Health Management

WHO/UNICEF JOINT STATEMENT

CLINICAL MANAGEMENT OF

ACUTE DIARRHOEA

Two recent advances in managing diarrhoeal disease newly formulated oral rehydration

salts (ORS) containing lower concentrations of glucose and salt, and success in using zinc

supplementation can drastically reduce the number of child deaths. The new methods,

used in addition to prevention and treatment of dehydration with appropriate fluids,

breastfeeding, continued feeding and selective use of antibiotics, will reduce the duration

and severity of diarrhoeal episodes and lower their incidence. Families and communities

are key to achieving the goals set for managing the disease by making the new

recommendations routine practice in the home and health facility.

ACUTE DIARRHOEA STILL A 18%

LEADING CAUSE OF CHILD 25%

DEATHS

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

detaicossa shtaeD

2002, acute diarrhoea continues to exact a high toll on

noitirtunlam htiw 15%

children in developing countries.

%45

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

23%

1990s, more than 1 million deaths related to diarrhoea 10%

may have been prevented each year, largely

attributable to the promotion and use of these 5%

4%

therapies. Today, however, there are indications that

Major causes of death among children

in some countries knowledge and use of appropriate

under five in developing countries, 2002

home therapies to successfully manage diarrhoea,

including ORT, may be declining.

Acute respiratory infections HIV/AIDS

THE GOALS

Diarrhoea Perinatal

The revised recommendations will help reduce mortality

Malaria Other

from diarrhoea, in line with global goals that aim to:

Measles

Reduce by one half deaths due to diarrhoea among

children under five by 2010 compared to 2000 Sources: For cause-specific mortality: The World Health Report

( A World Fit for Children, outcome document 2003, WHO, Geneva. For malnutrition: Pelletier, D. L., E. A. Frongillo,

of the UN Special Session on Children) and J. P. Habicht, Epidemiologic evidence for a potentiating effect

of malnutrition on child mortality, American Journal of Public

Health, vol. 83, no. 8, August 1993, pp. 1130-1133.

Reduce by two thirds the mortality rate among

children under five by 2015 compared to 1990 Note: The figures for proportional mortality related to children

(United Nations Millennium Development Goals) under five are currently under review by UNICEF and WHO.

2

JOINT STATEMENT facility. (See the Technical Annex on page 6 for

additional details.)

More than 1.5 million children under five continue to

die each year as a result of acute diarrhoea. The BUILDING ON PAST SUCCESSES

number can be dramatically reduced through critical ORS, ORT and other components of clinical

therapies such as prevention and treatment of management of diarrhoea have made a significant

dehydration with ORS and fluids available in the contribution to reducing deaths from diarrhoea.

home, breastfeeding, continued feeding, selective use However, if the global goals are to be met, there is still

of antibiotics and zinc supplementation for 10 14 days. much to do.

These new recommendations, formulated by UNICEF Family knowledge about diarrhoea must be reinforced

and WHO in collaboration with the United States in areas such as prevention, nutrition, ORT/ORS use,

Agency for International Development (USAID) and zinc supplementation, and when and where to seek

experts worldwide, take into account new research care. Where feasible, families should be encouraged

findings while building on past recommendations. to have ORS ready-to-mix packages and zinc (syrup or

Success in reducing death and illness due to tablet), readily available for use, as needed.

diarrhoea depends on acceptance of the scientific Breastfeeding should continue simultaneously with

basis and benefits of these therapies by governments the administration of appropriate fluids or ORS.

and the medical community. It also depends on

reinforcing family knowledge of prevention and

treatment of diarrhoea, and providing information and

support to underserved families.

PROGRESS AND CHALLENGES

NEW DEVELOPMENTS

Recent scientific advances have informed these

revised recommendations. They are:

Development of an improved formula for ORS

solution with reduced levels of glucose and salt,

which shortens the duration of diarrhoea and the

need for unscheduled intravenous fluids1

Demonstration that zinc supplements given during

an episode of acute diarrhoea reduce the duration

and severity of the episode2, and

Findings that zinc supplementation given for 10 14

days lowers the incidence of diarrhoea in the

following 2 3 months3

Many more lives can be saved if these advances are

used in conjunction with effective home treatment

and use of appropriate health services. To be most

effective, these revised recommendations must

become routine practice both in the home and health

3

RECOMMENDATIONS Provide children with 20 mg per day of zinc

supplementation for 10 14 days (10 mg per day for

The revised recommendations emphasize family and infants under six months old)

community understanding of managing diarrhoea.

