Dialogue on Diarrhoea, Issue 41, June 1990

ISSUE No. 41 June 1990

The international newsletter on the control of diarrhoea1 diseases ORT today and tomorrbw Infant and young child mortality could be greatly reduced if people used oral rehydration therapy correctly and often enough. DD, celebrating ten years of publication with this issue, has always reported on efforts to prevent and treat diarrhoea1 diseases. Promo- tion of ORT has been one of the main functions of the newsletter. GlobalproductionofORS is now morethan 350 million packets a year, and access to OR therapy has increased considerably in the last decade. At the same time, CDDprogrammes at all levels have made great progress in spreading messages about interventions which can prevent diarrhoea1 diseases. More and more families and health workers have learned to use ORT, and many deaths have been averted. It has also become increasingly clear that giving home fluids early to prevent dehydration and continuing to give nutritious foods is the best way to prevent a case ofdiar- rhoea from becoming serious. To treat diarrhoea at home, give extra fluids and continue giving nutritious foods. Still much to be done Despite these efforts, four million children a year still die from diarrhoea. ORS packets promoted as having an antidiarrhoeal Similarly, cereal-salt solutions have ad- are not available to every child in need of effect, which might lead to reduced use of vantages and disadvantages. If made with treatment for dehydration. Families in inappropriate drugs. local staple foods, they are cheap, easily remote areas may not be able to obtain the available, culturally acceptable and more packets, and poor families may not be able Home management likely to be given earlier in the illness. Also, to pay for them. Most cases of acute diarrhoea, if handled there is no risk of the osmotic diarrhoea In addition, while standard ORS treats properly and early enough at home, will not associated with solutions made with too dehydration effectively and safely, it does not require treatment with ORS. Home manage- much sugar. If too much cereal is added to stop the diarrhoea, which is almost always ment should be based on giving extra an oral rehydration solution, it becomes too the first concern of mothers. For this reason, amounts of safe fluids together with con- thick to drink. However, it is most impor- some health professionals and families still tinued feeding with the child’s normal tant that cereal based ORT solutions are not remain unconvinced about the benefits of diet.The choice of home fluids will depend confused with food, and that mothers do not ORS, and tend to give dangerous and inef- on local circumstances. In some areas, dilute the child’s usual foods to make home fective drugs. Recent research suggests that sugar-salt solutions have been used suc- fluids (For the latest guidelines from the cereal based ORS formulations reduce stool cessfully, but in others there have been pro- World Health Organization on the selection volume and duration of illness (see pages 4 blems with dangerous and ineffective of home fluids, see page 2). and 5). Therefore, cereal ORS could be solutions caused by incorrect mixing. KME, WAMC and KA

In this issue: 0 Home fluids for diarrhoea 0 Cereal based ORT - research reports Appropriate Health Resources & 0 Practical advice on cup feeding Technologies Action Group Ltd 0 Potassium - questions and answers

Dialogue on Diarrhoea, issue 41, June 1990. Published quarterly by AHRTAG, 1 London Bridge Street, London SE1 9SG, UK. 1 WHO guidelines

