No. 20, January 1995
How research findings have improved diarrhoea case management
In this issue:
Practical application of research
Treatment advice for diarrhoea
WHO's Division of Diarrhoeal and Acute Respiratory Disease Control (CDR),
among its many activities, supports research into ways of preventing and
treating diarrhoeal diseases. The research is coordinated by CDR's Programme
for Diarrhoeal Disease Control (CDD). Over the years this research has
evaluated a number of new or improved approaches to the control of diarrhoeal
Research findings have been the basis for CDD guidelines for the case
management of diarrhoea. As new research results have come to light, CDD
has adjusted its case management guidelines accordingly. The following
examples related to the nutritional management of patients with diarrhoea
show how research has been used to improve CDD's guidelines.
Changes to the CDD treatment chart over time
CDD's case management guidelines are presented in its diarrhoea management
chart. The chart shows health workers how to assess and manage patients
who reach a health facility with diarrhoea. The Programme distributed the
first such chart in 1980. It proposed that, to prevent dehydration in a
child with diarrhoea, the mother should:
* Give extra breast milk and/or other fluids until the diarrhoea stops.
* Continue normal feeding.
Between 1980 and 1987 research into diarrhoeal diseases produced a number
of findings on child nutrition. These confirmed the assumptions underlying
the 1980 recommendations, allowing further precision in the advice, and
clarified areas of previous uncertainty. The findings showed that:
complementary foods offered to children with diarrhoea usually have low
energy or nutrient density, so it is important to increase their energy
and nutrient density to achieve adequate intake during and after diarrhoea;
the body continues to absorb animal fats and vegetable oil during diarrhoea;
promoting improved feeding during an episode of diarrhoea and during convalescence
after-wards reduces the negative effects of the episode on a child's nutritional
status and does not make the symptoms worse;
promoting food safety is important to prevent diarrhoea;
continued breastfeeding reduces the severity of the episode of diarrhoea,
accelerates recovery and helps prevent further episodes.
The diarrhoea management chart was substantially revised in 1987 to reflect
the information that had become available since 1980. Consequently the
revised chart recommended:
Further studies related to the nutritional management of children with
diarrhoea were completed between 1987 and 1990. Among the more significant
findings of these studies were the following:
Give freshly prepared foods. Recommended foods are mixes of cereal and
beans, or cereal and meat or fish. Add a few drops of oil.
Give fresh fruit juices or bananas to provide potassium.
Cook and mash or grind food well so it will be easier to digest.
After the diarrhoea stops, give one extra meal each day for a week, or
until the child has regained normal weight.
Give breast milk or milk feeds prepared with twice the usual amount of
malnutrition is a significant risk factor for diarrhoea mortality;
breast milk represents a high proportion of the nutritional intake of infants
with diarrhoea; frequent breastfeeding increases both milk production and
the total duration of breastfeeding;
local cereal-milk mixtures can provide safe alternatives to milk for older
infants and young children with diarrhoea;
milk feeds do not need to be diluted for infants 6 months or older;
maternal encouragement may be important in improving the food intake of
children with diarrhoea;
it is important to promote the continuation of improved complementary foods
after the end of the diarrhoea episode;
persistent diarrhoea (lasting 14 days or longer) can represent up to 20%
of diarrhoea episodes and have a considerable negative effect on nutritional
In view of these findings, CDD again revised the diarrhoea management chart
in 1990. This revision incorporated the following recommendations:
If the child has persistent diarrhoea:
Give the child plenty of food to prevent malnutrition.
Continue to breastfeed frequently.
If the child is not breastfed, give the usual milk. If the child is less
than 6 months old and not yet taking solid foods, dilute milk or formula
with an equal amount of water for 2 days.
If the child is 6 months or older, or already taking solid foods, also
give cereal or another starchy food mixed, if possible, with pulses, vegetables,
and meat or fish. Add 1 or 2 teaspoonfuls of vegetable oil to each serving.
Encourage the child to eat; offer food at least 6 times a day.
Give the same foods after diarrhoea stops, and give an extra meal each
day for 2 weeks.
Dilute any animal milk with an equal volume of water or replace it with
a fermented milk product such as yoghurt.
Assure full energy intake by giving 6 meals a day of thick cereal and added
oil, mixed with vegetables, pulses, meat or fish.
Bring the child back in 5 days; if the diarrhoea has not stopped refer
In 1992 results became available from a randomized trial that examined
the safety of feeding non-breastfed infants younger than 6 months with
their usual milk feeds. The research showed that:
This finding led CDD to further revise the diarrhoea management chart in
1992. In this latest revision:
full-strength milk feeds can be given to non-breastfed infants younger
than 6 months during diarrhoea as they provide greater nutrient intake
and do not make the symptoms of diarrhoea worse.
The recommendation to dilute milk for infants younger than 6 months
with acute diarrhoea was removed.
The CDD diarrhoea management chart reflects the fullest and most recent
knowledge obtained from reliable research findings. As new findings become
available and point to improved ways of managing diarrhoea in young children,
however, CDD will revise the diarrhoea management chart further.
For instance, a multicentre trial evaluating guidelines for the management
of persistent diarrhoea has recently been completed. Its findings will
lead to new recommendations on management of persistent diarrhoea that
will be incorporated into future versions of the chart.
This close link between research and the establishment of case management
guidelines will con-tinue to be an essential element in CDD's work.
For further information, contact:
The Director, Division of Diarrhoeal and Acute Respiratory Disease
World Health Organization, 1211 Geneva 27, Switzerland
Tel: +41 22 791-2632, Fax: +41 22 791-4853,