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Unit 1 - The Epidemiology and Etiology of Diarrhoea
Unit 2 - Pathopysiology of Watery Diarrhoea: Dehydration and Rehydration
Unit 3 - Assessing the Diarrhoea Patient
Unit 4 - Treatment of Diarrhoea at Home
Unit 5 - Treatment of Dehydrated Patients
Unit 6 - Dysentery, Persistent Diarrhoea, and Diarrhoea Associated with Other Illnesses
Unit 7 - Diarrhoea and Nutrition
Unit 8 - Prevention of Diarrhoea

Unit 8 - Prevention of Diarrhoea
Medical Education: Teaching Medical Students about Diarrhoeal Diseases

World Health Organization 1992

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What mothers should do
What mothers should do
When to begin weaning
What foods to give
Preparing and giving weaning foods
What families should do HAND-WASHING
What families should do USE OF LATRINES
What families should do MEASLES IMMUNIZATION
What families should do



Proper case management, consisting of oral rehydration therapy and feeding, can reduce the adverse effects of diarrhoea, which include dehydration, nutritional damage, and risk of death. Other measures are required, however, if the incidence of diarrhoeal episodes is to be substantially reduced; these include interventions that either reduce the spread of the microbes that cause diarrhoea or increase the child's resistance to infection with these agents. Prevention of diarrhoea, properly carried out, can be as important as case management, and may be the only way of avoiding deaths where treatment is not readily available.

A number of interventions have been proposed for preventing diarrhoea in young children, most of which involve measures related to infant feeding practices, personal hygiene, cleanliness of food, provision of safe water, safe disposal of faeces, and immunization. An analysis of the effectiveness, feasibility, and cost of each proposed intervention has shown that some are particularly effective and affordable, whereas others are impractical or ineffective, or require further evaluation. The review concluded that efforts to prevent diarrhoea, and thus to reduce deaths not prevented by proper case management, should focus on a few interventions of proven efficacy. The seven practices identified as targets for promotion are:

  • breast-feeding;
  • improved weaning practices;
  • use of plenty of water for hygiene and use of clean water for drinking;
  • hand-washing;
  • use of latrines;
  • safe disposal of the stools of young children; and
  • measles immunization.
These topics are considered in detail in this unit.


Although breast milk is the best and safest food for young infants, the incidence of breast-feeding is declining in most developing countries. The reasons for this decline include the belief that bottle-feeding is "modern", the aggressive promotion of infant formulas, the need for mothers to work away from their children, the lack of facilities for breast-feeding at places of work, fear of not being able to breast-feed adequately, and a lack of medical and nursing support for mothers who want lto breast-feed.

Nearly all women can breast-feed satisfactorily and breast-feeding has many benefits for both infant and mother (Figure 8.1). Some major benefits are that breast-fed babies have fewer episodes of diarrhoea, less severe episodes, and a lower risk of dying from diarrhoea than babies who are not breast-fed. For example, during the first six months of life, the risk of having severe diarrhoea that requires hospitalization can be 30 times greater for non-breast-fed infants than for those who are exclusively breast-fed (Figure 8.2).

Figure 8.1. Breast feeding has many advantages for both infant and motherFigure 8.2 Relative risk of severe diarrhoea during the first 6 months of life.

Adapted from: Mahmood D.A., Feaham R.G., & Huttly S.R.A. Infant feeding and risk of severe diarrhoea in Basrah city, Iraq: A case-control study. Bulletin of the World Health Organization, 1989, 67: 701-706.

