Read the paragraph and sort out treatment plans and management
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python3 << 'EOF' import pdfplumber pdf_path = "/tmp/workspace/attachments/3df56843-7899-4193-bef3-1c60235bac48/diarreha who guidelines.pdf" with pdfplumber.open(pdf_path) as pdf: print(f"Total pages: {len(pdf.pages)}") for i, page in enumerate(pdf.pages[:5]): text = page.extract_text() if text: print(f"\n--- PAGE {i+1} ---") print(text[:2000]) EOF
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python3 << 'EOF' import pdfplumber pdf_path = "/tmp/workspace/attachments/3df56843-7899-4193-bef3-1c60235bac48/diarreha who guidelines.pdf" with pdfplumber.open(pdf_path) as pdf: full_text = "" for i, page in enumerate(pdf.pages): text = page.extract_text() if text: full_text += f"\n\n--- PAGE {i+1} ---\n" + text print(full_text) EOF
Here is a fully organized summary of all treatment plans and management strategies from the WHO Diarrhoea Guidelines:
WHO Diarrhoea Treatment Plans & Management
TREATMENT PLAN A - Home Therapy (No Signs of Dehydration)
Goal: Prevent dehydration and malnutrition at home.
4 Rules:
-
Give more fluids than usual
- Suitable fluids with salt: ORS solution, salted rice water, vegetable/chicken soup with salt
- Suitable fluids without salt: plain water, unsalted rice water, yoghurt drinks, green coconut water, weak unsweetened tea
- Fluids to AVOID: carbonated beverages, commercial fruit juices, sweetened tea, coffee, medicinal teas
- Dose after each loose stool:
- Under 2 years: 50-100 ml
- 2-10 years: 100-200 ml
- Older children/adults: as much as they want
-
Give zinc supplementation
- 10-20 mg/day for 10-14 days
- Can be given as syrup or dispersible tablets
- Reduces duration/severity and lowers risk of future episodes for 2-3 months
-
Continue feeding
- Never withhold food; do not dilute usual foods
- Continue breastfeeding always
- Infants not breastfed: usual milk/formula every 3 hours by cup
- Offer food every 3-4 hours (6 times a day)
- Recommended foods: cereals, vegetables, meat/fish/egg, bananas, yoghurt, potassium-rich foods
- After diarrhoea stops: give one extra meal per day for at least 2 weeks
-
Take child to a health worker if:
- Many watery stools, repeated vomiting, very thirsty, eating/drinking poorly, develops fever, blood in stool, or no improvement in 3 days
TREATMENT PLAN B - Oral Rehydration Therapy (Some Dehydration)
Setting: Health facility
ORS amounts in first 4 hours (by weight/age):
| Age | Weight | ORS Volume |
|---|---|---|
| <4 months | <5 kg | 200-400 ml |
| 4-11 months | 5-7.9 kg | 400-600 ml |
| 12-23 months | 8-10.9 kg | 600-800 ml |
| 2-4 years | 11-15.9 kg | 800-1200 ml |
| 5-14 years | 16-29.9 kg | 1200-2200 ml |
| ≥15 years | ≥30 kg | 2200-4000 ml |
(Approximate calculation: weight in kg × 75 ml)
How to give:
- Use clean spoon or cup, not bottles
- Children under 2: one teaspoon every 1-2 minutes
- If vomiting: wait 5-10 min, restart more slowly (one spoon every 2-3 min)
- Continue breastfeeding throughout
After 4 hours - reassess and decide:
- Signs of severe dehydration → move to Plan C
- Still some dehydration → repeat Plan B; also offer food and fluids
- No signs of dehydration → patient is fully rehydrated; switch to Plan A; give 2 days' ORS packets to take home
If ORT fails:
- Nasogastric (NG) tube: ORS at 20 ml/kg/hr for 6 hours
- IV Ringer's Lactate at 75 ml/kg over 4 hours
Zinc: Begin as soon as child can eat after initial 4-hour rehydration.