Prevention or treatment? Selection of home fluids To treat dehydration, once it has developed, it is essential to replace water and salts lost during diarrhoea. Giving Home treatment of acute diarrhoea Food-salt solutions the standard WHO/UNICEF formula should: Food-salt solutions could provide an alter- ORS is the best way to do this, because 0 prevent dehydration by giving native to SSS. They can be made from it provides exactly the right balance of increased fluids; and ordinary ingredients and might be more glucose and salts. Other solutions con- 0 maintain nutrition by continuing to likely to be given in larger amounts. Food- taining the right amounts of sugar and breastfeed or by giving acceptable, salt solutions could include commonly salt, such as a carefully measured sugar- nutritious foods. available fluids looked on as drinks, which salt solution, are also good. It is always are familiar, easy to prepare and acceptable better to give fluids of some sort than not ORS solution made from a packet of oral for giving to children with diarrhoea. Such to give fluids at all. rehydration salts is designed to treat drinks include food based fluids which To prevent dehydration, the formula dehydration, but can also be used to pre- contain cooked starch and protein, such as of solutions given is less important: the vent it. Where ORS is not available, other cereal soup or porridge. The addition of main thing is to give extra fluids as soon fluids should be used to prevent dehydra- salt (up to 3g/l) would increase their effec- as diarrhoea begins, and to continue tion. Fluids recommended, in addition to tiveness for ORT. Food-salt solutions may feeding. Home management is important breastmilk, include: also promote sodium absorption more because, if effective treatment for diar- 0 sugar-salt solutions effectively than sugar-salt solutions rhoea is given at home, dehydration can 0 food based fluids, such as cereal gruels because they contain more of the carrier be prevented in many cases. or soups molecules (glucose and amino acids derived from starch and protein) necessary What about cereals? 0 plain fluids such as water or weak teas for water and salt absorption in the gut. Oral rehydration solutions made from without sugar. This means that food-salt solutions may the same formula of salts as decrease stool output and reduce losses of WHO/UNICEF glucose ORS, but with Sugar-salt solutions salt and water. rice powder instead of glucose, have pro- . . Experience in many countries has shown Whether or not mothers should be ved effective in treating dehydration. that families may be unable to make special encouraged to add salt to food based fluids More research is. nevertheless, needed fluids correctly. Some ingredients may not will depend on the amount of salt usually on some aspects of cereal based ORS be available; it may not be possible to carry included in food for children, and the before it can be widelv promoted. Home out the careful measuring needed; or the feasibility of teaching mothers to add the made cereal based fluids have also been recipe may be forgotten over time. Sugar- right amount of salt. found to be at least as good as other salt solutions (SSS) made with too much If food based fluids are recommended home fluids for ORT. salt or sugar are potentially dangerous for for diarrhoea, it is important that families young infants. Also it has been found that do not confuse fluids for rehydration with that children be given watered down ver- many families view SSS as ‘medicine’, and food, and that children with diarrhoea are sions of thicker foods which are part of the so too little fluid is often given too late. given enough to eat. It is not recommended normal diet. Food based fluids should be given in their usual form, except for the addition of salt if this is necessary. Messages about appropriate feeding as well as giving suitable fluids should continue. Familiar drinks Another approach is to promote drinks which are familiar and commonly available, but which contain no added salt and relatively little starch or protein. These include weak cereal solutions such as rice water, water in which other cereals have been cooked, and plain water. These solutions do not provide the salt, starch and protein necessary to prevent dehydration in cases of large stool losses. But they would adequately replace losses in most cases, especially if given as well as foods that contain some salt. Use of such drinks should be considered when the use of food based Always continue breastfeeding a child with diarrhoea. fluids containing salt is not feasible.

2 Dialogue on Diarrhoea, issue 41, June 1990. Published quarterly by AHRTAG, 1 London Bridge Street, London SE1 9SG, UK. How to...

