Worms in children and deworming tablets: what parents should know

Intestinal worms are common in Indian children, but most children with a few worms have no symptoms at all. Regular deworming with albendazole, given free on National Deworming Day, is safe. Handwashing, toilets and footwear matter just as much, because children pick worms up again. Here are the questions parents ask Dr Dutta most about worms and deworming tablets.

How do children get worms?

Most worms spread through soil dirtied by human stool. Children swallow the eggs from unwashed hands, raw vegetables or unsafe water, and hookworm larvae can enter through bare feet.¹

The common gut worms are roundworm, whipworm and hookworm. Their eggs need about 3 weeks in soil before they can infect anyone, so they do not pass directly from one person to another.¹ Children who play in mud, eat with unwashed hands, or walk barefoot near drains are most at risk.

Threadworms (also called pinworms) are different. They spread directly between people, through eggs on fingers, bedding and toys.²

How common are worms in Indian children?

Very common. A review of 44 Indian studies covering over 34,000 children found roundworm in about 1 in 4 children, whipworm in about 1 in 8, and hookworm in about 1 in 10.³

Rates varied hugely from place to place. The biggest risk factors were open defecation and washing hands with water only, without soap.³ Children in crowded areas, slums and villages without toilets are at highest risk, but city children in good homes get worms too.

What are the signs of worms in a child?

Most children with a light infection have no signs at all. Heavier infections can cause tummy pain, loose stools, poor appetite, weakness and poor growth.¹

Other things parents notice:

• worms in the stool, or a roundworm coming out in vomit
• itching around the bottom at night (usually threadworms)
• pale skin and tiredness from anaemia (hookworm)
• a child who is not gaining weight despite eating

A very heavy roundworm load can block the bowel, which needs surgery.¹ A swollen tummy with repeated vomiting needs a doctor the same day.

Many signs blamed on worms, such as a big appetite, nose picking or drooling, are not reliable.

Can worms cause anaemia in children?

Yes, especially hookworm. Hookworms feed on blood from the gut wall, and over months this slow blood loss can cause anaemia (too little haemoglobin, the iron-rich protein that carries oxygen in blood).¹

Worms also reduce appetite and the absorption of nutrients.¹ But worms are only one cause of anaemia. In India, poor iron intake is the bigger cause in most children.

A large Cochrane review found that giving deworming tablets to all children in a community probably made little or no difference to average haemoglobin.⁴ So if your child is pale, do not just give a deworming tablet and wait. Ask for a blood test, and give iron-rich foods: green leafy vegetables, dal, eggs, meat or fish, with citrus fruit to help absorption. Jaggery adds very little usable iron, so do not rely on it.

My child is pale and tired. How do I know if it is anaemia?

The only reliable way is a blood test for haemoglobin. Signs like pale palms, pale inner eyelids, tiredness and poor concentration suggest it, but they appear late.

Other clues are breathlessness on climbing stairs, a fast heartbeat, eating mud, chalk or ice, and frequent illnesses. Your paediatrician will check the haemoglobin, may look for the cause, and usually prescribes iron drops or tablets for a few months. Deworming may be given along with this, but on its own it is rarely enough.

Does teeth grinding mean my child has worms?

Not usually. Teeth grinding at night is common in healthy children and usually has nothing to do with worms.

One study in Egypt did find that mothers reported grinding more often in children whose stool tests showed worms or other gut parasites.⁵ But that kind of study cannot show that worms cause grinding, and it relied on parents' reports.

Grinding is often linked to sleep, stress, a blocked nose or the teeth settling as they come in. A deworming tablet is harmless if it is due anyway, but do not expect it to stop the grinding. If grinding is loud and every night, or your child snores or wakes tired, see your doctor or dentist.

Why does my child's bottom itch at night?

Night-time itching around the bottom is the classic sign of threadworms. The female worms come out at night to lay eggs around the anus, and the eggs cause intense itching.²

You may see tiny white worms, like bits of thread, in the stool or around the bottom while your child sleeps. Children may be irritable and wake at night. Girls may also itch around the vagina.²

Scratching puts eggs under the nails. From there they reach the mouth, clothes, toys and food, so the cycle continues.² A doctor can confirm it with a sticky tape test, pressed on the skin around the bottom first thing in the morning.⁶

How are threadworms treated?

