Diarrhoea Dialogue

ISSUE No. 2

BREAST OR BOTTLE weamng toods based on local products; better health education, training and information on infant feeding; and We were delighted that so many readers commented on the the preparation of an international code of marketing tin of baby milk powder in the picture from the Philippines practice. The International Baby Food Action Network is on page seven of the fist issue of Diarrhoea Dialogue. acting as a watchdog meanwhile to discourage milk power Everyone needs to be very much aware of the dangers advertising which influences mothers not to breastfeed involved when bottle-feeding becomes fashionable in parts their babies. Obviously there is still a long way to go but the of the world where the milk powder will inevitably be way is becoming more clearly signposted. Papua New mixed with unsafe water in an unclean bottle, in insufficient Guinea seems to have got off to a flying start by making amounts. Poverty and ignorance are to blame, not the feeding bottles available only on prescription.(*) We hope mothers, if bottle-feeding replaces breastfeeding and the to hear what is happening in other countries to help meet feeding bottle becomes the baby-killer through diarrhoea1 the WHO/UNICEF recommendations. disease and malnutrition. 1 Code of marketing practice 1980. The Lancet vol I: 1239-1240 WHO/UNICEF 1979 Joint WHO/UNICEF meeting on infant and young child feeding. WHO, 1211 Geneva 27, Switzerland 2 Aidou J et al 1979 Bottle-feeding and the law in Papua New Guinea. The Lancet ~011: 155 WHO READS DIARRHOEA DIALOGUE The first and most important group we aim to reach are the primary health care workers - those who are actually caring for children with diarrhoea. Within this group, there will be people with little or no knowledge of English. We hope that their trainers will help here by passing on the information in the newsletter and translating useful articles (see note on page two). Secondly, we are aiming at health planners and administrators who need to know about the dimensions and nature of the diarrhoea problem, so that they can apply their management skills to combat it. The third group are scientists and research workers who require information about new methods and techniques being tried out in other parts of the world, but may not have the opportunity of seeing all the relevant journals and papers. Finally, we hope to reach all those who have a general interest in health matters. In each issue of the newsletter we intend to have items that will be of interest to all these groups. If you feel that the balance is wrong, let us have Better health eduaNio0 00 infant feeding. your views. WHO photo by J. Abcede. Response to the first issue of Diarrhoea Dialogue has Diarrhoea Dialogue is well aware of the many sides to the shown that the newsletter is reaching all of its target baby food controversy; later issues will highlight some of groups. Many of you have written to us already to give your these. Meanwhile it is good to see that the 33rd World views on the content, design and future development of the Health Assembly in May endorsed the recommendations publication. We have been delighted and encouraged by from the WHO/UNICEF meeting on infant and young your response and the evidence that the newsletter will child feeding, held in October of last year.(‘) These ask for serve a real need. promotion of breastfeeding; work on the development of W.A.M.C. and K.M.E.

In this issue . . . 0 Jon Rohde discusses the importance of drinking in diarrhoea AHRTAG 0 what are the signs of dehydration? Appropriate Health Resources 8 0 news from Bangladesh, Turkey and The Gambia Technologies Action Group Ltd 0 questions and answers

