Unit 4 - Treatment of Diarrhoea at Home
Medical Education: Teaching Medical Students about Diarrhoeal Diseases

World Health Organization 1992
http://apps.who.int/iris/handle/10665/40343

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INTRODUCTION TREATING DIARRHOEA AT HOME - TREATMENT PLAN A Give the child more fluids than usual What fluids to give How much fluid and how often Give the child plenty of food What foods to give How much food and how often Antidiarrhoeal drugs, antiemetics and antibiotics Problems in treating diarrhoea at home When to take the child to a health worker TALKING WITH MOTHERS ABOUT HOME TREATMENT Using examples, demonstrations, and practice Asking checking questions Providing illusrated instruction leaflets Giving encouragement and assistance EXERCISES

UNIT 4 - TREATMENT OF DIARRHOEA AT HOME

INTRODUCTION

Home treatment is an essential part of the correct management of acute diarrhoea. This is because diarrhoea begins at home and children seen at a health facility will usually continue to have diarrhoea after returning home. Children must receive proper treatment at home if dehydration and nutritional damage are to be prevented. Mothers who understand home treatment should begin it before seeking medical care. When "early home therapy" is given, dehydration and nutritional damage can often be prevented.

Each mother whose child is treated for acute diarrhoea at a health facility should be taught how to continue the treatment of her child at home, and how to give early home therapy for future episodes of diarrhoea. When properly informed, mothers should be able to:

prepare and give appropriate fluids for ORT;

feed a child with diarrhoea correctly; and

recognize when a child should be taken to a health worker.

The steps involved in home therapy, the information and skills that mothers need to carry it out, and ways in which these can be effectively communicated to them, are the subjects of this unit.

TREATING DIARRHOEA AT HOME - TREATMENT PLAN A

The management of acute watery diarrhoea at home (Treatment Plan A) is outlined in Figure 4.1. This plan should be used to treat children:

who have been seen at a health facility and found to have no signs of dehydration;

who have been treated at a health facility with Treatment Plans B or C until dehydration is corrected; or

who have recently developed diarrhoea, but have not visited a health facility.

The three basic rules of home therapy are considered below. These are:

give the child more fluids than usual, to prevent dehydration;

give the child plenty of food, to prevent undernutrition; and

take the child to a health facility if the diarrhoea does not get better, or if signs of dehydration or another serious illness develop.

Give the child more fluids than usual

Children with diarrhoea need more fluid than usual to replace that being lost in diarrhoeal stools and vomit. If suitable fluids are given in adequate volumes soon after diarrhoea starts, dehydration can often be prevented.

What fluids to give

Fluids that should be used at home to prevent dehydration include "recommended home fluids", certain other drinks usually available in the home, and in some instances ORS solution. Many countries have recommended specific home fluids for use in ORT; these are usually food-based drinks, such as undiluted cereal gruel, or sugar-salt solution (SSS). These fluids are suitable for home treatment of most children with diarrhoea. However, for patients who have been treated for dehydration at a health facility using Treatment Plans B or C, ORS solution should be used (see Unit 5). Some countries also advise the use of ORS solution for home treatment of all patients who are seen at a health facility and found not to be dehydrated, or for early home therapy of diarrhoea.

The appropriate composition of home fluids is considered in Unit 2. The main points to remember are that a home fluid should be:

Safe. In particular, it should not be hyperosmolar or contain too much salt. The risk of hyperosmolarity is reduced in solutions that use a cooked starch, such as rice powder, rather than sucrose as the source of glucose.

Effective. This is most likely if the concentrations of salt and starch (or sugar) in the fluid are in the ranges described in Unit 2. The molar ratio of glucose (derived from starch or sugar) and sodium should be at least 1:1.

Easy to prepare. The recipe should not be complicated and its preparation should not require much work or time. The required ingredients and measuring utensils should be readily available and inexpensive.

Acceptable. The fluid should be one that the mother is willing to give in large volumes to a child with diarrhoea and that the child will readily accept.

Fluids suitable for home therapy include:

Food-based fluids. Examples of food-based fluids are gruels made by boiling ground or powdered cereals (the gruel should be thick but drinkable), rice water or water in which other cereals have been cooked, home-made soups, and yoghurt-like drinks. These can either be prepared in a traditional way or a traditional recipe can be slightly modified, for example, by changing the amount of water used or adding a small amount of salt (see Unit 2, Table 2.3). However, such modifications may increase the risk of error.

