Childhood Diarrhoea & ORS — Complete Management
Diarrhoea is the third leading cause of under-5 mortality in India, killing approximately 1 lakh children annually. The good news: nearly all diarrhoea deaths are preventable with simple, cheap interventions — Oral Rehydration Solution (ORS), zinc supplementation, and continued feeding. India's under-5 diarrhoea mortality has declined by 70% since 1990 thanks to ORS scale-up, but coverage gaps remain in rural and tribal areas.
Diarrhoea is defined as the passage of 3 or more loose or watery stools in a 24-hour period. Acute diarrhoea lasts < 14 days, persistent ≥ 14 days, and dysentery is diarrhoea with visible blood. Most childhood diarrhoea in India is viral (rotavirus, norovirus, adenovirus) — self-limiting but causes dehydration. Bacterial causes: E. coli, Shigella, Salmonella, Campylobacter, Vibrio cholerae.
ORS is one of the most important medical inventions of the 20th century — a simple solution of glucose, sodium, potassium, and citrate that reverses dehydration through sodium-glucose co-transport across the intestinal epithelium. ORS has saved an estimated 5 crore lives globally since WHO adopted it in 1978.
| Type | Duration | Characteristics |
|---|---|---|
| Acute watery diarrhoea | < 14 days | Watery, no blood — viral or cholera |
| Dysentery | Any | Visible blood in stool — Shigella, Campylobacter, E. histolytica |
| Persistent diarrhoea | ≥ 14 days | May follow acute episode — requires special management |
| Sign | No Dehydration (Plan A) | Some Dehydration (Plan B) | Severe Dehydration (Plan C) |
|---|---|---|---|
| Condition | Well, alert | Restless, irritable | Lethargic, unconscious |
| Eyes | Normal | Sunken | Very sunken |
| Thirst | Drinks normally, not thirsty | Thirsty, drinks eagerly | Drinks poorly or unable to drink |
| Skin pinch | Goes back quickly | Goes back slowly | Goes back very slowly (> 2 sec) |
Two or more signs in column 2 = some dehydration. Two or more signs in column 3 = severe dehydration (emergency).
WHO ORS (new low-osmolarity formulation): Each litre contains:
- Sodium chloride: 2.6 g (Na+ 75 mmol/L)
- Potassium chloride: 1.5 g (K+ 20 mmol/L)
- Trisodium citrate dihydrate: 2.9 g (citrate 10 mmol/L)
- Anhydrous glucose: 13.5 g (glucose 75 mmol/L)
Low osmolarity (245 mOsm/L) compared to old ORS (311 mOsm/L) — reduces stool output, vomiting, and need for IV fluids.
Preparation: Dissolve one ORS sachet in 1 litre of safe drinking water (boiled and cooled). Use within 24 hours. Do NOT add extra water, sugar, or salt.
Zinc supplementation: 20 mg elemental zinc per day for 10-14 days (10 mg for age < 6 months). Reduces diarrhoea duration, severity, and recurrence over next 2-3 months. WHO and India's Diarrhoea Control Programme mandate zinc as part of standard management.
Plan A — No dehydration (home management):
- Give extra fluids: ORS, breastmilk, clean water, lemon water, rice water, dal water
- Give ORS: 50-100 ml after each loose stool for age < 2 years; 100-200 ml for age ≥ 2 years
- Continue feeding — do not stop breastmilk or normal food
- Give zinc 20 mg/day for 10-14 days
- Return immediately if: blood in stool, drinking poorly, fever, worsening
Plan B — Some dehydration (clinic):
- ORS 75 ml/kg over 4 hours in clinic under observation
- After 4 hours, reassess dehydration, reclassify, choose new plan
- If child is breastfed, continue during ORS therapy
- If still some dehydration, repeat Plan B
- If improved, switch to Plan A
Plan C — Severe dehydration (emergency):
- IV Ringer's Lactate (or Normal Saline if unavailable): 100 ml/kg in 3 stages
- Age < 12 months: 30 ml/kg in first hour, then 70 ml/kg over next 5 hours
- Age ≥ 12 months: 30 ml/kg in first 30 min, then 70 ml/kg over next 2.5 hours
- Reassess every 1-2 hours. If hydration improving, switch to Plan B after 6 hours (infants) or 3 hours (older children)
- If cholera suspected, give antibiotics: Doxycycline 3 mg/kg OD x 3 days (older children) or Azithromycin 20 mg/kg OD x 3 days (infants)
- If dysentery (Shigella): Ciprofloxacin 15 mg/kg BD x 3 days or Azithromycin; give Vitamin A if measles co-infection
- Rotavirus vaccine: Rotavac (Bharat Biotech) at 6, 10, 14 weeks — prevents 50-60% of severe rotavirus diarrhoea
- Exclusive breastfeeding for first 6 months
- Safe water: Boiled, filtered, or chlorinated water
- Hand hygiene: Soap and water before food preparation and after defecation
- Sanitation: Toilet use, no open defecation (Swachh Bharat)
- Safe food: Cooked fresh, covered storage, no bottle feeds
- Measles vaccination: Measles predisposes to severe diarrhoea
- Vitamin A supplementation: Reduces diarrhoea mortality
Diarrhoea management is a textbook example of how simple, cheap interventions can prevent millions of deaths. For UPSC CMS aspirants, WHO dehydration assessment, ORS composition, Plan A/B/C, and zinc supplementation are extremely high-yield paediatric topics.