heart failure and vitamin and
mineral deficiency.

4. Determine the degree of dehydration
A B C
LOOK AT:
CONDITIONa Well, alert Restless, irritable Lethargic or
unconscious
EYESb Normal Sunken Sunken
THIRST Drinks normally Thirsty, drinks Drinks poorly, or
, not thirsty eagerly not able to drink
FEEL: SKIN PINCHc Goes back quickly Goes back slowly Goes back very
slowly
DECIDE The patient has NO If the patient has If the patients has
SIGNS OF two or more signs in two or more signs in
DEHYDRATION B (or C), there is C, there is SEVERE
SOME DEHYDRATION
DEHYDRATION
Weigh the patient
TREAT Use Treatment Pan Weigh the patient and use Treatment
A and use Treatment Plan C URGENTLY
Plan B

5. Select a plan to prevent or treat dehydration
Choose the Treatment Plan that corresponds with the child's degree of
dehydration:
No signs of dehydration - follow Treatment Plan A at home to prevent
dehydration and malnutrition
Some dehydration - follow Treatment Plan B to treat dehydration
Severe dehydration - follow Treatment Plan C to treat severe dehydration
urgently

6. Estimate the fluid deficit
Children with some dehydration or severe dehydration
should be weighed without clothing, as an aid in
estimating their fluid requirements. If weighing is not
possible, a child's age may be used to estimate the weight
A child's fluid deficit can be estimated as follows:
Assessment Fluid deficit as % of body weight Fluid deficit in ml/kg body
weight
No signs of dehydration <5% <50 ml/kg
Some dehydration 5-10% 50-100 ml/kg
Severe dehydration >10% >100 ml/kg

7. MANAGEMENT OF ACUTE DIARRHOEA (WITHOUT
BLOOD)
Objectives
The objectives of treatment are to:
•prevent dehydration, if there are no signs of dehydration;
•treat dehydration, when it is present;
•prevent nutritional damage, by feeding during and after
diarrhoea; and
•reduce the duration and severity of diarrhoea, and the occurrence
of future episodes, by giving supplemental zinc.

8. Treatment Plan A: home therapy to prevent dehydration and
malnutrition
Rule 1: Give the child more fluids than usual, to prevent
dehydration
Suitable fluids
Fluids that normally contain salt, such as:
ORS solution
salted drinks (e.g. salted rice water or a salted yoghurt drink)
vegetable or chicken soup with salt.
Fluids that do not contain salt, such as:
plain water
water in which a cereal has been cooked (e.g. unsalted rice water)
unsalted soup
yoghurt drinks without salt
green coconut water
weak tea (unsweetened)
unsweetened fresh fruit juice.

9. Unsuitable fluids
drinks sweetened with sugar, which can cause osmotic diarrhoea and
hypernatraemia. examples are:
soft drinks
sweetened fruit drinks
sweetened tea.
fluids with stimulant, diuretic or purgative effects, for example:
coffee
some medicinal teas or infusions.
How much fluid to give
The general rule is: give as much fluid as the child or adult wants until
diarrhoea stops.
As a guide, after each loose stool, give: .
• children under 2 years of age: 50-100 ml (a quarter to half a large cup) of
fluid;
• children aged 2 to 10 years: 100-200 ml (a half to one large cup);

10. Rule 2: Give supplemental zinc (10 - 20 mg) to the child,
every morning for 14 days
Rule 3: Continue to feed the child, to prevent
malnutrition
Rule 4: Take the child to a health worker if there are signs
of dehydration or other problems
The mother should take her child to a health worker if the child:
starts to pass many watery stools;
has repeated vomiting;
becomes very thirsty;
is eating or drinking poorly;
develops a fever;
has blood in the stool

11. Treatment Plan B: oral rehydration therapy for children with
some dehydration
Children with some dehydration should receive oral rehydration therapy (ORT) with
ORS solution in a health facility following Treatment Plan B, as described below.
Guidelines for treating children and adults with some dehydration
APPROXIMATE AMOUNT OF ORS SOLUTION TO GIVE IN THE FIRST 4 HOURS
Agea Less than 4 – 11 12 – 23 2 –4 years 5 – 14 years 15 years or
4 months months months older
Weight Less than 5–7.9 kg 8-10.9 kg 11-15.9kg 6-29.9kg 30 kg or
5 kg more
In ml 200-400 400-600 600-800 800-1200 1200-2200 2200-4000
in local
measure

12. How to give ORS solution
oA family member should be taught to prepare and give ORS
solution.
oThe solution should be given to infants and young children
using a clean spoon or cup. Feeding bottles should not be used.
oFor babies, a dropper or syringe (without the needle) can be used
to put small amounts of solution into the mouth.
o Children under 2 years of age should be offered a teaspoonful
every 12 minutes; older children (and adults) may take frequent
sips directly from the cup.

