Unit 4 - Treatment of Diarrhoea at Home
Medical Education: Teaching Medical Students about Diarrhoeal Diseases
TREATING DIARRHOEA AT HOME - TREATMENT PLAN A
Give the child more
fluids than usual
What fluids to give
How much fluid and how often
Give the child plenty of food
What foods to give
How much food and
Antidiarrhoeal drugs, antiemetics and antibiotics
treating diarrhoea at home
When to take the child to a health worker
TALKING WITH MOTHERS ABOUT HOME TREATMENT
demonstrations, and practice
Asking checking questions
illusrated instruction leaflets
Giving encouragement and assistance
UNIT 4 - TREATMENT OF DIARRHOEA AT HOME
Home treatment is an essential part of the correct management of acute
diarrhoea. This is because diarrhoea begins at home and children seen at a
health facility will usually continue to have diarrhoea after returning home.
Children must receive proper treatment at home if dehydration and nutritional
damage are to be prevented. Mothers who understand home treatment should begin
it before seeking medical care. When "early home therapy" is given,
dehydration and nutritional damage can often be prevented.
prepare and give appropriate fluids for ORT;
Each mother whose child is treated for acute diarrhoea at a health facility
should be taught how to continue the treatment of her child at home, and how to
give early home therapy for future episodes of diarrhoea. When properly
informed, mothers should be able to:
feed a child with diarrhoea correctly; and
recognize when a child should be taken to a health worker.
The steps involved in home therapy,
the information and skills that mothers need to carry it out, and ways in which
these can be effectively communicated to them, are the subjects of this unit.
DIARRHOEA AT HOME - TREATMENT PLAN A
The management of acute watery diarrhoea at home (Treatment Plan A) is
outlined in Figure 4.1. This plan should be used to treat children:
who have been seen at a health facility and found to have no signs of
who have been treated at a health facility with Treatment Plans B or C
until dehydration is corrected; or
who have recently developed diarrhoea, but have not visited a health
The three basic rules of
home therapy are considered below. These are:
give the child more fluids than usual, to prevent dehydration;
give the child plenty of food, to prevent undernutrition; and
take the child to a health facility if the diarrhoea does not get better,
or if signs of dehydration or another serious illness develop.
Give the child more fluids than
Children with diarrhoea need more fluid than usual to replace that being lost
in diarrhoeal stools and vomit. If suitable fluids are given in adequate volumes
soon after diarrhoea starts, dehydration can often be prevented.
What fluids to give
Fluids that should be used at home to prevent dehydration include
"recommended home fluids", certain other drinks usually available in the home,
and in some instances ORS solution. Many countries have recommended specific
home fluids for use in ORT; these are usually food-based drinks, such as
undiluted cereal gruel, or sugar-salt solution (SSS). These fluids are suitable
for home treatment of most children with diarrhoea. However, for patients who
have been treated for dehydration at a health facility using Treatment Plans B
or C, ORS solution should be used (see Unit 5). Some countries also advise the
use of ORS solution for home treatment of all patients who are seen at a health
facility and found not to be dehydrated, or for early home therapy of
Safe. In particular, it should not be hyperosmolar or contain too
much salt. The risk of hyperosmolarity is reduced in solutions that use a cooked
starch, such as rice powder, rather than sucrose as the source of glucose.
The appropriate composition of home fluids is considered in Unit 2. The main
points to remember are that a home fluid should be:
Effective. This is most likely if the concentrations of salt and
starch (or sugar) in the fluid are in the ranges described in Unit 2. The molar
ratio of glucose (derived from starch or sugar) and sodium should be at least
Easy to prepare. The recipe should not be complicated and its
preparation should not require much work or time. The required ingredients and
measuring utensils should be readily available and inexpensive.
Acceptable. The fluid should be one that the mother is willing to
give in large volumes to a child with diarrhoea and that the child will readily
Fluids suitable for home therapy
Food-based fluids. Examples of food-based fluids are gruels made
by boiling ground or powdered cereals (the gruel should be thick but drinkable),
rice water or water in which other cereals have been cooked, home-made soups,
and yoghurt-like drinks. These can either be prepared in a traditional way or a
traditional recipe can be slightly modified, for example, by changing the amount
of water used or adding a small amount of salt (see Unit 2, Table 2.3). However,
such modifications may increase the risk of error.
Salt-sugar solution (SSS). When properly prepared and given in
sufficient volume, SSS is both safe and effective. However, the preparation of
SSS requires three correct measurements - sugar, salt, and water - and mothers
frequently have difficulty in remembering the recipe or in preparing SSS
correctly; this often results in solutions that are hyperosmolar and unsafe.
