Paediatric problems in tropical gastroenterology.
Authors: J A Walker-Smith
Journal: Gut (1994)

Leading article -Tropial infectn ofthe gastrointestinal tract and liver seris Paediatric problems in tropical gastroenterologyAfter the introduction of oral rehydration therapy for the treatment of acute diarrhoea in infancy and childhood, the case management of such diarrhoea has considerably improved both in hospital and at home.This has in tropical communities led to a sharp decline in the numbers of deaths from diarrhoea.Indeed fewer children are being seen with severe dehydration and the World Health Organisation believe 90% of all deaths from diarrhoea in children may be prevented.Chronic diarrhoea has emerged, however, as an important problem as a result of this improvement in mortality and in particular, persistent diarrhoea -that is, diarrhoea that begins acutely but persists, continuing beyond two weeks after the onset of the acute diarrhoea.The causes of this symptom are many and the best treatment for persistent diarrhoea is not yet agreed. Acute diarrhoea ACUTE INFECTIVE DIARRHOEADespite improved treatment with oral rehydration therapy, acute diarrhoea of infective origin remains an important problem in the developing world.A two year study of this problem in children aged less than three years in China, India, Mexico, Mynamar (Burma), and Pakistan has been published.1A total of 36 400 children with diarrhoea were studied and 3279 age matched controls.Sixty per cent were boys and roughly 60% were aged less than one year.Only three infectious agents were found to be consistently or substantially increased in the children with diarrhoea.These were: rotavirus (16% diarrhoea, 2% controls), shigellae (11% diarrhoea, 1% controls), and enterotoxigenic Escherichia coli (16% diarrhoea, 5% controls).Rotavirus is clearly the most frequently identified cause of acute diarrhoea in childhood in tropical communities, just as it is temperate communities.Its peak age in tropical countries is between the age of 6 and 12 months, although it can occur in younger infants.In tropical communities the typical peak associated with cooler weather is not seen and sometimes there is no sea- sonal trend at all, suggesting that it is present all the year round, with low level transmission maintaining the infection in the community.2While it is clear that rotavirus is spread by the faecal-oral route, its persistence in developed communities where there is good sanitation and a high level of breast feeding, suggests that airborne and droplet transmission are also possible.PREVENTIVE METHODSThe present problem of high infantile diarrhoeal mortality in the developing world has important analogies with the high and sometimes rising infant mortality from diarrhoeal disease in countries such as Britain, Australia, and New Zealand that occurred at the beginning of the twentieth century.This occurred despite the development of clean water and vastly improved sanitation.Newman,3 writing in 1906, stated that infantile diarrhoea mortality was a disease of urban deprivation.He found that infantile diarrhoeal diseases were: (a) very much more fatal in urban rather than rural districts; (b) more dangerous to boys than girls; (c) more severe in first year of life; (d) aggravated by bad housing, poverty, artificial feeding, and domestic insanitation.