Integrated Management of Newborn and Childhood Illness Module: 5. Management of Diarrhoeal Disease in Young Infants and Children

Study Session 5.  Management of Diarrhoeal Disease in Young Infants and Children

Introduction

You may recall from Study Session 1 of this Module that diarrhoea is the second most important cause of death among children under the age of five years. As a Health Extension Practitioner, therefore, you need to know how to assess and classify a sick child with diarrhoea. This study session includes case studies based on common experiences which will also help you understand how to treat a sick child with diarrhoea and what follow-up care is required. This study session is in two parts; the first six sections deal with management of diarrhoeal disease in children and the last section looks at how you manage diarrhoea in young infants. Although the classification is the same for both age groups, the treatment is different and you need to be aware of this difference.

Learning Outcomes for Study Session 5

When you have studied this session, you should be able to:

5.1  Define and use correctly all of the key words printed in bold. (SAQs 5.1, 5.2, 5.3 and 5.4)

5.2  Assess a child presenting with diarrhoea. (SAQ 5.1)

5.3  Classify the illness in a child who has diarrhoea. (SAQs 5.2 and 5.3)

5.4  Treat the child with diarrhoea. (SAQ 5.3)

5.5  Give follow-up care for a child with diarrhoea. (SAQ 5.3)

5.1  Assess and classify diarrhoea

There are different kinds of diarrhoea and you will need to know how to identify and assess these. Diarrhoea may be loose or watery, with blood in the stool and may be with or without mucus. It frequently leads to dehydration in the child, and can be serious enough to lead not only to malnutrition but also to the child’s death. It may be acute or persistent (you will learn about the difference between these below) and can be linked to a number of diseases, including cholera and dysentery. The most common cause of dysentery is Shigella bacteria (amoebic dysentery is not common in young children).

A child may have both watery diarrhoea and dysentery. The death of a child with acute diarrhoea is usually due to dehydration.

• Diarrhoea is the passage of three or more loose or watery stools per day.
• Persistent diarrhoea: diarrhoea which lasts 14 days or more (in a young infant this would be classified as severe persistent diarrhoea).
• Dysentery: diarrhoea with blood in the stool, with or without mucus.

5.2  Assess diarrhoea in children

All sick children that come to your health post should be checked for diarrhoea.

When you checked for general danger signs, you checked to see if the child was lethargic or unconscious. If the child is lethargic or unconscious, he has a general danger sign. Remember to use this general danger sign when you classify and record the child’s diarrhoea.

The sign restless and irritable is present if the child is restless and irritable all the time or every time he is touched and handled. If an infant or child is calm when breastfeeding, but again becomes restless and irritable when breastfeeding stops, he has the sign ‘restless and irritable’. However, many children are upset just because they are in the health post and in unfamiliar surroundings. Usually these children can be consoled and calmed. They do not have the sign ‘restless and irritable’.

• The eyes of a child who is dehydrated may look sunken. Decide if you think the eyes are sunken. Then ask the mother if she thinks her child’s eyes look unusual. Her opinion helps you confirm whether the child’s eyes are sunken.
• You should note that in a severely malnourished child who is visibly wasted, the eyes may always look sunken, even if the child is not dehydrated. However, although sunken eyes is less reliable in a visibly wasted child, you should still use the sign to classify the child’s dehydration.

• Ask the mother to offer the child some water in a cup or spoon. Watch the child drink. A child is not able to drink if he is not able to suck or swallow when offered a drink. A child may not be able to drink because he is lethargic or unconscious.
• A child is drinking poorly if the child is weak and cannot drink without help. He may be able to swallow only if fluid is put in his mouth.
• A child has the sign drinking eagerly, or thirsty if it is clear that the child wants to drink. Look to see if the child reaches out for the cup or spoon when you offer him water. When the water is taken away, see if the child is unhappy because he wants to drink more.
• If the child takes a drink only with encouragement and does not want to drink more, or refuses to drink, he does not have the sign ‘drinking eagerly, thirsty’.

• Ask the mother to place the child on the examining table so that the child is flat on his back with his arms at his sides (not over his head) and his legs straight. Or, ask the mother to hold the child so he is lying flat on her lap. Locate the area on the child’s abdomen halfway between the umbilicus and the side of the abdomen. To do the skin pinch, use your thumb and first finger. Do not use your fingertips because this will cause pain. Place your hand so that when you pinch the skin, the fold of skin will be in a line up and down the child’s body and not across the child’s body. Firmly pick up all of the layers of skin and the tissue under them. Pinch the skin for one second and then release it. If the skin stays up for even a brief time after you release it, decide that the skin pinch goes back slowly.
• When you release the skin, look to see if the skin pinch goes back:
  • very slowly (longer than two seconds)
  • slowly
  • immediately.