Also, sugar or salt may be unavailable. For these reasons, many governments now
recommend food-based fluids that do not contain sucrose, do not involve a
special recipe, and are less likely to be unsafe.
Water. Although water provides no salt or source of glucose, it is
universally available and the idea of giving large volumes to a child with
diarrhoea is generally acceptable. Moreover, water is rapidly absorbed from the
intestine and, when given with a diet that contains cooked cereals and some
salt, would be adequate treatment for the majority of children with diarrhoea
who are not dehydrated.
ORS solution. Although not usually considered a "home fluid", ORS
solution can be used in the home to prevent dehydration. ORS packets may be
dispensed at health facilities for use at home, both to treat patients who have
not become dehydrated and to continue the treatment of patients who have been
rehydrated at the facility. ORS packets may also be available commercially for
use in early home therapy. However, some commercial glucose-electrolyte products
have compositions which differ appreciably from ORS and may be less
How much fluid and how often
Provide more fluid than usual. The general rule is to give the child as much
fluid as he or she wants and to continue using ORT until diarrhoea stops.
Remember that a child younger than 2 years cannot ask for something to drink;
however, irritability and fussy behaviour are often signs of thirst. Young
children must be offered fluids to determine whether they are thirsty and want
to drink. When a child no longer accepts fluid, it is usually because enough has
been taken to replace the losses caused by diarrhoea. Infants should be allowed
to breast-feed as often and as long as they want.
The following is a general guide for the amount of fluid to be given at home
after each loose stool:
Show the mother how to measure the
approximate amount of fluid to be given after each loose stool using a cup or
some other container available to her at home (or that she can take home).
Explain that the fluid should be given by teaspoon to children under 2 years of
age: a teaspoonful every 1-2 minutes. Feeding bottles should not be used.
Older children should take the fluid directly from a cup, by frequent sips. If
vomiting occurs, the mother should stop giving the fluid for 10 minutes and then
start again, but give it more slowly, e.g., a spoonful every 2-3 minutes. If ORS solution is to be used at home, show the mother how to measure the
correct amount of water, using the type of container available to her at home,
and then how to mix the solution. Then give her enough packets to last two days.
This should be enough to provide 500, 1000, or 2000 ml/day for children aged
less than 2 years, 2 up to 10 years, and 10 years or older and adults,
respectively. When providing ORS packets, explain to the mother that the
entire packet must be mixed at one time and that any ORS solution unused
after 24 hours must be thrown away. Thus, if a packet makes one litre of
solution, a child requiring 500 ml/day would need two packets, one for each day.
If diarrhoea continues after the ORS packets have been used up, the mother
should give the child a recommended home fluid, such as undiluted cereal gruel,
or water; or return to the health facility for more ORS packets.
- children under 2 years: 50-100 ml
- children aged 2 up to 10 years: 100-200 ml
- children 10 years of age or older and adults should take as much as they
Give the child plenty of food
What foods to give
Breast-feeding should be continued without interruption. For infants under 6
months of age who normally take formula or cow's milk (and are not yet taking
soft foods), milk should be given at half strength (by diluting it with an equal
amount of clean water) for two days. After two days, the usual formula or milk
should be given. For other infants and children, the usual cow's milk should be
given throughout the illness.
Children with diarrhoea who are 6 months of age or older (and younger infants
who have already begun to take soft foods) should also be given soft or
semi-solid weaning foods. In general, such foods should provide at least half of
the energy in the diet. Guidelines concerning the type of foods to be given are
shown in Figure 4.1 and discussed in detail in Unit 7.
How much food and how often
During diarrhoea, give the child as much food as he or she wants. Offer food
every 3-4 hours (six times a day). Small, frequent feedings are tolerated better
than large feedings given less frequently. Many children have anorexia; they
need to be coaxed to eat.
After the diarrhoea has stopped, give the child at least one more meal than
usual each day for two weeks, using the same energy-rich foods that were given
during diarrhoea; undernourished children should follow this same regimen for an
even longer period (see Unit 7). The child should continue to receive these food
mixtures as his or her regular diet, even after extra meals are no longer
Antidiarrhoeal drugs, antiemetics and antibiotics
A wide variety of drugs or combinations of drugs is sold for the treatment of
acute diarrhoea and vomiting. "Antidiarrhoeal" drugs include: antimotility
agents (e.g., loperamide, diphenoxylate, codeine, tincture of opium), adsorbents
(e.g., kaolin, attapulgite, smectite), live bacterial cultures (e.g.,
Lactobacillus, Streptococcus faecium), and charcoal. Antiemetics
include phenergan and chlorpromazine. None of these has proved to have
practical benefits for children with acute diarrhoea, and some may have
dangerous side effects. These drugs should never be given to children
below 5 years of age.