Food: No food (except breastmilk) during initial 4 hours; food every 3-4 hours if Plan B extends beyond 4 hours.
TREATMENT PLAN C - Severe Dehydration (Urgent)
Setting: Hospital (if possible)
IV Rehydration - Ringer's Lactate Solution 100 ml/kg:
| Patient | First 30 ml/kg | Then 70 ml/kg |
|---|---|---|
| Infants (<12 months) | over 1 hour | over 5 hours |
| Older children/adults | over 30 minutes | over 2.5 hours |
- Reassess every 15-30 min until radial pulse is strong; then every hour
- Give ORS by mouth while setting up the IV drip (children who can drink)
- Also start oral ORS (~5 ml/kg/hr) once child can drink (within 3-4 hours in infants, 1-2 hours in older patients)
After 3 hours (older patients) or 6 hours (infants) - reassess:
- Still severe dehydration → repeat Plan C
- Some dehydration → discontinue IV, give ORS for 4 hours (Plan B)
- No dehydration → switch to Plan A
If IV not available:
- NG tube: 20 ml/kg/hr for 6 hours (total 120 ml/kg)
- If NG not possible and child can drink: oral ORS at 20 ml/kg/hr for 6 hours
- If neither is possible: transfer immediately to facility with IV capability
MANAGEMENT OF CHOLERA (Suspected)
- Treat dehydration per Plan B or C (as appropriate)
- For severe dehydration/shock: restore blood volume rapidly (adults ~50 kg: 2 L within 30 min, remainder within 3 hours)
- Rice-based ORS preferred over standard ORS for cholera
- Unusually large ORS volumes may be needed (average 200 ml/kg in first 24 hours, some up to 350 ml/kg)
- Antimicrobial therapy (all severe dehydration cases):
- 1st choice: Doxycycline (adults 300 mg once) or Tetracycline (adults 500 mg 4x/day × 3 days; children 12.5 mg/kg 4x/day × 3 days)
- Alternative: Erythromycin (children 12.5 mg/kg 4x/day × 3 days; adults 250 mg 4x/day × 3 days)
- First dose given 4-6 hours after starting rehydration (when vomiting stops)
MANAGEMENT OF ACUTE BLOODY DIARRHOEA (Dysentery)
- Assess and treat/prevent dehydration per Plan A/B/C
- Continue feeding
- Antimicrobial therapy for 3-5 days:
- 1st choice: Ciprofloxacin (children 15 mg/kg 2x/day × 3 days; adults 500 mg 2x/day × 3 days)
- Alternatives: Pivmecillinam (children 20 mg/kg 4x/day × 5 days) or Ceftriaxone IM (children 50-100 mg/kg once/day × 2-5 days)
- Follow-up after 2 days if: initially dehydrated, under 1 year, had measles in last 6 weeks, not improving
- If no improvement after 2 days → change antimicrobial; if still no improvement → refer to hospital
- Ineffective antimicrobials for Shigella (never use): metronidazole, streptomycin, tetracyclines, chloramphenicol, sulfonamides, amoxycillin, nitrofurans, aminoglycosides, 1st/2nd generation cephalosporins
- Amoebiasis: treat ONLY if trophozoites of E. histolytica (with RBCs) confirmed in fresh stool by reliable lab
MANAGEMENT OF PERSISTENT DIARRHOEA (≥14 days)
Objectives: Restore weight gain and normal intestinal function.