Salt-sugar solution (SSS). When properly prepared and given in sufficient volume, SSS is both safe and effective. However, the preparation of SSS requires three correct measurements - sugar, salt, and water - and mothers frequently have difficulty in remembering the recipe or in preparing SSS correctly; this often results in solutions that are hyperosmolar and unsafe. Also, sugar or salt may be unavailable. For these reasons, many governments now recommend food-based fluids that do not contain sucrose, do not involve a special recipe, and are less likely to be unsafe.

Water. Although water provides no salt or source of glucose, it is universally available and the idea of giving large volumes to a child with diarrhoea is generally acceptable. Moreover, water is rapidly absorbed from the intestine and, when given with a diet that contains cooked cereals and some salt, would be adequate treatment for the majority of children with diarrhoea who are not dehydrated.

ORS solution. Although not usually considered a "home fluid", ORS solution can be used in the home to prevent dehydration. ORS packets may be dispensed at health facilities for use at home, both to treat patients who have not become dehydrated and to continue the treatment of patients who have been rehydrated at the facility. ORS packets may also be available commercially for use in early home therapy. However, some commercial glucose-electrolyte products have compositions which differ appreciably from ORS and may be less satisfactory.

How much fluid and how often

Provide more fluid than usual. The general rule is to give the child as much fluid as he or she wants and to continue using ORT until diarrhoea stops. Remember that a child younger than 2 years cannot ask for something to drink; however, irritability and fussy behaviour are often signs of thirst. Young children must be offered fluids to determine whether they are thirsty and want to drink. When a child no longer accepts fluid, it is usually because enough has been taken to replace the losses caused by diarrhoea. Infants should be allowed to breast-feed as often and as long as they want.

The following is a general guide for the amount of fluid to be given at home after each loose stool:

• children under 2 years: 50-100 ml
  
  • children aged 2 up to 10 years: 100-200 ml
    
  • children 10 years of age or older and adults should take as much as they want.

Show the mother how to measure the approximate amount of fluid to be given after each loose stool using a cup or some other container available to her at home (or that she can take home). Explain that the fluid should be given by teaspoon to children under 2 years of age: a teaspoonful every 1-2 minutes. Feeding bottles should not be used. Older children should take the fluid directly from a cup, by frequent sips. If vomiting occurs, the mother should stop giving the fluid for 10 minutes and then start again, but give it more slowly, e.g., a spoonful every 2-3 minutes. If ORS solution is to be used at home, show the mother how to measure the correct amount of water, using the type of container available to her at home, and then how to mix the solution. Then give her enough packets to last two days. This should be enough to provide 500, 1000, or 2000 ml/day for children aged less than 2 years, 2 up to 10 years, and 10 years or older and adults, respectively. When providing ORS packets, explain to the mother that the entire packet must be mixed at one time and that any ORS solution unused after 24 hours must be thrown away. Thus, if a packet makes one litre of solution, a child requiring 500 ml/day would need two packets, one for each day. If diarrhoea continues after the ORS packets have been used up, the mother should give the child a recommended home fluid, such as undiluted cereal gruel, or water; or return to the health facility for more ORS packets.

Give the child plenty of food

What foods to give

Breast-feeding should be continued without interruption. For infants under 6 months of age who normally take formula or cow's milk (and are not yet taking soft foods), milk should be given at half strength (by diluting it with an equal amount of clean water) for two days. After two days, the usual formula or milk should be given. For other infants and children, the usual cow's milk should be given throughout the illness.

Children with diarrhoea who are 6 months of age or older (and younger infants who have already begun to take soft foods) should also be given soft or semi-solid weaning foods. In general, such foods should provide at least half of the energy in the diet. Guidelines concerning the type of foods to be given are shown in Figure 4.1 and discussed in detail in Unit 7.

How much food and how often

During diarrhoea, give the child as much food as he or she wants. Offer food every 3-4 hours (six times a day). Small, frequent feedings are tolerated better than large feedings given less frequently. Many children have anorexia; they need to be coaxed to eat.

After the diarrhoea has stopped, give the child at least one more meal than usual each day for two weeks, using the same energy-rich foods that were given during diarrhoea; undernourished children should follow this same regimen for an even longer period (see Unit 7). The child should continue to receive these food mixtures as his or her regular diet, even after extra meals are no longer required.

Antidiarrhoeal drugs, antiemetics and antibiotics

A wide variety of drugs or combinations of drugs is sold for the treatment of acute diarrhoea and vomiting. "Antidiarrhoeal" drugs include: antimotility agents (e.g., loperamide, diphenoxylate, codeine, tincture of opium), adsorbents (e.g., kaolin, attapulgite, smectite), live bacterial cultures (e.g., Lactobacillus, Streptococcus faecium), and charcoal. Antiemetics include phenergan and chlorpromazine. None of these has proved to have practical benefits for children with acute diarrhoea, and some may have dangerous side effects. These drugs should never be given to children below 5 years of age.

