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Care priority and warning signs
Care priority
Routine Management / Treat with Antibiotic
Red flags
- Signs of severe dehydration.
- High fever.
- Convulsions.
- Abdominal distension or severe pain.
- Failure to respond to first-line antibiotic.
Assessment
- Ask: Does the child have diarrhoea?
- Ask: Is there blood in the stool? (Confirm visually if possible, or rely on mother's report).
Classification
- Blood in the stool -> DYSENTERY
Key features
- Presence of blood in the stool is the defining feature.
- Requires treatment with an antibiotic effective against Shigella (first-line typically Ciprofloxacin in this guideline).
Management
Non-pharmacological management
- Treat dehydration according to classification (Plan A, B, or C) if present.
- Advise on increased fluid intake (Plan A principles).
- Continue feeding.
Pharmacological treatment
- Give oral Ciprofloxacin twice daily for 3 days. Dosage (15mg/kg/day divided twice daily): Age <6m: 125mg per dose (1/4 of 500mg tab or 1/2 of 250mg tab). Age 6m-5y: 250mg per dose (1/2 of 500mg tab or 1 of 250mg tab).
- Give Zinc Sulphate 10-20mg once daily for 10 days (as per doses in Plan A/B).
Pre-referral treatment
- If severe dehydration or another severe classification is present, provide appropriate pre-referral treatments along with the first dose of Ciprofloxacin if possible before urgent referral.
Follow-up
- Follow up in 2 days.
- At follow-up (Day 2):
- Assess general condition, check for fever, dehydration, abdominal pain, number of stools, blood in stool, feeding.
- If dehydrated: Treat dehydration (Plan B or C).
- If condition is worse (more stools, more blood, higher fever, worse abdominal pain, poor feeding) OR same: Change to second-line oral antibiotic recommended locally for Shigella (treat for 5 days). Advise return in 2 days OR Refer to hospital (especially if <12m, dehydrated on first visit, or had measles recently).
- If improving (fewer stools, less blood, less fever, less pain, eating better): Continue Ciprofloxacin for the full 3 days. Ensure mother understands oral rehydration and feeding.
Counselling points
- Explain the diagnosis (dysentery) and the need for antibiotic.
- Teach how to give Ciprofloxacin: correct dose, frequency (twice daily), duration (full 3 days).
- Teach how to give Zinc for 10 days.
- Advise on giving extra fluids (ORS/home fluids) and continuing feeding.
- Advise when to return immediately (danger signs, signs of dehydration, worsening dysentery).
- Advise on follow-up visit in 2 days.
Differential diagnosis
- Amoebiasis (less common cause of dysentery in young children compared to Shigella)
- Campylobacter infection
- Salmonella infection (non-typhoidal)
- E. coli (invasive strains)
- Intussusception (may present with 'red currant jelly' stool)
- Anal fissure (streaks of fresh blood on stool surface)
- Allergic colitis (e.g., milk protein allergy)
Complications
- Severe dehydration
- Sepsis
- Intestinal perforation (rare)
- Toxic megacolon (rare)
- Hemolytic Uremic Syndrome (HUS - associated with E.coli O157:H7, rare Shigella strains)
- Reactive arthritis
- Persistent diarrhoea
- Malnutrition
Prevention
- Handwashing with soap (especially after toilet use, before handling food).
- Safe disposal of faeces.
- Use of safe drinking water.
- Safe food handling practices.
- Exclusive breastfeeding.
- Measles vaccination.
References
IMCI Chart Booklet - Page 3, Page 14 (Ciprofloxacin), Page 16 (Zinc), Page 22 (Follow-up)