Important advantages of breast-feeding are:

  • Exclusive breast-feeding during the first 4-6 months greatly reduces the risk of severe or fatal diarrhoea.
  • Breast-feeding is clean; it does not require the use of bottles, nipples, water, and formula which are easily contaminated with bacteria that may cause diarrhoea.
  • Breast milk has immunological properties (especially antibodies) that protect the infant from infection, and especially from diarrhoea; these are not present in animal milk or formula.
  • The composition of breast milk is always ideal for the infant; formula or cow's milk may be made too dilute (which reduces its nutritional value) or too concentrated (so that it does not provide sufficient water) and may provide too much salt and sugar.
  • Breast milk is a complete food; it provides all the nutrients and water needed by a healthy infant during the first 4-6 months of life. (However low-birth weight infants benefit from the provision of iron, if available.)
  • Breast-feeding is cheap; there are none of the expenses associated with feeding breast milk substitutes, e.g., the costs of fuel, utensils, and special formulas, and of the mother's time in formula preparation.
  • Breast-feeding helps with birth spacing; mothers who breast-feed usually have a longer period of infertility after giving birth than mothers who do not breast-feed.
  • Milk intolerance rarely occurs in infants who take only breast milk.
  • Breast-feeding immediately after delivery encourages the "bonding" of the mother to her infant, which has important emotional benefits for both and helps to secure the child's place within the family.
  • If possible, infants should be exclusively breast-fed during the first 4-6 months of life. This means that a healthy baby who is growing normally should receive only breast milk and no other fluids or foods such as water, tea, juices, or formula.

    Between 4 and 6 months of age, infants should start to receive cereals and other foods to meet their increased nutritional requirements, but breast-feeding should be continued at least until one year of age. Breast milk given after the age of 6 months is an important source of nutrients and it continues to help protect the child from repeated episodes of severe diarrhoea.

    Efforts to promote breast-feeding are especially important during pregnancy, at the time of birth (breast-feeding should begin as soon as possible after birth) and when problems are encountered after breast-feeding has been established. Most of these difficulties can be easily managed. Some ways of helping mothers to overcome problems related to breast-feeding are summarized in Table 8.1.

    Table 8.1 Common difficulties with breast-feeding

    Has a flat nipple Show her how to make her nipples longer by squeezing them each day during pregnancy (..)Show her how to help the baby to suck by pressing the areola together before putting it into the baby's mouth.
    Has an engorged breast (the breast is too full of milk) Show her how to express milk manually. Tell her to continue breast-feeding at frequent intervals.
    Has a cracked or sore nipple Show her how to empty the milk from the breast manually and feed it to her baby. Tell her to:
    o Continue breast-feeding the baby. Try short, frequent feeds from the sore nipple.
    o Change the position of the baby so his mouth does not always hold the nipple in the same position.
    o Let the nipple dry in the air after breast-feeding or expressing milk.
    o Make sure that, when the baby feeds after the sore has healed, the whole nipple is put into the baby's mouth so that the gums bite on the areola behind the nipple
    Has an infected breast (signs of infection include a swollen,painful, and reddened breast with tender lymph nodes under the arm) Give her an antibiotic (e.g., penicillin). Tell her to continue breast-feeding and explain that milk from the infected breast is still safe for her baby. Start feedings on the unaffected breast, then move the infant to the affected breast after let-down has occurred. Severe pain may require the expression of some milk by hand.
    Says she does not have enough breast milk Determine whether the baby's weight gain is normal.
    o If the baby's weight gain is normal, try to find out why the mother is anxious. Reassure her that her baby is growing normally and that she is producing enough milk.
    o If the baby's weight gain is less than normal, suggest that she try to increase the supply of milk by breast-feeding as often and as long as the baby wants. If the baby still does not gain weight, supplement the breast milk with formula, offering it after the breast-feed. If the infant is at least 4 months old, supplement the milk with cereal, well-cooked vegetables, and other weaning foods (see Unit 7).

    What doctors should do

  • Encourage hospital policies and routine procedures after delivery that promote the breast-feeding of neonates. For example, allow newborns to start breast-feeding within 2-3 hours after birth; keep all healthy babies close to their mothers in the same room (termed "rooming-in"); give no food or fluids to newborns except breast milk; do not distribute (or allow sales representatives or nurses to distribute) samples of milk formula or feeding bottles to the mothers.

