Definition of Diarrhea
Passage of unusually loose or watery stools usually at least three times in a 24 hour period. However it is the consistency of the stools rather than the number that is most important.

What is not diarrhea?

1.	Frequent passing of formed stools
2.	Loose, pasty stools on babies only on breast milk

Types of diarrhea

-	Acute watery diarrhea (including cholera)
-	Acute bloody diarrhea (dysentery)
-	Persistent diarrhea (lasts 14 days or longer)
-	Diarrhea with severe malnutrition (Marasmus or Kwashiorkar)

Assessment of the child with diarrhea
A child with diarrhea should be assessed for dehydration, bloody diarrhea, persistent diarrhea, malnutrition and serious non-intestinal infections so that an appropriate treatment plan can be developed and implemented without delay.

Dehydration

	No dehydration	Some dehydration	Severe dehydration
Condition	Well, alert	Restless, irritable	Lethargic or unconscious
Eyes	Normal	Sunken	Sunken
Thirst	Drinks normally, not thirsty	Thirsty, drinks eagerly	Drinks poorly, or not able to drink
Skin pinch	Goes back quickly	Goes back slowly	Goes back very slowly
Treatment	Plan A	Plan B	Plan C
Fluid deficit	< 5% of body wt or < 50 ml/kg body wt	5-10% of body wt or 50-100 ml/kg of body wt	> 10% of body wt or > 100 ml/kg of body wt

Management of Acute Diarrhea (without blood)
The objectives of treatment are to:

•	Prevent dehydration
•	Treat dehydration when present
•	Prevent malnutrition
•	Reduce duration and severity of diarrhea and occurence of future episodes by giving supplemental zinc

Plan A:
Home therapy to prevent dehydration and malnutrition: Children with no signs of dehydration need extra fluid and salt to replace their losses of water and electolytes due to diarrhea.

Fluids to be given

•	ORS
•	Salted drinks eg. salted rice water or salted yoghurt drink
•	Vegetable or chicken soup with salt
•	Home based ORS: 3 gm of table salt and 18 gm of common sugar in one liter of water.

Plain water should also be given. Commercial carbonated beverages, fruit juices, sweetened tea, coffee, medicinal tea should be avoided.

How much to give

•	Give as much fluid as the child wants until diarrhea stops
•	Children < 2 years of age : 50-100 ml of fluid
•	Children 2 years - 10 years : 100-200 ml
•	Older children and adults : As much as they want

What feeds to give?
The infant's usual diet should be continued during diarrhea and increased afterwards. Breastfeeding should always be continued.

ZInc supplement
(10-20 mg) every day for 10 to 14 days should be given.

Plan B:
Oral rehydration therapy for children with some dehydration: ORS + Zinc supplementation

Amount of ORS to be given in 1st 4 hours

Age*	< 4 mths	4-11 mths	12-23 mths	2-4 years	5-15 years	15 years or older
Weight	< 5 kg	5-7.9 kg	8-10.9 kg	11-15.9 kg	16-29.9 kg	30 kg or more
ml	200-400	400-600	600-800	800-1200	1200-2200	2200-4000

*Age should be used only if weight is not known.

Approximate amount of ORS required (in ml) can also be calculated by multiplying the patient's weight in kg by 75. If more ORS is required, give more. Except for breast milk, food should not be given during the initial 4 hour rehydration period. However children continued on treatment Plan B longer than 4 hours should be given some food every 3-4 hours as in Plan A. After 4 hours, reassess the child and decide what treatment to be given next as per Grade of dehydration. Children who continue to have some dehydration even after 4 hours should receive ORS by nasogastric tube or RL intravenously (75 ml/kg in 4 hours). If abdominal distension then oral rehydration should be withheld and only IV rehydration should be given.

Plan C: For patients with severe dehydration
Preferred treatment is rapid intravenous rehydration. Give 100 ml/kg RL or normal saline solution as follows:

Age	First give 30 ml/kg n	Then give 70 ml/kg in
Infants	1 hour *	5 hours
Older children	30 min *	2½ hours

* Repeat once if pulses are weak or not detectable.

