Paediatrics
Acute Watery Diarrhoea in Children
بچوں میں اسہال
A leading cause of death in under-5 children in Pakistan, but largely preventable with ORS and zinc. Antibiotics are rarely needed.
- ICD-10
- A09
- Source
- General reference written by the assistant (not from the OPD book); needs clinical review
- Status
- Draft
Not yet reviewed by a clinician. Check doses and brands against current national guidelines before use.
Symptoms
- Three or more loose, watery stools a day
- Vomiting
- Thirst, sunken eyes, dry mouth
- Fever (sometimes)
- Reduced urine
Red flags Refer urgently if any are present
- Lethargy, unconscious, floppy
- Unable to drink or drinking poorly
- Sunken eyes with skin pinch going back very slowly (severe dehydration)
- Blood in stool (dysentery)
- Diarrhoea lasting 14 days or more
- Severe malnutrition or an infant under 2 months
Diagnosis
- Clinical assessment of dehydration: general condition, eyes, thirst, skin pinch
- Stool culture/microscopy only for dysentery, suspected cholera or outbreaks
Treatment
Step 1 of 5
Assess dehydration
WHO / IMCI classification: no dehydration, some dehydration, severe dehydration.
- Look at general condition, eyes, thirst and skin pinch
- Ask duration, blood in stool, vomiting, urine output
- Weigh the child and look for malnutrition
Step 2 of 5
Plan A: no dehydration (home care)
- Give extra fluids: ORS, soup, rice water, yoghurt drink (lassi) without sugar
- Child under 2: 50–100 mL ORS after each loose stool; 2 to 10 years: 100–200 mL
- Continue breastfeeding and normal feeding; do not stop food
- Give zinc for 10–14 days
- Return if not improving in 2 days, or if danger signs appear
Prescription
DoseAfter every loose stool, in small frequent sips
Brands WHO low-osmolarity ORS sachet
Until diarrhoea stops
Free ORS is stocked at government facilities and distributed by Lady Health Workers. Many private ORS brands exist; check the sachet states the WHO low-osmolarity formula.
Caution: Mix with the exact volume of clean water stated on the sachet; Discard made-up solution after 24 hours
Zinc sulfateMicronutrient
DoseUnder 6 months 10 mg daily; 6 months or older 20 mg daily
Brands Zincat
10–14 days
Zinc dispersible tablets are part of the national diarrhoea management protocol.
Step 3 of 5
Plan B: some dehydration
- Give ORS in the clinic over 4 hours: 75 mL/kg
- Reassess after 4 hours and classify again
- Show the caregiver how to give ORS; continue breastfeeding
- If vomiting, wait 10 minutes and continue more slowly
Prescription
Dose75 mL/kg over 4 hours
Brands WHO low-osmolarity ORS sachet
4 hours
Free ORS is stocked at government facilities and distributed by Lady Health Workers. Many private ORS brands exist; check the sachet states the WHO low-osmolarity formula.
Caution: Mix with the exact volume of clean water stated on the sachet; Discard made-up solution after 24 hours
Zinc sulfateMicronutrient
DoseUnder 6 months 10 mg daily; 6 months or older 20 mg daily
Brands Zincat
10–14 days
Zinc dispersible tablets are part of the national diarrhoea management protocol.
Step 4 of 5
Plan C: severe dehydration
- Start IV fluids at once: Ringer's lactate 100 mL/kg (30 mL/kg within 30 min for infants under 12 months, 1 h for older children, then 70 mL/kg over the next 5 h / 2.5 h)
- Reassess frequently; start ORS as soon as the child can drink
- Refer to hospital if IV therapy is unavailable, use nasogastric ORS en route (20 mL/kg/h)
- Treat suspected cholera and dysentery with an appropriate antibiotic per local sensitivity
Prescription
Ringer's lactate (Hartmann's solution)IV crystalloid
Dose100 mL/kg in total (see split above)
Brands Generic / hospital supply
3–6 hours
Caution: Monitor for fluid overload, especially in dengue critical-phase recovery
AzithromycinMacrolide antibiotic
DoseChild 10–20 mg/kg single or 3-day course
Brands Zithromax, Azomax, Azitma, Arzomic, Zyto, Genthro
Only for cholera or dysentery
Not for simple watery diarrhoea
Caution: QT prolongation; caution with other QT-prolonging drugs
Step 5 of 5
Recovery and nutrition
- Give one extra meal a day for 2 weeks after diarrhoea stops
- Check immunisation status: rotavirus and pneumococcal vaccines
- Counsel on hand washing, clean water, and safe stool disposal
Prevention
- Exclusive breastfeeding for 6 months
- Rotavirus vaccine (in Pakistan's EPI schedule)
- Hand washing with soap; safe water; sanitation
- Vitamin A supplementation per EPI/nutrition guidance
Guideline sources
- WHO Pocket book of hospital care for children
- WHO/UNICEF ORS and zinc guidance
- IMCI Pakistan