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Oral rehydration ORT in Turkey Several interesting results emerged bibliography from an oral rehydration therapy (ORT) field study carried out in Ankara last year. Auxiliary nurse midwives were assigned to give ORT at home and to teach mothers to use the fluid. The ingredients were provided pre-packaged, mostly by UNICEF. The study was preceded by an information drive to educate the mothers on the need for early administration of the rehydration fluid and the im- casual factor in weanhg diarrhoea. portance of feeding a child suffering WHO photo by J. Mohr This is a very valuable review, which from diarrhoea. Members of the United Kingdom summarises 133 publications dealing The mothers’ acceptance of ORT Medical Research Council Dunn Nutri- with oral therapy of diarrhoea. The was high. It was found that consump- tion Unit carried out a study in Keneba, contents are set out in chronological tion of the oral fluid increased when its a subsistence farming community in order under five different headings: taste was good. Some of the locally The Gambia. They discovered that a history, clinical trials, composition, made mixtures were not found to be as high proportion of food consumed by impact and implementation. Each palatable as the one supplied by infants and young children was over- paper, study or letter is reviewed, often UNICEF, and this was reflected in the grown with bacteria. More thorough with a short comment on the relevance acceptance of fluid by the children. caoking methods failed to prevent con- of the authors’ conclusions. Some Another interesting observation was tamination, the most effective solution articles naturally cover several topics the clear preferences of the mothers to being to eat the food as soon as possible and there is adequate cross-referencing. use ready-made packages rather than after preparation. It provides important reference text the “pinch and scoop” method. Unfortunately, the conveniently thin for field and research workers con- In the Turkish experience, the use of gruels given to infants when breast- cerned with diarrhoea1 disease. Could ORT can be increased bv: feeding has stopped are not only poor it be improved in any way? It contains 0 participation of the community in nutritionally but also easily contami- indexes by author and country, but not the programme nated. During the rainy season when by subject. An alternative to a subject 0 provision of the ingredients in pack- diarrhoea1 illness is at a peak, levels of index might be to break down the five ages carrying health education food and water contamination are also major titles into sub-titles for the main messages to the mothers greatest. The seasonal nature of in- areas covered. 0 distribution of the packages through tensive farming also results in a lower- Even with the concerted efforts of grocers’ stores, in addition to the ing of the standards of child care at this individuals and organisations all over health services, to ensure availa- time. the world, diarrhoea1 disease and its bility Barrel1 R. A. E., Rowland M. G. M. serious consequences are likely to be a 0 inclusion of ORT in the curriculum 1979 Infant foods as a potential source problem for many years. Readers of of medical students and adopting of diarrhoea1 illness in rural West Diarrhoea Dialogue have already been this method of treatment in hos- Africa. Transactions of the Royal asking for an annotated bibliography pitals. Society of Tropical Medicine and about diarrhoea1 disease. This publi- Bertan M., Egeman A. 1979 ORT: Hygiene ~0173 (1): 85-90. cation meets that need and will be of the Turkish experience. WHO practical value well into the future. Chronicle ~0133: 132. However, because knowledge about Reproduction and prevention and management of diarrhoea is constantly increasing, the translation bibliography will need to be revised Infant foods and We are happy for readers to translate and updated every year or two. It is and reproduce articles or abstracts good to know there are plans to do this. weanling diarrhoea from Diarrhoea Dialogue in their own Free copies of the bibliography are In rural areas of The Gambia where publications with a suitable acknow- available from PAHO, 525, Twenty- there may be a shortage of firewood, it ledgement to AHRTAG. Please send third Street, N. W., Washington D.C., is common practice to prepare enough us a copy! Many of you have written to 20037, U.S.A. infant foods to last all day rather than ask whether the newsletter will be Baumslag Net al 1980 Oral for one meal. The food frequently published in other languages in the rehydration therapy: an annotated becomes contaminated, especially future. Translation into French, bibliography. Pan American Health during the rainy season. This con- Spanish, Portuguese and Arabic is Organization. ~~112, Spanish and tamination may be a casual factor in being planned and we will keep you English, free. weanling diarrhoea. informed about availability.

2 Diarrhoea Dialogue, issue 2, August 1980. Produced quarterly by AHRTAG at 85 Marylebone High Street, London Wl M 3DE. news n n n news n n n news n n n news n n n

