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Every child who presents with diarrhoea should be carefully assessed before his or her treatment is planned. Clinical assessment consists of a brief history, including previous treatment attempted, and examining the child.

Its objectives are to:

Detect dehydration and degree of dehydration by using standardized clinical features (IMCI)

Diagnose dysentery if present from history of bloody diarrhoea Diagnose persistent diarrhoea from the duration of the diarrhoea Determine the patient’s nutritional status

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Diagnose concurrent illness, such as meningitis, septicaemia resulting in some traditional treatment of diarrhoea and pneumonia

Determine the child’s immunization status, especially that of measles

Delete the sections highlighted and use table 12 in the WHO pocket book of Hospital care for children

Assessing and management of a child for dehydration

Detection of dehydration is based entirely on signs observed as shown table 3 below.

Table 3 Assessment for dehydration

General Condition^* Well, alert Restless or Lethargic or

irritable unconscious floppy

Eyes Normal Sunken Very sunken and dry

Thirst^* Drinks normally Thirsty, drinks Drinks poorly or

not thirsty eagerly unable to drink

2. FEEL

Skin Pinch^* Goes back Goes back Goes back

quickly slowly very slowly > 2 seconds

DECIDE: (Classify) NO SIGNS OF SOME SEVERE

DEHYDRATION DEHYDRATION DEHYDRATION

TREAT: Use plan A use plan B Use Plan C

*Key signs

NB skin turgor is not reliable in a malnourished child. Sunken fontanelle in babies can also be used.

A child is in shock when the following are present: cold extremities, weak peripheral pulses, low blood pressure and reduced urine output.

To decide on the presence and degree of dehydration of dehydration, one needs at least 2 (two) of the four signs shown in Table 3. Once the degree of dehydration has been made, the treatment plans A, B or C should be used as appropriate.

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In this space insert charts 13, 14, and 15 i.e. plans A, B, and C of diarrhoea treatment from the WHO pocket book of hospital care for children

Age < 4

Home treatment as given in (plan A) is an essential part of the correct management of diarrhoea in order to prevent dehydration and nutritional damage are to be prevented.

Effective home treatment of diarrhoea can only be given by the mother/care giver. It is she who must prepare the oral fluid and give it correctly provide nutritious and well prepared food and decide when the child needs to return to the treatment center. She can do these tasks only if she understands clearly what need to be done and how to do it. The best opportunity to learn about the home treatment of diarrhoea is when she brings her child to the treatment center for diarrhoea. The mother must be trained on how to continue the treatment of her child at home, and how to give early home therapy for future episodes of diarrhoea. When properly trained a mother should be able to:

Prepare and give appropriate fluids for ORT

Give the child plenty of nutritious food to prevent malnutrition

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

Talking with the mother about home treatment

A doctor must be able to communicate effectively with the mother. To improve his communication capacity the doctor must learn to:

Listen to the mother and must take her concerns seriously Speak to her in terms she can understand

Be supportive and encouraging giving her praise and help rather than criticism Use teaching methods that require her active participation.

Assessment of the patient for other problems (figure 6)

Once a patient has been assessed for dehydration, he/she should be assessed and managed for:

Dysentery from the positive history of blood in stool. The patient with dysentery should be put on an antibiotic recommended by the country’s IMCI guidelines (see also table 1). A stool taken for culture and sensitivity may be useful.

Persistent diarrhoea. The patient with persistent diarrhoea should be carefully investigated and all possible ailments identified and treated.

Malnutrition using the age and the weight to or weight to height/length decide on the presence of wasting or stunting and oedema to decide on presence of severe

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oedematous (kwashiorkor or marasmic kwashiorkor) or severe non-oedematous malnutrition (marasmus). Children who are malnourished must be given prescribed feeding treatment to provide 100-200 calories per kilogramme body weight per day and four (4) grammes of protein per kilogramme body weight per day.

Figure 6: Assessment of the Patient for other problems

ASK ABOUT BLOOD IN THE STOOL

ASK WHEN IF DIARRHOEA HAS LASTED AT LEAST 14 DAYS Refer to hospital if:

The child is under 6 months

Dehydration is present (refer the child after treatment of dehydration) Otherwise, teach the mother to feed her child as in plan A except:

Replace animal milk with a fermented milk product such as yoghurt

Assure full energy intake by giving 6 meals a day of thick cereal and added oil, mixed with vegetables, pulses, meat or fish.

Tell the mother to bring the child back after 5 days:

If diarrhoea has not stopped, refer to hospital If diarrhoea has stopped tell the mother to|

Use the same foods for the child’s regular diet

After 1 more week gradually resume the usual animal milk Give an extra meal each day for at least 1 month.

LOOK FOR SEVERE UNDERNUTRITION

ASK ABOUT FEVER ANDTAKE TEMPERATURE