Antibiotics also should not be used routinely; they are of benefit
only to children with dysentery or suspected cholera (see Units 5 and 6).
Antiparasitic drugs are rarely indicated; their use is also described in
The overuse of antidiarrhoeal and antiemetic drugs, antibiotics and
antiparasitic agents often delays the initiation of ORT or a visit to the health
facility to seek help; it also consumes precious financial resources of the
Problems in treating diarrhoea at home
The mother may encounter a variety of problems in treating her child with
diarrhoea at home. Most of these can be avoided or solved by ensuring that she
understands the importance of home treatment, is able to carry it out, knows
what difficulties to expect, and receives constructive help and encouragement
when problems arise. Table 4.1 describes some of the problems that are
encountered most frequently and possible ways of solving or preventing them.
When to take the child to a health worker
The mother should be taught to watch for signs of worsening diarrhoea,
dehydration, or any other serious problem. Symptoms the mother can recognize
which indicate that diarrhoea is worsening or that dehydration is developing
the passage of many watery stools;
increased thirst; and
failure to eat or drink normally.
Children with dehydration may also be
irritable and show no interest in playing. The mother should be instructed to
bring her child to a health facility if the diarrhoea does not improve after
three days, or if any of the signs described above appear. She should also bring
the child if other problems develop, such as:
blood in the stool.
TALKING WITH MOTHERS
ABOUT HOME TREATMENT
Effective home treatment of diarrhoea can be given only by the child's mother
(or other caretaker). It is she who must prepare the oral fluid and give it
correctly, provide nutritious, well-prepared foods, and decide when the child
needs to return to the treatment centre. The mother can only do these tasks
correctly if she understands clearly what needs to be done and how to do it. The
best opportunity for a mother to learn about home treatment of diarrhoea is when
she brings her child to the treatment centre because the child has diarrhoea.
Unfortunately, this opportunity is often lost because doctors or health workers
do not communicate well with mothers; as a result, mothers frequently return
home without the understanding needed to continue treating their children
There are a number of reasons why doctors tend to communicate poorly with
mothers. For example, doctors have a "scientific" perspective and often speak in
technical terms, they are authority figures, they are busy and have little time
to spend with each mother, and they often "educate" mothers by telling them what
to do. In contrast, the mother's perspective is usually traditional and
unscientific, she does not understand technical terms, she may be easily
frightened by authority figures, and she learns best through demonstration and
practice in an atmosphere of patience, encouragement, and understanding.
A doctor who cannot communicate well with mothers will be ineffective in
preparing them to carry out home treatment. To improve their communications with
mothers, doctors must learn to:
o listen to the mother and take her concerns seriously;
speak to her in terms she can understand;
be supportive and encouraging, giving her praise and help rather than
use teaching methods that require her active participation.
In real-life situations, doctors are
rarely able to spend the time required to teach each mother how to carry out
home treatment of diarrhoea: this must usually be done by other health workers.
However, doctors must supervise this activity and this can only be done
successfully if they themselves understand the principles of effective
Some specific approaches that can be taken to improve communications with
mothers and, especially, to help them to learn how to treat diarrhoea at home
are considered below.
Using examples, demonstrations, and practice
Giving clear instructions on how to carry out home treatment is important,
but represents only the first step in the training of mothers. Combining
instruction with the use of examples, demonstrations, and practice can greatly
facilitate the learning process. For instance, a health worker teaching a mother
how to carry out ORT at home can make the message clearer by showing her a
half-cup (100 ml) of ORS solution (with a line marking the appropriate level)
while instructing her to give her child that amount after each loose stool. Or,
a mother could be encouraged to watch another mother giving an infant ORS
solution with a spoon so that she can see how to hold her child and how
frequently to give the spoonfuls of fluid. She should then practise giving ORS
solution to her own child, with guidance. As she tries, the health worker can
see which parts of the task are difficult, and can explain or demonstrate how
they should be done. Once the mother has performed the task correctly, the
health worker can be confident that she has learned it.
Showing pictures: use a drawing or a poster of a mother breast-feeding
while discussing the importance of this practice for an infant's health.