    Weaning is the process by which an infant gradually becomes accustomed to an adult diet. During weaning, supplementory foods other than milk are introduced in order to meet the child's increased nutritional demands. However, breast milk remains an important part of the diet.

    Weaning is a hazardous period for many infants. This is because the child may not receive food of adequate nutritional value and the food and drinks provided may be contaminated with pathogenic microbes, including those that cause diarrhoea. The danger is that the child will become undernourished due to an inadequate diet and repeated episodes of diarrhoea, or will succumb to dehydration caused by an acute episode of diarrhoea. Unfortunately, these processes are inter-related: undernutrition increases the child's susceptibility to infection so that the child experiences more frequent and more severe episodes of diarrhoea, and diarrhoea accelerates the development of undernutrition (see Unit 7, Figure 7.2).

    Some specific problems associated with weaning that can lead to undernutrition or diarrhoea are:

  • delaying the start of weaning beyond 4-6 months of age;
  • weaning too abruptly;
  • giving too few meals per day;
  • giving supplementory foods with a low content of protein and particularly energy;
  • preparing and storing weaning foods in a way that permits bacterial contamination and growth; and
  • giving milk or other drinks prepared with contaminated water or in a contaminated feeding bottle.
  • What mothers should do

    When to begin weaning

    Weaning should begin when the child is 4-6 months old. While continuing to breast-feed, the mother should give a little well-cooked soft or mashed food, such as cereals and vegetables, twice each day. When the child is 6 months of age, the variety of foods should be increased and meals should be given at least four times per day, in addition to breast-feeding. After 1 year of age, the child should eat all types of food; vegetables, cereals, and meat should continue to be well-cooked, and mashed or ground. Food should be given 4-6 times per day. If possible, breast-feeding should be continued.

    What foods to give

    Cereals and starchy roots are the most widely used weaning foods, but these are relatively low in energy. They should be given as a thick pap or porridge, using a spoon, and not as a dilute drink. The energy content should be increased by mixing one or two teaspoonfuls of vegetable oil into each serving. The objective is to achieve an energy intake of about 110 kcal/kg/day. Between the age of 6 months and one year, pulses, fruit, green vegetables, eggs, meat, fish, and milk products should be added to the diet. In areas where vitamin A deficiency is a problem, the diet should include orange, yellow, or dark-green vegetables, yellow fruit, red palm oil, and, if possible, liver, full-cream dairy products, or fish. Weaning foods are considered in greater detail in Unit 7.

    Preparing and giving weaning foods

    Mothers should be taught ways of preparing, giving, and storing weaning foods that minimize the risk of bacterial contamination. These include:

  • Washing her hands before preparing weaning foods and before feeding the baby.
  • Preparing the food in a clean place.
  • Cooking or boiling the food well when preparing it.
  • If possible, preparing the food immediately before it will be eaten.
  • Covering food that is being kept. Keeping food in a cool place; refrigerating it if possible.
  • If cooked food was prepared more than two hours before it is used, reheating it until it is thoroughly hot before giving it to the baby.
  • Feeding the baby with a clean spoon, from a cup, or with a special feeding spoon (Figure 8.4). Feeding bottles should never be used.
  • Figure 8.4 How to feed liquids to an infant

    Source: King, M., King F., & Martodipoero, S. Primary Child Care. A Manual for Health Workers. Book One. Oxford University Press, 1978.
  • Washing uncooked food in clean water before feeding it to the baby; an exception is fruit that is peeled before it is eaten, such as a banana.
  • What doctors should do

  • Make the assessment of weaning diets and weaning education a routine element of well-baby programmes. This should be coordinated with the use of growth charts to identify children with growth faltering, for whom improved feeding is especially important.
  • Evaluate the nutritional status of children with diarrhoea, by measuring mid-upper arm circumference, weight for age, or weight for height:
  • refer all children with severe undernutrition to a treatment centre where nutritional rehabilitation is possible;
  • for moderately undernourished children, ask about the child's weaning diet and feeding practices. Advise the mother on ways of increasing the child's intake of safely prepared, energy-rich foods. If possible, follow up the child after diarrhoea stops until the weight or rate of growth has become normal;
  • otherwise, provide advice on correct feeding during diarrhoea and afterwards (giving one extra meal each day for at least two weeks after diarrhoea stops).

