Diarrhoea in children

Diarrhoea means passing three or more loose or watery stools in a day, or passing them more often than is normal for that child. Most episodes are acute and watery, and last from a few hours to a few days. Diarrhoea with blood in it is called dysentery, and diarrhoea lasting fourteen days or more is called persistent.

The illness itself usually passes. What harms a child is the water and salts lost in the stools, and the meals missed while it lasts. Rehydration, zinc and continued feeding answer all three.

Along with the loose motions there is often tummy pain or cramps, a fever, poor appetite and vomiting. In children the motions usually settle within five to seven days and the vomiting within a day or two.

The signs that matter most are the signs of fluid loss. Early on a child is restless or irritable and drinks thirstily, with fewer wet nappies, darker urine and a dry mouth. As more fluid is lost the child becomes sleepy or floppy, the eyes look sunken, there are no tears, and skin gently pinched up on the tummy goes back slowly.

See a doctor within a day or two if the child is restless and thirsty, has fewer wet nappies or dark urine, has a fever with the motions, is under six months old, is losing weight, or if the diarrhoea has gone on for more than a week.

Diarrhoea is usually an infection of the gut. Viruses such as rotavirus and norovirus are the commonest cause in young children. Bacteria such as certain types of E. coli, Salmonella and Shigella, and parasites, also cause it.

The germs travel from stool to mouth: in water that is not safe, in food handled with unwashed hands, from dirty utensils and feeding bottles, and from poor sanitation. Some diarrhoea follows a course of antibiotics or comes from a food the child does not tolerate.

• Drinking water that is not safe, and no safe place to store it
• Poor sanitation and crowded living
• Not being exclusively breastfed in the first six months
• Bottles and utensils that are hard to clean well
• Being under two years old
• Malnutrition, which makes diarrhoea more likely and more severe
• The pre-monsoon and monsoon months, when episodes rise
• Rotavirus vaccine not given

• Dehydration, which is the main reason children become seriously ill
• Loss of body salts, which can affect the heart and the brain
• Malnutrition, because each episode costs a child growth
• Persistent diarrhoea lasting fourteen days or more
• Dysentery, when there is blood in the stools

• Safe drinking water, stored covered and poured rather than dipped into
• Washing hands with soap after the toilet, after changing a nappy and before handling food
• Only breast milk for the first six months, then breastfeeding alongside family food
• Freshly cooked, covered food, and clean utensils and feeding bottles
• Rotavirus vaccination, which is part of the national immunisation schedule
• Use of a toilet, and safe disposal of children's stools
• Keeping ORS packets and zinc tablets at home before they are needed

Diagnosis is mostly a matter of looking at the child. The doctor asks how many stools, whether there is blood, how much the child is drinking and how often they are passing urine, then checks alertness, the eyes, the mouth, the weight and the skin pinch to judge how much fluid has been lost.

Tests are not usually needed. A stool test may be sent if there is blood, if the diarrhoea is persistent, or in an outbreak. Blood tests are done if the child is very dehydrated or drip fluids are needed.

Oral rehydration solution is the main treatment. It is made up exactly as the packet says and given in small sips, often, after every loose stool, and offered again if the child vomits. A child with some dehydration may be kept at the health facility for a few hours to be given ORS under supervision.

Zinc is given every day for 10 to 14 days alongside ORS, and is continued even after the motions have stopped. It shortens the episode, reduces the amount passed, and lowers the chance of another episode in the following months.

Feeding continues throughout. Breastfeeding carries on and is offered more often, formula is made at normal strength, and older children go back to usual food as soon as they will take it, with an extra meal a day for a fortnight afterwards to make up lost growth. Severe dehydration is treated with fluids through a drip. Antibiotics are used only in particular situations, such as dysentery or cholera, and anti-diarrhoeal medicines are not given to children.