panied by fever, vomiting and abdomi- hospital for a ten day follow up. Age, Stickiness and nal pain. The rate of secondary infection socio-economic status and neighbour- ranges from 20-25 per cent. In hos- hoods were matched in selecting con- sickness pitalized cases, the mortality rates for trols. Two to three pieces of soap and A symposium held at the Ciba Founda- severe shigellosis have been from 10 to earthenware pitchers for carrying tion in May discussed the relationship 15 times higher than for cholera - water were supplied to the study between the adhesion of micro- indicating that simple rehydration is families. People were advised to wash organisms and disease. Several parti- inadequate for treating this bacillus. their hands with soap and water before cipants illustrated how this area of The use of vaccines has not been meals. Regular checks were made to scientific research has particular encouraging and resistance to multiple see whether or not the soap was being relevance for the mechanisms and antibiotics is increasing. The whole used. control of some diarrhoeas. Bacteria situation is compounded by the appal- The overall secondary infection rate such as Escherichia coli can stick to the ling lack of sanitation in Dacca. in the hand-washing group was 10.4 per gut lining by means of hair-like struc- Members of the International Centre cent and in the control group 32.4 per tures called ‘pili’ or ‘fimbriae’ which for Diarrhoea1 Disease Research, cent. The secondary case rate in the enable them to colonise and cause Bangladesh (ICDDR,B) decided to hand-washing group was 2.2 per cent diarrhoea. Bacteria that don’t stick are find out whether a simple intervention, and in the control group 14.2 per cent. expelled without causing any symptoms without ofher changes in the environ- Providing soap and water considerably in the host. Veterinary scientists have ment or community, might lower the reduced both the secondary infection already discovered that strains of E. rate of shigellosis. Hand washing with rate and the severe effects of the coli that were causing diarrhoea in soap and water was chosen as a disease. It seems that a simple inter- piglets were not virulent unless they possibility. vention such as this, easily understood possessed pili called K88. A vaccine On the basis of stool cultures, cases and implemented even in adverse based on K88 has now been developed and controls were selected from the surroundings, can be very beneficial. that protects by preventing the adhe- (Personal communication from sion of E. coli to the intestine of Dr M. U. Khan) piglets. The mother pig is vaccinated and her milk contains the protective anti-body against K88. CHILD-to-child Dr M. M. Levine and his colleagues A programme is being run at the Insti- at Maryland University, Baltimore are tute of Child Health in London pro- looking at strains of E. coli that cause moting ways in which children can infant and travellers’ diarrhoea. There contribute to the healthy development are antigenically distinct types of pili of younger brothers and sisters. For and scientists must aim to make a example, older children can give oral vaccine that stimulates the body’s rehydration to younger members of the defence against sufficient of them to family with diarrhoea. Do you know of give wide protection from virulent any cases where this is happening? The strains. The Maryland team are looking Institute of Child Health is offering a for the most suitable combination to prize of books to anyone whose true test as a basis for a vaccine. Dr Levine account of older children helping to thinks that it will need to consist of rehydrate younger children is published about five sorts of pili. in Diarrhoea Dialogue. Please send Ciba Foundation 1981 Adhesion and your letters to the Executive Editor, microorganism pathogenicity (Ciba Diarrhoea Dialogue, AHRTAG, 85 Foundation Symposium 80). Pitman Marylebone High Street, London Medical, Tunbridge Wells. WlM 3DE, England.

Soap, water and The next issue. . . shigellosis 0 is planned for November/December 1980 Approximately six per cent of Dacca’s 0 will contain a main feature on health population is affected by shigellosis and education in relation to diarrhoea the incidence is increasing steadily. 0 will report on a diarrhoea1 diseases Shigellosis is an infection of the large control training programme for intestine by a group of bacteria which national programme managers be- frequently cause dysentery; diarrhoea ing organized by WHO with blood, pus and mucus in the Handwashing -a simple but effecttve prac- . will continue our practical advice tice to encourage. stools. It is an acute condition coming I- series on suddenly and is usually accom- WHO photo by D. Henrioud I

Diarrhoea Dialogue, issue 2, August 1980. Produced quarterly by AHRTAG at 85 Marylebone High Street, London Wl M 3DE. 3 Attitudes and beliefs about diarrhoea:

challenging traditional beliefs as far as possible - only questioning them To drink or not where they are definitely incompatible with the marketing objectives. to drink We must be absolutely clear about the product we are marketing; precisely what do we want the consumer to do? It Jon Rohde discusses the importance of mothers’ attitudes is drinking in response to diarrhoea towards drinking in the setting up of an effective oral that is the key element of oral rehydra- rehydration programme. tion. We do not necessarily need to change the concept of what diarrhoea is While the scientific community contin- Social marketing, however, has to or even the fact that it is potentially ues its debate on the ideal composition, start with the consumer. In marketing dangerous. Once the concept of drink- packaging and delivery of oral rehydra- oral rehydration we must first under- ing is accepted in the society then it is tion solution, many mothers continue stand the attitudes of the mother and relatively easy to discuss what is the to withhold fluid from children with design our product accordingly. Inter- best drink in the circumstances. diarrhoea. And why not? They know views with 254 mothers in a rural that when a child with diarrhoea is given Javanese community revealed that: extra fluid to drink he passes yet more 0 diarrhoea is not considered an liquid messy stools. This is true even illness but a normal occurrence in the with the most modem rehydration mix- young child’s life. tures. Although oral rehydration does 0 it is surely not dangerous, for all save lives, its widespread use will be young children suffer multiple episodes determined by complex cultural and of diarrhoea and most of them continue social factors which are little influenced to live in reasonably good health. by scientific advances. We must under- 0 appropriate medicine and visits to a stand the beliefs conditioning response health centre are not considered neces- to diarrhoea before an effective strat- sary for a condition which is not accept- egy can be developed to promote oral ed as one of ill health. rehydration. Seen in this light, it is hardly suprising that our scientific arguments for OR Local beliefs have little relevance in rural Java. Until now, a scientific approach has been used to market ORT, based on Marketing a message three main points: The usual health education approach is 1tlsdrlnkhglnt-eqwse todiarrhoeatllatis 0 diarrhoea is an illness to change the knowledge and attitudes the key element of oral rebydration. 0 it may be dangerous or even fatal of target groups, whereas effective WHO photo by P.A. Pittet 0 one effective modem remedy exists marketing strategy is based on the that can be drunk to overcome this present values and practices of the Strategy danger. consumer. Such a strategy should avoid Different concepts of diarrhoea drawn from several cultures suggest a variety Local Belief Possible Marketing Message of marketing possibilities. The health profession has tied its marketing strat- 1 Diarrhoea is a cleansing of Drink to replenish water, the egy for ORT exclusively to the last the body. cleansing element of the body. examole on the chart. However. a 2 The body dehydrates and loses Let the body drink to give strength. majoXty of health workers interviewed strength during diarrhoea. in Indonesia subscribed to views one, 3 Diarrhoea is a normal part of It is time to provide a tonic - two or three in preference to seven, growing up. extra fluid - to strengthen the despite an extensive re-education child’s developing body. campaign by the Ministry of Health 4 Diarrhoea is a hot illness. Respond with a cold drink. over the past five years. It is obvious therefore- that we must follow the 5 Athletes drink extra fluid to Diarrhoea also causes loss of example of the extensive ‘jamu’ replace salt and water lost in body salts and fluid. Let your (Javanese traditional herbal medicines) sweat. child regain strength through industry more closely if we are to drinking. develop a successful strategy. 6 Diarrhoea is an old and There are many useful traditional traditionally known condition remedies for diarrhoea. Communication of imbalance in life forces. The message should be communicated 7 Diarrhoea is a disease. Lives can be saved with the to mothers by as many means as pos- It kills by dehydration. newest remedy - oral rehydration. sible. Using the mass media is one

4 Diarrhoea Dialogue, issue 2, August 1980. Produced quarterly by AHRTAG at 85 Marylebone High Street, London Wl M 3DE. the mother’s role

obvious way to achieve this, but health planners have rarely maximised the potential. The “ . . .-that refreshes” means Coca Cola all over the world - has any health message ever been as widely popularized? Successful communication implies reaching decision makers at all levels; 1 this can sometimes be best achieved I through young people. In 1978, a village household survey in central Java revealed a universal withholding of fluid from children with diarrhoea. Six months later, after primary school teachers had given simple lessons on preparing and giving home-made sugar-salt solution, 80 per cent of the heads of these same households advised drinking extra fluid for diarrhoea.“’