Examples, demonstrations, and practice may include:
Using specific names or instructions appropriate to local circumstances
(instead of stating a general rule): advise the mother to give "banana or green
coconut water" (which are rich in potassium), instead of simply telling her to
give her child "fruit"; explain that she should feed her child "six times a day"
instead of "frequently" or "more often than usual".
Demonstrating a practice: show the mother how to measure the correct amount
of water for preparing ORS solution, using a container of a type that is
available to her at home.
Showing an object: show the mother an infant feeding bottle when explaining
that this should not be used for giving milk or other fluids to her
infant. Show a cup and spoon for comparison.
Telling a story: a story of how another mother dealt with problems that
arose while treating her child at home can help to prepare a mother for
difficulties she may have to face. Stress that giving food and fluids will keep
the baby strong and help the baby to continue growing, even while he or she has
Practising a procedure: let the mother practice preparing and giving ORS
solution to her child using a cup and spoon.
Asking checking questions
Asking simple checking questions is a very effective way of confirming what a
mother has learned about home therapy. For example, after explaining how to
treat the child's diarrhoea at home, the doctor might ask: "Describe how you
would prepare the drink for Ana" or "Tell me the signs that mean you should
bring Ana back to me".
Three-year-old Mo was treated for dehydration and is now ready to go home.
The nurse has talked to his mother about what she should do at home to care for
A checking question should be phrased in such a way that the answer cannot be
just "yes" or "no". For example, it is not effective to ask: "Do you understand
the signs that mean you should bring Ana back to see me?". The mother is likely
to answer "yes", whether she understands them or not.
If a nurse or other staff member is given the responsibility of teaching
mothers, checking questions can be used to monitor their effectiveness. For
The doctor should not ask the mother, "Did the nurse explain to you how to
mix ORS?", or "Do you know how to mix ORS?", since the mother would probably be
afraid to answer "no". Instead, the doctor should ask "How much water will you
mix with that ORS packet?", "How much of the solution will you give to Mo?",
"How long did the nurse tell you to continue giving the ORS?", "What else will
you give him to eat and drink?", "When will you bring Mo back to see the nurse
Providing illustrated instruction
A specifically prepared pamphlet (or card) can greatly improve communication
with the mother. It should summarize the important elements of caring for a
child with diarrhoea at home, and should have words and pictures that illustrate
these points. When a pamphlet is being developed, it should be carefully tested
to determine whether mothers understand its messages. An example of the possible
content and layout of a mother's pamphlet is shown in Figure 4.2.
There are many reasons why a mother's pamphlet is useful. For example:
- The pamphlet will simplify the task of training health workers in the
messages to tell mothers.
- Referring to the pamphlet will bring to mind the main points to be covered
when giving instructions to mothers.
- When she is at home, the pamphlet will remind the mother of what she was
taught at the treatment facility, and support her if other family members should
disagree with her treatment.
- Mothers who cannot read will find the pictures helpful; otherwise they can
have a family member or neighbour read out the written instructions, and thus
other people will learn from the pamphlet too.
- If the mother keeps the pamphlet, the next time her child has diarrhoea she
can refer to it and remind herself what to do.
- The mother will appreciate being given something during her visit,
especially if she is not given a medicine.
Give encouragement and
Using examples, demonstrations, and a mother's pamphlet and asking checking
questions can help to ensure that a mother understands home therapy, but they do
not guarantee that she will practise it. There are a number of reasons why a
mother may not carry out the instructions received at a health facility. For
Home treatment may seem to be unrewarding:
she may expect ORT to stop the diarrhoea, and be discouraged when it does
ORT may appear to have undesirable effects, such as making the child vomit
home treatment is time-consuming and may be difficult, e.g., coaxing a sick
child to eat can be frustrating.
The necessary materials for ORT are not available: she may not have salt in
her house or a container to measure water.
These problems can best be overcome
by giving the mother encouragement and support. Several approaches should be
Emphasize the positive: Explain that ORT will make the child stronger and
that continued feeding will help it to grow. Encourage the mother to look at the
whole child, not just its stools. She should note that, after giving ORT and
feeding, the child is usually less fussy and more contented. Explain that, so
long as this is the case, her treatment is successful and the diarrhoea will
Give praise: Praise is essential in building up a mother's confidence that
she can treat her child successfully at home. Opportunities to praise the mother
occur when she answers a checking question correctly, performs a practical task
correctly (even if guidance was provided), or replies correctly on aspects of
diarrhoea management at home, such as continued feeding.
Show interest: Discuss with the mother how she will practise home therapy.
