Unit 8 - Prevention of Diarrhoea
Medical Education: Teaching Medical Students about Diarrhoeal Diseases
UNIT 8 - PREVENTION OF DIARRHOEA
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:
These topics are considered in detail in
- improved weaning practices;
- use of plenty of water for hygiene and use of clean water for drinking;
- use of latrines;
- safe disposal of the stools of young children; and
- measles immunization.
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.
Exclusive breast-feeding during the first 4-6 months greatly reduces the
risk of severe or fatal diarrhoea.
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
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:
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
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
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 Common difficulties with breast-feeding
|IF THE MOTHER:
||THEN THE HEALTH WORKER SHOULD:|
|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
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. |
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
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
IMPROVED WEANING PRACTICES
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.
delaying the start of weaning beyond 4-6 months of age;
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:
weaning too abruptly;
giving too few meals per day;
giving supplementory foods with a low content of protein and particularly
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
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
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
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
PROPER USE OF WATER
FOR HYGIENE AND DRINKING
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
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
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
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.
SAFE DISPOSAL OF THE
STOOLS OF YOUNG CHILDREN
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
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.
MOTHERS ABOUT PREVENTING DIARRHOEA
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
HOW DOCTORS CAN
HELP TO PREVENT DIARRHOEA
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.)
2. Which of the following are correct
statements concerning breast-feeding? (There may be more than one correct
- Control of flies.
- Hand-washing after defecation, before preparing food, and before eating.
- Exclusive breast-feeding for the first 4-6 months of life; continued
breast-feeding for at least one year.
- Immunization for measles at 9 months of age.
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.)
- The protection of breast-fed infants against diarrhoea is not affected
when other foods or drinks are given.
- 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
- 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.
- Milk intolerance occurs with equal frequency in breast-fed and bottle-fed
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.)
- Storing cooked weaning foods at room temperature for several hours; then
giving them to the child without reheating them.
- Giving weaning foods that have a low content of energy and protein.
- Starting to give weaning foods at 4-6 months of age.
- Giving milk or other drinks in a feeding bottle.
- Giving three meals a day to a 1-year-old child.
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.)
- Stools of infants are less likely to cause disease than those of adults.
- Where water is scarce, it may be used more than once for washing hands.
- At 5 or 6 years of age, children need not use a latrine.
- After cleaning a baby who has defecated, it is important for a mother to
wash her hands.
- It is important that clean water be used for all household purposes,
- Before eating.
- Before breast-feeding an infant.
- After defecation.
- After touching an infant's stool.
- Before drinking water.
10 November, 2012