Important Health Programs

Control of Diarrheal Diseases

(CDD)
Assistant Professor
Dr. Batool Ali Ghalib Yassin
Department of Family & Community Medicine
College of Medicine – University of Baghdad

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 Objectives
By the end of this lecture you will be able
to:
• Define and classify diarrhea
• Identify the level of dehydration according
to the CDD program adopted by WHO and
implemented by MOH-Iraq
• Follow the guidelines of managing a child
with diarrhea
• Appraise the role of zinc in childhood
diarrhea

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Control of Diarrhoeal diseases
(CDD)
Diarrhoea: Passage • Breast fed infants
of liquid or watery usually pass semi-
stool for at least 3 solid, pasty and
times during 24 yellow stools.
hours. Consistency is
more important than Sometimes, they
frequency. pass stool after
each breast feed.
This is not
diarrhoea.

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 Clinical type of diarrhea

Acute • Loose or watery stools without

visible blood,
watery • Duration less than 14 days
(usually 5-7 days).

Acute • Loose or watery stools with

visible red blood,
bloody • Duration less than 14 days.

Persistent • Loose or watery stools with

or without visible blood,
diarrhea • Duration 14 days or more

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 Control of Diarrhoeal diseases
(CDD)
• The 500,000,000 children under 5 y of age are the major victims of diarrhoea,
• It is estimated that U5 children may develop 1-12 episodes (attacks) of
diarrhoea per year,
Facts • This will lead to growth failure & complications.

• 3,000,000 children die from diarrhoea all over the world.

• This means 6 children per minute.
Annually

• A high percentage of hospital beds are occupied by children with diarrhoea

• Usually present at the late stage of severe dehydration, which requires admission
to hospital, professional care, drugs, fluids, giving sets, etc. (very high cost).
Impact • The prognosis is usually bad probably ending in death.

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Causative Agents; Viruses, Bacteria & Protozoa

Contributing Spoilt Food

Factors (not well
preserved)

Dirty Hands
Unclean Water (Mothers &
Kids)

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 Control of Diarrhoeal Diseases (CDD)

Malnutrition
25gm loss of
growth
Diarrhoea weight for each
retardation
day of diarrhoea
under weight

Reduced
immunity leading
to further
episodes of Causes of weight
diarrhoea loss

Reduced Reduced food

Catabolic losses
absorption intake
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 Dehydration
• is a protective mechanism.
• It washes away micro-organisms and toxins from the gastro-intestinal tract.
Diarrhoea • It is usually self limiting and is not a killer.

• Is the killer
• It is a defence mechanism where the body will increase peristalsis & fluid loss.
• The amount of fluid in a child is limited & this will lead to a fluid- electrolyte
deficit”.
Dehydration • Is a deficit in water and electrolytes (Sodium, Potassium, Chloride and
Bicarbonate) resulting from losses in stool, vomiting, urine, fever, sweat and
breathing. When these losses are not adequately replaced, this deficit will
develop.

• Degree of dehydration; No dehydration, some dehydration and severe

dehydration.
Aim is to • Clinical type of diarrhea; Acute watery, Acute bloody or Persistent diarrhea
assess
• Nutritional status
• Concurrent illnesses
• Immunization status
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 Assessment of Diarrhoea cases for dehydration
Classification
Sign
A B C
General Well, Alert Restless, Lethargic,
Condition Irritable Unconscious
Eyes Normal Sunken * Sunken*
Tears Normal Absent Absent
Mouth & Moist Dry Very Dry
Tongue
Thirst Drinks Eager to drink Unable to drink
normally
Skin pinch Goes Back Goes Back Goes Back Very
Quickly Very Slowly Slowly
(1 sec) (2 or more sec)
Classification No Some Severe
Dehydration dehydration Dehydration
Treatment Plan A Plan B Plan C 9
(Home) (PHC) (Hospital)
Assessment of Diarrhoea cases for dehydration

Degree of Loss in body Estimated Treatment

Dehydration weight fluid deficit plan

No signs of
<5% < 50 ml/kg A
dehydration

Some 50-100
5-10 % B
dehydration ml/kg

Severe
>10 % >100ml/kg C
dehydration

In a diarrhoea case, sometimes we don’t have the 4 signs in the

same category. Two signs in the category, are enough to classify the
case. E.g. 1 sign in A & 1 sign in B + 2 signs in C, so we classify as C.10
 Assess Degree of
Dehydration

No dehydration Some dehydration Severe dehydration

Plan A Plan B Plan C

Aim: To prevent Aim: to correct Aim :to correct

dehydration dehydration dehydration urgently

Give extra fluid: ORS in Clinic Give Ringer’s lactate OR

ORS &/or 75 ml/Kg body weight normal saline by IV
home fluids over a 4 hr period or Naso-Gastric tube

Continue Assess hourly 100 ml/kg

Breastfeeding Continue Breastfeeding Over 6 hrs for infants
or feeding or feeding Over 3 hrs for older children

Teach the mother

Give 100-200 ml of clean Reassess hourly & after
How to prepare fluid
water. (for Bottle fed) Completing treatment
Recognize danger signs

