October/ 2019

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW) for the Management of

ACUTE DIARRHOEA
ICD-10-R19.7
ASK FOR SKIN PINCH TEST REFER TO HOSPITAL
• Duration • Locate the area on the child’s • Severe malnutrition/ HIV
• Blood in stool abdomen halfway between the • Severe dehydration
• Vomiting, fever, cough, recent umbilicus and the side of the • Hypernatremic (Na >145 mmol/L) /
measles, HIV status (if known) abdomen. hyponatremic dehydration (Na
• Immunization status and pre • Use thumb and first finger to pinch <135 mmol/L)
DIARRHOEA IS
illness feeding practices and not finger tips. • Dysentery with age <1 yr/ measles
• >3 loose or watery
• Fluids/ food/ drugs and other • The fold of the skin should be in a line in past 6 weeks/ dehydration/ sick
stools/ day
remedies taken during illness up and down the child’s body. • Dysentery with no improvement
• Acute Diarrhoea
• Firmly pick up all layers of the skin and on antibiotics
<14 days
tissue under them. • Persistent diarrhea with
• Persistent
• Pinch the skin for one second and then dehydration
diarrhoea >14 days EXAMINATION release it. Look to see if the skin pinch • Persistent diarrhea with serious
• Dysentery – blood • General condition of child goes back: systemic infection such as
in stools • Nutritional status (weight/ • Very slowly (longer than 2 seconds) pneumonia, sepsis, infants <4
weight for height / MUAC) • Slowly (skin stays up even for a months of age, or when there is
• Classify malnutrition if any brief instant) no improvement with treatment
• Signs of dehydration & • Immediately (normal) over 5 days
classify dehydration

MANAGEMENT
CLASSIFY DEHYDRATION

2 of the following: 2 of the following:

Not enough signs to a) Restless, irritable a) Lethargy/ unconscious
classify some or severe b) Sunken eyes b) Sunken eyes
dehydration c) Drinks eagerly, thirsty c) Not able to drink/ drinking poorly
d) Skin pinch - goes back very slowly d) Skin pinch - goes back slowly