    Most infectious agents that cause diarrhoea are transmitted by the faecal-oral route. This includes transmission by contaminated drinking water or contaminated food, and person-to-person spread. A plentiful supply of clean water helps to encourage hygienic practices, such as hand-washing, cleaning of eating utensils, and cleaning of latrines; these practices can interrupt the spread of infectious agents that cause diarrhoea. To facilitate good hygiene, it is more important that the water supply be abdundant than clean, although both qualities are desirable. Clean water is essential, however, for drinking and for preparing food.

    Families that have ready access to a generous supply of water, and to clean water for drinking and preparing food, have less diarrhoea than families whose access to water is difficult or whose drinking water is heavily contaminated. Improved water supplies can result from government-sponsored programmes, in which families and communities may play an important role, or from other community or family efforts, such as collecting and storing rainwater. Families can reduce their risk of diarrhoea by using the cleanest available water for drinking and protecting it from contamination, and by ensuring a plentiful supply of water for hygiene purposes.

    What families should do

  • Use the most readily available water for personal and domestic hygiene. If this water is likely to be contaminated, store it separately from water used for drinking or preparing food.
  • Collect drinking water from the cleanest available source.
  • Protect water sources by keeping animals away, by locating latrines more than 10 metres away and downhill, and by digging drainage ditches to divert storm-water.
  • Collect and store drinking water in clean containers. Keep the storage container covered and do not allow children or animals to drink from it. Allow no one, especially not a child, to put his or her hand into the storage container. Take out water only with a long-handled dipper that is kept especially for that purpose. Empty and rinse out the container once a week.
  • Boil water that will be used to make food or drinks for young children. Boil other drinking water if sufficient fuel is available. Water needs only to boil for a few seconds; vigorous boiling is unnecessary and wastes fuel.

    Parents can help to protect young children against diarrhoea by adopting certain hygiene practices. One very important practice is hand-washing (Figure 8.3). Hand-washing is especially effective for preventing the spread of Shigella, which is the most important cause of dysentery. For example, a study in Bangladesh has shown that handwashing with soap and water reduced the incidence of secondary cases of shigellosis 7-fold (from 14% to 2%) in households where a case of shigellosis had been detected (Khan, M.V. Interruption of shigellosis by handwashing. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1982, 76: 164-168).

    Figure 8.5. Hands should be washed carefully after defecation and before handling food and before eating.

    Good hand-washing requires the use of soap (or a local substitute), plenty of water, and careful cleaning of all parts of the hands. If water is scarce, it can be used more than once to wash hands. It can then be used to wash the floor, to clean the latrine, or to irrigate the vegetable garden.

    What families should do

  • Create a place within the home for hand-washing. This should have a wash basin, a container for water, and soap (or a local substitute).
  • All members should wash their hands well (i) after cleaning a child who has defecated, or after disposing of a child's stool, (ii) after defecating, (iii) before preparing food, (iv) before eating, and (v) before feeding a child.
  • An adult or older sibling should wash the hands of young children.

    Human faeces should be disposed of in a way that prevents them from coming into contact with hands or contaminating a water source. This is best achieved through regular use of a well-maintained latrine. The proper use of latrines can reduce the risk of diarrhoea to almost the same extent as improved water supplies, but the greatest benefit occurs when improvements in sanitation and water supply are combined and education is given on hygienic practices.