Recommendations . ..make a rice 1. Home fluids to prevent dehydration (in order of effectiveness) include: based drink for oral rehydration salts (ORS) solution (although designed to treat dehydra- oral rehydration tion, ORS may be used, if available, as a home fluid from the start of diar- 01 rhoea to prevent dehydration) With careful teaching and food based fluids (such as soups and practice, mothers in porridges) Pakistan have learnt to sugar-salt solution other drinks (including plain water) make this safe and effec- Food should always be given as well, tive rice based drink for with all of these fluids. oral rehydration. 2. Any home fluids used should be: 0 readily available - easy to make from Take one handful (20 to 25 grams) of cheap, widely available ingredients rice grain. Wash and soak the rice in 2 0 0 safe - so that the recipe will not con- water until it is soft. tain too much salt (or sugar) even if it is only followed approximately Grind the soaked rice with pestle and 0 familiar - the fluid or recipe should be mortar (or any other grinder) until it well known becomes a paste. 0 acceptable for use during diarrhoea - Rut two and a quarter glasses of water with acceptable taste and no cultural (about 6OOml) into a cooking pot and barriers mix in the rice paste. 0 easily and readily given in large enough quantities Stir well, and heat the mixture until it 3. Home fluids should contain salt if possi- begins to bubble and boil. Then take 3 0 ble.Otherwise, salt can be given in food. the pan off the fire, and leave the solu- Unsalted fluids should still be given if it tion to cool. is not possible or practical to give fluids containing salt. Add one three finger (up to the first 4. For food based fluids, it is usually best finger joints) pinch of salt (1.5 grams) to use recipes which normally include a to the mixture, and stir well. The solu- safe amount of salt. Otherwise, salt can be tion is now ready to be given to the added, if this is practical - 3g of salt per person with diarrhoea. litre of fluid is ideal (but up to 6g per litre would still be safe). Storage: this solution should be covered and kept in a cool clean place. It should 5. If sugar-salt solution is used, a recom- 4 mended composition is 50 mmol/litre of be used not more than six to eight hours c salt and of sugar (3g of salt and 18g of after preparation. After this time, throw sugar per litre of water). away any solution which is left over. 6. Home fluids should not be prepared by diluting weaning foods. Pictures and text taken from Elliott, K, 7. When food based fluids are used for et al. (eds), 1990. Cereal based oral home treatment, it is very important to rehydration therapy for diarrhoea (sym- make sure that they are not regarded as posium report), page 51. Aga Khan food, because this could result in a sick Foundation and International Child child getting too little to eat. Health Foundation. See page 5 for publication details. 5 These guidelines and recommendations 0 were developed at an international Further reading: Molla, A M, et al., meeting of experts held by the World 1989. Food based oral rehydration salt Health Organization in Baltimore, USA, solutions for acute childhood diarrhoea. in March 1990. Lancet ii: 429-31.

Dialogue on Diarrhoea, issue 41, June 1990. Published quarterly by AHRTAG, 1 London Bridge Street, London SE1 9SG, UK. 3 Research reports

