Diarrhoea in Children: How to Make ORS and When It Is an Emergency
Diarrhoea means three or more loose or watery stools in a day, or a clear change from what is normal for that child. Almost all of it is caused by an infection and settles within a week. The danger is not the diarrhoea itself but the water and salts lost with it, so the whole of treatment is replacing them. Give oral rehydration solution after every loose stool: under two years, 50 to 100 ml; two to ten years, 100 to 200 ml; older children, as much as they will take. Mix one sachet in the exact volume of clean water printed on the packet, usually one litre but sometimes 200 ml, using boiled and cooled or safe bottled water, and never add sugar, salt, milk or juice to it. Throw away any left after 24 hours. Give zinc as well: 20 mg once daily for ten to fourteen days from six months of age, 10 mg daily below six months, which shortens the illness and reduces the chance of it returning. Keep breastfeeding and keep feeding normal food. Do not give anti-diarrhoeal medicines to a child and do not give antibiotics unless a doctor prescribes them. Go to hospital for sunken eyes, no urine for six hours or more, a child too sleepy to drink, blood in the stool, or repeated vomiting that stops fluids staying down.
Health writers · Aslam Clinic
What diarrhoea is, and what it is not
Diarrhoea means three or more loose or watery stools in a day, or a clear change from what is usual for that child. The change matters more than the count.
A breastfed baby normally passes soft, yellow, sometimes frequent stools, occasionally after every feed. That is not diarrhoea. What is different in diarrhoea is that the stools become watery and much more frequent than that baby's normal, and the child may vomit or become less lively.
Most childhood diarrhoea is caused by a , most often rotavirus in the youngest children, and it settles within three to seven days without any specific medicine. Contaminated water and food are the other route, carrying such as E. coli, shigella, salmonella and, in an , cholera. Some parasites cause a longer, more grumbling illness. None of that changes the first priority, which is fluid.
How to tell how dehydrated a child is
| What you check | No dehydration | Some dehydration | Severe dehydration |
|---|---|---|---|
| How the child is | Alert, behaving normally | Restless, irritable, clingy | Lethargic, floppy or unconscious |
| Eyes | Normal | Sunken | Deeply sunken |
| Drinking | Drinks normally | Thirsty, drinks eagerly | Drinks poorly, or unable to drink |
| Skin pinch on the abdomen | Flattens at once | Flattens slowly | Takes more than two seconds |
| Urine | As usual | Less than usual, darker | None for 6 hours or more |
| Tears | Present | Reduced | Absent |
| What it needs | ORS at home after every stool, plus zinc | ORS given steadily, ideally supervised at a clinic that day | Emergency. A drip is needed now, not ORS |
How to prepare ORS, exactly
is not just sugary water. It contains a precise balance of and , because the sugar is what pulls the salt and water across the gut wall and into the body. That balance is why the proportions matter and why making it stronger is harmful rather than helpful. Sachets cost a few rupees at any pharmacy and are free at government health facilities.
- Wash your hands with soap before you start.
- Read the sachet. Most WHO-standard sachets are made for one litre. Several brands sold in Pakistan are made for 200 ml or 500 ml. The correct volume is printed on the packet. Using the wrong one either wastes the sachet or makes a solution that is dangerously concentrated.
- Measure clean water into a clean jug or bottle. Use water that has been boiled and cooled, or safe bottled or filtered water. If you must boil, bring it to a rolling boil for one minute and let it cool completely before mixing.
- Pour in the whole sachet and stir until it is fully dissolved. Never use part of a sachet.
- Do not add anything. No extra sugar, no extra salt, no milk, no juice, no honey, no fizzy drink. Do not mix it into milk or soup.
- Taste it if you are unsure. It should taste no saltier than tears. If it tastes strongly salty, throw it away and start again.
- Keep it covered. Use within 24 hours, then throw the rest away and make fresh. Do not keep it in a warm place.
How much to give, and how
- After every loose stool: under 2 years, 50 to 100 ml — roughly a quarter to half a large cup. Age 2 to 10, 100 to 200 ml. Over 10, as much as the child will drink.
- Give it slowly. A teaspoon or two every one to two minutes for a small child. A cup drunk fast usually comes straight back up.
