Nigerian Journal of Paediatrics

Pre-presentation management metabolic state and outcome of children admitted for diarrhoea disease in Calabar Nigeria

Niger J Paediatr 2018; 45 (3): 145 - 150

ORIGINAL

Uka VK

CC – BY

Pre-presentation management,

Samson-Akpan PE

Okpara HC

metabolic state and outcome of

Ekanem EE

children admitted for diarrhoea

disease in Calabar, Nigeria

DOI:http://dx.doi.org/10.4314/njp.v45i3.2

Accepted: 25th June 2018

Abstract : Background: Much of

tions at home and nine (20.45%)

the activities for the prevention

zinc. Twelve (27.27%) had mild,

Ekanem EE (

)

and management of diarrhoea

26 (45.4%) moderate and 3

Department of Paediatrics,

should occur or be initiated at

(6.82%) severe dehydration.

University of Calabar, Calabar,

home. In addition, management

Twenty (63.64%) had metabolic

Nigeria

is guided by clinical and meta-

acidosis, 18(40.91%) hyponatrae-

Email: profekanem@gmail.com

bolic state.

This work was de-

mia and 18(40.9%) azotaemia sug-

signed to examine some pre-

gesting Acute Kidney Injury. Two

Uka VK, Samson-Akpan PE

hospital management practices

(4.50%) had hypoglycaemia while

Department of Nursing Science,

and the metabolic state of children

16(36.30%) had hypozincaemia.

University of Calabar, Calabar,

with diarrhoea in Calabar, Nige-

Conclusion: A majority of children

Nigeria

ria.

with diarrhoea have oral electro-

Methodology: Prospective study

lytes solution before presentation

Okpara HC

of the pre-presentation manage-

in the hospital and all had contin-

Department of Chemical Pathology,

ment, clinical and metabolic states

ued feeding. There is a high pro-

University of Calabar, Calabar,

of children with diarrhoea pre-

portion with hyponatremia and

Nigeria

senting at University of Calabar

more than a third hadazotaemia.

Teaching Hospital, Calabar from

Modality of treatment at home did

April to November 2016. History

not seem to affect these parame-

was used to determine pre-

ters, perhaps because all subjects

presentation management while

had continued feeding. Further

blood glucose and electrolytes

studies on the appropriateness of

were determined before initiation

low osmolarity ORS in this envi-

of treatment.

ronment and renal function of chil-

Results: Forty-four children aged

dren with diarrhoeaare recom-

4 – 13years, mean 18.65 ±

mended.

17.37months were recruited into

the study.

Forty (90.91%) had

Key Word: Diarrhoea, Pre-

acute watery diarrhoea and 4

hospital Management, electrolytes

(9.09%) had dysentery. Of these,

derangement

72.27%had oral electrolyte solu-

Introduction

ported in 2009 that only 8.7% of children received ORS

for current episode of diarrhoea and 77.9% received

While there has been remarkable reduction in diarrhoea

antibiotics while 4.0% of parents withheld foods. Othero

et al in Kenya reported in 2005 that 27.8% of the chil-

morbidity and mortality in recent years, it still causes

more than half a million (525,000) under five childhood

dren had no fluids at all during diarrhoeal episodes, 70%

deaths annually.

1-4

When diarrhoea occurs good man-

of mothers decreased fluid intake and only 10.0% in-

agement with the use of appropriate oral rehydration

creased fluid intake. Almost 90% of the mothers with-

held milk, including breast milk. On the other hand, in

fluids to prevent or correct dehydration, vitamin A, zinc,

Nigeria, Uchendu et al in a hospital based study in 2011

and continued feeding are essential to lessen morbidity

and prevent mortality.

3-6

Much of these should be done

reported that 73.1% of the children with diarrhoea had

or initiated at home.

some form of oral rehydration fluid before presentation

Home management of diarrhoea can significantly affect

at hospital, out of which 80.7% had (standard) ORS and

ultimate outcome. Several studies in Africa and other

94.8% continued feeds. A recent study in Port Harcourt,

parts of the developed have shown widely different mo-

Nigeria showed that more than 70 percent presenting

dalities of pre-facility presentation management of diar-

with diarrhoea at a cottage hospital had some form of

rhoeal disease in children. In India Ahmed et al re-

oral rehydration fluid before presentation, with 97.4% of

146

these having standard ORS solution, with a majority

obtained from all participating parents/caregivers, with

(57.4%) having antimicrobials while more than a third

assurance that refusal to participate would not prejudice

had anti-emetics. Thus home/pre-presentation manage-

the care of their children/wards.

ment of childhood appears to vary between and within

country, with implications for in-facility management

and health education activities.

