Management of Diarrhoeal Dehydration in Childhood: A Review for Clinicians in Developing Countries

Combatting infectious diarrhea: innovations in treatment and vaccination strategies

INTRODUCTION

The escalating prevalence of infectious diseases is an important cause of concern in society. Particularly in several developing countries, infectious diarrhea poses a major problem, with a high fatality rate, especially among young children. The condition is divided into four classes, namely, acute diarrhea, invasive diarrhea, acute bloody diarrhea, and chronic diarrhea. Various pathogenic agents, such as bacteria, viruses, protozoans, and helminths, contribute to the onset of this condition.

AREAS COVERED

The review discusses the scenario of infectious diarrhea, the prevalent types, as well as approaches to management including preventive, therapeutic, and vaccination strategies. The vaccination techniques are extensively discussed including the available vaccines, their advantages as well as limitations.

EXPERT OPINION

There are several approaches available to develop new-improved vaccines. In addition, route of immunization is important and aerosols/nasal sprays, oral route, skin patches, powders, and liquid jets to minimize needles can be used. Plant-based vaccines, such as rice, might save packing and refrigeration costs by being long-lasting, non-refrigerable, and immunogenic. Future research should utilize predetermined PCR testing intervals and symptom monitoring to identify persistent pathogens after therapy and symptom remission.

Mothers participation in caring for hospitalized children with acute gastroenteritis: A quasi-experimental study

AIMS

To identify informational and practical deficits of mothers of hospitalized children with acute gastroenteritis and to determine the effect of intervention on enhancing mothers' participation in providing care.

DESIGN

This study was a two-group pre- and post-test quasi-experimental study.

METHODS

Sample size was eighty mothers of hospitalized children younger than 5 years with acute gastroenteritis in each group using consecutive sampling method. Based on the needs assessment, the training and practical demonstration were performed individually in the intervention group. The control group received usual and standard care. The care practice of mothers were observed before and three times after the intervention at a 1-day interval. The confidence level was 0.95.

RESULTS

After intervention, there was a significant increase in the mothers' care practice in the intervention group and a significant difference between the two groups. The participatory care approach could enhance mothers' practice in providing care to the hospitalized children with AGE.

Dose-response relationship between diarrhea quantity and mortality in critical care patients: A retrospective cohort study

BACKGROUND

Previous studies have shown that diarrhea, defined as a dichotomized cutoff, is associated with increased mortality of patients in intensive care units (ICUs). This study aimed to examine the dose-response relationship between the quantity of diarrhea and mortality in ICU patients with newly developed diarrhea.

METHODS

We conducted this single-center retrospective cohort study. We consecutively included all adult patients with newly developed diarrhea in the ICU between January 2017 and December 2018. Newly developed diarrhea was defined according to the World Health Organization definition. The consistency of diarrhea was evaluated by the Bristol stool chart scale, and the quantity of diarrhea was assessed on the day when patients newly developed diarrhea. The primary outcome was in-hospital mortality. The risk ratio (RR) and 95% confidence interval (CI) for the association between diarrhea quantity and mortality were estimated using multivariable modified Poisson regression models.

RESULTS

Among the 231 participants, 68.4% were men; the median age was 72 years. The median diarrhea quantity was 401g (interquartile range [IQR] 230‒645g), and in-hospital mortality was 22.9%. More diarrhea at baseline was associated with higher in-hospital mortality; the adjusted RR (95% CI) per 200-g increase was 1.10 (1.01‒1.20), p = 0.029. In sensitivity analyses with near quartile categories of diarrhea quantity (<250g, 250-399g, 400-649g, ≥650g), the adjusted RRs for each respective category were 1.00 (reference), 1.02 (0.51-2.04), 1.29 (0.69-2.43), and 1.77 (0.99-3.21), p for trend = 0.033.

CONCLUSIONS

A greater quantity of diarrhea was an independent risk factor for in-hospital mortality. The diarrhea quantity may be an indicator of disease severity in ICU patients.

Understanding the use of oral rehydration therapy: A narrative review from clinical practice to main recommendations

Background and Aims

Fluid loss due to diarrhea remains a significant cause of mortality among children under the age of 5.

Methods

Oral rehydration therapy (ORT) is a first‐line therapeutic measure to compensate the volume loss due to diarrhea and vomiting among gastroenteritis patients. Despite adequate knowledge, the practice of ORT is limited, particularly in developing countries.

Results

Several recommendations are provided regarding the use of ORT to treat hypovolemia, however, the information regarding its adequate usage is restricted within the healthcare centers and professionals.

Conclusion

This review highlights the importance of providing recommendations regarding the use of ORT. We also discuss the barriers and alternatives that might limit its use.

