Diarrhoea remains one of the most common causes of morbidity and mortality in children worldwide. Almost every child will experience diarrhea at some point and the potential for dehydration is great, hence any form of loose stools should not be taken lightly. In this article I have noted down basic points which can help in preventing diarrhea and managing mild form of dehydration at home

* Please Note: Do not link diarrhoea as a result of teething in babies. There isn’t any relation. Yes it may occur at the time of teething, since babies have a tendency of introducing objects into their mouth during teething, which many a times may be contaminated by diarrhoea causing germs.

When can loose stools termed as acute Diarrhoea?

It is defined as 3 or more watery stools in 24 hours

What causes diarrhoea?

1. Infection of the gut is the common cause. (The medical term for infection of the gut is gastroenteritis.)
   1. ROTAVIRUS (Most common cause)
      1. Infection with a virus called rotavirus is the most common cause of diarrhoea.
      2. Severity: Worldwide Rotavirus is responsible for 6,11,000 childhood deaths out of which more than 80% occur in low-income countries
      3. Spread: Rotavirus disease is highly contagious. The germ is present in the stool of an infected person and can remain viable for a long time on contaminated surfaces, including people’s hands. Children catch it by touching something that’s contaminated and then putting their hands in their mouth. The spread of rotavirus infection is a particular problem in day care settings, where it can be easily spread from child to child. It’s also easily spread by day care workers, especially when they change diapers without washing their hands afterward.
      4. Vaccination: Vaccination against rotavirus is now available in India. Details given at the end of the article.
   2. FOOD POISONING: Eating food infected with germs causes some cases of diarrhoea. Food poisoning infection is usually caused by a germ called a bacterium. Common examples are species of bacteria called Campylobacter, Salmonella and Escherichia coli (usually shortened to E. coli). Poisons (toxins) produced by bacteria can also cause food poisoning. Another group of microbes called parasites can also be a cause of food poisoning.
   3. WATER CONTAMINATED by bacteria or other germs is another common cause of infective diarrhoea, particularly in countries with poor sanitation.
2. Non-infectious causes of sudden-onset (acute) diarrhoea are uncommon in children. For example, inflammation of the gut (colitis), food intolerance and various rare disorders of the gut.

What are the symptoms of acute infectious diarrhoea?

• Symptoms can range from a mild stomach upset for a day or two with slight diarrhoea, to severe watery diarrhoea for several days or longer.
• Crampy pains in the tummy (abdomen) are common. Pains may ease each time some diarrhoea is passed.
• Vomiting, Fever, aching limbs and headache may also develop.
• Diarrhoea often lasts for 3-5 days, sometimes longer. It often continues for a few days after any vomiting stops. Slightly loose stools may continue (persist) for a week or so further before a normal pattern returns. Sometimes the symptoms last longer.

What is dehydration?

Dehydration is caused by a loss of body fluids, which are made up of water and salts. When sick children have diarrhea or are vomiting, they can lose large amounts of salts and water from their bodies can become dehydrated very quickly. Dehydration can be very dangerous, especially for babies and toddlers.

Which children are more prone to develop dehydration in diarrhoea?

Dehydration in children with sudden-onset (acute) diarrhoea is more likely to occur in:

1. Babies under the age of 1 year (and particularly those under 6 months old). This is because babies don’t need to lose much fluid to lose a significant proportion of their total body fluid.
2. Babies under the age of 1 year who were a low birth weight and who have not caught up with their weight.
3. A breast-fed baby who has stopped breast-feeding during their illness.
4. Any baby or child who does not drink much when they have infection of the gut (gastroenteritis).
5. Any baby or child with severe diarrhoea and being sick (vomiting). (In particular, if they have passed six or more diarrhoeal stools and/or vomited three or more times in the previous 24 hours.)

What are the signs of dehydration?

Symptoms of dehydration in children include:

• Passing less amount of urine.
• A dry mouth.
• A dry tongue and lips.
• Fewer tears when crying.
• Sunken eyes.
• Being irritable or lacking in energy (lethargic)

When should you call the doctor or take the child to the hospital?

Call your doctor right away if your child:

1. Seems very sick
2. Has had diarrhea more than three days
3. Is younger than 6 months old
4. Is vomiting bloody green or yellow fluid
5. Can’t hold down fluids or has vomited more than two times
6. Has a fever over 105° F or is under age 6 months with a fever over 100.4° F (determined by a rectal thermometer)
7. Seems dehydrated
8. Has bloody stool
9. Is less than a month old with three or more episodes of diarrhea
10. Passes more than four diarrhea stools in eight hours and isn’t drinking enough
11. Has a weak immune system
12. Has a rash
13. Has stomach pain for more than two hours
14. Has not urinated in 6 hours if a baby or 12 hours if a child

What other precautions are to be taken when a child has a diarrhoeal episode at home?