This work was designed to examine pre-presentation

Results

management, metabolic state and outcome of children

presenting with diarrhoea at the University of Calabar

Forty-four children were recruited into the study. The

Teaching Hospital, Calabar, Nigeria.

age range was 4 – 13 months with a mean age of 18.7 ±

17. 4 months. Twenty four of the children were males

and 20 females give a male to female ratio of 1:2:1.

The mean duration of diarrhea before presentation was

Materials and Methods

3.0 ± 2.8 with a range of 2 - .4 days. Forty (90.9%) of

the children had acute watery diarrhoea while 4(9.1%)

This was a prospective study of all children admitted

had dysentery. None had persistent diarrhoae. Twenty

into the DTTU of the University of Calabar Teaching

eight (63.6%) had associated vomiting.

Twenty six

Hospital from April to November, 2016. A self-

(45.5%) of the subjects presented with moderate dehy-

developed questionnaire with four sections covering

dration. Twelve (27.3%) had mild dehydration while 3

socio-demographic characteristics of child and mother,

(6.8%) had severe dehydration. Three (6.8%) had no

pre-presentation management, clinical and metabolic

signs of dehydration.

states, and outcome, was used to collect data.The instru-

ment was assessed for face validity with a test-re-test

Pre-presentation management

used to ascertain its reliability.

Fifteen (34.1%) of the children had exclusive breast

After informed consent of parent/care-giver, history and

feeding in the first six months of life. All the children

physical examination with attention to state of hydration

had continued feeding at home during the episode of

was obtained. Three milliliters (3ml) of venous blood

diarrhoea.

was drawn from each patient; 1.5ml each was added into

a plain bottle and fluoride oxalate bottle. The specimens

Fluids

were taken to the Chemical Pathology Laboratory of the

samehospital where they were centrifuged at 3000rpm

Thirty-two (72.3%) of the children had oral fluids before

for 10munites. The supernatant serum (from the plain

presentation. Of these 6(13.6%) had low osmolarity Oral

bottle) for electrolytes and zinc analyses were stored at –

Rehydration Salt Solution (ORS), 17(38.6%) standard

20 C for a maximum period of two weeks before batch

ORS and 9(20.5%) salt-sugar-solution.

analysis.

The supernatant plasma (from the fluoride

Nine (20.5%) had zinc,13(29.6%) had anti-microbialsas

oxalate bottle) was separated and immediately used for

follows;

8(18.2%)

metronidazole;

(4.6%)

co-

glucose analysis.

trimoxazole; 2(4.6%) cephalosporin and 1(2.3%) amox-

icillin/clavitunate. One (2.3%) each had metroclopraim-

The plasma glucose was analyzed using the glucose oxi-

ide and “Lucozade”

dasephotomeric method produced by Biolabo® (Biolabo

SA 02160, maicy France). The serum electrolytes were

Clinical state

analyzed using an ion selective electrode (ISE) machine

(ISE model unit – 910C, URIT Medical Electronic Co,

Table 1 shows the clinical state of the children in rela-

Ltd, China). The serum zinc analysis was carried out

tion to modalities of pre-presentation management. De-

using an atomic absorption spectrophometer (AAS

gree of hydration was not influenced by the administra-

Model 205, Bulk Scientific, United Sates of America).

tion of zinc nor by the type of oral rehydration fluid

used.

Data Analysis

Metabolic State

Data was entered into an Excel spreadsheet then trans-

ferred to stata 10 (stata Corp Texas) for analysis. Fre-

Table 2 shows the metabolic state of the children on

quencies, simple proportions and percentages were used

admission.

The important abnormalities were meta-

to analyze the data. Chi-square test was used to test

bolic acidosis in 28 or 63.6% of the children, hypozin-

associations.

caemia (16 or 36.3%), raised creatinine (14 or 31.8%)

hyponatraemia (18 or 40.9%) and hypokalaemia (6 or

Ethical Issues

13.6%).

Two (4.6%) of the children had hypogly-

ceamia. Eighteen (40.9%), 95Cl 26.3% – 56.8% of the

Ethical clearance for the study was obtained from the

children

had

azotaemia,

(increased

urea

and/or

Health Research Ethics Committee of the University of

creatinine).