When they become routine practice, caretakers will Advise mothers of the need to increase fluids and

act quickly at the first sign of diarrhoea, rather than continue feeding during future episodes.

waiting before treating the child. The aim is that the

recommendations become routine practice both in the Health-care workers treating children for diarrhoea are

home and health-care facility. encouraged to provide caretakers with two 1-litre

packets of the new ORS, for home-use until the

MOTHERS AND OTHER CAREGIVERS SHOULD diarrhoea stops. Caretakers should also be provided

Prevent dehydration through the early administration with enough zinc supplements to continue home

of increased amounts of appropriate fluids available treatment for 10 14 days. Printed material (including

in the home, and ORS solution, if on hand text and illustrations) with advice on preventing and

treating diarrhoea at home should accompany the

Continue feeding (or increase breastfeeding) during, ORS and zinc supplements.

and increase all feeding after the episode

COUNTRIES SHOULD

Recognize the signs of dehydration and take the Develop a 3 5 year plan to reduce mortality rates

child to a health-care provider for ORS or from diarrhoeal diseases

intravenous electrolyte solution, as well as

familiarize themselves with other symptoms Assess progress in controlling diarrhoeal diseases by

requiring medical treatment (e.g., bloody diarrhoea) monitoring usage rates of ORT/ORS, home-based

treatment and zinc supplementation

Provide children with 20 mg per day of zinc

supplementation for 10 14 days (10 mg per day for Using the media and face-to-face communication,

infants under six months old). promote and refine messages on diarrhoea

prevention, home management of diarrhoea and

HEALTH-CARE WORKERS SHOULD4 appropriate care-seeking

Counsel mothers to begin administering suitable

available home fluids immediately upon onset of Prioritize improving the availability of the new ORS

diarrhoea in a child solution and zinc supplements through private and

public channels

Treat dehydration with ORS solution (or with an

intravenous electrolyte solution in cases of severe Craft suitable strategies to educate health-care

dehydration) workers at all levels about using the new ORS and

zinc supplements in treating diarrhoea

Emphasize continued feeding or increased breast-

feeding during, and increased feeding after the Promote the availability of a zinc formulation that is

diarrhoeal episode cost-effective and easily administered to both infants

and children

Use antibiotics only when appropriate, i.e. in the

presence of bloody diarrhoea or shigellosis, and Identify obstacles to the use of ORS, zinc

abstain from administering anti-diarrhoeal drugs supplements and home-based treatments in

managing acute diarrhoea.

4

UNICEF, WHO AND OTHER PARTNERS WILL Supplying new ORS and zinc supplements to

SUPPORT THESE ACTIONS BY countries that cannot manufacture them to quality

Advocating, facilitating and investing resources to standards

ensure country adoption and implementation of

these revised recommendations Helping with communication efforts aimed at

enhancing prevention and management of

Working with governments and the private sector, diarrhoea, including promoting routine use of new

including non-governmental organizations and ORS and zinc supplements.

businesses, to rapidly disseminate these

recommendations

Joy Phumaphi Joe Judd

Assistant Director General Director

Family and Community Health Programme Division

World Health Organization United Nations Children s Fund

Geneva New York

REFERENCES

1. Department of Child and Adolescent Health and Development, World Health Organization, Reduced osmolarity oral rehydration salts

(ORS) formulation Report from a meeting of experts jointly organized by UNICEF and WHO (WHO/FCH/CAH/01.22), New York, 18 July

2001 .

2. Bahl, R., et al., Effect of zinc supplementation on clinical course of acute diarrhoea Report of a Meeting, New Delhi, 7-8 May 2001.

Journal of Health, Population and Nutrition, vol. 19, no. 4, December 2001, pp. 338-346.

3. Bhutta Z.A., Black, R.E., Brown K. H., et al., Prevention of diarrhoea and pneumonia by zinc supplementation in children in developing

countries: Pooled analysis of randomized controlled trials, Zinc Investigators Collaborative Group, Journal of Paediatrics, vol. 135, no.

6, December 1999, pp. 689-697.

4. For more details on the management of acute diarrhoea, consult The Treatment of Diarrhoea A manual for physicians and other senior

health workers, WHO/CAH/03.7, World Health Organization, Geneva.