Four pillars of treatment:
- Fluids: ORS per Plan A/B/C; IV rehydration if glucose malabsorption suspected
- Nutritious diet (low lactose):
- Outpatients: continue breastfeeding; yoghurt instead of animal milk; limit animal milk to 50 ml/kg/day; small frequent meals (at least 6x/day)
- Hospital - 1st diet (reduced lactose): cow's milk + cooked cereal + vegetable oil + sugar (83 kcal/100g); target 110 kcal/kg/day
- Hospital - 2nd diet (lactose-free, reduced starch): egg + rice + vegetable oil + glucose (75 kcal/100g); used if 1st diet fails
- Supplementary vitamins and minerals for 2 weeks:
- At least 2 RDAs of: folate (50 μg/day), zinc (10 mg/day), vitamin A (400 μg/day), copper (1 mg/day), magnesium (80 mg/day)
- Targeted antimicrobials for diagnosed infections:
- Bloody diarrhoea → treat for Shigella (see above)
- Amoebiasis → Metronidazole (children 10 mg/kg 3x/day × 5-10 days; adults 750 mg 3x/day × 5-10 days) - only if confirmed
- Giardiasis → Metronidazole (children 5 mg/kg 3x/day × 5 days; adults 250 mg 3x/day × 5 days) - only if cysts/trophozoites confirmed
Admit to hospital if: serious systemic infection, signs of dehydration, or infant under 4 months.
Monitor: weight daily; re-evaluate outpatients after 7 days; refer if no weight gain or diarrhoea not improving.
MANAGEMENT OF DIARRHOEA WITH SEVERE MALNUTRITION
- Always treat in hospital
- Dehydration assessment is unreliable; assume dehydration if history of watery diarrhoea
- Rehydration: oral or NG only (NOT IV except for shock); 70-100 ml/kg over 12 hours; start ~10 ml/kg/hr
- Modified ORS (do NOT use full-strength ORS): dissolve 1 ORS packet in 2 L water + 45 ml KCl solution + 50 g sucrose → lower Na (37.5 mmol/L), higher K (40 mmol/L)
- Feeding begins 2-3 hours after starting rehydration, every 2-3 hours, day and night
- Initial diet: skimmed milk 25g + vegetable oil 20g + sugar 60g + rice powder 60g + water to 1000 ml (75 kcal/100 ml); give 130 ml/kg/day
- Subsequent diet (after appetite returns): skimmed milk 80g + vegetable oil 60g + sugar 50g + water to 1000 ml (100 kcal/100 ml); target 120-200 ml/kg/day
- Add mineral/vitamin mixture to both diets (KCl, K citrate, MgCl₂, Zn acetate, CuSO₄, NaSeO₄, KI)
- Antimicrobials: ALL severely malnourished children get broad-spectrum cover on admission: gentamicin + ampicillin (or equivalent broad-spectrum combination)
- Supplementary iron: only after weight gain is established
MANAGEMENT OF ASSOCIATED PROBLEMS
| Problem | Management |
|---|---|
| Fever | Treat underlying infection; paracetamol for high fever (≥39°C); screen for malaria if in endemic area; check for pneumonia, UTI, otitis media |
| Convulsions | Febrile: paracetamol + tepid sponging; Hypoglycaemia: 5 ml/kg of 10% glucose IV over 5 min; Hyper/hyponatraemia: treat with ORS |
| Vitamin A deficiency | Oral vitamin A: 200,000 units (1-5 yrs), 100,000 units (6-12 months), 50,000 units (<6 months); give 2 doses on consecutive days |
| Hypernatraemia | Treat with ORS solution (normalizes Na within 24 hours); avoid IV |
| Hyponatraemia | ORS solution is safe and effective (except children with oedema) |
| Hypokalaemia | ORS solution + potassium-rich foods (bananas, coconut water, fruit juice) |
DRUGS TO AVOID (Never Use in Children)
- Antidiarrhoeal drugs: adsorbents (kaolin, attapulgite), antimotility drugs (loperamide, diphenoxylate, codeine), bismuth subsalicylate
- Antiemetics (prochlorperazine, chlorpromazine)
- Cardiac stimulants/vasopressors (for dehydration shock)
- Blood/plasma (for dehydration - use electrolyte fluids instead)
- Steroids
- Purgatives
- Routine antimicrobials for non-specific diarrhoea
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