Diarrhoea in a small child: what to do at home, and when to go

Parents watch the stool. What matters is the water. A small body holds much less fluid in reserve than an adult one, and loose stool several times an hour empties that reserve fast. That is what makes a child collapse, and it is what a health facility is treating when a child arrives late.

It moves quickly. A child who was walking about in the morning can be limp by nightfall. This is why the response starts at the first loose stool rather than on the second day when it has not settled.

The second cost is weight. A week of diarrhoea in a child who is already small takes back weeks of gain, particularly if the household stops feeding her while it lasts. That is why feeding through it is part of the treatment, not a separate question.

Start oral rehydration salts. Do not wait to see if it settles. If there is a sachet in the house, use it now. If there is not, send somebody for one while you keep the child drinking whatever clean fluid she will take.

Mix one whole sachet into the amount of clean water printed on the packet, using water that has been boiled and cooled or treated. Never use less water than it says, and never mix it into milk, porridge or soda. Mix the whole sachet, not part of it, and make a fresh lot rather than keeping yesterday's.

Then keep breastfeeding, more often than usual. A breastfeeding child should carry on at the breast right through the illness. Breastmilk is fluid and food at the same time, and there is no reason to stop.

Stop trying to give a cup. A sick child will push away a cup and take a spoon. Give a spoonful every minute or two, sitting with her, for as long as it takes. It is slow and it is boring and it is the part that saves children.

Give more after each loose stool. That is the rhythm: she loses some, you put some back. A rough guide is that she should be taking more fluid than usual across the day, not the same amount.

If she vomits, do not give up on it. Wait a short while until the vomiting settles, then start again more slowly, smaller amounts, longer gaps. Most children keep down what they are given slowly even when they cannot keep down a cupful. If she vomits everything, repeatedly, that is a reason to go to a facility.

The sign that it is working is ordinary: she is passing urine, her mouth is not dry, and she is still responding to you. Those three tell you more than the number of stools does.

They are water and salts in the right balance, so that the body can take them up while the gut is losing fluid. They are not a medicine that stops diarrhoea, and it is a mistake to judge them by whether the stool slows down.

The stool will usually carry on for a while after you have started. That does not mean it is not working. What it is doing is keeping the child out of danger while the illness runs its course.

Do not add sugar to the mix, do not make it stronger than the packet says, and do not buy tablets from a shop to stop a small child's diarrhoea. Medicines that stop the gut are not for young children and can make things considerably worse.

Zinc is given alongside oral rehydration salts at health facilities as part of the standard treatment for diarrhoea in young children, and village health teams in many parishes hold both.

The important thing for a household to know is that it is given as a short course that continues after the stool has settled. Households commonly stop it the day the child looks better, which is the day it is doing the rest of its work.

How much and for how many days are for the health worker to decide, based on the child's age. Take what you are given, finish it, and ask the health worker to write the days down if you are not sure.

Keep feeding. This is the point where households are most often given the wrong advice, usually kindly, by somebody who believes that food feeds the diarrhoea. It does not. A child who is starved through an episode comes out of it weaker and takes much longer to get the weight back.

Offer small amounts often, softer and wetter than usual. Porridge with groundnut paste stirred in. Mashed sweet potato or matoke with a little oil. Well-cooked beans mashed soft. Do not withhold the foods she normally eats unless a health worker tells you to.

Then, once the diarrhoea has stopped, add an extra meal a day for the next couple of weeks. Her appetite will come back stronger than usual, and that is the body catching up. That fortnight is when the lost weight is regained, or is not.

Home treatment is right for a child who is drinking and staying alert. These signs end that, and mean a facility the same day, not the next outreach.

One episode is bad luck. Repeated episodes are usually about water, hands or the latrine, and it is worth spending a week on the cause rather than waiting for the next one.

Look at the drinking water first: where it is collected, whether it is boiled or treated, and what happens to it in the house. A covered pot with its own cup, so nobody dips a hand or a shared mug into it, prevents a surprising amount.

Then handwashing with soap or with ash at the moments that matter: after the latrine, after cleaning a child, and before food is handled or a child is fed. And if several children in the village have it at the same time, tell the village health team member. That pattern is something the health system needs to know about quickly.