Mothers and nursing staff were enthusiastic about its use. Cereal based ORT Although this pilot project involved very DD presents short reports of four recent studies. small numbers of patients, the results were encouraging and suggest that sweet potato solution could be both safe and effective recipes, a fluid was produced by boiling Sorghum ORS: Rwanda for ORT, and culturally acceptable. Fur- two pieces of kaukau in 1.5 litres of water ther studies are planned for 1990 to con- Sorghum flour is the main ingredient of for 35 minutes. The potato was then firm the safety of solutions prepared at traditional weaning foods in Rwanda. It mashed and water added to make one litre home by mothers. was tested as a base for ORS in the of drinkable solution. Three grams of salt Howard, P, et al., 1989. Proposed use of treatment of 100 children with acute were also added. diarrhoea. The children included in the sweet potato water as a jluid for oral study were boys with good nutritional rehydration therapy for diarrhoea. Papua status, aged six to 24 months, who Glossary New Guinea Institute of Medical Research, had had diarrhoea for less than three Goroka, Papua New Guinea. days with moderate dehydration (loss Dehydration: the loss of water and salts of five to nine per cent of body weight). caused by diarrhoea. Serious dehydra- Children were not included if they tion can cause death. had dysentery, fever on admission Oral rehydration therapy (ORT): the Wheat ORS in (temperature over 39°C) and/or the administration of fluid by mouth to pre- refugee camps vent or correct dehydration. presence of another severe infection Mothers in Afghan refugee camps in Oral rehydration salts (ORS): the (such as pneumonia or measles). During Pakistan have been taught to use packet standard WHO/UNICEF formula of the first six hours (the ‘rehydration oral rehydration salts, and to mix a home glucose and salts for ORT. Also known phase’) children were given lOOml/kg of sugar-salt solution (SSS) for children with as ‘glucose ORS’. Dissolving the salts either sorghum based ORS or diarrhoea. However, most mothers mix in water makes ORS solution. WHO/UNICEF ORS . Breastfeeding was SSS incorrectly, leading to the risk of an Cereal based ORS: the standard continued during the rehydration phase ineffective or harmful solution. Because WHO/UNICEF recommended formula and food (milk and bananas) was re- research shows positive results with cereal but with 50 grams of cereal instead of introduced as soon as rehydration was based ORS, it has been suggested that 20 grams of glucose (to be added to one achieved. home made wheat and/or rice solutions litre of water). The cereal contains On admission, there was no difference would be better home solutions. starch which is broken down into between the children given sorghum Research was undertaken to find out if glucose during digestion. ORS and those given glucose ORS. mothers would use wheat based solutions Cereal based ORT: the giving by However, the sorghum based ORS group - wheat is cheap and widely available. mouth of a rehydrating fluid which is showed a significant reduction in the Women (mostly non-literate) were taught a thick but drinkable mixture of a star- duration of diarrhoea, in the total ORS the wheat solution recipe: two fistfuls of chy food (approximately 50 to 80 grams intake and in the total output of stools. wheat flour and a two to three finger pinch per litre of water) preferably with salt This study was a hospital based clinical of salt per litre of water. Teaching was added (about three grams per litre of trial, and it remains to be seen whether carried out in homes and basic health fluid). an ORT fluid based on sorghum can be centres by trained female health workers. Sugar salt solution (SSS): a solution used successfully in the community. Follow up visits were carried out between containing only sugar, salt and water in L,epage, P, et al., 1989. Food based oral two weeks and two months later to find precise quantities (18 grams of sugar, rehydration salt solution for acute out: if mothers could still make the recipe three grams of salt and one litre of childhood diarrhoea. correctly; if they had used it when their water). children had diarrhoea; and what they thought of it. Of the 64 women inter- Sweet potato water: The sweet potato solution was then com- viewed, 60 per cent said they gave one I Papua New Guinea pared with the standard WHO formula of the rehydration solutions on the first day In Papua New Guinea, there are limited ORS in a small study. Thirteen children of diarrhoea (other fluids given on the first I choices for the selection of suitable home with mild to moderate dehydration caused day included a yoghurt drink, green tea, fluids because no cereal grains are grown by acute diarrhoea were treated with traditional herbal drinks and rice water). locally. In the coastal and lowland areas WHO/UNICEF ORS and ten were treated There were no cultural beliefs to prevent coconut water is widely available and with kaukau-salt solution. The ages in both the use of a wheat based solution for health workers recommend it for preven- groups ranged from four to 23 months and diarrhoea. Depending on the location and ting dehydration. However, in the there were approximately the same number the method of teaching used, between highlands no suitable fluids are available. of cases of mild and moderate dehydration 40 and 94 per cent of the women could This problem led to a pilot study of the in each group. The average time for demonstrate making the wheat based efficacy and safety of a solution made from rehydration was the approximately the solution correctly. They liked the wheat kaukau (sweet potato) - the staple crop in same for both groups. There were no side solution, as the taste is familiar and wheat many parts of the country, widely grown effects in the kaukau group and all infants flour is used every day to make bread, in the highlands. After trying various seemed to like the taste of the solution. Continued on page 5

4 Dialogue on Diarrhoea, issue 41, June 1990. Published quarterly by AHFITAG, 1 London Bridge Street, London SE1 9SG, UK. Research reports

