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Treatment is with metronidazole mgs three times a day for five days , and diloxanide furoate mgs three times a day for ten days for those who continue to have cysts in their stools. Particularly in Egypt and the Sudan, intermittent large-intestinal diarrhoea can result from Schistosoma mansoni and S.

Praziquantel or oxamniquine are now the treatments of choice; older drugs are less effective and also more toxic. In children, heavy infections with Trichuris trichiura may very occasionally produce chronic, bloody diarrhoea and mebendazole mgs three times a day for three days is the treatment of choice.

Infections associated with antibiotics Antibiotics are widely used in developing countries and antibiotic-associated, pseudo-membranous colitis is an occasional sequel, especially with clindamycin, and lincomycin, but most antibiotics have been incriminated in this condition. Bowel damage is probably caused by the toxin from growth of a bacterium, Clostridium dificile, in the gut. Treatment with other antimicrobials, vancomycin and metronidazole is usually effective. They may be started or exacerbated when visitors move from temperate climates to the tropics. Colonic carcinoma is also unusual in tropical populations but should not be forgotten as a treatable cause of chronic bloody diarrhoea.

Professor G. Diarrhoea Dialogue 7: Diarrhoea Dialogue 8: Diarrhoea Dialogue 6: Feeding and chronic diarrhoea After initial rehydration, proper feeding is essential for recovery from chronic diarrhoea. Adequate protein, energy and other essential nutrients must be provided from food to reduce the risk of further episodes of diarrhoea, protein energy malnutrition PEM and death. Starvation is never appropriate. Even in chronic diarrhoea some food will be absorbed and is important for bowel function as well as nutrition.

Feeding by mouth limits the atrophic changes in the small intestine and pancreas associated with complete withdrawal of oral feeds. It is also psychologically valuable to maintain eating habits. Importance of breast milk Breast feeding should be continued wherever possible, even during initial rehydration, because breast milk provides important immunological protection against infection as well as being the safest, cheapest and most nutritious food for young children with chronic diarrhoea.

Where socially acceptable, freshly expressed, donated breast milk or 'wet nursing' can help out if the mother's own supply is insufficient or has been discontinued and cannot be re-established. Cow's milk may damage the intestinal lining causing subsequent intolerance. It should therefore be avoided where alternatives are available but soya-based formulae e. Home made versions, like ground nut milk, and some commercial preparations are not sufficient as the only food source 1. Sucrose cane and beet sugar intolerance is thought to be uncommon.

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Starches, such as rice powder or arrowroot, are well tolerated but again, in chronic diarrhoea, their low protein, mineral and energy content demands very careful supplementation. Supplementary foods Supplementary solids should be given as milk free multi-mixes made from locally available foods selected for high energy and nutrient content. Small portions should be offered five to eight times a day and the child coaxed to eat. Oral fluids to maintain hydration must be continued for as long as diarrhoea persists.

Body stores of potassium are depleted in chronic diarrhoea so foods high in potassium are important, for example, bananas, orange and pineapple. Highly spiced foods, e. Food should be freshly prepared, ideally for each meal, to reduce the risk of microbial infection.

Take great care to protect and preserve food which will be fed later. At the Hospital for Sick Children, London, I frequently use a diet made from commercially prepared comminuted very finely ground chicken 2. This can be adapted for developing countries see Table A. Other mammalian milks are sometimes tolerated by children sensitized to cow's milk protein, but these need modification for infants along the lines given for goat's milk in Table B.

In a very sick infant the diet can be started at half strength, the sugar introduced to the full dose over three to four days and the oil emulsion added on the fifth to seventh day. A complete mineral supplement including macro calcium, phosphorous, magnesium, sodium, potassium and trace minerals zinc, copper, iron, etc. If possible, mothers and other relatives should help, not only with the actual feeding, but also with the preparation of any special diet. This will encourage them to continue to provide suitable food after the child returns home.

It is important to follow up undernourished children, especially those with chronic diarrhoea.

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Long-term malnutrition predisposes to further infections creating the vicious cycle of more malnutrition leading to death. British Medical Journal 2: Journal of Human Nutrition From: Andre Briend, Dakar, SenegalIn my clinic every morning I give children a bowl of soured milk ml plus three spoons of cooking oil 30 ml and three pieces of sugar 15 g , and I advise the mother to give more of the mixture in the afternoon.

This seems to be well tolerated and also very much appreciated by children which is very important. I used this mixture after several empirical attempts to find something cheap, palatable and nutritious, but I must admit I have never tested its value by a rigid scientific protocol. I would appreciate the opinion of Diarrhoea Dialogue. Children at Dr Sultana Khanam's nutrition centre in Dacca. In this issue of Diarrhoea Dialogue we are concerned about nourishment for children with diarrhoea, particularly those with chronic diarrhoea who often have protein-energy malnutrition PEM.

There is still much uncertainty about what food is best and this will certainly vary in different parts of the world. The principles and the ingredients you use are sound. Food should be nutritious, readily available, acceptable and effective. I realize that there is quite a wide variation among "experts" as to the sodium concentration of the rehydration fluid. What is considered the optimum range and the limits of safety? One tends to ask, "does it really matter, as long as the child drinks something, be it tea, Coca-Cola or fruit juice". The purpose of oral rehydration in diarrhoea is to replace the water and electrolytes salts that have been lost in stools, and also to correct other metabolic imbalances.

For example, many children with severe diarrhoea have become acidotic and have deep rapid respiration. The "ideal" replacement fluid for a particular case depends on the cause of diarrhoea and the severity of the losses when the child is seen by the health worker.