Calabar Teaching Hospital, Calabar, with reference

number: UCTH/HREC/33/337. Informed consent was

147

Table 1: Levels of some metabolites in 44 children with Diarrhoea

Metabolite(mmol|L)

Range

Mean

Low

Normal

Elevated

Zinc(0.06 – 1.20)

0.0 – 70

1.14

1.35

16[36.36]

15[34.09]

13[29.38]

Sodium(135 – 145)

120.7 – 146.0

135.22

6.23

18[40.91]

25[36.82]

1[2.27]

Potassium(3.5 – 5.5)

3.0 – 5.4

4.01

0.55

6[13.64]

38[86.36]

0[0.00]

Chloride(98 – 106)

840 – 106.1

98.25

5.98

15[34.09]

27[61.36]

2[4.5]

Bicarbonate (2.00 – 26.0) –

18.1 – 26.0

21.46

2.35

28[63.64]

16[36.36]

0[0.00]

Urea (1.8 – 6.4)

1.8 – 7.8

4.46

1.69

3[6.82]

39[77.27]

7[15.91]

Creatinine (18.0 – 35.0)

18 – 46.2

23.39

8.95

0[0.00]

30[68.18]

14[31.82]

Glucose (3.6 – 5.8)

1.8 – 7.9

4.72

1.24

2[4.55]

42[95.45]

0[0.00]

Key: ( ) = Reference values

The low exclusive breastfeeding rate among these chil-

( ) = Percentage

dren is in keeping with the situation in Nigeria, reported

to be the poorest in the world.

7 – 9

Gratifyingly, all the

Table 2: Home Treatment and Clinical State on Presentation

subjects continued feeding during the episodes of diar-

Home

Mild

Moder-

Severe

rhoea. This is different from the situation in the past

[4]

Treatment

dehy-

ate

dehydra-

dration

dratio

dehy-

tion

and reflects some gains in the health education on the

dration

management of diarrhoea disease at home. More than

No Zinc

0.39

0.94

seventy percent of the children had some form of oral

Zinc

fluid, though the correctness of the constitution was not

SSS

assessed. This is not satisfactory as all children with

Low

2.93

0.18

diarrhoea should have extra fluids as soon as the diar-

os-

rhoea starts. All the children had continued feeding

molomity

ORS

during the episodes of diarrhea. This is most salutary

Standard

and is much different from the report in India in 2009

ORS

where up to four percent had no feeds during diarrhoeal

episodes are in Kenya where about 90% of the children

Table 3 shows the metabolic state in relation to type of

pre-presentation oral rehydration solution used. Type of

had milk, or including breast milk withheld in a 2005

report. This may reflect the high level of maternal edu-

home fluid did not affect the distribution of electrolyte

changes.

cation in Cross River state of Nigeria which has adult

English language literacy rate for both sexes of more

than seventy six percent, and similar to report in the

Outcome

nearby Enugu state in Nigeria with adult English literacy

rate of more than sixty four percent,

Four (9.1%) children had intravenous fluids initially and

and more than

later low osmolarity ORS. Forty (90.9%) had low os-

seventy three percent of children with diarrhea were

offered oral rehydration fluid at home. Maternal educa-

molarity ORS till discharge home.Median duration of

stay in the hospital was 24hours (1QR 1- 48hours).

tion is known to affect both the incidence and home

management of childhood diarrhoea.

12,13

There was zero case fatality.

Table 3: Home Management and Metabolic State

Only a fifth of the children had zinc. This reflects weak

SSS

LOORS

SORS

knowledge of this relatively recent recommendation by

the pre-presentation care-givers. Zinc supplementation

Hyponatraemia

0.03

0.98

has been demonstrated to reduce the duration of acute

Hypokalaemia

2.89

0.24

diarrhoea; and for persistent diarrhoea duration and the

Hypochloraemia

1.99

0.37

probability of treatment failure or death. Zinc supple-

Azotaemia

0.74

0.69

ments for 10-14 days during diarrhoeal episode has also

been shown to reduce further occurrences in the subse-

Key

quent 2-3 months and is currently recommended as a

SSS:

Salt sugar solution

LOORS: Low osmolarity ORS

routine.

Mechanism of action of zinc is not fully un-

SORS:

Standard ORS

derstood but includes improvement of water and electro-

lytes absorption, regeneration of intestinal epithelium,

increase in the level of brush boarder enzymes and en-

hancement of immune response against the diarrhoea

Discussion

pathogens. The rate of antimicrobial use in the present

study was 18.2% though only 4(9.1%) had dysentery.

The age distribution of the children was expected and is

This is a lot better than the situation in Kashmir, India

in keeping with the known epidemiology of the diar-

where the rate of antibiotic use was close to 78% and in

rhoea disease. The slight male preponderance is also

Port Harcourt, Nigeria where nearly sixty percent had

typical, so also the preponderance of acute watery diar-

antimicrobials.

Only one child had anti-emetic in the

rhoea.

1-3,5

Appropriate home management of diarrhoea,

current study. This again may reflect the high maternal

including appropriate oral dehydration fluid, continuing

literacy rate in the area and is markedly different from

feeding, zinc therapy, are important modalities of reduc-

the report from Port Harcourt where more than a third of

ing morbidity and mortality from diarrhoea disease.

