1. Diarrhoea and Dehydration Paediatric Palliative Care For Home Based Carers Funded by British High Commission, Pretoria Small Grant Scheme

2. What is Diarrhoea?  Loose or watery stools  Above 12 months of age, more than 3 loose stools per day (Eddleston & Plerini, 1999)  Often accompanied by fever, nausea, vomiting, abdominal pain  May be explosive or foul smelling  May contain blood  May be green Different categories of diarrhoea (WHO):  Acute, watery diarrhoea for 14 days or less  Persistent diarrhoea for longer than 14 days  Dysentery: diarrhoea with blood, with/without fever

3. Remember!  Every child’s stools and stool pattern differ  Ask the care givers what the child’s ‘normal’ stools are like  A young, breast-fed baby may have many soft, watery stools in a day  This is NOT diarrhoea ©TALC

4. Causes of Diarrhoea All images ©TALC  Unhygienic food preparation  Unsafe storage of food  Inadequate hand washing  Antibiotics and other drugs  Malnutrition  No access to clean water  HIV itself

5. ALL Children are at risk…  Dependent on others for good hygiene  Does not know to wash his hands  Puts hands/objects in his mouth as part of his development  Will play in/with anything!  There immune system is still developing

6. Children with HIV Increased risk of Diarrhoea:  More susceptible to infections causing diarrhoea  HIV damages the gut so food is not absorbed properly  Commonly malnourished, increasing severity and frequency of diarrhoea  Multiple drugs are being taken which cause diarrhoea ©TALC

7. Preventing Diarrhoea  Good personal hygiene  Hand washing  Improve access to clean water  Safe, clean preparation of food  Safe storage of food  Sterilisation of feeding implements  Improve sanitation  Good nutrition  Breastfeeding  Safe disposal of soiled materials ©TALC

8. Breaking the Cycle Flies Faeces Fingers Food Cover Food Wash hands before eating and preparing food Bury faeces, use latrine Wash hands after defecation Adapted from Lankester, 2000

9. Effects of Diarrhoea Diarrhoea may cause great discomfort to a child Diarrhoea may also be accompanied by or cause:  fever  abdominal pain ©TALC

10. Effects of Diarrhoea Diarrhoea increases the risk of skin breakdown A child with HIV is then more likely to get skin infections which may be painful and difficult to treat Skin breakdown and infections must be prevented

11. Effects of Diarrhoea  Children with diarrhoea are at risk of dehydration  Children become dehydrated more quickly than adults  May occur over days or very quickly indeed  Dehydration will lead to death if not managed appropriately and quickly ©TALC

12. Getting it Right! All around the world, children with diarrhoea are dying from dehydration because carers:  Stop fluids and food  Do not know what fluids to give  Do not know the signs of dehydration  Do not know how quickly a child becomes dehydrated  Do not act quickly enough  Have not been taught how to make and use ORS  DO not know what to do when the child vomits or refuses to drink

13. How Do I Assess Dehydration? Does the child have Diarrhoea?  Restless, irritable  Sunken eyes  Drinks eagerly, thirsty  Sunken fontanelle  Skin pinch goes back slowly  Dry tongue, no tears ©TALC

14. Signs of Dehydration  Not able to drink/ drinking poorly  Weak, inactive or unconscious  Watery stools  Vomiting  Has small amount of dark urine  Has stopped passing urine ©TALC

16. Plan A: Treat for Diarrhoea at Home Counsel the mother on the 3 Rules of Home Treatment: Give Extra Fluid Continue Feeding When to Return ©TALC

17. Plan A: Give Extra Fluid  As much as the child will take!  Breastfeed frequently and for longer at each feed  If exclusively breast-fed, give SSS in addition to breast milk  If child is not receiving breast milk or is not exclusively breastfed, give one or more of:  Porridge, Amasi (Maas), SSS, ORS ©TALC

18. Plan A: ORS and SSS To make SSS: 1 litre boiled (or clean) water + 8 teaspoons sugar + Half a teaspoon salt ORS Teach the Mother How to mix and Give SSS or ORS Used to prevent dehydrationUsed to correct dehydration and can be life-saving!

19. Plan A: Giving ORS & SSS Show the mother how much fluid to give in addition to the usual fluid intake: Up to 2 Years: 50 – 100 ml after each loose stool 2 Years or more: 100 – 200 ml after each loose stool Tell the mother to:  Give frequent, small sips from a cup  If the child vomits, wait 10 minutes. Then continue, but more slowly  Continue giving extra fluid until the diarrhoea stops

20. Plan A: Continue Feeding A child with diarrhoea loses the nutrients he needs for: Growth, Energy and a Strong immune system Diarrhoea may therefore lead to:  Malnutrition  A weakened immune system  More infections This is particularly worrying for a child with HIV who:  Is normally malnourished  Has a weakened immune system  More likely to get infections ©TALC

21. Plan A: Continue Feeding  It is therefore extremely important to continue feeding a child with diarrhoea  Even if the diarrhoea continues!  DO not be surprised if the child loses weight having been ill with diarrhoea  BUT, it is important to help the child regain that weight by encouraging an extra meal a day for two weeks  Sometimes, a doctor may advise that the child does not taken certain foods ie milk. If the mother has been told this, encourage her to take that advise

22. Plan B: Treat for Some Dehydration with ORS If a child with diarrhoea has been assessed and considered to have some dehydration, the child needs rehydration with ORS Refer to clinic immediately

23. Infection Control Risk of Infection to Others  Others may be infected by the germs causing diarrhoea eg Salmonella  Others may be infected by HIV is diarrhoea contains blood ©TALC

24. Handling Soiled Linen  Wear Gloves  Cut small holes in a plastic bag and line a container with it  Pour Jik 1:10 in to the plastic bag  Put the dirty wound dressing, newspaper etc in to the plastic bag for half an hour  Remove the bag, allowing the fluid to run into the container  Put the plastic bag into a second plastic bag  Dispose of it into a pit toilet or bury it OR  Wear gloves  Place waste in to double plastic bags  Knot bags and bury them or dispose in pit  Wash hands

25. Summary  Children with HIV will experience episodes of diarrhoea  Diarrhoea may resolve itself without drugs  Prevent dehydration using Plan A  Treat dehydration using Plan B and C  Provide nutritious foods throughout  Refer if: a) diarrhoea persists after three days, refer for diagnosis and treatment of underlying cause b) child becomes sicker, develops danger signs You can easily prevent many children from dying!