International meeting A symposium held in Karachi, Pakistan in November 1989 brought together many experts to discuss the latest findings from studies of cereal based solutions for oral rehydration therapy. Participants examined the scientific evidence supporting the claim that cereal based ORS solutions can reduce stool volume and duration of diarrhoea. Clinical trials reported showed that a range of cereals and starchy foods are as effective as glucose in ORS for preventing and treating dehydration. Cereal ORS has been found to be especially successful in cases of cholera. Fur- ther research was recommended ii? patients with non-cholera diarrhoea, and in young children under four months of age or with malnutrition. Cereal based ORS may prove a useful alternative to standard ORS, but more research is needed to define its relative usefulness for young children with acute diarrhoea. And it is important to find out if cereal ORS is better than standard ORS given with cooked cereal food. Programme issties Cereal based oral rehydration solution may reduce the duration of diarrhoea. The potential advantages and difficulties of introducing cereal based ORS into diarrhoea1 Continued from page 4 Bangladesh: field trials disease control programmes were also Mothers also found the recipe easy to discussed. Where programmes have make. of rice based ORS established widespread distribution of ORS When discussing which solution the Studies were carried out on rice based oral packets, or have a policy of promoting sugar- women preferred, and why, most mothers rehydration therapy from 1982 to 1987. salt solutions, it may not be advisable to said all the solutions were good. When Packets of rice based ORS were given to introduce cereal ORS as an option, because asked which was easier, a significant one group of mothers; glucose ORS this may cause confusion or undermine number said that the wheat, .salt and water packets to another; and no packets to a existing health education. Where this is not the solution was a little easier than both rice third group of mothers who had access to case, and communities do not have access to water and SSS, because rice needed to be local treatment facilities. All the mothers standard ORS (in packets or otherwise) cereal cleaned and washed and cooked longer, of children aged under four years in the ORS could be an acceptable and effective and SSS needed correct measurement. first two groups were taught to prepare and option. While many thought rice water tasted use ORS. best, they suggested that it was not prac- Use of ORT was highest in the rice ORS Home use issues tical because of its expense (rice is con- group, and lowest in the control group Specific considerations discussed relating to sidered to be a luxury and is not kept in (where drugs were also most often used). promotion of cereal-salt solutions for home most Afghan homes). The Afghan women Duration of diarrhoea1 illness was shortest use included: in this study learned the new recipe in the group given rice ORS, in which which cereals are most available and quickly and had good recall when more than 60 per cent of children with non- acceptable, as well as effective followed up. They knew why and when dysenteric diarrhoea recovered within requirements for home preparation of to give ORT, and continued to give other three days, and less than one per cent suf- cereal based solutions, including mothers’ foods in addition to the wheat solution, fered beyond 14 days. Of the children time and fuel availability showing that they did not confuse the given glucose ORS, 30 per cent recovered teaching and training required to ensure wheat-salt solution and food. For Afghan within three days, and about three per cent that cereal-salt solutions are safe and given families, sugar is expensive, ORS packets still had diarrhoea after 14 days. In the in timely and adequate amounts unavailable, and it may not be possible third group, only six per cent had ensuring that the potential problem of con- to mix SSS correctly. Therefore, it is recovered in three days, and 12 per cent fusion between cereal based ORT and food worthwhile to continue to study wheat had diarrhoea after 14 days. is avoided. based, or both wheat and rice based solu- Bari, A, et al., 1989. CommuniQ study oj Copies of the meeting proceedings are tions as alternatives or additions to the n’ce based ORS in rural Bangladesh, Inter- available. Details from Aga Khan Founda- sugar-salt solution being taught now. national Centre for Diarrhoea1 Diseases tion, P 0 Box 435, 1211 Geneva 6, Siener, K, 1989. Wheat based ORS for Research, Bangladesh. Switzerland; and ICHF, American City Afghans, International Rescue Committee, More information about these and other Building, Suite 325, 10277 Wincopin Peshawar, Pakistan. studies is available from DD. Circle, Columbia MD 21044, USA.

Dialogue on Diarrhoea, issue 41, June 1990. Published quarterly by AHRTAG, 1 London Bridge Street, London SE1 9SG, UK. 5 Practical advice

How to feed a baby who cannot breastfeed

Cup feeding is much safer than bottle feeding and can be more practical than using a spoon.

Breastmilk is always the best food for is the best and safest alternative. babies. who need nothing else until they Breastfeeding may not be possible if: are four to six months old. But, babies . a baby is too weak to suck, for who are very small or ill may be too weak example during and after illness, or if to suck at the breast, and so must be fed it is born early and very small - xpress breastmilk into a cup for a baby with breastmilk if possible - in another who cannot breastfeed. way. 0 the mother is very ill, or the baby has no mother or other woman to breastfeed it The baby can then still have the benefits Why is cup feeding necessary? . of breastmilk, even if it cannot breastfeed. the mother cannot stay with her baby Other milks should be given only if no Breastfeeding is the ideal way to feed a all day and a relative or friend has to breastmilk is available from the mother, baby because breastmilk is the best feed the baby. possible food and drink, and it gives the another woman or a breastmilk bank. baby protection against diseases. With breastfeeding, food for the baby is always When can you start cup ready and free from germs; and both Can you give breastmilk from feeding? mother and babv benefit from close a cup? 2 contact. However, another way of feeding Yes, definitely. If breastfeeding is not Whenever it is necessary - even straight is necessary when breastfeeding is not possible, the second best option is for the after birth.Any baby who can swallow can possible, and feeding with a cup or spoon mother to express breastmilk into a cup. drink from a cup.