Antibiotics also should not be used routinely; they are of benefit only to children with dysentery or suspected cholera (see Units 5 and 6). Antiparasitic drugs are rarely indicated; their use is also described in Unit 6).

The overuse of antidiarrhoeal and antiemetic drugs, antibiotics and antiparasitic agents often delays the initiation of ORT or a visit to the health facility to seek help; it also consumes precious financial resources of the family unnecessarily.

Problems in treating diarrhoea at home

The mother may encounter a variety of problems in treating her child with diarrhoea at home. Most of these can be avoided or solved by ensuring that she understands the importance of home treatment, is able to carry it out, knows what difficulties to expect, and receives constructive help and encouragement when problems arise. Table 4.1 describes some of the problems that are encountered most frequently and possible ways of solving or preventing them.

When to take the child to a health worker

The mother should be taught to watch for signs of worsening diarrhoea, dehydration, or any other serious problem. Symptoms the mother can recognize which indicate that diarrhoea is worsening or that dehydration is developing include:

the passage of many watery stools;

repeated vomiting;

increased thirst; and

failure to eat or drink normally.

Children with dehydration may also be irritable and show no interest in playing. The mother should be instructed to bring her child to a health facility if the diarrhoea does not improve after three days, or if any of the signs described above appear. She should also bring the child if other problems develop, such as:

fever; or

blood in the stool.

TALKING WITH MOTHERS ABOUT HOME TREATMENT

Effective home treatment of diarrhoea can be given only by the child's mother (or other caretaker). It is she who must prepare the oral fluid and give it correctly, provide nutritious, well-prepared foods, and decide when the child needs to return to the treatment centre. The mother can only do these tasks correctly if she understands clearly what needs to be done and how to do it. The best opportunity for a mother to learn about home treatment of diarrhoea is when she brings her child to the treatment centre because the child has diarrhoea. Unfortunately, this opportunity is often lost because doctors or health workers do not communicate well with mothers; as a result, mothers frequently return home without the understanding needed to continue treating their children effectively.

There are a number of reasons why doctors tend to communicate poorly with mothers. For example, doctors have a "scientific" perspective and often speak in technical terms, they are authority figures, they are busy and have little time to spend with each mother, and they often "educate" mothers by telling them what to do. In contrast, the mother's perspective is usually traditional and unscientific, she does not understand technical terms, she may be easily frightened by authority figures, and she learns best through demonstration and practice in an atmosphere of patience, encouragement, and understanding.

A doctor who cannot communicate well with mothers will be ineffective in preparing them to carry out home treatment. To improve their communications with mothers, doctors must learn to:

o listen to the mother and take her concerns seriously;

speak to her in terms she can understand;

be supportive and encouraging, giving her praise and help rather than criticism; and

use teaching methods that require her active participation.

In real-life situations, doctors are rarely able to spend the time required to teach each mother how to carry out home treatment of diarrhoea: this must usually be done by other health workers. However, doctors must supervise this activity and this can only be done successfully if they themselves understand the principles of effective communication.

Some specific approaches that can be taken to improve communications with mothers and, especially, to help them to learn how to treat diarrhoea at home are considered below.

Using examples, demonstrations, and practice

Giving clear instructions on how to carry out home treatment is important, but represents only the first step in the training of mothers. Combining instruction with the use of examples, demonstrations, and practice can greatly facilitate the learning process. For instance, a health worker teaching a mother how to carry out ORT at home can make the message clearer by showing her a half-cup (100 ml) of ORS solution (with a line marking the appropriate level) while instructing her to give her child that amount after each loose stool. Or, a mother could be encouraged to watch another mother giving an infant ORS solution with a spoon so that she can see how to hold her child and how frequently to give the spoonfuls of fluid. She should then practise giving ORS solution to her own child, with guidance. As she tries, the health worker can see which parts of the task are difficult, and can explain or demonstrate how they should be done. Once the mother has performed the task correctly, the health worker can be confident that she has learned it.

Examples, demonstrations, and practice may include:

Showing pictures: use a drawing or a poster of a mother breast-feeding while discussing the importance of this practice for an infant's health.