PHOTO CREDITS: Cover: A young Bangladeshi mother helps her healthy baby to stand, UNICEF/HQ93-1880/Shamsuz Zaman;

Page 3: A health-care worker spoon-feeds an ORS solution to a sick infant in the paediatrics ward of Kaduna Hospital, Nigeria,

UNICEF/HQ97-1147/Giacomo Pirozzi

5

TECHNICAL ANNEX

ADVANCES IN MANAGING DIARRHOEAL DISEASES

RECOMMENDED FORMULATION

NEW AND IMPROVED ORS WILL SAVE MORE LIVES

Because of the improved effectiveness of

For more than 25 years, WHO and UNICEF have

reduced osmolarity ORS solution, especially for

recommended a single formulation of glucose-

children with acute, non-cholera diarrhoea, WHO

based ORS to prevent or treat diarrhoeal

and UNICEF are recommending that countries

dehydration, no matter the cause or affected age

manufacture and use the following formulation

group. This solution has played a major role in

in place of the previously recommended ORS

dramatically reducing global mortality due to

solution.

diarrhoea. During this time, researchers sought

to develop an improved ORS formulation that

was as safe and effective as the original in

COMPOSITION OF REDUCED OSMOLARITY ORS

preventing and treating diarrhoeal dehydration

but also reduced stool output or offered Reduced osmolarity ORS grams/litre

additional clinical benefits, or both.

Sodium chloride 2.6

One research effort focused on reducing the Glucose, anhydrous 13.5

osmolarity of ORS solution to avoid possible Potassium chloride 1.5

adverse effects of hypertonicity on net fluid

Trisodium citrate,

2.9

absorption. Reducing the concentrations of dihydrate

glucose and salt (NaCl) in the solution

Total weight 20.5

accomplished this goal. Studies of this approach

show that decreasing the sodium concentration of Reduced osmolarity ORS mmol/litre

the ORS solution to 75 mEq/l, the glucose

Sodium 75

concentration to 75 mmol/l, and the total

Chloride 65

osmolarity to 245 mOsm/l improved the efficacy of

the ORS regimen for children with acute non- Glucose, anhydrous 75

cholera diarrhoea. Potassium 20

Citrate 10

The need for unscheduled supplemental

Total osmolarity 245

intravenous therapy in children given the new

ORS fell by 33 per cent. An analysis of this and

other recent studies of reduced osmolarity ORS

solutions (osmolarity 210-268 mOsm/l, sodium

50 75 mEq/l) found that stool output decreased

by about 20 per cent and vomiting by about 30

per cent. The reduced osmolarity (245 mOsm/l)

solution also appeared to be as safe and effective

as standard ORS for use in children with cholera.

6

ZINC SUPPLEMENTS REDUCE THE SEVERITY AND

DURATION OF DIARRHOEA

Twelve studies examined the impact of zinc

supplements on the management of acute

diarrhoea. Eleven of these showed a reduction in

the duration of the diarrhoeal episode; in eight of

these, the reduction was statistically significant.

Five of the above studies also collected data on

stool volume or frequency, and found that zinc

supplements reduced stool output or frequency.

The data shows that zinc supplementation during

and until cessation of diarrhoea (either syrup

containing 20 mg of elemental zinc per 5 ml, or

tablets of 20 mg zinc such as zinc sulphate,

gluconate or acetate) has a significant and

beneficial impact on the clinical course of acute

diarrhoea, reducing both its duration and severity.

ZINC SUPPLEMENTS PREVENT SUBSEQUENT

EPISODES OF DIARRHOEA

Other studies evaluating the effect of zinc

supplementation on diarrhoeal diseases found a

preventive and long-lasting impact. These

studies show that 10 mg to 20 mg of zinc per day

for 10 14 days reduced the number of episodes

of diarrhoea in the 2 3 months after the

supplementation regimen.

WHO and UNICEF therefore recommend daily

20 mg zinc supplements for 10 14 days for

children with acute diarrhoea, and 10 mg per day

for infants under six months old, to curtail the

severity of the episode and prevent further

occurrences in the ensuing 2-3 months.

7

Reprinted August 2004

The United Nations Children s Fund/World Health Organization, 2004

This document may be freely reviewed, abstracted, reproduced and translated,

but it cannot be sold or used for commercial purposes.

Ordering code: WHO/FCH/CAH/04.7 or UNICEF/PD/Diarrhoea/01

Copies of this statement and further information may be requested from:

United Nations Children's Fund

World Health Organization

Health Section, Programme Division

Department of Child and Adolescent Health and Development

3 United Nations Plaza

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1211 Geneva 27

Tel: 1-212-***-****

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