13. Monitoring the progress of oral rehydration therapy
Check the child from time to time during rehydration to ensure that ORS
solution is being taken satisfactorily and that signs of dehydration are not
worsening.
If at any time the child develops signs of severe dehydration, shift to
Treatment Plan C.
If there are no signs of dehydration, the child should be considered fully
rehydrated.
When rehydration is complete: - the skin pinch is normal;
- thirst has subsided;
- urine is passed;
-the child becomes quiet, is no longer irritable and often falls asleep.

14. When oral rehydration fails or is not appropriate
The usual causes for these “failures” are:
 continuing rapid stool loss (more than 15-20 ml/kg/hour), as
occurs in some children with cholera;
 insufficient intake of ORS solution owing to fatigue or lethargy;
 frequent, severe vomiting.

15. Giving Zinc
Begin to give supplemental zinc, as in Treatment Plan A, as soon the
child is able to eat following the initial four-hour rehydration
period.
Giving food
Except for breastmilk, food should not be given during the initial
four-hour rehydration period.
All children older than 6 months should be given some food before
being sent home.

16. Treatment Plan C: for patients with severe dehydration
Guidelines for intravenous rehydration
The preferred treatment for children with severe dehydration is
rapid intravenous rehydration, following Treatment Plan C.
Children who can drink, even poorly, should be given ORS solution
by mouth until the IV drip is running.
In addition, all children should start to receive some ORS solution
(about 5 ml/kg/h) when they can drink without difficulty, which is
usually within 34 hours (for infants) or 12 hours (for older patients).

17. Guidelines for intravenous treatment of children and adults
with severe dehydration
Give 100 ml/kg Ringer's Lactate Solutiona divided as follows:
Age First give Then give
30 ml/kg in: 70 ml/kg in:
Infants
(under 12 months) 1 hourb 5 hours
Older 30 minutesb 21/2 hours
a IfRinger's Lactate Solution is not available, normal saline may be used (See
Annex 2).
b Repeat once if radial pulse is still very weak or not detectable.

18. Monitoring the progress of intravenous rehydration
Patients should be reassessed every 15-30 minutes until a strong
radial pulse is present.
If signs of severe dehydration are still present, repeat the IV fluid
infusion as outlined in Treatment Plan C.
If the child is improving but still shows signs of some dehydration,
discontinue the IV infusion and give ORS solution for four hours, as
specified in Treatment Plan B.
If there are no signs of dehydration, follow Treatment Plan A.

19. Giving Zinc
Begin to give supplemental zinc, as in Treatment Plan A, as soon the
child is able to eat.
Giving food
Except for breastmilk, food should not be given during the initial
rehydration period.
All children older than 6 months should be given some food before
being sent home.

20. What to do if intravenous therapy is not available
If IV therapy is not available at the facility, but can be given nearby
(i.e. within 30 minutes), send the child immediately for IV
treatment.
If the child can drink, give the mother some ORS solution and show
her how to give it to her child during the journey.
If IV therapy is not available nearby, give ORS solution by NG tube,
at a rate of 20 ml/kg body weight per hour for six hours (total of 120
ml/kg body weight).
If NG treatment is not possible but the child can drink, ORS
solution should be given by mouth at a rate of 20 ml/kg body weight
per hour for six hours (total of 120 ml/kg body weight).

21. Vitamin A deficiency
Diarrhoea reduces the absorption of, and increases the need for,
vitamin A..
especially a problem when diarrhoea occurs during or shortly after
measles, or in children who are already malnourished.
children with diarrhoea should be examined routinely for corneal
clouding and conjunctival lesions (Bitot's spots).
oral vitamin A should be given at once and again the next day: 200
000 units/dose for age 12 months to 5 years, 100 000 units for age 6
months to 12 months, and 50 000 units for age less than 6 months.

