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Nigerian J Paediatrics 2018 vol 45 issue 3

Nigerian J Paediatrics 2018 vol 45 issue 3

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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 ฑ
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-
8
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
8
fluids to prevent or correct dehydration, vitamin A, zinc,
Nigeria, Uchendu et al in a hospital based study in 2011
9
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.
5
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-
7
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-
10
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 ฑ
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 ฑ 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
0
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;
2
(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 Biolaboฎ (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
SD
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-
X
2
Home
No
Mild
Moder-
Severe
P
rhoea. This is different from the situation in the past
[4]
Treatment
dehy-
dehy-
ate
dehydra-
dration
dratio
dehy-
tion
and reflects some gains in the health education on the
n
dration
management of diarrhoea disease at home. More than
No Zinc
2
4
15
2
0.39
0.94
seventy percent of the children had some form of oral
Zinc
1
4
11
1
fluid, though the correctness of the constitution was not
SSS
1
1
6
1
assessed. This is not satisfactory as all children with
Low
0
2
2
4
2.93
0.18
diarrhoea should have extra fluids as soon as the diar-
os-
rhoea starts. All the children had continued feeding
4
molomity
ORS
during the episodes of diarrhea. This is most salutary
Standard
1
5
9
2
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
7
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-
8
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
11
Outcome
nearby Enugu state in Nigeria with adult English literacy
rate of more than sixty four percent,
11
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-
9
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
X
2
P
knowledge of this relatively recent recommendation by
the pre-presentation care-givers. Zinc supplementation
Hyponatraemia
4
2
8
0.03
0.98
has been demonstrated to reduce the duration of acute
Hypokalaemia
3
0
2
2.89
0.24
diarrhoea; and for persistent diarrhoea duration and the
Hypochloraemia
3
0
6
1.99
0.37
probability of treatment failure or death. Zinc supple-
14
Azotaemia
4
1
5
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
14
SSS:
Salt sugar solution
LOORS: Low osmolarity ORS
routine.
15
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
14
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
7
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.
10
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
10
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
10
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
17
the 11.0 percent reported by Huq et al in Bangladesh
18
Conclusion
and 7.7 percent by Onyiriuka et al in Benin city, Nige-
19
ria and the 5.3% in Lagos, Nigeria by Oyenusi et al.
20
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.
16
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
21
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-
22
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
of
Calabar
Senate
Grant
proportion (more than a third) of the children with hy-
No.TETFUND|DESS|UNICAL|CALABAR|RP|VOL.IV
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-
08
tions for long term follow up of such patients. Acute
27
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.
28
This warrants long-term fol-
low-up of patients with first episodes of AKI, even if
they presented with normal renal function. Since AKI
28
149
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