Threadworms are treated with a single deworming dose, usually repeated after 2 weeks, plus treating everyone in the house at the same time.⁶

NHS advice is to treat every household member aged 2 or over, even those without symptoms, and to see a doctor for a child under 2.² The medicine kills worms but not eggs, and eggs can survive up to 2 weeks outside the body.² So hygiene matters:

• keep nails short and scrub under them
• a bath or wash every morning
• wash night clothes, sheets and towels in hot water
• do not share towels

Children do not need to miss school.²

How often should children be dewormed in India?

In India, children aged 1 to 19 years are dewormed twice a year under government programmes.⁷

WHO advises regular deworming of children who live in areas where worms are common, without first testing each child.¹ India is one such country, and government programmes call for deworming every 6 months for children and teenagers aged 1 to 19.⁷

A child with symptoms, or a family with a threadworm problem, may need treatment outside these rounds. Your paediatrician will advise.

What is National Deworming Day?

National Deworming Day is the government programme that gives a free albendazole tablet to every child aged 1 to 19 years, at schools and anganwadi centres, on a fixed day.⁷

Children who are absent are covered on a "mop-up" day soon after. Children who are ill on the day should not be given the tablet, and should take it after recovering.⁷ Teachers and anganwadi workers give the tablet under supervision, and children are asked to wait for a while afterwards in case of side effects.⁷

Many states hold two rounds a year.

What is the albendazole dose for children?

Under the national programme, children aged 1 to 2 years get half a 400 mg albendazole tablet, and children aged 2 to 19 years get one full tablet.⁷

Older children should chew the tablet and drink some water. For toddlers, the guideline advises breaking the tablet, crushing it between two spoons, and giving it with water.⁷ Never force a whole tablet into a small child's mouth, as they can choke.

Syrups are also available. If you buy albendazole privately, check the dose with your doctor.

Is albendazole safe for my child?

Yes. Albendazole has been given to millions of children with few side effects, and those that happen are mild.¹

Some children have mild tummy pain, nausea, vomiting, headache or dizziness after the tablet. These are more common in children with many worms, and usually pass on their own.⁷ The programme guidance says that if symptoms last more than 24 hours or are severe, something else is likely to be going on and the child should be taken to a health facility.⁷

It is fine to take the tablet on an empty stomach.⁷

Can babies under 1 year be dewormed?

Routine deworming in India starts at 1 year of age.⁷ Babies under 1 year should only be given worm medicine if a doctor has checked them.

Young babies who are exclusively breastfed rarely get worms, because they are not yet putting soil and food into their mouths. Worms become more common once a baby starts crawling and eating solid food. For threadworms in a child under 2, see a doctor rather than buying medicine from the chemist.²

Does deworming help children grow taller or do better at school?

For a child with a heavy worm load, treatment clearly helps. But giving tablets to every child in a community has shown little effect on average height, haemoglobin or school marks in recent trials.⁴

The Cochrane review found that older studies showed weight gains, but newer and larger trials since 2000 did not.⁴ WHO points to a large fall in illness from worms in the decade when deworming programmes expanded.¹

My view: deworming is safe, cheap and worth doing. But it does not replace good food, iron, toilets and handwashing.

How can I prevent worms in my child?

Handwashing with soap, using toilets, wearing footwear outdoors and clean water prevent most worm infections.

A review of 94 studies found that handwashing with soap, access to toilets and treated water were all linked with fewer worm infections. Wearing shoes was linked with about 70% lower odds of hookworm.⁸

• Wash your child's hands with soap before meals and after the toilet.
• Keep nails short and clean.
• Make your child wear chappals outside, especially near drains and fields.
• Wash, peel or cook vegetables and fruit before eating.¹
• Give boiled or safely filtered water.

When should I take my child to a doctor about worms?

See a doctor if your child has:

• a swollen, painful tummy with repeated vomiting, or worms in the vomit
• blood or mucus in the stool
• pale skin, breathlessness or unusual tiredness
• weight loss or poor growth
• bottom itching that continues after treatment and hygiene steps
• symptoms lasting more than 24 hours after a deworming tablet, or severe symptoms after it⁷
• a baby under 1 year, or a child under 2 with threadworms