How do you feed a baby with a cup? Cups are better than bottles because... Just hold the baby comfortably in your arms, and hold the cup to his or her CUPS have a simple shape and BOTTLES and teats have many lips.Be careful not to tip the cup too far can be easily cleaned with awkward corners which cannot be or too fast for the baby to swallow all of soap and water. cleaned except by boiling. the milk coming out of it.Give a little at a time, with short rests in between, Open CUPS do not encourage BOTTLES encourage the unsafe especially if the baby is sick or weak. Ordinary open cups should be used, not storage of feeds or carrying storage of feeds, increasing those with covers or spouts which are too them about for several hours. the chances for germs to breed. difficult to clean, and need to be sterilised like bottles. . CUPS do not make babies BOTTLES teach babies to suck unable or unwilling to suck at in a way which makes them less the breast. willing to breastfeed. What about bottle-feeding? Bottle-feeding is dangerous because it is CUPS used in hospital and by BOTTLES used in hospital very difficult to keep bottles and teats health workers teach the provide an example which clean and free from germs without careful community a method which is cannot be safely or cheaply and regular sterilisation. Feeding bottles safe +o use at home. followed by mothers at home. are a major cause of infant diarrhoea.Because the bottles must be Using CUPS means that the BOTTLES can be propped up, boiled before each feed, bottle-feeding costs a lot in fuel, water and time. Bottle- small infant has some contact depriving the baby of human feeding also stops babies wanting to suck contact. with the mother or another at the breast and makes them suck in a person during feeds. way which can cause sore nipples. Bottle- feeding should always be avoided.

6 Dialogue on Diarrhoea, issue 41, June 1990. Published quarterly by AHRTAG, 1 London Bridge Street, London SE1 9SG, UK. Questions and answers

What about spoon feeding? Spoon feeding is much safer than bottle feeding because spoons and bowls or cup are much easier to clean. But it can tak a very long time to give a baby enoug food or fluid using a spoon. Both th mother (or other caretaker) and baby ar w likely to get tired or distracted before th Q What is the relationship between Q What are good sources of baby has had enough food. However, if th diarrhoea and potassium? potassium? baby can take only very small amounts a milk, for example when there are breathin, A During diarrhoea, fluids and salts, A Fruits and vegetables are good difficulties, or you think the baby ma: including potassium chloride, are lost from sources. Those with the most potassium (in choke or vomit, then it may be better ti the body. If potassium (K+) lost is not mm01 per 1OOg) include spinach (12.6) use a spoon than a cup. replaced, low levels in the blood result (this avocado (10.3), banana (9.0), pumpkin is hypokalaemia). However, most of the (8.0) and coconut water (8.0). Plantain, potassium in the body is stored in the cells, papaya, oranges, grapefruit, tomato juice, and so measuring the level of potassium in carrot, pineapple, soya and peanuts are the blood does not always give a true also good sources. Thirty grams of banana indication of the status of body potassium. supplies approximately 115mg of K + ; the Children with protracted diarrhoea and same amount of KS- would also be sup- malnutrition are especially likely to be plied by 6g of defatted soy flour, or 20g potassium-depleted. It may be wise to con- of lentils, peanuts or potatoes, and 30g of sider any child who is undernourished and whole wheat flour or dark green leafy who has had diarrhoea for more than a few vegetables (DGLV). Soy flour should be days likely to be hypokalaemic, and to take toasted, and DGLV should be steamed appropriate action. (since K+ is soluble in water). In general, leaves may contain more potassium than fruits, although it will Q What are the signs of hypo- depend on the type of soil in which the kalaemia? plant is grown. Where soil is very deficient in K +, plants do not grow well, but pro- Hypokalaemia can lead to vomiting, A bably maintain a minimal concentration of anorexia or obstruction of the bowel. The potassium. signs of severe K+ loss are weak and For small children who cannot eat large relaxed muscles, abdominal distension, Even very small babies can drink from a cup quantities of starchy foods like bananas, and slowing of the heart rate. drinking water which has been dripped Acknowledgement: the information OI through about 5g of wood ash may be a this page is taken from the IBFAT Q Does oral rehydration therapy more effective way of increasing potassium (International Baby Food Action Net replace lost potassium? intake. The ash should be fresh (but work) Statement on Cups. Copie cooled) and therefore free of germs. The available from IBFAN-Africa, P 0 Bo: Children with diarrhoea need ash from some fresh water weeds, such as 34308, Nairobi, Kenya. A potassium during rehydration to prevent or the water hyacinth, is an even richer source replace any K + loss. Packets of ORS for- of K+. More information mula contain enough potassium chloride (1.5 grams per packet for a litre of water) Feeding low birth weight babies to replace losses during diarrhoea. Proper Q When should potassium rich foods IBFAN, 1986, VHS, 29 minutes. A train use of ORS usually ensures that any be given? ing video tape for health workers. Thi hypokalaemia is corrected within 24 to 36 video demonstrates cup feeding of babie hours of starting oral rehydration therapy. A Foods rich in K + should be given dur- as small as 1.7kg. Copies are availabll Where packets of WHO/UNICEF ORS ing diarrhoea and for at least a week after- from: UNICEF, Communication an are unavailable, home made sugar-salt wards to ensure that potassium levels are Information Services, P 0 Box 44145 solutions (SSS) and home available fluids returned to normal. Nairobi, Kenya; or contact the UNICEI are usually used to prevent and (if office in your country. necessary) treat dehydration. SSS does not References Breastfeeding - Dialogue on Diarrboe; contain potassium, and other home Dialogue on Diarrhoea issues 3 Health Basics series, originally published available solutions also may not. It is (Potassium losses and replacement in diar- as an insert in DD issue 37, June 1989. Si: therefore important to give children ade- rhoea) and 5 (Pin’e, N W). pages of information on breastfeeding quate amounts of locally available May, R J D, and Booth, I W, 1988. Acute including sources of further information potassium-containing foods to replace diarrhoea: who needs potassium? and publications. Copies available free o losses, ‘and to help restore appetite and (Editorial). J. Trop. Paed. 34:2-3. charge from AHRTAG. food intake.