Reassess patient every 1-2 hours. If hydration is not improving, give the IV drip more rapidly. After completion of IV fluids, reassess the patient and choose the appropriate treatment Plan (A, B or C). If IV therapy is not available, then ORS by nasogastric tube or orally at 20 ml/kg/hour for 6 hours (total of 120/kg) should be given. If abdomen becomes swollen or the child vomits repeatedly, then ORS should be given more slowly.

Management of suspected cholera
Initial treatment follows the same as that of some or severe dehydration. With cholera, unusually large amounts of ORS solution may be required to replace large continuing losses of watery stool after dehydration is corrected (Rice based ORS is superior to standard ORS for cholera and used whenever its preparation is convenient. It does not have benefit in children with acute non-cholera diarrhea). After being rehydrated, patients should be reassessed every 1-2 hours for signs of dehydration. Antimicrobial in form of doxycycline (in children more than 8 years) or erythromycin (12.5 mg/kg/dose qds for 3 days) is recommended.

Management of Acute bloody diarrhea (dysentery)
Any child with bloody diarrhea and severe malnutrition should be referred immediately to hospital. All other children should be assessed, given appropriate fluids to prevent or treat dehydration and feeding should be continued as described earlier. In addition, antibiotic such as Ciprofloxacin (15 mg/kg/dose bd for 3 days or alternately Ceftriaxone (50 mg-100 mg/kg OD IM for 2 to 5 days). Should be given to treat shigellosis as shigella causes most episodes of bloody diarrhea in children. Antimicrobials that are ineffective for treatment of shigellosis are Metronidazole, aminoglycosides, tetracycline, chloramphenicol, sulphonamides, amoxycillin, nitrofurans and 1st and 2nd generation cephalosporins. If there is no improvement after two days, antimicrobial should be changed to another recommended for shigella in the area to be given for 5 days. If there is no improvement, then hospitalize. Treatment for amoebiasis should be given if stool shows trophozoites of histolytica or treatment for shigella fails inspite of 2 different antimicrobials.

Management of persistent diarrhea
The objective of treatment is to restore weight gain and normal intestinal function. Treatment consists of appropriate fluids to prevent or treat dehydration, a nutritious diet that does not cause diarrhea to worsen, supplementary vitamins and minerals, including zinc for 10-14 days and antimicrobial to treat diagnosed infections.

Feeding recommendations

•	Continue breast feeding in those children on breast feeds
•	If yoghurt is available, give it in place of any animal milk usually taken by the child or else give lactose free milk formula otherwise limit animal milk to 50 ml/kg/day. Mix the milk with the child's cereal. Do not dilute the milk.
•	Give frequent small meals at least 6 times a day and other non-milk feeds appropriate for child's age should be given to ensure an adequate energy intake.

Special diets
Reduced lactose diet: With this diet 130 ml/kg provides 110 kcal/kg. This diet should be started as soon as the child can eat and can be given 6 times a day.

•  Full fat dried milk	:	11 gm (or whole liquid milk : 85 ml)
•  Rice to be cooked	:	15 gm (uncooked rise)
•  Vegetable oil	:	3.5 gm
•  Cane sugar	:	3 gm
•  Water to make	:	200 ml

Lactose free with reduced starch diet: This is meant for children who do not improve with reduced lactose diet. With this diet 145 ml/kg provides 110 cal/kg.

•  Whole egg	:	64 gm
•  Rice	:	3 gm
•  Vegetable oil	:	4 gm
•  Glucose	:	3 gm
•  Water to make	:	200 ml

If finely ground, cooked chicken meat (12 gm) can be used in place of whole egg. The first diet should be given for seven days, unless signs of dietary failure occur earlier in which case the first diet should be stopped and the second diet given also for 7 days. Child responding satisfactory to either diet should be given additional fresh fruit and well cooked vegetables. After seven days treatment with the effective diet, age appropriate diet including milk providing at least 110 kcal/kg/day should be given.