The photographs in Figure 5.1 show you how to do the skin pinch test and what the child’s skin looks like when the skin pinch does not go back immediately.

The skin pinch test is not always an accurate sign of dehydration because in a child with severe malnutrition, the skin may go back slowly even if the child is not dehydrated. In an overweight child, or a child with oedema, the skin may go back immediately even if the child is dehydrated. However even though skin pinch is less reliable in these children, you should still use it to classify the child's dehydration.

Figure 5.1  Skin pinch test. (Source: IMCI Training Guide, Ethiopia)

Following your assessment of the child for diarrhoea and dehydration, your next step is to classify the diarrhoea. How you do this will depend on the age of the child, and you are going to look at this next.

5.3  Classifying diarrhoea

There are three classification tables for classifying diarrhoea:

• All children with diarrhoea are classified for dehydration.
• If a child has had diarrhoea for 14 days or more, the child should be classified as having persistent diarrhoea.
• If a child has blood in the stool, the child should be classified as having dysentery.

You are now going to look at each of these classifications in turn, beginning with classifying dehydration.

5.3.1  Classifying dehydration

There are three possible classifications of dehydration in a child with diarrhoea:

• Severe dehydration
• Some dehydration
• No dehydration.

The relevant section from the Assess and Classify chart booklet is set out in Table 5.1. The treatment plans A, B and C referred to in the third column are explained in Section 5.4 below.

Table 5.1  Classification of dehydration in a child (1).

View larger image

To classify the child’s dehydration, begin with the top (pink) row.

• If two or more of the signs in the pink row are present, you should classify the child as having SEVERE DEHYDRATION.
• If two or more of the signs are not present, look at the middle (yellow) row. If two or more of the signs are present, you should classify the child as having SOME DEHYDRATION.
• If two or more of the signs from the yellow row are not present, classify the child has having NO DEHYDRATION (bottom, green row). The child does not have enough signs to be classified as having SOME DEHYDRATION.

Case Study 5.1 below provides an example for you to see how you would classify a child in practice.

Case Study 5.1  Amina’s story

A four-month-old child named Amina was brought to the health post because she had had diarrhoea for five days. She did not have danger signs and she was not coughing. However Amina was restless and irritable every time the health worker touched her and would not settle even when her mother tried to soothe her. The only time she was calm was when her mother was breastfeeding her. Amina was able to feed strongly. The health worker assessed the child’s diarrhoea. She recorded the following signs:

View larger image

Look at Table 5.2 below. Amina does not have any signs in the pink row. Therefore Amina does not have SEVERE DEHYDRATION.

Table 5.2  Classification of dehydration in a child (2).

View larger image

Amina had two signs from the yellow row. Therefore the health worker classified Amina's dehydration as SOME DEHYDRATION.

The health worker recorded Amina’s classification on the recording form which is reproduced in Box 5.2 below.

Box 5.2  Recording form for Amina

View larger image

Now complete Activity 5.1.

You are now going to look at what treatment can be provided for a child with diarrhoea, depending on the level of dehydration you have classified.

5.4  Treatment for dehydration

There are three treatment plans for treating children with dehydration and for diarrhoea: Plan C sets out the steps for treating children with severe dehydration, Plan B is for children with some dehydration, and Plan A sets out home treatment for children with diarrhoea but no dehydration.

First you are going to look at how to treat severe dehydration, using Plan C.

5.4.1  Severe dehydration

Any child with dehydration needs fluid replacement. A child classified with severe dehydration needs fluids quickly. ‘Plan C: Treat Severe Dehydration Quickly’ describes how to give fluids to severely dehydrated children and is set out in Box 5.3 below.

Note that giving intravenous (IV) fluid therapy through a sterile tube and cannula into a small child’s vein requires special training in addition to any training you may have received on giving IV fluids to adults.

Box 5.3  Plan C: Steps for treating severe dehydration

View larger image

You are now going to look at how to treat a child classified with some dehydration.

5.4.2  Some dehydration

Although this is not as serious as ‘severe dehydration’ it is still important that you treat a child who has ‘some dehydration’ in order to prevent his situation becoming worse. Box 5.4 below sets out Plan B: the steps to take to treat a child with some dehydration.