Using specific names or instructions appropriate to local circumstances (instead of stating a general rule): advise the mother to give "banana or green coconut water" (which are rich in potassium), instead of simply telling her to give her child "fruit"; explain that she should feed her child "six times a day" instead of "frequently" or "more often than usual".

Demonstrating a practice: show the mother how to measure the correct amount of water for preparing ORS solution, using a container of a type that is available to her at home.

Showing an object: show the mother an infant feeding bottle when explaining that this should not be used for giving milk or other fluids to her infant. Show a cup and spoon for comparison.

Telling a story: a story of how another mother dealt with problems that arose while treating her child at home can help to prepare a mother for difficulties she may have to face. Stress that giving food and fluids will keep the baby strong and help the baby to continue growing, even while he or she has diarrhoea.

Practising a procedure: let the mother practice preparing and giving ORS solution to her child using a cup and spoon.

Asking checking questions

Asking simple checking questions is a very effective way of confirming what a mother has learned about home therapy. For example, after explaining how to treat the child's diarrhoea at home, the doctor might ask: "Describe how you would prepare the drink for Ana" or "Tell me the signs that mean you should bring Ana back to me".

A checking question should be phrased in such a way that the answer cannot be just "yes" or "no". For example, it is not effective to ask: "Do you understand the signs that mean you should bring Ana back to see me?". The mother is likely to answer "yes", whether she understands them or not.

If a nurse or other staff member is given the responsibility of teaching mothers, checking questions can be used to monitor their effectiveness. For example:

Three-year-old Mo was treated for dehydration and is now ready to go home. The nurse has talked to his mother about what she should do at home to care for Mo.

The doctor should not ask the mother, "Did the nurse explain to you how to mix ORS?", or "Do you know how to mix ORS?", since the mother would probably be afraid to answer "no". Instead, the doctor should ask "How much water will you mix with that ORS packet?", "How much of the solution will you give to Mo?", "How long did the nurse tell you to continue giving the ORS?", "What else will you give him to eat and drink?", "When will you bring Mo back to see the nurse again?".

Providing illustrated instruction leaflets

A specifically prepared pamphlet (or card) can greatly improve communication with the mother. It should summarize the important elements of caring for a child with diarrhoea at home, and should have words and pictures that illustrate these points. When a pamphlet is being developed, it should be carefully tested to determine whether mothers understand its messages. An example of the possible content and layout of a mother's pamphlet is shown in Figure 4.2.

There are many reasons why a mother's pamphlet is useful. For example:

• The pamphlet will simplify the task of training health workers in the messages to tell mothers.
  
• Referring to the pamphlet will bring to mind the main points to be covered when giving instructions to mothers.
  
• When she is at home, the pamphlet will remind the mother of what she was taught at the treatment facility, and support her if other family members should disagree with her treatment.
  
• Mothers who cannot read will find the pictures helpful; otherwise they can have a family member or neighbour read out the written instructions, and thus other people will learn from the pamphlet too.
  
• If the mother keeps the pamphlet, the next time her child has diarrhoea she can refer to it and remind herself what to do.
  
• The mother will appreciate being given something during her visit, especially if she is not given a medicine.

Give encouragement and assistance

Using examples, demonstrations, and a mother's pamphlet and asking checking questions can help to ensure that a mother understands home therapy, but they do not guarantee that she will practise it. There are a number of reasons why a mother may not carry out the instructions received at a health facility. For example:

Home treatment may seem to be unrewarding:

she may expect ORT to stop the diarrhoea, and be discouraged when it does not;

ORT may appear to have undesirable effects, such as making the child vomit more;

home treatment is time-consuming and may be difficult, e.g., coaxing a sick child to eat can be frustrating.

The necessary materials for ORT are not available: she may not have salt in her house or a container to measure water.

These problems can best be overcome by giving the mother encouragement and support. Several approaches should be used:

Emphasize the positive: Explain that ORT will make the child stronger and that continued feeding will help it to grow. Encourage the mother to look at the whole child, not just its stools. She should note that, after giving ORT and feeding, the child is usually less fussy and more contented. Explain that, so long as this is the case, her treatment is successful and the diarrhoea will soon stop.

Give praise: Praise is essential in building up a mother's confidence that she can treat her child successfully at home. Opportunities to praise the mother occur when she answers a checking question correctly, performs a practical task correctly (even if guidance was provided), or replies correctly on aspects of diarrhoea management at home, such as continued feeding.

Show interest: Discuss with the mother how she will practise home therapy. Ask, for example, "what foods will you give your child?". When the mother answers, confirm that the food is suitable, or suggest another choice. Also discuss how she will prepare the food. By showing interest, the health worker will reinforce the mother's commitment to carry out treatment recommendations.

