CDI Module 18: Community Management
of Diarrhea
©Jhpiego Corporation
The Johns Hopkins University
A Training Program on CommunityDirected Intervention (CDI) to Improve
Access to Essential Health Services
Module 18 Objectives
By the end of this module, learners will:
 State the burden of diarrheal illnesses
 Define types of diarrheal diseases
 Describe steps in recognizing and classifying
diarrhea
 List causes of diarrhea and ways to prevent diarrhea
 Describe management of diarrhea
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Why We Cannot Ignore Diarrhea
in Efforts to Control Malaria
Diarrheal disease:
 Is a leading cause of death in children under five
years old
 Is both preventable and treatable
 Kills 1.5 million children every year
Globally, about two billion cases of diarrheal
disease occur every year
Source: WHO Fact sheet N°330, August 2009
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More Reasons We Cannot Ignore Diarrhea
in Efforts to Control Malaria
Diarrheal disease:
 Mainly affects children under two years old
 Is more common in babies under six months of
age who are on infant feeding formula or cow’s
milk
 Is a leading cause of malnutrition in children
under five years old
Any effort to improve overall child survival must
make reducing diarrhea’s death toll a priority
Source: WHO Fact sheet N°330, August 2009
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Global Annual Child Deaths
4%
5%
23%
10%
Deaths
associated
with
Malnutrition
= 54%
25%
15%
HIV/AIDS
Measles
Malaria
Diarrhea
ARI*
Others
Perinatal
18%
*Acute respiratory infection
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The Diarrhea Burden
 Diarrhea is defined as the passage of three or
more loose or watery stools in a 24-hour period
 With the use of oral rehydration therapy (ORT),
the annual death rate for children under five
suffering from acute diarrhea has fallen over the
years but:
 Acute diarrhea continues to exact a high toll of over
one million child deaths annually in developing
countries
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Recognizing Diarrhea:
Stooling and Dehydration
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Recognizing Diarrhea
 Mothers usually know when their children have
diarrhea and may use a local word for diarrhea
 They may say that the child has loose or watery
stools—but frequent passage of normal, formed
stools is not diarrhea
 Diarrhea is defined as passage of three or more
loose or watery stools in a 24-hour period
 Diarrhea kills a child through dehydration—the
loss of too much fluid
8
Three Classifications of Diarrhea
Acute Diarrhea
 Diarrhea that has lasted less than 14 days
 Acute diarrhea is a major cause of dehydration and
leads to death among children under five years of
age
Persistent Diarrhea
 Diarrhea that lasts 14 days or more
Dysentery
 Blood in the stool, with or without mucus
 Dysentery is commonly caused by Shigella bacteria
in children under five years of age
All three forms are dangerous
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Most Important Signs
 The child is lethargic or unconscious—general
danger sign
 The child is restless and irritable all the time, or
every time she or he is touched and handled
 An infant or child who is calm when breastfeeding
but becomes restless and irritable when he or she
stops breastfeeding, is classified as "restless and
irritable”
 Many children are upset just because they are in the
clinic
 Usually these children can be consoled and calmed
 These children are not classified as "restless and irritable”
10
Danger Signs and Symptoms
 If the child has two or
more of the following
signs, he or she is
classified as having
SOME DEHYDRATION:
 Is restless and irritable
 Has sunken eyes
 Is thirsty (drinks eagerly
and clearly wants to drink)
 Exhibits a skin pinch that
goes back slowly
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Causes and Prevention
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Diarrhea Is Caused by Dirty
Water, Food and Hands
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Preventing Diarrhea
Preventing children from developing diarrhea in the
first place is essential for reducing child deaths
Key prevention measures include:
 Promoting adequate nutrition (including breastfeeding
and zinc intake)
 Raising immunization rates
 Reducing indoor and outdoor access to oral fecal matter
Recent research also suggests that handwashing
plays a role in reducing the incidence of diarrhea
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Preventive Measures: Breastfeeding, Handwashing with Soap
and Reduced Access to Oral Fecal Matter
15
Case Management
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Results of Past Efforts
Diarrhea oral rehydration solution (ORS) and
increased fluids have helped but:
 Only 26% of children <5 years of age with diarrhea
received ORS packets or pre-packaged liquid
(Demographic and Health Survey [DHS] 2008)
 Only 25% of children <5 years of age with diarrhea
received oral rehydration therapy (ORT) or
increased fluids with continued feeding, a slight
decrease from 28% in 2003 (Millennium
Development Goal [MDG] Countdown)
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For Common Diarrhea, Drugs
Are Generally NOT the Right Choice of Treatment
 Generally, if the child continues to receive plenty
of fluids and food to replace what is lost through
stooling, diarrhea will resolve itself
 Unless we really know that the diarrhea is
caused by a bacterium like Shigella, treatment
with antibiotics can make it worse
 Treatment with medicines like kaolin slow down
the diarrhea, but also keep the germs in the gut
 So, it is better to keep giving fluids, not drugs
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ORS/ORT: Fluids and Food
Tell us some of the local foods
and fluids that can help children
with diarrhea
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Sources of Zinc
Zinc reduces stooling
and is found in foods
and tablets.
Food (and tablets) with zinc
Diarrhea depletes the body’s stores
of zinc
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Case Management Steps for
the Community-Directed Distributor (CDD)
 Ask about the frequency and nature of stooling
 If one of the three types of diarrhea is recognized,
commence case management
 Mix and begin using ORS
 Explain the need to continue breastfeeding in a child of
appropriate age
 Review importance of continued feeding and fluids by asking
caregiver the child’s normal diet and suggesting additional items
for increasing zinc and fluids
 Explain dangers of drugs and how ORS works
 Refer any child who is severely dehydrated immediately
 Explain preventive measures like handwashing and
feeding with clean cups, hands and utensils
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Both ORS and Zinc Are Needed
Facilitators of CDD
training should use the
following:
 Role play to help in
recognizing diarrhea
 Demonstration of
ORS preparation with
re-demonstration
 Role play of
counseling about
prevention
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Summary/Discussion
 Diarrhea is a major killer of children and also
leads to malnutrition, which kills more children
 Please tell us how to recognize a child with
diarrhea
 Please remind us of the major causes of
diarrhea
 List the different ways to prevent diarrhea
 Explain the best case management steps for
diarrhea
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