Who this is for: GPs and medical officers assessing children under 5 with acute diarrhoea in OPD settings, using the WHO IMCI framework to decide between home care, clinic rehydration and urgent referral.

Epidemiology in Pakistan

Diarrhoeal disease remains one of the top killers of Pakistani children, accounting for roughly 10 to 15 percent of under-5 deaths, with the average child suffering several episodes per year. Rotavirus, enterotoxigenic E. coli and other faecal-oral pathogens dominate; rotavirus vaccine has been in the national EPI schedule since 2017 but coverage is incomplete. Deaths are almost entirely from dehydration, which means almost all are preventable with ORS, zinc and correct triage; yet irrational antibiotic and antimotility prescriptions remain widespread in general practice.

Assessment: classify dehydration per IMCI

First ask duration (14 days or more is persistent diarrhoea) and blood in stool (dysentery). Then classify hydration with four IMCI signs: general condition, sunken eyes, thirst, and skin pinch on the abdomen.

  • Severe dehydration (any two): lethargic or unconscious; sunken eyes; unable to drink or drinking poorly; skin pinch goes back very slowly (2 seconds or more). This is Plan C and a referral emergency.
  • Some dehydration (any two): restless or irritable; sunken eyes; drinks eagerly, thirsty; skin pinch goes back slowly. Plan B in the clinic.
  • No dehydration: none of the above patterns. Plan A at home.

Also weigh the child (dosing and trend), check temperature, and screen the IMCI danger signs that apply to every sick child: unable to drink or breastfeed, vomits everything, convulsions, lethargy or unconsciousness. Any danger sign overrides everything and mandates referral.

Differentials and traps: dysentery (bloody stool), cholera-pattern profuse rice-water stools during outbreaks (interior Sindh and flood-affected districts), surgical abdomen (intussusception: episodic screaming, redcurrant stool, sausage mass; appendicitis in older children), severe acute malnutrition (skin pinch unreliable, low threshold to refer, rehydrate cautiously per SAM protocols), and diarrhoea secondary to sepsis, UTI or otitis media in infants.

Management by plan

Plan A (no dehydration, home care), the four rules:

  1. Give extra fluids: low-osmolarity ORS after each loose stool: 50 to 100 ml per stool under 2 years, 100 to 200 ml for 2 years and over, plus normal fluids; continue breastfeeding freely.
  2. Zinc for 10 to 14 days: 10 mg daily under 6 months, 20 mg daily for 6 months and over. Zinc shortens the episode and reduces recurrence for 2 to 3 months; dispersible tablets are cheap and DRAP-registered.
  3. Continue feeding: age-appropriate food during and extra food after the episode; do not rest the gut.
  4. Teach return-immediately signs: blood in stool, poor drinking, worsening, fever, vomiting everything.

Plan B (some dehydration, treat in clinic): give ORS 75 ml per kg over 4 hours by cup and spoon in small frequent sips, breastfeeding continuing throughout. Vomiting is not failure: pause 10 minutes, resume slower. Reassess at 4 hours and reclassify: improved to no dehydration means go home on Plan A (with zinc); unchanged means repeat Plan B; worse means Plan C. If the child simply cannot drink enough, nasogastric ORS at 20 ml per kg per hour for 6 hours is the WHO-sanctioned bridge where a tube is available, otherwise refer.

Plan C (severe dehydration): IV Ringer lactate 100 ml per kg: for infants under 12 months, 30 ml per kg over 1 hour then 70 ml per kg over 5 hours; for children 12 months to 5 years, 30 ml per kg over 30 minutes then 70 ml per kg over 2.5 hours. If you cannot give IV fluids, start ORS by NG tube or mouth en route and refer urgently; do not let the referral letter delay the first fluids.

What not to prescribe: no antimotility agents (loperamide is contraindicated in children), no routine antibiotics for watery diarrhoea, no antiemetic syrups as a reflex, no expensive probiotic cocktails in place of ORS. Antibiotics have exactly two OPD indications: dysentery (ciprofloxacin 15 mg per kg twice daily for 3 days per WHO) and suspected cholera in an outbreak (single-dose doxycycline or azithromycin per local health authority guidance), plus antibiotics as part of referral care for the severely ill.

Persistent diarrhoea (14 days or more) with any dehydration, or with malnutrition, is a referral; without either, work up feeding practices, consider lactose load reduction, give zinc and multivitamins, and review closely.

Red flags: refer or admit

Any general danger sign; severe dehydration; severe acute malnutrition; persistent vomiting of all intake; suspected surgical abdomen; high fever with toxicity; age under 2 months with diarrhoea (classify as possible serious bacterial infection); caregiver unable to manage home therapy.

Follow-up schedule

Review dysentery and persistent diarrhoea at 2 to 3 days (per IMCI follow-up rules), Plan B children within 24 to 48 hours, and any child whose caregiver reports return signs immediately. Check weight at follow-up; falling weight across episodes flags malnutrition needing nutrition-programme referral. MyPatient AI-prepared intakes record stool frequency, fluid intake and vaccination status before the consult, which keeps the short visit focused on classification and coaching. Give caregivers the patient guide to share on mixing and giving ORS at home.

Key points

  • Classify every child: severe dehydration (Plan C), some (Plan B, ORS 75 ml per kg over 4 hours), none (Plan A).
  • Zinc 20 mg daily (10 mg under 6 months) for 10 to 14 days in every episode.
  • Continue breastfeeding and feeding throughout; never rest the gut.
  • Antibiotics only for dysentery or outbreak cholera; antimotility drugs are contraindicated.
  • Danger signs, malnutrition, infancy under 2 months and persistent vomiting mean referral.
  • Vomiting ORS is managed by pausing and slowing, not by abandoning oral rehydration.

References

  • Integrated Management of Childhood Illness (IMCI) Chart Booklet. World Health Organization and UNICEF, 2014.
  • The Treatment of Diarrhoea: A Manual for Physicians and Other Senior Health Workers. World Health Organization, 2005.
  • Pocket Book of Hospital Care for Children, 2nd edition. World Health Organization, 2013.
  • WHO/UNICEF Joint Statement: Clinical Management of Acute Diarrhoea. WHO and UNICEF, 2004.
  • Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025 (GAPPD). WHO and UNICEF, 2013.

Clinical judgement and local protocols take precedence.