Dialogue on Diarrhoea, issue 41, June 1990. Published quarterly by AHRTAG, 1 London Bridge Street, London SE1 9SG, UK. 7 letters.. Jetters.. Jetters.. .

Traditional recipe Dr N Pierce of WHO replies: ORS for diabetics? Drs Meng and van Bruggen are correct that Thank you for DO39 on traditional beliefs ORS does not stop diarrhoea immediately, I have a problem for which an explanation and treatments for diarrhoea. The Burundian but neither do ‘anti-diarrhoeal’ drugs (they from your organisation will be of great help traditional method is to give the patient some only restrict bowel movements). It is better to me and my colleagues. The problem is honey and salt in a glass of water. I know to tell parents that ORS is medicine to make about management of moderate and severe this from experience - when I was a small their child feel better, and stronger. ORS will dehydration using ORS in diabetics (insulin child, my mother gave me this mixture, and make the diarrhoea stop, but after a few days. dependent and non-insulin dependent alike), it always seemed to help. since sugar forms a major part of the Simeon Bandy A Yera, P 0 Box 97, Local beliefs formula. Gitega, Burundi. Joshua N Wilson, Nguru Clinics and Following the ‘Viewpoints’ on local beliefs Maternity, P 0 Box 104, Nguru, Bomo Does ORS treat about diarrhoea (DD 39)) I would like to add State, Nigeria. some information from Kerala. Fewer diarrhoea? children here are dying of dehydration, Dr Peter Milla, Senior Lecturer,Institute Diarrhoea is recognised as one of the main because there is good access to medical ser- of Child Health, London, replies: killer diseases in children in developing vices. But, many people do not know how The problem is probably best considered in countries. Though the diarrhoea itself (more diarrhoea is caused, often believing that two parts: insulin dependent diabetes and than three loose stools per day) is usually a teething is responsible. non-insulin dependent diabetes. self-limiting problem, the death of many Mothers often give very diluted feeds of As far as insulin dependent diabetes is con- children can be caused by both the short and cows milk or infant formula to sick children, cerned, the difficulty is no greater than that long term effects of diarrhoea, including fearing that less watery food will cause posed for any severe infection in a diabetic dehydration and malnutrition. Many efforts indigestion. This means that many children dependent upon insulin, when control of the in Third World countries are therefore are underfed and sometimes malnourished. diabetes may be disturbed. The carbohydrate directed at the fight against these results of Fewer mothers from richer families are load imposed by oral rehydration solution is diarrhoea, not against the diarrhoea itself. breastfeeding their babies. Most people do not likely to be greater than that contained In this, ORS plays an important role. not understand that diarrhoea is caused by in the diabetic’s normal diet. Clearly, In our approach to the parents of sick germs in food or water, and that however, the electrolyte disturbance may children we should be very explicit. What breastfeeding provides the best and cleanest make control of the diabetes more difficult parents worry about most is the diarrhoea, possible food. Often, mothers go from one and it should be managed in the same way not dehydration