Assist with problems. Ask questions to determine whether the mother has the required materials for home therapy, e.g., a container to measure water. If this is not available, suggest how one might be obtained.

Avoid giving too much information at one time. Teach the mother only what she can remember and use. It is most important that mothers understand what fluids and food to give at home, and what signs mean they should bring the child back to the health centre. Messages on how to prevent diarrhoea should usually be reserved for mothers who already know how to treat their child at home.

EXERCISES

1. A mother has brought her 11-month-old daughter to a health centre because the child has diarrhoea. The mother is breast-feeding the child. She says she lives far from the health centre and might not be able to come back for several days, even if the child gets worse. The mother mentions that she usually gives her child weak tea when she has diarrhoea, but has heard that the health centre has something better.

The health worker assesses the child for signs of dehydration, but finds none. He decides to treat the child according to Treatment Plan A. Which of the following steps should the health worker take? (There may be more than one correct answer.)

1. Advise the mother to continue breast-feeding the child as often and as long as the child wants.
   
2. Give the mother enough ORS packets to last two days. Show her how to mix ORS solution and how much to give after each loose stool.
   
3. Advise the mother to give her daughter rice with added vegetable oil, well-cooked vegetables, and, if possible, some well-ground meat, in addition to breast milk. These should be given in small feedings, at last six times a day.
   
4. Explain that, if the diarrhoea continues after the ORS has been used up, she should give undiluted cereal gruel in its place, while continuing to give breast milk and other foods.
   
5. Explain that if the diarrhoea continues for 3-4 days, she should discontinue breast-feeding until it stops.

2. Which of the following fluids are acceptable for ORT at home? (There may be more than one correct answer.)

1. Cow's milk or formula
   
2. Rice water
   
3. A commercial fruit drink
   
4. An undiluted cereal gruel
   
5. A soft drink

3. Harish, aged 9 months, has had watery diarrhoea for two days. He has been weaned and eats a mixed diet of rice, pulses, vegetables, and cow's milk. During the illness, however, his mother has given him only soft, boiled rice and tea. She has also obtained a medicine from the chemist which is given to stop the diarrhoea. When seen at the health centre, Harish has no signs of dehydration and is well nourished. Which of the following recommendations are appropriate? (There may be more than one correct answer.)

1. The mother should be encouraged to give Harish extra fluids at home, for example some soup or water after each watery stool.
   
2. The medication obtained from the chemist should be stopped.
   
3. Harish should resume his normal diet; however his milk should be diluted with an equal volume of water for the next two days.
   
4. Harish should be brought back to the clinic if he does not eat or drink normally at home, or if he starts to pass many large watery stools.

4. Juma, a 14-month-old boy, has had diarrhoea for three days and has been assessed as having some dehydration. He has been treated with ORS solution at the clinic and is now ready to go home. The doctor wishes to do everything possible to ensure that Juma will be well treated at home and will not need to return to the clinic. Which of the following steps would be appropriate? (There may be more than one correct answer.)

1. Give Juma's mother enough ORS packets for two days, show her how to mix ORS solution, and explain how much should be given after each loose stool.
   
2. Give Juma an antibiotic to help stop his diarrhoea.
   
3. Explain to Juma's mother the importance of continuing to give Juma plenty of food.
   
4. Teach Juma's mother the signs that mean she should bring him back to the clinic.

5. If a mother is to be successful in carrying out ORT at home, it is important that she learn how this is done. Which one of the following methods is most effective in teaching mothers how to give ORT?

1. The doctor explains how it is done.
   
2. Posters on the clinic walls show how ORT is given.
   
3. A nurse or health worker demonstrates ORT.
   
4. The mother practises giving ORT with the guidance of a health worker.
   
5. The mother is given an illustrated pamphlet that explains how ORT is carried out.

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ANSWERS

1. A-D are all correct for Plan A.

2. B, D. Commercial fruit drinks and soft drinks are often hyperosmolar owing to their high sugar content. They also contain little or no sodium. If given to replace stool losses they could worsen the situation by causing osmotic diarrhoea.

3. A, B, D. Harish should resume his normal diet. However, as he is over 6 months of age, his milk feeds need not be diluted. Thus, C is not correct.

4. A, C, D. Antibiotics are not helpful in most episodes of diarrhoea. They should be used only for cases of dysentery and suspected cases of cholera.

5. D. All of the described methods are helpful, but the most effective is letting the mother practise ORT under the supervision of a health worker.

updated: 7 June, 2017