Supplementary multivitamins and minerals
Should be given for two weeks and include at least two recommended daily allowances (RDAs) of folate, Vitamin A, Zinc, Magnesium and Copper.

Management of Diarrhea with severe malnutrition
Management of dehydration: Should take place in a hospital. Rehydration is per oral. IV rehydration should be used only for treatment of shock as it can cause over hydration and heart failure. Oral rehydration should be done slowly giving 70-100 ml/kg over 12 hours and starting by giving about 10 ml/kg/hour during the 1st 2 hours. Fluids given to maintain hydration after dehydration has been corrected as per treatment Plan A. Reduced ORS (containing 75 mEq/L of sodium) should be dissolved in 2 litres of water (instead of one litre) and 45 ml of potassium chloride and 50 gm sucrose should be added. This modified solution provides less sodium (37.5 mmol/L), more potassium (40 mmol/L) and added sugar (25 gm/L) which is appropriate for severely malnourished children with diarrhea.

Feeding: Breast feeding should be continued.

Initial diet: From admission till the child's appetite returns to normal. Diet contains 75 kcal/100 ml.

•  Skimmed milk powder	:	25 gm
•  Vegetable oil	:	20 gm
•  Sugar	:	60 gm
•  Rice powder (or other cereal powder)	:	60 gm
•  Water to make	:	1000 ml

Combine the ingredients and boil gently for 5 mins to cook the cereal powder. Children should receive 130 ml/kg/day orally or through nasogastric tube in 8-12 divided feeds.

Subsequent diet: After appetite returns, children should be given the diet containing 100 kcal/100 ml

•  Skimmed milk powder	:	80 gm
•  Vegetable oil	:	60 gm
•  Sugar	:	50 gm
•  Water to make	:	1000 ml

Minimum daily intake of 120 ml/kg/day and increasing to 200 ml/kg/day or even more gradually should be the aim.

Vitamins, minerals and salts
The following mixture of salts should be added to every 2 litres of both liquid diets.

KCL	:      3.6 gm
K 3 citrate	:      1.3 gm
Mg Cl 2 .6H 2 O	:      1.2 gm
Zn acetate.2H 2 O	:     130 mg
CuSO 4 .7H 2 O	:       22 mg
NaSeO 4 .10H 2 O	:     0.44 mg
KI	:     0.20 mg

Multivitamin mixtures that provide at least twice RDA of all vitamins should be added to the diet or given separately. Iron should be given when weight gain is established. Vitamin A should be given at 2,00,000 units/dose for 2 days for children 12 months to 5 years and at 1,00,000 units for children 6 months to 12 months and at 50,000 units for children less than 6 months in those with Vitamin A deficiency or had measles in the past one month.

Antimicrobials
All severely malnourished children should receive broad spectrum antibiotics for infections.

Prevention of Diarrhea
Till 6 months of age, infants should be exclusively breast fed. Breast feeding should continue until at least 2 years of age. If breast feeding is not possible, cow's milk (modified if given to infants younger than 6 months) or milk formula should be given from a cup. Complementary foods should be started from 6 months onwards. Drinking water should be clean and stored in clean containers. Boiling water is preferred for drinking, (water needs only to be brought to a rolling boiling as vigorous or prolonged boiling is unnecessary). All family members should wash their hands thoroughly after defecation, after cleaning a child who has defecated, after disposing of a child's stool, before preparing food and before eating. Good hand washing requires use of soap or local substitute such as ashes or soil. Raw food should not be eaten except fruits and vegetables that are peeled and eaten immediately. Eat food while it is still hot or reheat it thoroughly before eating and food should be protected from flies by means of fly screens. Proper disposal of feces in a designated area helps prevent spread of diarrheal agents. All infants should be immunized against measles at recommended age.

Further Reading:
The Treatment of Diarrhoea. A manual for physicians and other senior health workers. World Health organization. Geneva, 2005.