Availability and impact It is vital that ORS is widely available before we attempt to market it and that the campaign reaches as many people as possible. While the effectiveness of oral rehydration in treating diarrhoea Photograph courtesy df Enriqueta 0. Sullesta cannot be questioned, its promotion itimate concern that mistakes in pre- have its own supply of ORS -although through the formal health system is paring such a solution may offset some this would be determined by finance, likely to reach only a small number of of the beneficial effects of the improved logistic support and shelf life of the people. But a broad campaign accepted rehydration mixtures. packets. Health workers are taught to by mothers at all levels of society to recognize simple signs of dehydration give extra drinking water to children Plastic spoon or failure of ORT, assuring rapid with diarrhoea could in itself lead to a A further refinement is to provide a referral to the health centre or district reduction in dehydration and deaths more reliable way to make rehydration hospital for serious cases. All children from diarrhoea. solution, such as the two-ended spoon. however would receive fluid to drink This was pioneered in Indonesia and from the first sign of diarrhoea. Measuring shown to be used properly by the vast Once the idea of drinking more majority of mothers there.(*) The cheap Conclusion becomes acceptable, the most appro- plastic spoon may perhaps serve as a The attitudes and beliefs of the mother priate fluid must be chosen depending reminder and a stimulus to the mother are crucial to the successful use of on cost, availability and the physical to provide fluid in both the right ORT. Only through sympathetic state of the child. The next step may be composition and quantity to her child, understanding of her attitude towards to provide home-made sugar-salt solu- starting with the earliest sign of diar- diarrhoea can we develop an appro- tion as a technical improvement on rhoea. The spoon can carry the import- priate, acceptable and effective strat- plain water. Finger pinches of salt, ant message not only of how to make egy that can rely on her active support. various hand or finger measures of the fluid, how much to give, but the What to drink and how to make it are of sugar and a variety of local containers importance of referral to the formal minor importance until mothers firmly such as gourds, coconut shells and tin health system if diarrhoea continues for believe that for diarrhoea their children cans have been tried for standard water more than 24 hours. Wholesale distri- should drink more. volume. Teaspoons, bottle caps, match bution of such spoons must obviously “)Rohde JE, Sadjimin T 1980 Elemen- boxes and drink bottles, even poly- be accompanied by clear instructions as tary school pupils as health educators: thene bags have all undergone field to their use. role of school health programme in trials for accuracy and acceptability in primary health care. The Lancet ~011: measuring the necessary quantities of Packets 91-92 sugar, salt and water. Success depends Village health posts can supply pack- “‘Hendrata L et al 1980. Pediatrica not only on the measuring technique aged ORS. Mothers initiate rehydra- indonesiana ~0120: 91-92 used, but also on training and the tion at home knowing that ORS is Jon E. Rohde, formerly at the Rockefeller existing socio-cultural conditions. available nearby if diarrhoea continues. Foundation, Yogyakarta, Indonesia and Given even the most successful strategy As demand increases it may become now c/o USAID, Port-au-Prince, Depart- for home made solutions there is leg- feasible to expect each household to ment of State, Washington DC 20521, USA.

Diarrhoea Dialogue, issue 2, August 1980. Produced quarterly by AHRTAG at 85 Marylebone High Street, London WlM 3DE. 5 Practical advice series