Ask, for example, "what foods will you give your child?". When the mother
answers, confirm that the food is suitable, or suggest another choice. Also
discuss how she will prepare the food. By showing interest, the health worker
will reinforce the mother's commitment to carry out treatment recommendations.
Assist with problems. Ask questions to determine whether the mother has the
required materials for home therapy, e.g., a container to measure water. If this
is not available, suggest how one might be obtained.
Avoid giving too much information at one time. Teach the mother only what
she can remember and use. It is most important that mothers understand what
fluids and food to give at home, and what signs mean they should bring the child
back to the health centre. Messages on how to prevent diarrhoea should usually
be reserved for mothers who already know how to treat their child at home.
1. A mother has brought her 11-month-old daughter to a health centre
because the child has diarrhoea. The mother is breast-feeding the child. She
says she lives far from the health centre and might not be able to come back for
several days, even if the child gets worse. The mother mentions that she usually
gives her child weak tea when she has diarrhoea, but has heard that the health
centre has something better.
The health worker assesses the child for signs of dehydration, but finds
none. He decides to treat the child according to Treatment Plan A. Which of the
following steps should the health worker take? (There may be more than one
2. Which of the following fluids
are acceptable for ORT at home? (There may be more than one correct answer.)
- Advise the mother to continue breast-feeding the child as often and as
long as the child wants.
- Give the mother enough ORS packets to last two days. Show her how to mix
ORS solution and how much to give after each loose stool.
- Advise the mother to give her daughter rice with added vegetable oil,
well-cooked vegetables, and, if possible, some well-ground meat, in addition to
breast milk. These should be given in small feedings, at last six times a day.
- Explain that, if the diarrhoea continues after the ORS has been used up,
she should give undiluted cereal gruel in its place, while continuing to give
breast milk and other foods.
- Explain that if the diarrhoea continues for 3-4 days, she should
discontinue breast-feeding until it stops.
3. Harish, aged 9 months, has
had watery diarrhoea for two days. He has been weaned and eats a mixed diet of
rice, pulses, vegetables, and cow's milk. During the illness, however, his
mother has given him only soft, boiled rice and tea. She has also obtained a
medicine from the chemist which is given to stop the diarrhoea. When seen at the
health centre, Harish has no signs of dehydration and is well nourished. Which
of the following recommendations are appropriate? (There may be more than one
- Cow's milk or formula
- Rice water
- A commercial fruit drink
- An undiluted cereal gruel
- A soft drink
4. Juma, a 14-month-old boy, has
had diarrhoea for three days and has been assessed as having some dehydration.
He has been treated with ORS solution at the clinic and is now ready to go home.
The doctor wishes to do everything possible to ensure that Juma will be well
treated at home and will not need to return to the clinic. Which of the
following steps would be appropriate? (There may be more than one correct
- The mother should be encouraged to give Harish extra fluids at home, for
example some soup or water after each watery stool.
- The medication obtained from the chemist should be stopped.
- Harish should resume his normal diet; however his milk should be diluted
with an equal volume of water for the next two days.
- Harish should be brought back to the clinic if he does not eat or drink
normally at home, or if he starts to pass many large watery stools.
5. If a mother is to be
successful in carrying out ORT at home, it is important that she learn how this
is done. Which one of the following methods is most effective in teaching
mothers how to give ORT?
- Give Juma's mother enough ORS packets for two days, show her how to mix
ORS solution, and explain how much should be given after each loose stool.
- Give Juma an antibiotic to help stop his diarrhoea.
- Explain to Juma's mother the importance of continuing to give Juma plenty
- Teach Juma's mother the signs that mean she should bring him back to the
- The doctor explains how it is done.
- Posters on the clinic walls show how ORT is given.
- A nurse or health worker demonstrates ORT.
- The mother practises giving ORT with the guidance of a health worker.
- The mother is given an illustrated pamphlet that explains how ORT is
1. A-D are all correct for Plan A.
2. B, D. Commercial fruit drinks and soft drinks are often hyperosmolar
owing to their high sugar content. They also contain little or no sodium. If
given to replace stool losses they could worsen the situation by causing osmotic
3. A, B, D. Harish should resume his normal diet. However, as he is
over 6 months of age, his milk feeds need not be diluted. Thus, C is not
4. A, C, D. Antibiotics are not helpful in most episodes of diarrhoea. They
should be used only for cases of dysentery and suspected cases of cholera.
5. D. All of the described methods are helpful, but the most effective
is letting the mother practise ORT under the supervision of a health worker.
updated: 23 April, 2014