Clinical Profile and Risk Factors for Persistent Diarrhoea in Children Under Five Years of Age in an Urban Referral Centre

INTRODUCTION: Persistent diarrhoea is an important cause of illness and death in children in developing countries. Moreover, as acute diarrhoea is more widely and successfully treated with oral rehydration therapy, the proportion of diarrhoeal deaths associated with persistent diarrhoea have increased. Although there is no consensus on the definition of persistent diarrhoea, most investigators use a working definition of diarrhoea that lasts for more than two weeks. It is essential to understand different terminologies which have been used in connection with diarrhoeal episodes of longer than 2 weeks duration. The prolonged diarrhoeal episode can basically be divided in to three main types: 1. ACUTE ONSET PERSISTENT DIARRHOEA: These episodes begin acutely but instead of settling down within 7-14 days, as is normally expected, continue beyond 14 days1, Terminologies like ‘persistent’, ‘protracted’, ‘intractable’, post enteritis syndrome’, ‘chronic malnourishing diarrhoea’ etc. have been used to describe these acute onset but prolonged episodes of diarrhoea. In fact Labenthal labeled even these episodes as chronic diarrhoea. I) SIMPLE PERSISTENT DIARRHOEA: WHO defined simple persistent diarrhoea as episodes of acute diarrhoea lasting more than 14 days duration.1 This is the most accepted field definition and it is estimated that about 3-20% of acute diarrhoeal episodes may become persistent when the definition of ‘passage of 3 or more stools for 14 days or more’ is applied. However, field studies indicate that most of these episodes are benign in nature and not affecting general well being and nutrition of the child concerned. II) Persistent Protracted Diarrhoea: Some of the episodes of persistent diarrhoea may be complicated by weight loss, warranting active intervention. These complicated persistent diarrhoeal episodes have been referred to as protracted diarrhoea by Shanta Krishnan et al10. This terminology should be reserved only for those episodes of persistent diarrhoea which are accompanied with weight loss. Although some children may show weight loss even earlier than 14 days, studies by Bhan et al have shown that 14 days duration has a statistical cut off which defines increased morbidity and mortality with these episodes. AIM OF THE STUDY: To study the clinical profile of persistent diarrhoea in children under five years of age in an urban referral centre. To identify the host and environmental risk factors associated with persistent diarrhoea in children under five years of age in an urban referral centre. DISCUSSION: The total number of children under five years of age with persistent diarrhoea were 70 during the study period. In our study persistent diarrhoea was common in children of age between 1 month and 1 year (68.57%). Observation in the present study was in favour of the WHO report that persistent diarrhoea commonly involved children aged less than 1 year1. P Dutta et al in their study also concluded that children aged between 7 and 18 months had increased incidence of persistent diarrhoea3. Persistent diarrhoea was observed in 55.71% male children and 44.29% female children, with slight male preponderance. This is similar to study done by M bori-Ngacha DA et al24. Undernutrition was observed in 85.71% of all cases of persistent diarrhoea. Grade III protein energy malnutrition presented in 25.71% of cases. Undernutrition was common in children of age between 6 months and 1 year (96%). In P Dutta et al study, Grade II-IV was observed in 70.8% of all cases of persistent diarrhoea3. In present study, it was 65.71%. Undernutrition was common in male children (87.18%) when compared to female children (83.87%). SK Mittal in his work and WHO report states that protein energy malnutrition was an important risk factor for persistent diarrhoea.1,2 In the present study, 54.28% of children were fed with animal / artificial milk before 6 months of age. Of these 36.84% of children were fed before 2 months and 42.11% fed at age between 4 and 6 months. Dairy milk was the predominant milk provided other than breast milk before 6 months of age (47.37%). SK Mittal in their study and WHO report states that early introduction of animal / artificial milk was a risk factor for persistent diarrhoea.1,2 Previous episodes of diarrhoea were observed in 40 percent of cases. This was common in children of age under 1 year (43.75%). Previous episodes of diarrhoea were common in male children (46.15%) than female children (32.26%). The observation in the present study goes with the WHO report that following an episode of acute watery diarrhoea and following an episode of persistent diarrhoea, the risk of developing persistent diarrhoea in the forth coming months increased 2 to 4 fold and 3 to 6 fold respectively. SUMMARY AND CONCLUSION: 1. Persistent diarrhoea was common in children under 1 year of age. 2. Under nutrition was commonly found in children under 1 year of age with persistent diarrhoea. 3. More than half of persistent diarrhoea cases were fed with animal / artificial milk before 6 4. Secondary lactose intolerance and previous episodes of diarrhoea were common among children under 1 year. 5. In Parenteral infections, UTI and septicemia were commonly seen. Severe form of persistent diarrhoea and dehydration occurred in more than half of cases. 6. More than eighty percent of persistent diarrhoea cases were managed with low milk and no milk, low starch diet in our study. 7. Case fatality rate for persistent diarrhoea was 10% in the study population. 8. Significant independent risk factors for persistent diarrhoea in multivariate analysis were use of unsafe drinking water, irrational use of antibiotics, parenteral infections and protein energy malnutrition. The persistence of acute diarrhoeal episodes can be prevented by a) All children should be provided with safe drinking water b) Antibiotics should be avoided for acute watery diarrhoea unless clearly indicated. c) All children with diarrhoea should be examined and investigated for parenteral infections such as urinary tract infection, septicemia, pneumonia and prompt treatment should be given. d) Promote and encourage exclusive breast feeding upto 6 months. e) Advise appropriate complementary feeding.