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Acute childhood diarrhea: The second most common childhood killer disease worldwide

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By Yankuba Jatta

Gastroenteritis (diarrhea) indicates infection of the stomach and bowels caused by germs. Viruses are the most common cause (mostly rotavirus), but also bacterial agents (like Shigella, Escherichia coli, Salmonella, Campylobacter jejuni, Vibrio cholera, Clostridium species, Staphylococcus aureus) and parasitic agents (like Giardia lamblia, Cryptosporium parvuum, Entamoeba histolytica) account for significant number of cases. Acute gastroenteritis is a sudden change in frequency and consistency of stools or more than ten (10) stools in infants, for less than 14 days. Diarrhea is defined as having sudden loose or watery stools at least three times per day, or more frequently than normal for an individual. Frequent passing of formed stools is not diarrhea nor is passing of loose “pasty” stools by breastfed babies.
The incubation period from ingestion of the germ to clinical symptoms may vary from six (6) hours to three (3) days in most of the cases.

After Pneumonia, diarrheal disease is the most common killer disease in children (18%), more than Malaria, Measles and HIV combined, with an estimation of 1.5 million deaths globally every year. The Centers for Disease Control and Prevention (CDC) estimated that 1 out of every 12 childhood death is due to diarrheal disease.

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Gastroenteritis is due to infection acquired through the fecal-oral route or by ingestion of contaminated food or water. Many of these infections are food-borne illnesses. The risk of diarrhea increased with the ingestion of insufficiently cooked meat, improperly refrigerated cooked foods, unpasteurized milk, contaminated eggs, undercooked or raw seafood, young age <5 years, immunodeficiency, measles, malnutrition, and lack of exclusive breastfeeding.

The clinical signs and symptoms of gastroenteritis varied according to the cause. The most common clinical presentations are nausea and vomiting and watery stools associated with abdominal pain, fever, headache, weight loss, fatigue and weakness, increase urge and frequency to pass stool, bloody stool (shigella). The diagnosis of gastroenteritis in a previously healthy children is made base on clinical recognition and evaluation and appropriate laboratory investigations, if indicated. Laboratory investigations is indicated for children with bloody stool, immunodeficiency patient with diarrhea, outbreaks with suspected hemolytic-uremic syndrome (caused by Shigella or Escherichia coli).

There are three main forms of acute childhood diarrhea, all of which are potentially life-threatening and require different treatment courses:
¦ Acute watery diarrhea: includes cholera and is associated with significant fluid loss and rapid dehydration in an infected individual. It usually lasts for several hours or days. The pathogens that generally cause acute watery diarrhea include V. cholerae or E. coli bacteria, as well as rotavirus.

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¦ Bloody diarrhea: often referred to as dysentery, is marked by visible blood in the stools. It is associated with intestinal damage and nutrient losses in an infected individual. The most common cause of bloody diarrhoea is Shigella, a bacterial agent that is also the most common cause of severe cases.
¦ Persistent diarrhea: is an episode of diarrhea, with or without blood, that lasts at least 14 days. Undernourished children and those with other illnesses, such as AIDS, are more likely to develop persistent diarrhea.Diarrhea, in turn, tends to worsen their condition.

With delays in diagnosis and in the institution of proper treatment, acute gastroenteritis would result to patient developing dehydration with associated complications. These can be life-threatening in infants and young children. The complications of dehydration depends on the degree of fluid loss. The fluid loss can result to no dehydration, some dehydration or severe dehydration. In no dehydration, the child is conscious and alert but having gastroenteritis. In Some dehydration, the child will have symptoms like irritability, restlessness, eager to drink, fast breathing, slightly sunken eyes, decreased tears, dry mouth and tongue, skin-fold recoil in <2 seconds, decreased urine output. In severe dehydration, the child will present with lethargy, unconscious, unable to drink, heart beating fast, weak, thread pulses, deep breathing, deeply sunken eyes, absent tears, skinfold recoil in > 2 seconds, minimal urine output, and cold hands and feet.