0 Loss of skiu elasticity The skin of a healthy child is elastic. If you pinch the How to recognize skin of the abdomen and then let go, the skin quickly flattens again. De- hydration makes a child’s skin dry and dehydration less elastic so when pinched it sticks up for some seconds before going flat Diarrhoea kills because it causes amount of dark coloured urine. Mothers again. If a child is very thin or very fat, dehydration. The stools of a healthy usually know how much urine their loss of skin elasticity is not easy to child contain relatively little water but a children have passed, so ask them if detect and therefore not a helpful sign child with diarrhoea passes very watery there has been less that usual. in diagnosing dehydration. stools which also contain vital salts 0 Condition If there is no dehydra- 0 Pulse Dehydration makes a child’s (sodium, sodium chloride, potassium tion, a child will appear alert and well. pulse faster and weaker. When he and bicarbonate). If the losses are At a later stage, he will be weak, becomes severely dehydrated, it may great, both the water and the salts must irritable and may look unwell or sleepy. not be possible to feel the pulse at the be replaced or the child will die. To A severely dehydrated child may wrist, you may have to feel at the groin recognize the signs of dehydration it is appear very sleepy or be unconscious. or listen to the heart. (With very severe necessary to ask, look, feel and, if He may also have fits or convulsions: dehydration, the pulse is sometimes possible, weigh the child. 0 Sunken eyes A child’s eyes lie in slow). soft, wet, fatty tissue. If he becomes Important signs and symptoms dehydrated, this tissue shrinks and 0 Stools Ask about the number and becomes drier and his eyes sink back size of the diarrhoea stools. Has there into his skull. His eyes also lose their also been vomiting? These answers shining appearance and stay half open may also give clues to the severity of when he is asleep. dehydration. 0 Dry mouth A dehydrated child l Thirst This may be the earliest cannot make enough saliva and so his sign of dehydration. Until a child has mouth and tongue become dry. This is lost more than five per cent of his body an important sign. weight, dehydration causes few signs. 0 Breathing Sometimes, a severely A seriously dehydratedchild. When severely dehydrated, a child may dehydrated child breathes fast and Photograph courtesy of TALC not be fully conscious and may be deeply. This kind of breathing occurs 0 Sunken fontanelle The fontanelle unable to drink. when a child has been dehydrated for is the soft place between the bones at 0 Urine A healthy child usually some days or has been rehydrated with the top of a baby’s skull. It is large when passes urine about every three hours. the wrong fluids. Do not mistake this he is born but closes over by the time he The body of a dehydrated child tries to deep, fast breathing for the shallow, is about 18 months old. When a baby save water and only produces a small rapid breathing of pneumonia. becomes dehydrated, his brain and tissues in the skull lose water and shrink. The fontanelle sinks down between the bones of the skull. 0 Loss of weight This may occur quickly during a few hours or over several days. A severely dehydrated child may have lost a tenth or more of his normal body weight. If he weighed ten kilograms before the onset of diarrhoea, he may have lost at least a kilo of water and may now weigh only nine kilograms. Loss of weight due to malnutrition occurs more slowly over several weeks or months. 0 little or no urine; l fast, weak pulse the urine is dark Conclusion Dehydrated children need urgent rehydration and should be encouraged to 0 sudden weight loss 0 loss of elasticity or stretchiiess of the drink even if vomiting occurs. Those skin with severe dehydiatio and complica- tions such as convul

6 Diarrhoea Dialogue, issue 2, August 1980. Produced quarterly by AHRTAG at 85 Marylebone High Street, London Wl M 3DE. Questions and answers