- If the child vomits, stop for ten minutes, then start again more slowly. Vomiting is not a reason to give up on ORS; it is a reason to slow down.
- Use a spoon, a cup or a syringe rather than a bottle for a small child, so you can control the pace.
- Keep breastfeeding throughout, and more often than usual. Breast milk is fluid, food and protection all at once. ORS is given in addition to breastfeeding, never instead of it.
- Also offer other safe fluids — plain water, rice water, thin yoghurt lassi without sugar, clear soup with a little salt.
- Keep going until the diarrhoea stops, and continue offering extra fluid for a day afterwards.
Zinc
Zinc is the second half of the treatment and is skipped far too often. WHO and UNICEF recommend it for every episode of childhood diarrhoea. It shortens the illness by about a day, reduces how severe it is, and lowers the chance of another episode in the following two to three months. It is sold over the counter as a syrup or dispersible tablet and is inexpensive.
- From six months of age: 20 mg once a day for 10 to 14 days.
- Under six months: 10 mg once a day for 10 to 14 days.
- Continue the full ten to fourteen days even after the diarrhoea has stopped. That is what produces the protection against the next episode.
- A dispersible tablet can be dissolved in a little breast milk, ORS or clean water.
- It may cause some vomiting in the first day or two, particularly on an empty stomach. Give it after a feed.
Feeding through and after the illness
Withholding food is an old instruction and a harmful one. The gut recovers faster when it is fed, and a child who stops eating for several days loses weight that takes weeks to regain.
- Keep breastfeeding on demand, and offer the breast more often than usual.
- Do not dilute formula or animal milk with extra water. Give it at normal strength.
- Offer small amounts of ordinary food often, rather than three large meals. Khichri, boiled rice, dal, banana, potato, plain roti, and dahi are all suitable and are what most homes already have.
- Yoghurt is well tolerated and useful.
- Avoid very sugary drinks, packaged juices and fizzy drinks throughout, and avoid very oily food while the gut is upset.
- After the illness, give one extra meal a day for two weeks. This is how the lost weight is regained, and it is the step most often forgotten.
What not to give
- Anti-diarrhoeal medicines such as loperamide. They stop the gut moving rather than treating anything, and in young children they can cause dangerous abdominal swelling and drowsiness. WHO advises against them in children outright.
- , unless a doctor prescribes them. Most diarrhoea is viral, antibiotics do not help it, and they frequently make it worse. They are reserved for bloody diarrhoea, suspected cholera and specific confirmed infections, where an untreated infection can progress to . Careless use is a direct cause of the drug-resistant typhoid now seen across Pakistan.
- Injections bought from a medical store to stop the motions. There is no such safe treatment for a child.
- Anti-vomiting medicines given without advice. Some are unsuitable for children and can cause muscle spasms and drowsiness.
- Stopping breastfeeding. This is common advice and it is wrong. It removes the safest fluid and the best nutrition the child has.
Preventing the next episode
- Handwashing with soap after using the toilet, after cleaning a child, and before preparing food or feeding. This alone prevents a large share of episodes.
- Safe drinking water. Boil for one minute at a rolling boil and store covered, or use a reliable filter or chlorination drops. Store water in a covered container with a tap or a ladle, not a cup dipped in by hand.
- Rotavirus , given free in Pakistan's EPI schedule at six and ten weeks of age. It prevents the most severe form of infant diarrhoea.
- Exclusive breastfeeding for the first six months, then continued breastfeeding alongside food.
- Safe food — cooked thoroughly, eaten fresh, kept covered, and not left standing in the heat. Wash fruit and vegetables in clean water.
- Safe disposal of stools, including a baby's, and cleaning the area afterwards.
- Keep the child's card up to date and take it to every visit.
When to see a doctor
Go to hospital immediately for any danger sign in the box above. See a doctor the same day if the child is under six months, if there is blood in the stool, if there is high fever, if vomiting means ORS will not stay down, or if the child is not improving after two days of proper rehydration. Book an appointment for diarrhoea lasting more than a week, for weight loss, or if episodes keep returning. If your child also has a fever, our article on fever in children sets out the danger signs to check alongside these.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