The main principle in treating gastroenteritis is based on correcting the dehydration, encourage feeding and diet selection and zinc supplementation. Children, especially infants, are more susceptible than adults to dehydration because of the greater basal fluid and electrolyte requirements per kg and because they are dependent on others to meet these demands. Dehydration must be evaluated rapidly and be corrected within 4-6 hours according to the degree of dehydration and estimated daily requirements. Children who are in shock or unable to drink oral fluids, requires initial intravenous rehydration, but oral rehydration is the preferred mode of rehydration. Risks associated with severe dehydration that might necessitate intravenous resuscitation include: age < 6 months, prematurity, chronic illness, fever >38°C if <3 months or >39°C if 3-36 months, bloody diarrhea, persistent vomiting, poor urine output, sunken eyes, and a depressed level of consciousness. Oral rehydration can also be given by a nasogastric tube if needed; this is not the usual route. Oral rehydration solution (ORS) is the standard fluid for rehydration in gastroenteritis. It is available in a sachet and needed to be diluted following the manufacturer’s instructions.

In no dehydration, 10 milliliters per kilogram of the child’s weight of ORS is given after each loose stool. In some dehydration and severe dehydration, the child needs to be taken to a health facility for proper management. In all cases encourage and continue feeding. Avoid fatty foods or foods high in simple sugars (juices, sweets, carbonated sodas) which might exacerbate the diarrhea. WHO and UNICEF recommend that all children with acute diarrhea should receive oral zinc in some form for 10-14 days. Zinc reduced duration and severity of diarrhea and could prevent a large proportion of cases from recurring. Antiemetic are of no value and associated with potentially serious side effects (lethargy, dystonia, malignant hyperpyrexia). Anti-motility agents are contraindicated. Antibiotic treatment is not necessary but given only in dysentery (bloody diarrhea) or persistent diarrhea (diarrhea last for more than two weeks).

The decline in diarrheal mortality, despite the lack of significant changes in incidence, is the result of prevention. The main preventive measures include:
Exclusive breast-feeding (administration of no other fluids or foods for the first 6 months of life) is widely regarded as one of the most effective interventions to reduce the risk of premature childhood mortality and the potential to prevent 13% of all death of children <5 years of age. It protects very young infants from diarrheal disease through the promotion of passive immunity and through reduction in the intake of potentially contaminated food and water.

Improved complementary feeding practices. Maternal or caregivers education on safe preparation, good quality, good storage, and timely introduction (at 6 months) of complementary feeding with continued breast-feeding can prevent malnutrition, reduce diarrheal disease, and reduce mortality in children. Malnutrition is an independent risk for the frequency and severity of diarrheal illness. Vitamin A supplementation reduces all-cause childhood mortality by 21% and diarrhea-specific mortality by 31%. Vitamin A supplementation is part of the childhood immunization program in The Gambia and is given beginning at six (6) months of age to 60 months of age with interval of every six (6) months, at an initial dose of 100,000 IU and 200,000 IU subsequently.

Rotavirus immunization. Rotavirus is the most common cause of diarrheal disease in children (accounting for 29% of all deaths due to diarrhea among children <5 years of age). The introduction of rotavirus is associated with significant reduction in severe diarrhea and associated mortality. The rotavirus is also part of the childhood immunization program in The Gambia, and is given at second (2), third (3), and fourth (4) months of life.

Improved water and sanitary facilities and promotion of personal and domestic hygiene. Improvement in standards of hygiene, sanitation, water supply, and routine hand washing can reduce up to 88% of all diarrheal death worldwide.
Improved case management of diarrhea. WHO/UNICEF recommendations to use low-osmolality ORS and zinc supplementation for the management of diarrhea, coupled with selective and appropriate use of antibiotics, have the potential to reduce the number of diarrheal deaths among children.

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