From: Bertrand R. Saubolle, Katb- Breast milk depends upon the mother’s foods are gradually being added to mandu, Nepal. food intake and her body reserves and supplement and eventually to replace Thank you for a copy of the first issue of it is the baby’s sucking which makes the the breast milk. Diarrhoea Dialogue. I am a primary milk flow. The baby should be put to About rehydrating with contami- school teacher in Kathmandu Valley the breast as soon as possible after birth nated water-we shall be discussing this with no medical training. I often walk and encouraged to suck very often even in detail in future issues. The current through a neighbouring village where I when there seems to be very little milk. belief is that bad water is better than no havIe been struck by the number of The baby should suck at both breasts water in diarrhoea. In your situation do people suffering from intestinal dis- every time, starting on alternate sides, try to keep breastfeeding going, how- orders, the commonest being worms, so that both breasts are stimulated as ever severe the diarrhoea, because the diarrhoea and dysentery. For several frequently as possible. The colostrum milk will provide some protection as years I have supplied them with San- (the yellowish fluid which is in the well as additional fluid. tonine for worms and sulphaguanadine breast at birth and during the first day for diarrhoea. As these poor villagers or two afterwards) is valuable to the From: Maurice Bauhabu, Saginaw, are not accustomed to medicines, I baby both as food intake and because it U.S.A. administer very small doses and obtain contains protective substances. Can we have more discussion of the remarkable results. People are cured of It is virtually impossible for a mother diagnosis of diarrhoea please? A brief7y diarrhoea in three days, but after a not to be able to produce milk for her annotated bibliography on oral re- fortnight they come back for more pills. baby if the baby sucks frequently hydration therapy would also be useful. I have come to the conclusion that it is enough and if she eats and drinks as I would also like to see more emphasis not the pills that are required but the on the villager's problem of wanting and much as she can. The family needs to absolutely necessary measures of understand that the mother must eat at procuring clean water. elementary sanitation - pure drinking least her fair share of the food that is New knowledge about the pathological water and the use of toilets. Cured available because she is feeding both agents of diarrhoea will be presented in people promptly re-infect themselves by the baby and herself. It is the quantity later issues of Diarrhoea Dialogue. drinking contaminated water. of food the mother gets, that is more Detecting these infecting agents is You say on page five of the first issue important than the quality, but adding often technically difficult and expen- that ‘there is no excuse to stop breast- dark green leaves, some kind of pulses sive. The situation is complicated by feeding’, With many mothers here, it is (peas, beans, lentils etc) and perhaps a the fact that a number of the organisms not a question of stopping but beginning little fat such as oil or butter to the associated with diarrhoea may some- breastfeeding. They are so under- cereal will help. She also needs some times exist in the bowel without causing nourished that they simply cannot extra rest and a great deal of reas- loose stools or disease. Whatever the produce milk. I have seen very young surance and support from all around origin of diarrhoea, the end result is babies being fed on a gruel of rice or her - family, friends and health similar; a loss of water from the body wheat, whichever happens to be in workers. with various amounts of other com- season. The mothers long to breastfeed ponents and salts. The danger of It is of course the mother who should but they often just cannot. What is one to diarrhoea is due to this dehydration be eating the rice gruel rather than do in such cases? I have recommended a and the imbalance of electrolyte: and varied diet stressing high protein foods giving it to the baby. She is much less body constituents. Because of this, no such as eggs, soya beans, lentils and likely than the baby to develop diar- matter what the cause, the first action rhoea from contaminated water or food fruit. This is a mockery for the people, should be to replace the water lost. The because she has had time to build up however, who cannot afford a diet like more severe the losses, the more her own natural immunity. If she can this. They eat a little parched grain and, precise should be the replacement of if they can get it, rice with boiled nettle or breastfeed even for a few months, she fluids. There are relatively few cases of will pass some of her protection on to fern tips. Is there any medicine or other diarrhoea in which you need to know means that will activate the mothers’ the baby. the precise diagnosis in order to give glands and help them produce milk? Ideally, breastfeeding should con- specific medicine or treatment; re- For babies with diarrhoea, what is the tinue, with additional foods being hydration is always the first essential use of recommending OR T if the drink gradually given to the baby after the step to be taken. is prepared with contaminated water? first few months, for at least two years A useful annotated bibliography has Mothers cannot see why they should in the kind of situation you describe. now been published by PAHO (see waste firewood boiling water only to let Family spacing helps too. A birth review on page 2). Finally, issues four it cool so that the baby can drink it cold. interval of at least three years gives and five of Diarrhoea Dialogue will What is one to do? I feel frustrated and babies a better chance of survival in concentrate on the relationship be- at the end of my ability. When one poor circumstances. The mothers can tween diarrhoea, water and sanitation. works among the poorest of the poor, recover more of their own reserves The questions on this page have been what can one do to help without having between pregnancies and breastfeed- to do eraerything? answered by the editors. In future, we ing. The longer interval also means that plan to enlist the help of our panel of You raise two important points. How mothers can give the youngest child editorial advisers and other experts to can undernourished mothers produce more care and attention, especially provide as extensive an answering service milk? There is no magic medicine. through the weaning period when other as possible for readers.

Diarrhoea Dialogue, issue 2, August 1980. Produced quarterly by AHRTAG at 8.5 Marylebone High Street, London WlM 3DE. 7 letters n n n letters n n n letters n F n letters n n n