NO DEHYDRATION: PLAN A SOME DEHYDRATION: PLAN B SEVERE DEHYDRATION: PLAN C

• Fluids • Manage in clinic /daycare facility with recommended • Urgent referral to hospital
• Give extra fluids (as much as child amount of ORS (75 ml /kg) over 4 hour period • Mother to continue rehydration by giving
will take) until diarrhoea stops. • If weight is not known frequent sips of ORS during transport or use
• Use WHO ORS after each loose NG tube when possible in patients with
stool (in addition to usual fluid AGE
<4 4 -11 12 -23 2–4 5-14 15 years poor drinking
months months months years years or older
intake) NO
• Upto 2 years → 50 -100 ml 5 – 7.9 8 - 10.9 11 – 16 – 30 kg or
WEIGHT <5kg kg kg 15.9 kg 29.9 kg more CAN YOU GIVE INTRAVENOUS
• 2 years or more → 100 -200 ml (IV) FLUIDS IMMEDIATELY?
200 - 400 - 600 - 800 - 1200 - 2200 -
• On ORS packet check whether IN mL 400 600 800 1200 2200 4000
200ml or 1 litre of clean water is NO
needed • After 4 hours reassess the child, classify dehydration • Start IV fluid immediately
• Frequent small sips with spoon or and select appropriate plan (A /B/C) • Ideal fluid is Ringer lactate solution / Normal
cup. • Give extra fluids, zinc supplement, feeding advise and saline (DNS in malnourished)
• If child vomits, wait 10 minutes counselling regarding danger signs* as in plan A FIRST GIVE THEN GIVE 70
then continue slowly. • Follow up in 5 days if no improvement AGE
30 ML/KG IN ML/KG IN
• Homemade fluids- salted rice
Infant (< 12 1 hour 5 hours
water, salted yogurt drink, months)
vegetable or chicken soup with salt Older 30 minutes 2.5 hours
PATIENT EDUCATION
and clean water, unsweetened fresh
fruit juice and coconut water • Danger signs* • If child can drink, give ORS by mouth while
• Unsuitable fluids - carbonated • Hygiene practices the drip is set up
beverages, commercial fruit juice, • Hand washing , proper disposal of excreta • Assess heart rate/ respiratory rate/ BP/ CFT/
sweetened tea & coffee, other • Safe drinking water consciousness and recognize early shock
medicinal teas / infusions. • Appropriate feeding practices • Refer for hospitalization
• Zinc supplement (Zinc sulphate/ • Vaccination as per IAP guidelines • If prevalance of cholera –
carbonate / acetate) Doxycycline single dose 300mg or
• 2-6 months → 10 mg/day x 2 weeks Tetracycline 12.5mg/kg 4 times a day x 3 days.
• >6 months → 20 mg/day x 2 weeks INVESTIGATIONS For young children Erythromycin 12.5 mg/kg
• Counsel Mother/ Attender • Some dehydration: 4 times a day x 3 days
• Feeding advise Preferable Tests- electrolytes • Associated vomitings –
• Infants on breast feed, to Ondanstetron 0.15 mg/kg/dose IV/oral in
• Severe dehydration:
continue more frequent breast addition to rehydration therapy
Essential tests- CBC, electrolytes
feeding than usual. • Reassess every 15-30 minutes till a strong
Preferable Tests- Renal Function Tests, VBG
• Those not on breast feed to radial pulse is present and then every hour
• In suspected cholera cases:
continue their usual milk feed/ If hydration status is not improving, give IV
Preferable tests- stool for hanging drop and
formula at least once in 3 hours. drip more rapidly
stool culture
• Give age appropriate foods to >6 • After 6 hours (infants) and 3 hours (older
• Dysentery: (no response to antibiotic in 2
months old based on their pre patients) - evaluate for dehydration and
days) Preferable test- stool culture & stool choose the appropriate plan (A, B, or C) to
illness feeding pattern
routine for trophozoites of Amoeba continue treatment
• Persistent diarrhoea: • Give ORS (about 5 ml/kg/hour) as soon as
• Danger signs (return immediately) Preferable test- stool routine microscopy, the child can drink: usually after 3-4 hours
• Passing many watery stools urine routine microscopy, urine culture , (infants) or 1-2 hours (children)
• Repeated vomiting / very thirsty sepsis screen • Observe for 6 hours after the child has been
• Eating / drinking poorly
fully rehydrated.
• Develops fever / blood in stools
• In hypernatremic and hyponatremic
WHEN CONSIDERING ALTERNATIVE DIAGNOSIS OF dehydration child appears relatively less ill /
• Follow up in 5 days if no improvement PERSISTENT DIARRHOEA AND DYSENTRY more ill respectively and needs to be
referred for hospitalization
DISCHARGE CRITERIA
PERSISTENT DIARRHOEA • Suffcient rehydration (indicated by wt gain
• Appropriate fluids to prevent or treat dehydration &/ or clinical status)
• Nutrition: • IV fluids no longer needed
• If breastfeeding, give more frequent, longer breastfeeds, day and night. • Oral intake = / > losses
• Other milk: replace with increased breastfeeding, or with fermented milk • Medical f/u available
products, such as yogurt, or half the milk with nutrient-rich semi-solid food.
• For other foods, follow feeding recommendations for the child’s age: give
small, frequent meals (at least 6 times a day), and avoid very sweet foods or DYSENTERY
drinks.
• Treat dehydration according to assessment.
• Zinc for 14 days
• Supplement vitamins / minerals • Ciprofloxacin 15 mg/kg twice a day and reassess
• Antimicrobial to treat diagnosed infection after 2 days.
A) Intestinal infection: Improvement: 3 days of treatment
• If blood in stool: Treat like dysentery • No improvement → Cefixime 10 mg//kg/d, 2 div
• If stool routine suggestive of Amoebiasis: Treat for it doses. Reassess after 2 days. If better complete
• If stool suggestive of cyst/ Trophozoite of Giardia: Give Metronidazole 5 3 -5 days of treatment.
mg/kg/dose x 8 hourly x 5 -7 days • If stool routine positive for Ameobiasis :
B) Treat Non intestinal such as UTI/ Otitis Media Metronidazole 10mg/kg/dose 8 hourly x 7
• Follow up in 5 days days (10 days in severe cases)
• Refer to hospital (See box) • Refer to hospital (See box)

REFERENCES
1. IMCI (WHO) module on Diarrhea 2014.
2. WHO Treatment for Diarrhea - A manual for physicians and other senior health workers 2005.
3. WHO GLOBAL TASK FORCE ON CHOLERA CONTROL 2010.
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are
based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the
treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.