22. ANTIMICROBIALS AND DRUGS
Antimicrobials
 Antimicrobial therapy should not be given routinely to children
with diarrhoea.
Such treatment is ineffective and may be dangerous.
The diseases for which antimicrobials should be given are listed
below
Cases of bloody diarrhoea (dysentery)
Suspected cases of cholera with severe dehydration.
Laboratory proven, symptomatic infection with Giardia duodenalis.
diarrhoea associated with another acute infection (e.g.
pneumonia, urinary tract infection)

23. "Antidiarrhoeal" drugs
Adsorbents (e.g. kaolin, attapulgite, smectite, activated charcoal, cholestyramine)
Antimotility drugs (e.g. loperamide hydrochloride, diphenoxylate with atropine, tincture
of opium, camphorated tincture of opium, paregoric, codeine).
Bismuth subsalicylate. Bismuth subsalicylate decreases the number of diarrhoea
stools.
Antiemetics. These include drugs such as prochlorperazine and chlorpromazine,
Cardiac stimulants. Shock in acute diarrhoeal disease is caused by dehydration and
hypovolaemia.
Blood or plasma. Blood, plasma or synthetic plasma expanders are never indicated for
children with dehydration due to diarrhoea.
Steroids. Steroids have no benefit and are never indicated.
Purgatives. These can make diarrhoea and dehydration worse; they should never be
used.

24. Probiotics and Prebiotics
 No proven role in Indian scenario

25. Prevention of Diarrhoea
 Breastfeeding
 Improved feeding practices
 Use of safe water
 Handwashing
 Food safety
 Use of latrines and safe disposal of stools
 Measles immunization

26. References:-
1. Department of Child and Adolescent Health and Development, World Health Organization, ‘Reduced osmolarity oral
rehydration salts (ORS) formulation – Report from a meeting of experts jointly organized by UNICEF and WHO’
(WHO/FCH/CAH/01.22), New York, 18 July 2001 <http://www.who.int/child-adolescent-
health/New_Publications/NEWS/Expert_consultation.htm>.
2. Bahl, R., et al., ‘Effect of zinc supplementation on clinical course of acute diarrhoea‘ – Report of a Meeting, New Delhi, 7-
8 May 2001. Journal of Health, Population and Nutrition,vol. 19, no. 4, December 2001, pp. 338-346.
3. Bhutta Z.A., Black, R.E., Brown K. H., et al., ‘Prevention of diarrhoea and pneumonia by zinc supplementation in children
in developing countries: Pooled analysis of randomized controlled trials’, Zinc Investigators’ Collaborative Group, Journal
of Paediatrics,vol. 135, no. 6, December 1999, pp. 689-697. 2. Reduced osmolarity oral rehydration salts (ORS) formulation.
A report from a meeting of experts jointly organized by UNICEF and WHO. UNICEF HOUSE, New York, USA, 18 July, 2001.
WHO/FCH/CAH/0.1.22
3. Hahn SK, Kim YJ, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration due to
diarrhoea in children: systematic review. British Medical Journal, 2001; 323: 81-85.
4. Zinc Investigators’ Collaborative Group. Bhutta ZA,Bird SM, Black RE, Brown KH, Gardner JM, Hidayat
A et al. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries:
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of zinc for the treatment of acute diarrhea in young children. Pediatrics. 2002 May;109: 898- 903.
7. Bahl R, Bhandari N, Saksena M, Strand T, Kumar G.T, Bhan MK et al. Efficacy of zinc fortified oral
rehydration solution in 6-35 month old children with acute diarrhea. J Pediatr 2002;141:677-682.
8. Roy SK, Tomkins AM, Akramuzzaman SM, Behrens RH, Haider R, Mahalanabis D et al. Randomized
controlled trial of zinc supplementation in malnourished Bangladeshi children with acute
diarrhoea. Arch Dis Child 1997;77: 196-200.9. Dutta P, Mitra U, Datta A, Niyogi SK, Dutta S, Manna
B et al. Impact of zinc supplementation in malnourished children with acute diarrhoea. J Trop
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10. Baqui AH, Black RE, El Arifeen S, Yunus M, Chakraborty J, Ahmed S et al. Effect of zinc supplementation started during
diarrhoea on morbidity and mortality in Bangladeshi children: Community randomized trial. BMJ 2002;325(7372):1059. 11.
Effect of zinc supplementation on clinical course of acute diarrhoea. Report of a Meeting, New Delhi, 7-8 May 2001. J Health
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27. Thank You !