or malnutrition. Though in doctor to another looking for an instant cure as any other severe infective process. I think our approach we say that we treat the diar- for their child’s diarrhoea, not realising that that if one remembers that the carbohydrate rhoea, in fact it doesn’t always stop it. Some they are putting the child in danger by not intake of a patient with diabetes is likely to of the methods used by parents to stop the giving it enough food. be within the region of 100 to 200g of car- diarrhoea can seem much more efficacious People do not understand that fluids are bohydrate depending on the severity of the than ours. For example, if they restrict needed during diarrhoea - they believe that process and the presence or absence of feeding or buy ‘anti-diarrhoeal’ drugs in the giving a child more to drink will only peripheral insulin resistance, then this allows market, they see that the frequency of stools increase the diarrhoea. Many mothers here between four and ten litres of oral rehydra- seems to diminish, but when they give oral know about ORS, but instead of using it at tion solution to be used each day if the patient rehydration fluids and continue feeding, the home, they will want to see a doctor is taking no diet by mouth. number of loose stools does not always whatever their financial or educational status. With regard to non-insulin dependent diminish. This does not help to build trust In Kerala, a two child family is accepted by diabetics, then the limiting factors are the in ‘a new way to treat diarrhoea’. most parents, and they want to do everything disturbance caused by the diarrhoeal infec- This problem has been raised in discus- possible to make sure that the children are tion and the carbohydrate restrictions sions with health workers in Cambodia who healthy. In our practice, we have found that imposed by dietary management. For those remarked: ‘We tried it, but the diarrhoea did home fluids such as home made rehydration on alO0g carbohydrate diet, then this is the not stop! ’ We have realised that the parents solutions, coconut water, and arrowroot equivalent in carbohydrate terms to four i do not care so much, or understand, about gruel are more acceptable to children than litres of OR solution per day. I think in dehydration. commercial ORS . ordinary clinical practice it is unlikely that Dr Chhour Y Meng and Dr G van Brug- Dr K Jacob Roy, Tropical Health Foun- this will pose a major problem. gen, Phnom Penh National Paediatric dation of India, Guravayar Road, Kun- Hospital, Cambodia. namkulam 680503, Kerala, India.

Scientific editors: Dr Katherine Elliott (UK) and Dr William Cutting (UK) Editor: Kathy Attawell. Assistant editor: Nina Behrman Editorial advisers: Professor J Assi Adou (Ivory Coast), Professor AG Billoo (Pakistan), Dr David Candy (UK), Dr Richard Feachem (UK), Dr Shanti Ghosh (India), Dr Michael Gracey (Australia), Dr N Hirschhorn (USA), Dr Claudio Lanata (Peru), Professor Leonardo Mata(C&a Rica), Dr Jon Rohde (USA), Dr Mike Rowland (UK), Ms EO Sullesta (Philippines), Dr Andrew Tomkins (UK), Dr Paul Vesin (France) \b,ilh CII.-._,.rl ‘.-m A In II IC A\ nnr II IIA I I.IIPCC uI”n IT:^,^_..^ ^_ T\:^....b.^^^:^ -..I_,:-L--l L..

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8 Dialogue on Diarrhoea, issue 41, June 1990. Printed in the United Kingdom by Bourne Offset Limited. ISSN 0950-0235