    Every family should have and use a clean and well-maintained latrine. Families that do not have a latrine should build one, following a design recommended by the relevant government agency. When there is no latrine or pit, families should defecate as hygienically as possible, away from the path, and at least 10 metres away from any home or source of water. Consideration should be shown by not defecating uphill or upstream from other people. If possible, faeces should be covered with dirt.

    What families should do

  • Have a clean, functioning latrine that is used by all members of the family old enough to do so. Keep the latrine clean by regularly washing down fouled surfaces.
  • If there is no latrine:
  • defecate away from the house, and from areas where children play, and at least 10 metres from the water supply;
  • cover the faeces with earth; and
  • do not allow children to visit the defecation area alone; keep children's hands off the ground near the defecation area.

    In many communities the stools of infants and young children are considered harmless. However, young children are frequently infected with enteric pathogens and their stools are actually an important source of infection for others. This is true both for children with diarrhoea and for children with asymptomatic infections. Therefore, hygienic disposal of the faeces of all young children is an important aspect of diarrhoea prevention. Education is needed to warn families of the dangerous nature of young children's stools and to stress the importance of disposing of them properly.

    What families should do

  • Quickly collect the stool of a young child or baby, wrap it in a leaf or newspaper, and put it in the latrine, or bury it.
  • Help older children to defecate into a potty. Empty the stool immediately into a latrine and wash out the potty. Alternatively, have the child defecate onto a disposable surface, such as newspaper or a large leaf. Wrap up the stool and dispose of it in a latrine, or bury it.
  • Promptly clean a child who has defecated. Then wash their own and the child's hands with soap and water.

    Children who have measles, or have had the disease in the previous four weeks, have a substantially increased risk of developing severe or fatal diarrhoea or dysentery (there is some evidence that the increased risk lasts up to six months after measles). Because of the strong relationship between measles and serious diarrhoea, and the effectiveness of measles vaccine, measles immunization is a very cost-effective measure for reducing diarrhoea morbidity and deaths. Measles vaccine given at 9 months of age can prevent up to 25% of diarrhoea-associated deaths in children under 5 years of age.

    What families should do

  • Have children immunized against measles as soon after 9 months of age as possible.
  • What doctors should do

  • Include screening and referral for immunization, including measles immunization, as a routine in well-baby visits.
  • Ask mothers always to bring the child's immunization card when they come to the clinic for any reason. Check the immunization status of every patient and make sure that those who need it are immunized during the visit, unless there is a valid reason against it.

    Most activities that help to prevent diarrhoea must take place in the home. However, mothers and other family members cannot practice diarrhoea prevention until they have learned what this involves and understand how best to carry out each preventive activity. Information on the prevention of diarrhoea can be provided in a variety of ways, e.g., at community meetings, through schools, during home visits and visits to a health centre. The latter may be especially effective when the visit involves a child with diarrhoea: at this time the mother is particularly aware of the problem of diarrhoea and is more likely to be interested in knowing what steps she can take to prevent future episodes. Care should be taken, however, not to overwhelm the mother with information, as she will also be given instructions concerning home treatment of her child. If possible, messages on prevention should focus on the interventions that are considered most desirable for the particular child; this is especially important for preventive measures that concern feeding, which will depend upon the child's age and feeding status.

    Discussions with mothers about preventing diarrhoea should follow the same principles as those concerning home treatment of diarrhoea (Unit 4). They should be supportive and understanding, not critical. Remember that the goal is to help the mother to understand that she plays a very important role in assuring her child's health.