It also depends on a special mechanism of the bowel that enables it to absorb more fluid if water and electrolytes are mixed with carbohydrate, usually sugar or glucose in a particular proportion. Theoretically it should be possible to prepare a precise solution for an individual case. In practice the procedure is simplified and there are three sorts of fluid which are recommended. In mild cases where diarrhoea has just started and the losses from the body are slight, extra fluids of almost any sort are valuable and the body can make its own corrections.

Offer water, tea, fruit juice or whatever the child is used to drinking, and any fluid that is accepted by the local people as being suitable in diarrhoea. In severe cases the body needs a fluid which will correct the deficiencies more precisely.

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The mixture contains bicarbonate to correct acidosis, and quite a lot of sodium because a significant number of children with severe diarrhoea in some countries have cholera and they need extra salt. This mixture is safe for other sorts of diarrhoea too, so long as ORS solution is given only to replace stool losses, and extra simple fluid, like water and fruit juice, is given to provide for the ordinary daily intake and metabolic needs.

Sugar-salt fluid There are intermediate cases which do not need precise replacements, but will benefit from the greater uptake due to the "linked-absorption mechanism" when a sugar-salt fluid is given. Such a mixture is not dependent on the availability of special packets, can be made up in most kitchens and is known to be very effective. What is the best proportion of sugar and salt? It is not necessary to be absolutely accurate, but too much sugar and salt, especially salt, can be harmful. If 5 ml teaspoons are available, one level teaspoonful of salt and eight level teaspoonfuls of sugar in one litre of clean water is good.

Remember the correct amount of water is as important as the correct amount of sugar and salt! About a cupful ml of this mixture ought to be given for each stool passed. Where there is vomiting as well as diarrhoea, the fluid should be given in small, frequent sips.

The importance of continuing breastfeeding during diarrhoea. We have been using ORT both in our hospital paediatric wards and in the community quite successfully for the last few years. However, with few studies on the use and safety of ORS for newborns and infants we have been hesitant in using it for this age group. Normal feeds, whether breast milk or other were continued in all patients. Fortunately we have not come across any case with hypernatraemia or any untoward complications.

Though this is a preliminary study it has wider application especially in the community. I would much appreciate the experience of other workers in the use of ORT in newborns and small infants. Meenakshi N. Mehta, Professor of Paediatrics, L. Hospital, Sion, Bombay - , India. Holme T et al. Proceedings of the Third Nobel Conference.

As I see it, the essence of ORT is that it should be carried out by mothers and the key to its success lies in its early implementation - with or without packets. There are possibilities of error however oral rehydration solutions are made up. This brings us back to the vital importance of education and understanding in oral rehydration therapy. Don't let us make yet another simple life-saving remedy the prerogative of the professionals. Rees, P. Diarrhoea: a problem everywhere We have three community health workers working with non-English speaking women.

Some of the information in Diarrhoea Dialogue would be very useful to them. The most frequent reason for admission of children to hospital locally is gastroenteritis. Almost all the children admitted with diarrhoea have been bottle-fed. Sad to say, most health workers in the community do not seem to be familiar with simple oral rehydration therapy.

There is an implicit connection between the picture of the child with kwashiorkor and the picture showing local ingredients for oral rehydration fluid i. It should be stressed that children with kwashiorkor are particularly susceptible to oedema and congestive failure when given a salt load unaccompanied by potassium. The Lancet vol. On-line since What is diarrhoea? Why is it dangerous? Diarrhea Fact Sheet..

Causes 19 percent of child deaths.. How to prevent it.. Good foods during Diarrhoea.. Diarrhoea Management Training Course.. Clinical Management of Acute Diarrhoea.. Teaching Medical Students. Dialogue on Diarrhoea.. Subject Index.. Country Reference Index.. Author Index. How to treat dehydration.. Treatment Plans. Save 1 million a year..

How ORT works.. What the Experts say.. A Solution for survival.. Whiteman George W. Whiteman Tug Charles Clarke, N. Richardson, W. Williams Douglas H.

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Merchants and industrialists in particular prospered during this period. In the early Western Han, the wealthiest men in the empire were the merchants who produced and distributed salt and iron, [7] acquiring wealth that rivaled the annual tax revenues collected by the imperial court. Emperor Wu of Han r. However, these policies imposed great hardships on the people; banditry and armed revolts were occurring by Emperor Wu's death. As complaints surfaced criticizing more and more about the government's policies, the regent Huo Guang , who was the de facto ruler of China after Emperor Wu of Han , called a court conference to debate whether the policies of Emperor Wu should be continued.

The reformists, largely provincial Confucian scholars, backed privatization and a return to the laissez-faire policies of old. The modernists, on the other hand, largely represented the interests of the central government and were more in tune with legalist philosophy, as well as being admirers of the previous Qin dynasty , whose harsh and numerous laws had been based on legalist principles. The reformist view was based on the Confucian ideal which sought to bring about the betterment of man by conformity to fundamental moral principles.

To achieve this, they wished to reduce controls, demands for service, and taxation to a minimum. The reformists' criticism of the monopolies largely centered on the idea that the state "should not compete with the people for profit", as it would tend to oppress the citizenry while doing so; mercantile ventures were not "proper activities for the state". In addition, the reformists complained that the state monopolies oppressed the people by producing low-quality and impractical iron tools that were useless and made only to meet quotas, yet which the peasants had to pay for regardless of their quality.

The modernists were headed by Sang Hongyang , an ex-merchant who had been selected by Emperor Wu to administer to his new interventionist policies. They also claimed that private workshops were too small, unspecialized, and poorly equipped.