1. Diarrhoeal infections can very easily be passed on from person to person. Therefore, you and your child need to take measures to try to reduce this chance.
2. If your baby has diarrhoea, be especially careful to wash your hands (ideally with liquid soap) after changing nappies and before preparing, serving, or eating food. Dry your hands properly after washing.
3. For older children, whilst they have diarrhoea, the following are recommended:
   1. Regularly clean the toilets used, with disinfectant. Also, clean the flush handle, toilet seat, sink taps, bathroom surfaces and door handles at least daily with hot water and detergent. Disposable cleaning cloths should be used (or a cloth just for toilet use).
   2. If a potty has to be used, wear gloves when you handle it, dispose of the contents into a toilet, then wash the potty with hot water and detergent and leave it to dry.
   3. Make sure your child washes their hands after going to the toilet. Ideally, they should use liquid soap in warm running water but any soap is better than none. Dry properly after washing.
   4. If clothing or bedding is soiled, first remove any stools (faeces) into the toilet. Then wash in a separate wash at as high a temperature as possible.
   5. Don’t let your child share towels and flannels.
   6. Don’t let them help to prepare food for others.
   7. They should stay off school, nursery, etc, until at least 48 hours after the last episode of diarrhoea or being sick (vomiting). Sometimes this time may be longer with certain infections. Check with your doctor if you are not sure.
   8. If the cause of diarrhoea is known to be (or suspected to be) a germ called Cryptosporidium spp., your child should not swim in swimming pools for two weeks after the last episode of diarrhoea.

How to prevent maintain hygiene and prevent the occurrence of diarrhea & dehydration in children?

The advice given in the previous section is mainly aimed at preventing the spread of infection to other people. But, even when we are not in contact with someone with infectious diarrhoea, proper storage, preparation and cooking of food and good hygiene help to prevent us catching an infection.

1. In particular, always wash your hands and teach children to wash theirs:
   1. After going to the toilet (and after changing nappies).
   2. Before touching food. And also, between handling raw meat and food ready to be eaten. (There may be some germs (bacteria) on raw meat.)
   3. After gardening.
   4. After playing with pets (healthy animals can carry certain harmful bacteria).
   5. The simple measure of washing hands regularly and properly is known to make a big difference to the chance of developing gut infections and diarrhoea.
2. Always use boiled water for consumption
3. Avoid uncooked and stale food. Minimize consumption of outside food and prefer freshly home cooked meals.
4. Breast-feeding is also protective. Breast-fed babies are much less likely to develop infectious diarrhoea compared to bottle-fed babies.
5. Rotavirus Immunisation: As mentioned earlier, rotavirus is the most common cause of infective diarrhoea in children. There is an effective vaccine against rotavirus. In the India it has now been decided to routinely vaccinate babies against rotavirus. Drops (by mouth) have been available to prevent rotavirus, along with their other routine vaccinations. These drops are given at 2 and 3 months old.

Brand name	Schedule	Cost
ROTARIX (by GSK)	TWO doses are required at one month interval	Rs. 1099/dose(Total cost: Rs. 2198).
ROTATEQ (by MSD)	THREE doses are required at one month interval	Rs. 900/ dose(Total cost Rs. 2700)

What is an oral rehydration solution?

An oral rehydration solution (ORS) is a mixture of water, salts and sugar in specific amounts. These solutions can be absorbed even when your child is vomiting or has serious diarrhea.

Oral rehydration solutions can be used to:

1. keep children well hydrated when their diarrhea is serious.
2. replace lost fluids when children show signs of mild dehydration.
3. Oral rehydration solutions are available at pharmacies in ready-to-serve preparations. It is best to buy an ORS that has already been mixed.

It’s important to give small amounts of the ORS often (for example, 1 teaspoon every 5 minutes), gradually increasing the amount until your child can drink normally.

1. Babies under 6 months of age 30 to 90 mL  every hour
2. Children 6 months to 2 years of age 90 to 125 mL  every hour
3. Over 2 years of age 125 to 250 mL  every hour

How do I prepare an Oral Rehydration Salts ORS solution at home?

If ORS packets are not available, mix an oral rehydration solution using one of the following recipes; depending on ingredients and container availability:

Recipe for Making a 1 litre ORS solution using Sugar, Salt and Water:

1. Clean Water – 1 litre – 5 cupfuls (each cup about 200 ml.)
2. Sugar – Six level teaspoons
3. Salt – Half level teaspoon
4. Stir the mixture till the sugar dissolves.

• If your child refuses to take the ORS by the cup or bottle, give the solution using a medicine dropper, small teaspoon or frozen pops.
• If your child vomits, you may need to stop giving food and drink, but continue to give the ORS using a spoon.
• Talk to your doctor before giving over-the-counter medications to stop diarrhea.
• WHO recommends routine use of zinc supplementation, at a dosage of 20 milligrams per day for children older than six months or 10 mg per day in those younger than six months, for 10–14 days in addition to ORS. Do consult your doctor regarding the same

What foods should I avoid giving to my child?

Do not give your child sugary drinks like fruit juice or sweetened fruit drinks, carbonated drinks (pop/soda), sweetened tea, broth or rice water. These do not have the right amounts of water, salts and sugar and can make your child’s diarrhea worse.

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