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Prognostic significance of initial management of childhood diarrhoea in rural areas: an observational study

Background: To identify current evidence in order to guide scaling up of initial management of diarrhoea among children of age group 2-60 months in rural areas of the country. Methods: This hospital based cross sectional study included all children 2 months to 60 months of age admitted with chief complains of loose stools in the last 7 days over a period of one year. A pre-tested questionnaire was used as the data collection tool and face to face interviews were conducted on mothers of children. All the data were analyzed using IBM SPSS version 20 software. Chi-square/Fisher Exact/ Student t-test and ANOVA test has been used. Significance was assessed at 5%. Results: Data showed the use of antibiotic in 55.9% cases, IV fluids in 50.3%, ORS in 6.7%, zinc in 2.0% and blood transfusion in 13.8% cases as an initial management of diarrhoea in peripheral health care centers. Of these, 37.6% cases were severely dehydrated, and 8.14% cases were in shock at the time of admission. 10.1% mothers did not intervene in the first 3 days of the disease whereas 45.2% consulted some health care center only in the later part. 4.5% cases expired after admission of which 69% were malnourished. Conclusions: This study summarizes the importance of initial management of a child with diarrhoea in defining the further course of the disease and also the failure of effective promotion and propagation of the most appropriate and cost-effective therapy (ORS and Zinc) for diarrhoea in this part of the country. Pre-existing malnutrition further complicates the situation.


INTRODUCTION
Although India has made a steady progress in reducing diarrheal deaths in children younger than five years, it still remains an important killer in developing countries like ours. Remarkable reduction in mortality rates was observed after inception and introduction of various health programmed such as expanded programmed on immunization, control of diarrheal disease programmed and introduction of Oral Rehydration Therapy (ORT). Total deaths declined from 2.5 million in 2001 to 1.5 million in 2012. 1 Even though the total deaths have declined, the proportional mortality rate still remains high. Children under age 5 account for about half the cases and deaths. 2 Diarrheal control does not require higher technology. Simple measures like breast feeding, improved sanitation, safe drinking water, hand washing, hygienic practices and access to basic health care can control the major percentage of these episodes. 3 UNICEF diarrheal data 2015 states that only 39% infants of age less than 6 months receive exclusive breast feeding whereas only 35% children with diarrhoea receive ORT. 4 Large, protract ted outbreaks with high case-fatality ratios reflect a lack of adequate preparedness, early detection, prevention and timely access to healthcare. These explosive and deadly outbreaks affect the whole of society and can disrupt essential services. Information on diarrheal diseases, its determinants in India and preventive and control strategies in light of recent developments need to be reviewed for better planning and organization of health services within the community.

METHODS
This was a hospital based cross sectional study, in which all children in the age group of 2 months to 60 months were included over a period of one year who were admitted with chief complaints of loose stools in the last 7 days. A pre-tested questionnaire was used as the data collection tool and face to face interviews were conducted with mothers of children. Data regarding diarrheal episode, initial management done at home, family outlook towards diarrheal diseases, health seeking behavior of caretakers, use of ORS solutions and referral cards stating the treatment received were collected. Children of age less than 2 months or more than 60 months, diarrhoea lasting for more than 7 days at the time of admission, episodes of loose stools less than 3 per day, patients being treated on OPD basis and those with nonconsenting caregivers were excluded from the study.

Statistical analysis
All the data were analyzed using IBM SPSS version 20 software. Results on continuous measurements were presented on Mean SD (Min-Max) and results on categorical measurements were presented in Number (%). Significance was assessed at 5% level of significance. Chi-square/Fisher Exact test was used to find the significance of study parameters on categorical scale between two or more groups. Null hypothesis of discrepant results was declined when p-value were less ≤0.05.

RESULTS
This study revealed the distribution of cases according to their referrals from peripheral health centers. Out of 356 cases of diarrhea, 122(34.3%) were primary patients and attended the OPD of our tertiary care center themselves. 128(36.0%) were referred from district hospital, 96(27.0%) were referred from community health center and10(2.8%) were referred from primary health center (Table 1). This study also showed treatment received by the cases before being referred to the tertiary care. Antibiotic was given to 199(55.9%) cases, IV Fluid was given to 179(50.3%) cases, ORS was given to 24(6.7%) cases, zinc was given to 7(2.0%) and blood transfusion was given to 49(13.8%) cases as a primary management in acute diarrhea cases (Figure 1).   Table 2).
Condition of cases on admission in tertiary care center-Data revealed that out of 356 cases, 193(54.2%) were not having dehydration, 134(37.6%) were severely dehydrated and 29(8.14%) were in shock. Regarding the final outcome of cases, 260(73.0%) were successfully discharged while 16(4.5%) expired. (Figure 2) Mean duration of stay was calculated at 4.74±4.06 days.

Figure 2: Final outcome of cases.
Results also showed the frequency of expired cases according to nourishment. Out of 16 expired cases, 11(68.8%) were mal nourished and 5(31.3%) were well nourished. (Figure 3)

DISCUSSION
Diarrhoea is defined as at least three or more loose stools in 24 hours. However, it is the recent change in consistency and character of stools rather than the number of stools that is more important. The term 'diarrheal diseases' is used for a group of diseases in which the predominant symptom is diarrhoea. 5 Management of cases prior to reaching any tertiary care center is an important prognostic marker and defines the further course of the disease. Our study reveals a very dangerous trend prevailing in the peripheries and primary care centers of our country. Out of total 128 diarrheal cases that were referred to our center from other various health care setups, 55.9% received antibiotics. IV fluids were given to 50.3% cases and 13.8% received blood transfusions. ORS and Zinc which forms the backbone of acute diarrheal management was given in only 6.7% and 2.0% cases respectively. Low rates of use of ORS and zinc is also seen in other studies and points towards the failure of promotion and propagation of these in the community. 6,7 It also points towards the failure on the part of health care staff in this part of the country that is not providing the most appropriate and cost-effective therapy for diarrhoea. This not only negatively affects the economy of our country but also prolongs the treatment time and thus increases morbidity of the child.
Primary intervention by mother when diarrhoea started also has impact on prognosis of the child. First 3 days are most important, and mother's behavior and practices define the duration of the disease. Out of 356 cases, 10.1% did not consider diarrhoea to be dangerous and did no interventions in the initial phase of the disease. This was also noticed by Rita B in her study. 8 Our study also shows use of ORS by 14.9% mothers in the first 3 days whereas 27.2% visited some health care center. About 8.1% mothers started using boiled water after start of loose stools and 6.7% consulted ASHA/Anganwadi worker. The importance of primary management by mothers is also shown by Sutaria S et al, Khalili M et al, and others. [9][10][11][12] Clinical status at the time of admission also marks as an important prognostic factor. The more severe is the condition on admission higher is the morbidity and mortality. This also relates to the nutritional status of the subjects. A malnourished child is more likely to be morbid as compared to a well-nourished child when admitted under the same circumstances. Out of 356 cases of our study, 54.2% had no signs of dehydration at the time of admission while 37.6% had signs of severe dehydration and 8.14% presented with shock. Out of these, 4.5% expired and 73% were successfully discharged. Amongst those who expired, 69% were malnourished. These findings were supported by studies of Patwari AK et al and Molbak et al, in which they had reported that there was a marked negative relationship between diarrhoea and physical growth and development of a child. 13,14