    Most of the interventions described in this unit involve education - of mothers in particular, but also of other family members. The objective is to achieve a change in behaviour that diminishes the risk of diarrhoea, usually by reducing the transmission of infectious agents. In many situations this effort will be organized and led by doctors, and much of the educational activity will occur at health facilities. Specific ways in which doctors can help to organize or strengthen such educational efforts include:

  • Ensuring appropriate in-service training of the health facility staff. Most teaching of mothers about preventive measures, such as breast-feeding, weaning practices, hand-washing, and stool disposal, is carried out by health facility staff. Doctors should organize regular, in-service training of the staff to ensure that they understand the key messages mothers should receive and the most effective ways of conveying them. Staff should also be taught to practice appropriate preventive measures during their work, e.g., washing their hands with soap and water after examining a patient with diarrhoea.
  • Displaying promotional material on how to prevent diarrhoea. Educational posters should be displayed in areas of the health facility where they can be used to teach mothers how to prevent diarrhoea. They should cover all the preventive measures considered in this unit.
  • Being a good role model. Doctors should encourage in their own homes measures that prevent diarrhoea and protect the health of their children, such as exclusive breast-feeding for the first 4-6 months of life and continued breast-feeding for at least the first year. They should ensure that the health facility and its staff are good role models for the community. For example, water should be stored and handled safely, facilities for hand-washing should be available and carefully maintained, and the latrines should be well constructed and regularly cleaned.
  • Taking part in community-oriented activities to promote health. Giving talks or taking part in community meetings is an effective way of promoting certain preventive measures, such as appropriate weaning practices, measles (and other) immunizations, improvements in water supply and use, construction and use of latrines, etc.
  • Coordinating efforts for disease prevention with those of relevant government programmes. Doctors should learn about and use the resources of government programmes concerned with disease prevention.
  • This applies broadly to the areas of immunization, infant feeding practices, hygiene, sanitation, and water supply. These programmes are often valuable sources of teaching materials, such as wall posters or pamphlets for mothers, and may also provide guidelines for local practices, e.g., on the most appropriate weaning foods or designs for latrines.


    1. Which of the following measures are considered to be cost-effective with regard to the prevention of diarrhoea in young children? (There may be more than one correct answer.)

    1. Control of flies.
    2. Hand-washing after defecation, before preparing food, and before eating.
    3. Exclusive breast-feeding for the first 4-6 months of life; continued breast-feeding for at least one year.
    4. Immunization for measles at 9 months of age.
    2. Which of the following are correct statements concerning breast-feeding? (There may be more than one correct answer.)
    1. The protection of breast-fed infants against diarrhoea is not affected when other foods or drinks are given.
    2. Breast-fed infants below 4 months of age do not need other foods, but should be given water or other drinks, especially if they live in a hot, dry climate.
    3. Infants who are exclusively breast-fed have a greatly reduced risk of developing severe diarrhoea compared with infants taking animal milk or formula from a bottle.
    4. Milk intolerance occurs with equal frequency in breast-fed and bottle-fed infants.
    3. Many episodes of diarrhoea occur during the period of weaning, when undernutrition is also most prevalent. Which of the following factors contribute to these problems? (There may be more than one correct answer.)
    1. Storing cooked weaning foods at room temperature for several hours; then giving them to the child without reheating them.
    2. Giving weaning foods that have a low content of energy and protein.
    3. Starting to give weaning foods at 4-6 months of age.
    4. Giving milk or other drinks in a feeding bottle.
    5. Giving three meals a day to a 1-year-old child.
    4. Which of the following statements concerning behaviours that are related to the prevention of diarrhoea are correct? (There may be more than one correct answer.)
    1. Stools of infants are less likely to cause disease than those of adults.
    2. Where water is scarce, it may be used more than once for washing hands.
    3. At 5 or 6 years of age, children need not use a latrine.
    4. After cleaning a baby who has defecated, it is important for a mother to wash her hands.
    5. It is important that clean water be used for all household purposes, including hygiene.
    5. Hand-washing at appropriate times can help to prevent diarrhoea. Which of the following are important times for hand-washing? (There may be more than one correct answer.)
    1. Before eating.
    2. Before breast-feeding an infant.
    3. After defecation.
    4. After touching an infant's stool.
    5. Before drinking water.


    1. B,C,D

    2. C

    3. A,B,D,E

    4. B,D

    5. A,C,D

    updated: 7 June, 2017