4,5

the children had antiemetic is

with dire consequences

148

for some.

10,16

and CKD are currently considered inter-connected syn-

While only nine percent had dysentery, thirteen percent

dromes,

29-30

it would be desirable to investigate the inci-

had antimicrobials. Abuse of anti-microbials and anti-

dence of AKI in children with diarrhoea and establish

emetics in children with diarrhoea is a well-known phe-

the need and modalities to follow up these children.

nomenon in Nigeria. Fortunately only one child had an

Diarrhoea may be playing important role in the patho-

anti-emetic.

genesis of CKD in this environment.

The low incidence (4.5%) of hypoglycaemia in these

children is almost identical to the 4.0% recorded in the

same unit a few years earlier and is much lower than

the 11.0 percent reported by Huq et al in Bangladesh

Conclusion

and 7.7 percent by Onyiriuka et al in Benin city, Nige-

ria and the 5.3% in Lagos, Nigeria by Oyenusi et al.

Acute watery diarrhoea is the main type of diarrhoea

This may reflect the continued feeding of all the children

presenting in this centre, accounting for more than

in the current study. The single child with hypoglycae-

ninety percent of the cases. Most of the children had

mia had an anti-emetic. Anti-emetics have been associ-

moderate dehydration. EBF rate is low among these

ated with hypoglycaemia in childhood diarrhoae.

Per-

children and all had continued feeding during diarrhoea

haps children with diarrhoea and history of initiation of

while almost three quarters had some form of oral rehy-

anti-emetics, which interferes with feeding, should be

dration fluids before presentation. There was significant

screened for hypoglycaemia.

rate of abuse of anti-microbials. A large proportion were

hyponatraemic on admission, indicating a need to inves-

Forty percent of the children were hyponatraemic.

tigate the appropriateness of low osmolarity ORS in

However, their electrolyte levels were not re-assessed

children with diarrhoea in this environment. More than

after rehydration. It would be needful to assess the elec-

a third were zinc deficient. There is a high incidence of

trolyte and osmolarity changes of children in response to

azotaemia suggesting AKI in these children. This has

low osmolarity ORS in this environment in view of the

implications for the future development of CKD and the

high proportion of them with hyponatraemia. While low

need for long term follow-up of these children. Larger

osmolarity ORS has been demonstrated to be associated

studies to evaluate the suitability of low osmolarity ORS

with less vomiting and lower stool volume in children

in this environment AKI, in diarrhoea are warranted.

admitted with diarrhoea and is currently the recom-

Health education on home management of diarrhoea in

mended fluid by WHO, it has also been associated with

Calabar should emphasize zinc supplementation.

increased incidence of transient asymptomatic hypona-

This study has some obvious limitations. The sample

traemia. A little above a tenth of the children had meta-

size is small and details of the mixing of ORS solutions

bolic acidosis which is eminently correctable by stan-

were not obtained. All the same, it has made important

dard or low osmolarity ORS.

4,5

The modality of pre-

observations and raised important questions.

presentation management did not appear to affect the

distribution of electrolyte changes in these children. This

may reflect the effect of continued feeding during the

Conflict of Interest: None

diarrhoeal episodes and should be encouraged. The large

Funding:

University

Calabar

Senate

Grant

proportion (more than a third) of the children with hy-

pozincaemia in this study indicates that zinc deficiency

|08

and diarrhoea may be components of a vicious cycle.

Diarrhoea management is therefore a useful entry point

for the management of the widespread zinc deficiency in

children reported in this environment.

23,24

Medicine ven-

dors/patent medicine dealers play important roles in the

Acknowledgements

management of childhood diarrhoeal disease in Nige-

ria.

25,26

These should receive targeted education on the

We are grateful to the parents/guardians that participated

use of zinc and other aspects of diarrhoeal management.

with us in the management and study of these children.

Thanks also to the Resident Doctors and Nurses in the

The relatively high incidence of azotaemia in this study,

DDTU for their roles in the management of these chil-

probably occurring as a result of pre-renal AKI, is note-

dren. This study was supported by University of Calabar

worthy. Reversible acute kidney injury occurring in hos-

Senate Grant

pital has been shown to be associated with a significant

No.TETFUNDDESS|UNICALCALABAR|RP|VOL.IV|

risk for de novo chronic kidney disease, with implica-

tions for long term follow up of such patients. Acute

Kidney Injury and Chronic Kidney Disease (CKD), have

been considered a continuous spectrum with vascular

insufficiency, cell-cycle disruption and maladaptive re-

pair mechanism as some of the modulators of progres-

sion from AKI to CKD.

This warrants long-term fol-

low-up of patients with first episodes of AKI, even if

they presented with normal renal function. Since AKI

149

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