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IAP Guidelines 2006 on hospital based management of severely malnourished children (adapted from the WHO guidelines).
Indian Pediatrics. 2007 Jun 17; 44(6):443-461.Malnutrition in children is widely prevalent in India. It is estimated that 57 million children are underweight (moderate and severe). More than 50% of deaths in 0-4 years are associated with malnutrition. The median case fatality rate is approximately 23.5% in severe malnutrition, reaching 50% in edematous malnutrition. There is a need for standardized protocol-based management to improve the outcome of severely malnourished children. In 2006, Indian Academy of Pediatrics undertook the task of developing guidelines for the management of severely malnourished children based on adaptation from the WHO guidelines. We summarize below the revised consensus recommendations (and wherever relevant the rationale) of the group. (excerpt)
Journal of the Indian Medical Association. 2006 May; 104(5): p..Acute diarrhoeal diseases rank second amongst all infectious diseases as a killer in children below 5 years of age worldwide. Globally, 1.3 billion episodes occur annually, with an average of 2-3 episodes per child per year. The important aetiologic agents of diarrhoea and the guidelines for management are discussed. Management of acute diarrhoea is entirely based on clinical presentation of the cases. It includes assessment of the degree of dehydration clinically, rehydration therapy, feeding during diarrhoea, use of antibiotic(s) in selected cases, micronutrient supplementation and use of probiotics. Assessment of the degree of dehydration should be done following the WHO guidelines. Dehydration can be managed with oral rehydration salt (ORS) solution or intravenous fluids. Recently WHO has recommended a hypo-osmolar ORS solution for the treatment of all cases of acute diarrhoea including cholera. Feeding during and after diarrhoea (for at least 2-3 weeks) prevents malnutrition and growth retardation. Antibiotic therapy is not recommended for the treatment of diarrhoea routinely. Only cases of severe cholera and bloody diarrhoea (presumably shigellosis) should be treated with a suitable antibiotic. Pilot studies in several countries have shown that zinc supplementation during diarrhoea reduces the severity and duration of the disease as well as antidiarrhoeal and antimicrobial use rate. Probiotics may offer a safe intervention in acute infectious diarrhoea to reduce the duration and severity of the illness. (author's)
Geneva, Switzerland, WHO, Programme for the Control of Diarrhoeal Diseases, 1994. 13 p. (CDD/93.2)Why was Advising Mothers produced? Every child that is seen at a health facility with mild diarrhoea, and every dehydrated child that has been successfully treated at the facility, will be sent home to follow Plan A of the WHO/CDD Diarrhoea Management Chart, Case Management in the Home (give increased fluids, continue feeding, and seek medical care when needed). Unlike many other treatments, which are provided by the health worker, case management in the home is entirely the responsibility of the mother or other child caretaker. If correctly carried out, it can have a significant impact on the health of the child. How well the mother carries it out depends partly on how well the health worker advises her. Advising a mother on home case management is often the last activity carried out during a consultation, and often the least well done. The advice and the manner in which it is given are often not sufficient to enable the mother to understand and have confidence in her ability to care for her child's diarrhoea. There are many reasons for this: the health facility may be crowded, a health worker may have little time, and it is not always clear just how to advise the mother. When assessing and treating a child with diarrhoea at a health facility, the health worker should follow the same, systematic approach with every child: "Look, Ask, Feel, Decide, Treat." (excerpt)
Geneva, Switzerland, WHO, Programme for the Control of Diarrhoeal Diseases, 1994. 21 p. (WHO/CDD/94.49; CDD/93.1)Advising a mother on home case management is often the last activity carried out during a consultation, and often the least well done. The advice and the manner in which it is given are often not sufficient to enable the mother to understand and have confidence in her ability to care for her child's diarrhoea. There are many reasons for this: the health facility may be crowded, a health worker may have little time, and it is not always clear just how to advise the mother. When you assess and treat a child with diarrhoea at a health facility, there is a systematic approach which allows you to follow the same process each time: "Look, Ask, Feel, Decide, Treat." Advising a mother on how to care for the child at home may seem like a less structured activity; it is definitely one which calls for good judgement and understanding on your part. The purpose of this guide is to help you to improve this activity, by teaching a process which will allow you correctly and effectively to advise mothers on home case management. The process should also make it easier for mothers to remember the advice you give. The guide is to be used during a case management training course, or by health workers already trained in case management. (excerpt)
Geneva, Switzerland, WHO, 2004 Jan. 118 p. (Integrated Management of Adolescent and Adult Illness [IMAI] No. 1; WHO/CDS/IMAI/2004.1)The IMAI guidelines are aimed at first-level facility health workers and lay providers in low-resource settings. These health workers and lay providers may be working in a health centre or as part of a clinical team at the district clinic. The clinical guidelines have been simplified and systematized so that they can be used by nurses, clinical aids, and other multi-purpose health workers, working in good communication with a supervising MD/MO at the district clinic. Acute Care presents a syndromic approach to the most common adult illnesses including most opportunistic infections. Instructions are provided so the health worker knows which patients can be managed at the first-level facility and which require referral to the district hospital or further assessment by a more senior clinician. Preparing first-level facility health workers to treat the common, less severe opportunistic infections will allow them to stabilize many clinical stage 3 and 4 patients prior to ARV therapy without referral to the district. (excerpt)
Reduced osmolarity ORS more effective than standard WHO solution for treating acute diarrhea in children.
Global HealthLink. 2001 Nov-Dec; (112):16.According to UNICEF, diarrhea kills 8,000 children a day and remains one of the major killers of children under five globally. As dehydration is the main complication of diarrhea, treatment focuses upon rehydration through fluid replacement. Intravenous fluids were commonly used until the 1960s when ORS was developed as an alternative treatment. Today, ORS provides an inexpensive way to treat dehydration. The simple combination of sugar and salt effectively enhances fluid absorption in the small intestine. Currently, the World Health Organization (WHO) recommends a standard formulation of glucose-based ORS solution (90 mmol/l of sodium and 11 1 mmol/l of glucose with a total osmolarity of 31 1 mmol/l) for children with diarrhea. However, recent studies suggest that this formula may not be optimal, as increased glucose and sodium concentrations reduce fluid absorption due to higher osmotic loads. Based on these findings, controlled trials were conducted to evaluate the clinical effects of reduced osmolarity ORS (total osmolarity <250 mmol/l with reduced sodium) compared with standard WHO ORS. (excerpt)
Geneva, Switzerland, WHO, 2004. 7 p. (WHO/FCH/CAH/04.7; UNICEF/PD/Diarrhoea/01)Though the mortality rate for children under five suffering from acute diarrhoea has fallen from 4.5 million deaths annually in 1979 to 1.6 million deaths in 2002, acute diarrhoea continues to exact a high toll on children in developing countries. Oral rehydration salts (ORS) and oral rehydration therapy (ORT), adopted by UNICEF and WHO in the late 1970s, have been successful in helping manage diarrhoea among children. It is estimated that in the 1990s, more than 1 million deaths related to diarrhoea may have been prevented each year, largely attributable to the promotion and use of these therapies. Today, however, there are indications that in some countries knowledge and use of appropriate home therapies to successfully manage diarrhoea, including ORT, may be declining. (excerpt)