Teach the mother If the patient can drink,

How to prepare fluid give ORS in
Recognize danger signs 5ml/kg body weight/hr

Reassess Do not attempt NG rout

After 4 hours if not well trained
 Important Notes
• During treatment with plan B; the child may
develop puffiness of the face & eyes which is
a sign of over hydration. In that case;
• Stop ORS,
• Give fluids that doesn't contain much salt,
• Give the fluid slowly & send the child for
home treatment when puffiness has gone.
Role of Breast feeding throughout an
episode of diarrhoea:
1.Reduce the severity & duration
2.Reduce the risk of dehydration
3.Reduce the risk of diarrhoea worsening
nutritional status. 12
 Oral Rehydration Solution
Composition:
Sodium chloride: 3.5 gm, NaHCO3: 2.5 gm, KCl: 1.5 gm,
Glucose: 20 gm, In 1000ml (1litre) of water.
Some replace NaHCO3 by 2 gm Tri-sodium Citrate Di-
hydrate which lessens vomiting, is tastier and more stable in
humid and hot areas.
Advantages of ORS: Cheap, effective and easy to give at home
by the mother. This is why 95% of the cases are treated by ORS,
as children will not develop dehydration, when they get diarrhoea.
Preparation of ORS: The water should be boiled and cooled
before the powder is added to avoid the loss of bicarbonate, and
changes of concentration.
In winter, warm the solution to 40oC to increase
acceptability, increase the rate of absorption, decrease vomiting &
decrease the risk of a drop in the body temperature when large
volumes are consumed.
If no ORS is available we use home prepared fluids or
household food solutions, rice water, soups , fruit juices salt and
sugar solution (one teaspoon of salt + one table spoon of sugar).
Diarrhoea case fatality rate has decreased a lot after the
introduction of the ORS, due to the prevention of dehydration.
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Management of Chronic (Persistent)
Diarrhoea

child is under 6 child is over 6

months or is months and not
dehydrated dehydrated

- The management is mainly dietary.

Refer to the - Dilute any animal milk with an equal
hospital, volume of water or replace with
where fermented milk products such as yogurt.
dehydration is
- Increase energy intake: 6 meals per
corrected and
day of thick cereals, added oils or fat,
the case is
vegetables, fish or meat.
fully assessed.
- Reassess in 5 days. If diarrhoea
persists refer to hospital. If diarrhoea
has stopped, resume the usual animal
milk & give an extra meal every day for
one month, use growth charts.

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Management of Blood in Stool

Management of
Blood in Stool

Bacillary Amoebic
Dysentery Dysentery

Severe clinical symptoms are less

picture Co-trimoxazol severe,
Metronidazole
GSE : no or antibacterial GSE: amoebic (Flagyl)
amoebic of choice trophozoites are
trophozoites seen

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 Drugs not to be used for diarrhoea
1. Anti-bacterials: Most cases are viral. Antibacterials
are only used when there is lab evidence of bacterial
infections (mainly cholera and bacillary dysentery).
They will eventually lead to secondary infection due
to the inhibition of the growth of the normal flora.
2. Anti-protozoal: Used only when there is lab
evidence of amoebic dysentery or giardiasis.
3. Mycostatin: Monilia is a normal inhabitant of the
GIT. Mycostatin is only given when there is oral
thrush or anal moniliasis.
4. Anti-motility agents and anti-spasmodics: As
they may cause paralytic ileus in children.
5. Pectocaolines: Will coat the GIT, allow colonization
of the GIT bacteria with bacteria and lead to
persistent diarrhoea.
6. Anti-emetics: May cause CNS symptoms.
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 Zinc Supplement
• Zinc is an essential trace element.

• Clinical zinc deficiency in humans was first

described in 1961(consumption of diets
with low zinc bioavailability was associated
with “adolescent nutritional dwarfism”.

• Infants, children, Pregnant and lactating

(breast feeding) women, especially
teenagers are among those at Risk of
Zinc Deficiency
 The adverse effects of zinc
deficiency
• The adverse effects of zinc deficiency on immune
system function are likely to increase the
susceptibility of children to infectious diarrhea

• Persistent diarrhea contributes to zinc deficiency and

malnutrition.

• Zinc deficiency may potentiate the effects of toxins

produced by diarrhea-causing bacteria like E.coli.

• Zinc supplementation in combination with ORT

reduce the duration and severity of acute and
persistent childhood diarrhea and increase survival.
 Tolerable Upper Intake Level (UL) for Zinc

AGE GROUP UL (mg/day)

Infants 0-6 4
Infants 7-12 months 5
Children 1-3 years 7
Children 4-8 years 12
Children 9-13 years 23
Adolescents 14-18 years 34
Adults 19 years and older 40
 Recommended Zinc Supplement
 It is recommended zinc (10-20 mg/day) be given
for 10 to 14 days to all children with diarrhea.

 Zinc can be given as a syrup or as dispersible

tablets, whichever formulation is available and
affordable.

 By giving zinc as soon as diarrhea starts, the

duration and severity of the episode as well as the
risk of dehydration will be reduced.

 By continuing zinc supplementation for 10 to 14

days, the zinc lost during diarrhea is fully replaced
and the risk of the child having new episodes of
diarrhea in the following 2 to 3 months is reduced.