Oral rehydration Easy reading the spoons so that instructions are I read with interest the first issue of We have just received the first issue of printed on them in the Iban language. Diarrhoea Dialogue discussing the use Diarrhoea Dialogue and I would like to We have also translated the instruction of specially prepared oral rehydration congratulate you upon it. We are sheet into Iban, with some additional packages. However, it seems to me that strongly of the opinion that an eight instructions to grind rock salt into a fine in the short term such packages will be page publication such as this is likely to powder before use and to top up the too expensive and not readily available be read and the mixture which you have glass before tasting the mixture. for extensive use in developing of illustration and news seems excel- We have also adapted Jon E. countries. lent. I think too that your type is easily Rohde’s story of Abdul and Seri into a I work with a project for strength- read which is very important. We local cartoon book for distribution to ening health delivery systems in Central much look forward to receiving future the people as well as converting this and West Africa which is based at issues. into an audio visual set for use in the area. Boston University. As part of the P.J.S. Hamilton, Caribbean Epidem- We will be evaluating the use of the project, we recently developed training iology Centre, PO Box 164, Port-of- spoons and expect to collect samples of materials for trainers of village health Spain, Trinidad, West Indies. workers. The materials are currently the reconstituted oral rehydration fluid being field tested and a final version for laboratory analysis. will be ready sometime in 1981. Paul C.Y. Chen, Faculty of Medicine, One of the main tasks envisaged for University of Malaya, Kuala Lumpur the village health worker in these 22-11, West Malaysia. materials is the education of mothers in the use of oral rehydration. The train- Successful use of ORT ing materials have been reviewed by We are very interested in Diarrhoea health personnel with wide experience Dialogue and would like to continue in working in rural areas. They stressed receiving it. We have recently visited the need for health education and the several countries in the Caribbean to use of alternative methods of oral promote oral rehydration therapy, rehydration. The general need for notably - Belize, Guyana, Antigua, nutrition education is relation to the St. Vincent and St. Lucia. An explosive treatment of diarrhoea was also outbreak of diarrhoea in Antigua was stressed. successfully controlled with only four Sif Ericsson, Health Policy Institute, deaths out of 400 cases using oral Boston University, Boston, Massachu- rehydration fluid made up in the hos- setts, USA. pital. Even the records clerks were Oral rehydration therapy being given at rehydrating children. Appropriate and practical home. At Bustamante Hospital for Child- Thank you for sending me a copy of Photograph by Dr William Cutting ren, the method is now routine and the Diarrhoea Dialogue for inspection. I Teaching material infectious ward has been shut, drips was well impressed with it. It seems to Thank you very much for sending me have been almost discontinued and me that this is the appropriate literature the first issue of Diarrhoea Dialogue. I mortality is down. With early re-feed- for many people to have whose con- am writing in response to your question ing, hospital stay has been decreased cerns are with the many real and regarding teaching material available and nutrition improved. Getting it out practical difficulties of applying not in local languages. I currently have a into the other areas is a problem only oral rehydration but also public pilot project area in primary health because of supplies and training, but health preventive medicines. It seems care involving the use of young people we have assisted in one regional and to me clearly written and generally as well as traditional medicine men as other national seminars for the Carib- sound in content and I wish it great village based primary health care bean. The critical factor seems to be success. workers. As one aspect of the project whether or not the area has an inter- D.A.J. Tyrrell, Clinical Research we have introduced the use of special ested pediatrician. Centre, Division of Communicable spoons purchased from Professor P.S.E.G. Harland, Department of Diseases, Watford Road, Harrow, David Morley of the Institute of Child Child Health, University of the West i Middlesex. Health in London. We have modified Indies, Mona, Kingston 7, Jamaica.

Editors: Dr William Cutting (U.K.) and Dr Katherine Elliott (U.K.) Editorial advisers: Dr I. Dogramaci (Turkey), Dr Richard Feachem (U.K.), Dr Michael Gracey (Australia), Dr N. Hirschhorn (U.S.A), Dr D. Mahalanabis (India), Dr Leonardo Mata (Costa Rica), Dr Mujibur Rahaman (Bangladesh), Dr Jon Rohde (Rockefeller Foundation), Dr E. 0. Sullesta (Philippines), Dr Paul Vesin (France), Dr M. K. Were (Kenya). Diarrhoea Dialogue is produced by AHRTAG at 85 Marylebone High Executive editor: Denise Ayres With support from WHO and Street, London WIM 3DE. Designer: Dick lnglis UNDP Tel 01-486 4175.

8 Diarrhoea Dialogue Printed in the United Kingdom by Bourne Offset (Iver) Ltd.