Diarrhoea in Children: ORS, Zinc, Feeding and When to Go to Hospital

Diarrhoea, three or more loose or watery stools in a day, is one of the most common childhood illnesses, especially in babies and toddlers. Most episodes are caused by viruses such as rotavirus, last three to seven days and settle at home. The main danger is dehydration, the loss of body water and salts, which can be prevented and treated with oral rehydration solution (ORS). Knowing what to do, and when to seek help, protects your child.

Causes

• Viral infection (rotavirus, norovirus, adenovirus), the commonest cause
• Bacterial infection from contaminated food or water (E. coli, Salmonella, Shigella, cholera)
• Parasites such as Giardia
• Antibiotics, food intolerance or allergy, or too much fruit juice
• Poor hand-washing, unsafe water and unhygienic bottle feeding

Step 1: Replace fluids with ORS

ORS contains the right balance of salts and sugar to be absorbed in the gut, even when the child has diarrhoea. It is far better than water, juice, soft drinks or home-made salt-and-sugar mixes.

• Use packet ORS (for example Jeevani or other WHO-formula packets) from a pharmacy or health clinic.
• Mix exactly as written on the packet with the stated amount of clean, boiled and cooled water. Never add extra water or sugar.
• Give small, frequent sips from a spoon, cup or syringe, every few minutes. If the child vomits, wait 10 minutes and continue more slowly.
• After each loose stool, give about 50-100 mL if under 2 years, 100-200 mL if 2-10 years, and as much as wanted if older.
• Make fresh ORS each day, and discard leftover solution after 24 hours.

Breastfed babies should keep breastfeeding, and take ORS in addition.

Step 2: Give zinc

Zinc shortens diarrhoea and lowers the chance of another episode in the next two to three months. The WHO recommends:

• Under 6 months: 10 mg (half a tablet of 20 mg) once daily for 10-14 days
• 6 months and older: 20 mg once daily for 10-14 days

Dissolve the tablet in a little breast milk, ORS or clean water. Continue for the full course even after the diarrhoea stops.

Step 3: Keep feeding

• Continue breastfeeding as often as the baby wants.
• Continue formula at the usual strength. There is usually no need to dilute it or switch to lactose-free milk.
• Older children should keep eating: rice, rice porridge (kanda), banana, boiled potato, bread, dhal soup, boiled egg and well-cooked vegetables. Offer small, frequent meals.
• Avoid sugary drinks, fruit juice, soft drinks and very sweet or fatty foods while the child is ill.
• After diarrhoea stops, give an extra meal each day for a week or two to help recovery.

Signs of dehydration

Mild to moderate: thirsty and eager to drink, restless or irritable, dry mouth, fewer wet nappies, sunken eyes, skin that goes back slowly when pinched, sunken soft spot (fontanelle) in babies.

Severe (emergency): very sleepy or hard to wake, floppy, unable to drink, very sunken eyes, cold hands and feet, skin pinch goes back very slowly, very little or no urine, rapid breathing and weak pulse.

Go to hospital or see a doctor urgently if

• The baby is under 6 months old with watery diarrhoea, or any child is unable to drink or keeps vomiting everything
• There are signs of dehydration that do not improve in a few hours of ORS, or any sign of severe dehydration
• There is blood in the stool, severe abdominal pain or a swollen belly
• Fever of 39 °C or higher, or a child under 3 months with any fever. See fever in children
• Green (bile) vomit
• Diarrhoea lasts more than 7 days, or more than 14 days in any child (persistent diarrhoea)
• The child has a long-term illness, malnutrition or poor immunity
• During dengue season, if a child with fever has vomiting and abdominal pain. See dengue warning signs

What not to do

• Do not give anti-diarrhoea medicines such as loperamide, or anti-vomiting medicines, to young children unless a doctor prescribes them.
• Do not use antibiotics without a doctor's advice.
• Do not withhold food or fluids.
• Do not use herbal or traditional remedies in infants that may contain unsafe ingredients.
• Do not give only plain water, which may lower sodium levels in babies.

Prevention

• Wash hands with soap before preparing food and feeding, and after using the toilet or changing nappies.
• Give safe drinking water (boiled and cooled when unsure), and keep food covered and fresh.
• Breastfeed exclusively for the first six months.
• Clean and sterilise bottles, or avoid bottle feeding.
• Use latrines or toilets and dispose of nappies safely.
• Vaccination: rotavirus vaccine protects against severe diarrhoea where available, and measles vaccination prevents complicated diarrhoea. Ask your doctor about vaccines (see childhood vaccination).

When to see a doctor

See your doctor if your child's diarrhoea lasts more than a few days, if you are worried about dehydration, or if the child is very young. Trust your instincts: if a child looks very unwell, get help immediately.

References

• World Health Organization: diarrhoeal disease fact sheet and recommendations on ORS and zinc
• UNICEF/WHO: diarrhoea, the forgotten killer
• NICE guideline CG84: diarrhoea and vomiting caused by gastroenteritis in under 5s
• Sri Lanka Ministry of Health, Family Health Bureau: child health guidance