Doctors Revision

Pediatrics & Child Health

IMCI Approach: Diarrhoea & Dehydration (2m-5y)

Assessment, classification, and management of diarrhoea and dehydration in children aged 2 months to 5 years using the IMCI approach.

Also known as: IMCI Diarrhoea Management, Childhood Diarrhoea Assessment

Open in the interactive guide
On this page

Referral and warning signs

When to refer

Urgent Referral: Any child classified with Severe Dehydration OR Severe Persistent Diarrhoea OR Dysentery not improving after 3 days OR Any child with diarrhoea AND a General Danger Sign. Refer child with Persistent Diarrhoea (no dehydration) if not improving after 5 days. Refer child with Some Dehydration if associated with another severe classification or cannot drink.

Red flags

  • Any General Danger Sign.
  • Signs of Severe Dehydration.
  • Blood in stool.
  • Diarrhoea >= 14 days.
  • Signs of shock (cold extremities, weak pulse, delayed capillary refill).

Signs and symptoms

  • Ask:
  • - Does the child have diarrhoea?
  • - If yes, for how long?
  • - Is there blood in the stool?
  • Look and Feel (Assess for Dehydration):
  • - General Condition: Lethargic or unconscious? Restless or irritable?
  • - Eyes: Sunken?
  • - Thirst: Offers fluids - Unable to drink or drinks poorly? Drinks eagerly, thirsty?
  • - Skin Pinch (Abdomen): Goes back very slowly (>2 sec)? Goes back slowly (<2 sec)?

Risk factors

  • Poor sanitation and hygiene.
  • Contaminated water or food.
  • Malnutrition.
  • Lack of immunization (Rotavirus).
  • HIV infection.
  • Lack of exclusive breastfeeding (<6 months).

Diagnosis

Clinical assessment

History of diarrhoea duration and presence of blood. Assessment of dehydration level based on general condition, eyes, thirst, and skin pinch.

Investigations

  • Clinical assessment using IMCI algorithm is primary.
  • Stool microscopy/culture (usually referral level, indicated for persistent diarrhoea or dysentery not responding to treatment).
  • Electrolytes (referral level, if severe dehydration or IV fluids needed).

Diagnostic criteria

IMCI Classification based on signs: Dehydration: - Severe Dehydration: Any 2 signs: Lethargic/unconscious, Sunken eyes, Unable to drink/drinks poorly, Skin pinch >2 sec. - Some Dehydration: Any 2 signs: Restless/irritable, Sunken eyes, Drinks eagerly/thirsty, Skin pinch <2 sec. - No Dehydration: Not enough signs for Some or Severe. Duration/Blood: - Severe Persistent Diarrhoea: Diarrhoea >=14 days AND Dehydration present. - Persistent Diarrhoea: Diarrhoea >=14 days AND No Dehydration. - Dysentery: Blood in stool.

Management

Non-pharmacological management

  • All Diarrhoea:
  • - Fluid Management: Based on dehydration level (Plan A, B, or C).
  • - Zinc Supplementation: Give Zinc 20mg (1 tab) daily for 10 days (Age >6m) OR 10mg (1/2 tab) daily for 10 days (Age 2-6m).
  • - Continued Feeding: Continue breastfeeding frequently. Continue usual feeds, offer food more frequently.
  • - Counsel mother on danger signs and when to return immediately.
  • - Counsel on hygiene and sanitation.
  • Plan A (No Dehydration): Home management. Give extra fluids (ORS after each stool, age-appropriate amounts), continue feeding, Zinc. Follow up 5 days if not improving.
  • Plan B (Some Dehydration): Facility-based ORS therapy over 4 hours (approx. 75ml/kg). Reassess frequently. Start feeding after 4 hours. Teach Plan A for home. Follow up 5 days if not improving.
  • Plan C (Severe Dehydration): Urgent IV fluid resuscitation (Ringer's Lactate or Normal Saline 100ml/kg divided - see Emergencies chapter 1.1.3). Start ORS when able to drink. Reassess frequently. If IV not possible, NGT ORS (20ml/kg/hr for 6h) or urgent referral. If cholera suspected, give antibiotic.
  • Persistent Diarrhoea: Advise on specific feeding recommendations (nutrient-dense foods). Give multivitamins + Zinc for 14 days. Give Vitamin A. Follow up 5 days. If dehydrated or not improving, refer.
  • Dysentery: Treat dehydration if present. Give Ciprofloxacin (see below). Follow up 3 days.

Pharmacological treatment

  • Oral Rehydration Salts (ORS): Essential for all dehydration plans. Prepare and give as instructed.
  • Zinc Sulphate: 10mg (2-6m) or 20mg (>6m) daily for 10 days for ALL diarrhoea cases.
  • Dysentery: Ciprofloxacin 15 mg/kg PO BID for 3 days.
  • Cholera (Suspected, Severe Dehydration, Age >=2y): Add Erythromycin 12.5 mg/kg QID for 3 days (or alternative based on local sensitivity - Doxycycline/Azithromycin often used in adults).
  • Severe Persistent Diarrhoea: Vitamin A dose + Multivitamins including Zinc for 14 days.
  • Severe Dehydration (IV Fluids): Ringer's Lactate or Normal Saline (0.9% NaCl) - refer to specific IV fluid protocols (UCG 1.1.3.1).

Monitoring

Monitor hydration status frequently during rehydration (Plan B/C). Follow up as per classification (3 days dysentery, 5 days others if not improving). Assess feeding and weight. Monitor response to antibiotics if given.

Complications

  • Severe dehydration -> Shock, Renal failure, Death.
  • Electrolyte imbalance (hypokalaemia, hypernatraemia).
  • Malnutrition.
  • Persistent diarrhoea.
  • Haemolytic Uraemic Syndrome (HUS - rare, with E.coli O157).

Prevention

  • Exclusive breastfeeding for 6 months.
  • Improved sanitation and access to clean water.
  • Handwashing with soap.
  • Safe food preparation.
  • Rotavirus vaccination.
  • Measles vaccination.
  • Vitamin A supplementation.

Patient education

  • How to prepare and give ORS (frequent small sips).
  • Importance of Zinc for 10 days.
  • Need for continued feeding (more frequent small meals).
  • Signs of dehydration and when to return immediately.
  • Hygiene measures (handwashing, safe water/food).
  • How to give antibiotics if prescribed (Ciprofloxacin for dysentery).

Uganda-specific notes

Diarrhoea is a major killer of children under 5. Promotion of ORS + Zinc is critical. Rotavirus vaccine is included in EPI. Shigella is a common cause of dysentery; Ciprofloxacin is first-line. Cholera outbreaks occur periodically.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 17, Section 17.3.3

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 1, Section 1.1.3.1 (Dehydration Plans)

  • IMCI Chart Booklet, MOH Uganda

    (Diarrhoea Algorithm)

Scroll to Top