Effect of Bacterial Vaginosis (BV)-HIV-1 Co-existence on Maternal and Infant Health: A Secondary Data Analysis

Background: The lactobacillus-rich microbiome forms a defense system against infections. Babies are born sterile and acquire their microbiome from exposure to the mothers' vaginal and rectal microbiota. Bacterial vaginosis (BV), which is characterized by a deficit of the Lactobacilli genera, may predispose women and their babies to an increased frequency of illness. Objective: To determine the effect of BV on HIV-infected women's post-delivery health as well as the morbidity and mortality of the exposed infant at birth, 6 months, and at 12 months of life. Study Design: A retrospective cohort study was conducted using previously collected data to investigate whether there was an association between BV-HIV-1 infected mothers and subsequent infant morbidity and mortality over a 12-month period. Methods: Data for this analysis were extracted from the original data set. Women were categorized into two groups according to whether they had a positive or negative laboratory-based diagnosis of BV using the Nugent method. The two groups were compared for socio-demographic characteristics, prior to the pregnancy experience in their current pregnancy outcome and at post-delivery morbidity, and for the duration of hospital stay. BV-exposed and unexposed infants were compared in terms of morbidity and mortality at birth, and in the periods between birth and 6 months, and between 6 and 12 months, respectively, based on prospectively collected data of the mother's past and present illness, and clinical examination at scheduled and unscheduled visits during the follow-up period of the original study. The generalized estimating equation (GEE) was used to analyze the longitudinally collected data. We used the Kaplan-Meier (KM) method to generate the cumulative hazard curve and compared the mortality in the first year of life between the two groups. Results: In total, 365 patients were included in the study. Exposure to BV was associated with an adverse maternal condition (Relative Risk [RR], 2.45; 95% confidence interval [CI], 1.04-5.81, P = 0.04) and maternal hospital admission (RR, 1.99; 95% CI, 1.14-3.48, P = 0.02) but was not linked to any neonatal morbidity at birth. There was a higher frequency of gastro-intestinal morbidity among BV-exposed infants. At 6 months, infants of BV-exposed mothers had higher odds of bloody stool (Odds Ratio [OR], 3.08; 95% CI, 1.11-10.00, P = 0.04), dehydration (OR, 2.94; 95% CI, 1.44-6.37, P = 0.01), vomiting (OR, 1.64; 95% CI, 1.06-2.56, P = 0.03), and mouth ulcers (OR, 12.8; 95% CI, 2.27-241.21, P = 0.02). At 12 months, exposure to BV was associated with dehydration (OR, 1.81; 95% CI, 1.05-3.19, P = 0.03) and vomiting (OR, 1.39; 95% CI, 1.01-1.92, P = 0.04). KM survival analysis showed non-significant higher trends of deaths among BV-exposed infants (P = 0.65). Conclusion: This study demonstrates differences in maternal and infant morbidity outcomes associated with exposure to BV. Further research is required to determine whether treatment for maternal BV mitigates maternal and infant morbidity.

Awareness and attitude towards dehydration and its management amongst mothers and factors influence on in under-five children of Omdurman locality, Sudan

Dehydration is a significant depletion of body water and electrolytes. The awareness of dehydration signs is essential, and in-home mothers' practice and responses towards professional medical help are crucial. The study is a cross-sectional study enrolled 222 mothers with children under 5 years, and 198 of them participate in a semi-structured questionnaire that involves information of dehydration signs, oral rehydration solution and preparation and in-home practice and remedies used by mothers in the management of dehydration. Fifty-eight participants (29.3%) were found in the age group of 26-30 years, 78 participants (39.4%) received primary school education and 92 (46.5%) had one child under 5 years, whereas 17.7% received educational workshop or counselling. Main management practices performed by the mothers were over-the-counter medications (36.4%) and rice water (33.8%). The majority (88%) of the participants were aware about dehydration signs, which were significantly associated with educational levels, and workshop or counselling received from professional.

Acute Gastroenteritis in Children of the World: What Needs to Be Done?

The incidence of gastroenteritis has greatly reduced due to improved hygiene conditions in developing countries and the use of rotavirus vaccine. Still thousands of children, however, die from gastroenteritis, most of them in poor countries. Yet gastroenteritis management is simple, inexpensive, and effective and is largely the same all over the world. Universal guidelines for gastroenteritis guide the management and include simple interventions put forward early in the course of the disease. Treatment includes rehydration, continuing oral feeding, and anti-infective drugs in selected clinical conditions related to the symptoms or to host-related risk, and possible additional drug treatment to reduce the duration and severity of symptoms. There may be minor geographical differences in the treatment applied due to health care organizations that do not substantially change the standard universal recommendations. Prevention is recommended with sanitation interventions and rotavirus universal immunization. Implementation of those interventions through educational initiatives and local programs in target areas are needed. A series of recommendations for interventions, education, and research priorities are included here with the aim of reducing the burden of gastroenteritis, to be pursued by scientists, physicians, policy makers, and stakeholders involved. They include the need of recommendations for the management of gastroenteritis in malnourished children, in those with chronic conditions, in neonates, and in emergency settings. A reference system to score dehydration, the definition of optimal composition of rehydration solution and the indications for anti-infective therapy are also included. Rotavirus immunization should be actively promoted, and evidence-based guidelines should be universally implemented. Research priorities are also indicated.