5.4.3  No dehydration

A child with diarrhoea, even if classified as having no dehydration, still needs extra fluid to prevent dehydration occurring. A child who has no dehydration needs home treatment and the steps for this are set out in Plan A in Box 5.5.

You should now have a good understanding of how to treat a child with any of the three dehydration classifications. Next you are going to look at how to classify diarrhoea, beginning with persistent diarrhoea.

5.5  Classify persistent diarrhoea

After you have classified a child’s dehydration, you need to classify what kind of diarrhoea the child has. As you read earlier in this study session, a child who has had diarrhoea for 14 days or more should be classified as having persistent diarrhoea. There are two classifications of persistent diarrhoea, which are linked to the level of dehydration in the child (Box 5.6):

• severe persistent diarrhoea and
• persistent diarrhoea.

Box 5.6  Classification of persistent diarrhoea

View larger image

5.5.1  Severe persistent diarrhoea

If a child has had diarrhoea for 14 days or more and also has some or severe dehydration, you should classify the child’s illness as severe persistent diarrhoea.

5.5.2  Persistent diarrhoea

A child who has had diarrhoea for 14 days or more but who has no signs of dehydration is classified as having persistent diarrhoea.

5.5.3  Follow-up care for persistent diarrhoea

Children who have been classified with diarrhoea will need follow-up care to ensure that rehydration/hydration is maintained and to assess that the diarrhoea has stopped. You should give follow-up care after five days:

5.6  Classify dysentery

There is only one classification for dysentery; see Box 5.8 below:

Box 5.8  Classification for dysentery

View larger image

Classify a child with diarrhoea and blood in the stool as having dysentery.

5.6.1  Follow-up care for dysentery

For a child classified with dysentery, you need to provide follow-up care two days after the initial visit. Box 5.9 sets out the questions you need to ask at the follow-up care visit and what treatment should be provided. If you find the child’s symptoms are the same or have got worse, you should refer the child to hospital.

5.7  Classify diarrhoea in young infants

Diarrhoea in a young infant (below two months) is not classified in the same way as in an older infant or young child (two months to five years). The main difference is that for a young infant with diarrhoea lasting for 14 days or more the only classification is severe persistent diarrhoea. This is because 14 days represents a significant amount of time in a young infant’s life and they should be referred to hospital for treatment.

The main differences between classification and treatment for a young infant are the following:

• Movement only when stimulated or no movement even when stimulated (compared with lethargic or unconscious in a child).
• Treatment for a young infant with severe or some dehydration includes advising the mother how to keep her baby warm on the way to hospital.
• A young infant with diarrhoea lasting for 14 days or more is always classified as severe persistent diarrhoea (in a child, there also needs to be some or severe dehydration for a classification of severe persistent diarrhoea).

Table 5.4 sets out the classification and treatment of dehydration, dysentery and diarrhoea in the young infant. As you can see from Table 5.4, dysentery in a young child is a severe classification.

Table 5.4  How to classify and treat dehydration, diarrhoea and dysentery in a young infant.

View larger image

In this study session you have looked at how to assess, classify and treat children and young infants with diarrhoea and dehydration. As you read in the introduction, diarrhoea is the second major cause of death in Ethiopia of children under five years old. Your role as a Health Extension Practitioner is therefore crucial in identifying the severity of the diarrhoea and dehydration in the sick child or young infant brought to your health post and in providing the best possible treatment and follow-up care for them. Knowing when to refer a child or young infant urgently to hospital is also important, since in some cases the special treatment available there is more likely to be effective than the treatment you can provide in a health post, in particular if you have limited resources available.

Summary of Study Session 5

In Study Session 5, you have learned that:

1. Diarrhoea is a common illness among children under five years of age in Ethiopia.
2. To assess diarrhoea in a child or young infant the steps you should take are:
   • look for general danger signs
   • ask for duration of diarrhoea
   • assess for signs of dehydration
   • ask about blood in the stool.
3. Based on your findings on assessment, you classify the child for:
   • Dehydration
   • Persistent or severe persistent diarrhoea
   • Dysentery.
4. The classification and treatment in a child and a young infant are different; if a young infant has had diarrhoea for 14 days or more they should always be classified as having severe persistent diarrhoea.

Self-Assessment Questions (SAQs) for Study Session 5

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

Read Case Study 5.2 and then answer the questions below.