Treating dehydrating diarrhoea at district hospital level in sub-Saharan Africa: from policy to reality
Authors: Andrew C Argent
Journal: The Lancet Child & Adolescent Health (2018)

In the spectrum of human disease, diarrhoea would seem to be one of the more straightforward disorders, preventable by well recognised interventions and amenable to relatively simple treatment.1Bhutta ZA Das JK Walker N et al.Interventions to address deaths from childhood pneumonia and diarrhoea equitably: what works and at what cost?.Lancet. 2013; 381: 1417-1429Summary Full Text Full Text PDF PubMed Scopus (329) Google Scholar However, diarrhoea remains one of the most important causes of childhood mortality across the world, although there have been substantial improvements over the past decade.2Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Disease Study 2015.Lancet Infect Dis. 2017; 17: 909-948Summary Full Text Full Text PDF PubMed Scopus (663) Google Scholar Alarmingly, repeated episodes of diarrhoea in early childhood are associated with significant risks of stunting,3Bhutta ZA Nelson EA Lee WS et al.Recent advances and evidence gaps in persistent diarrhea.J Pediatr Gastroenterol Nutr. 2008; 47: 260-265Crossref PubMed Scopus (34) Google Scholar long-term adverse cognitive effects, and decreased work productivity later in life.4Guerrant RL Kosek M Lima AA Lorntz B Guyatt HL Updating the DALYs for diarrhoeal disease.Trends Parasitol. 2002; 18: 191-193Summary Full Text Full Text PDF PubMed Scopus (103) Google Scholar Some of the interventions credited with achieving reduced diarrhoea-related mortality include exclusive breastfeeding, provision of safe water and sanitation,5Baker KK O'Reilly CE Levine MM et al.Sanitation and Hygiene-Specific Risk Factors for Moderate-to-Severe Diarrhea in Young Children in the Global Enteric Multicenter Study, 2007–2011: Case-Control Study.PLoS Med. 2016; 13: e1002010Crossref PubMed Scopus (74) Google Scholar administration of measles vaccine, oral rehydration preparations,1Bhutta ZA Das JK Walker N et al.Interventions to address deaths from childhood pneumonia and diarrhoea equitably: what works and at what cost?.Lancet. 2013; 381: 1417-1429Summary Full Text Full Text PDF PubMed Scopus (329) Google Scholar and zinc supplementation.6Walker CL Black RE Zinc for the treatment of diarrhoea: effect on diarrhoea morbidity, mortality and incidence of future episodes.Int J Epidemiol. 2010; 39: i63-i69Crossref PubMed Scopus (143) Google Scholar There remains a substantial gap between resources allocated worldwide to reduction of diarrhoea associated mortality and the effect of the disorder, although there has been renewed focus on delineation of research priorities.7Zipursky A Wazny K Black R et al.Global action plan for childhood diarrhoea: Developing research priorities: Report from a Workshop of the Programme for Global Paediatric Research.J Glob Health. 2013; 3: 010406Crossref PubMed Scopus (12) Google Scholar Further improvements will depend on new avenues for prevention and treatment and on the provision of effective and appropriate care at district or first referral hospitals.8English M Esamai F Wasunna A et al.Delivery of paediatric care at the first-referral level in Kenya.Lancet. 2004; 364: 1622-1629Summary Full Text Full Text PDF PubMed Scopus (90) Google Scholar Effective therapeutic interventions at this level require provision of resources for rehydration: accurate recognition of clinical signs by health-care workers (often with limited training, and rapid turnover); and reliable implementation of effective protocols. The process of ensuring that these interventions occur reliably and consistently is challenging in contexts where data collection and quality assessment is limited. In The Lancet Child and Adolescent Health Samuel Akech and colleagues9Akech S Ayieko P Gathara D et al.Risk factors for mortality and effect of correct fluid prescription in children with diarrhoea and dehydration without severe acute malnutrition admitted to Kenyan hospitals: an observational, association study.Lancet Child Adolesc Health. 2018; (published online May 15.)http://dx.doi.org/10.1016/S2352-4642(18)30130-5Summary Full Text Full Text PDF Scopus (17) Google Scholar present data for the management of dehydrating diarrhoea in children admitted to 13 Kenyan first referral-level hospitals. The clinical information network that has been established over the past few years provides the context for this study. These hospitals are staffed mainly by junior doctors (with nursing and other personnel), with high turnover of staffing. The data were collected from routine clinical documentation (standardised admission and discharge forms) in the hospitals10Tuti T Bitok M Malla L et al.Improving documentation of clinical care within a clinical information network: an essential initial step in efforts to understand and improve care in Kenyan hospitals.BMJ Global Health. 2016; 1: e000028Crossref PubMed Scopus (44) Google Scholar (local teams extracted and entered the information into electronic systems11Tuti T Bitok M Paton C et al.Innovating to enhance clinical data management using non-commercial and open source solutions across a multi-center network supporting inpatient pediatric care and research in Kenya.JAMIA. 2016; 23: 184-192Google Scholar); were collated through the clinical information network and then analysed by the research team. A particular challenge in this study was the presence of missing data in multiple variables (only 24% of patients in the study had complete data), and the authors addressed these using techniques of multiple imputation.12Plumpton CO Morris T Hughes DA White IR Multiple imputation of multiple multi-item scales when a full imputation model is infeasible.BMC Res Notes. 2016; 9: 45Crossref PubMed Scopus (37) Google Scholar The focus of the study was twofold: first, to identify clinical risk factors for in-hospital death, and second, to assess risk modification associated with intended use of WHO and Kenyan fluid treatment guidance in these children. The majority of children (5160 [60%] of 8562) with diarrhoea and dehydration had some dehydration with 2434 (28%) having severe dehydration and 431 (5%) having shock. Most children (84%) had an additional diagnosis including slide-positive malaria (32%), pneumonia (36%), anaemia (5%), and possible meningitis (8%). Overall, 759 (9%) children died in this study, ranging from 240 (5%) of 5160 with some dehydration to 179 (42%) of 431 in those with shock. Half the deaths occurred within 1 day of admission. Overall, signs of respiratory or circulatory impairment, pallor, neurological signs and symptoms, prolonged diarrhoea (>14 days), age younger than 1 year, and female sex were associated with increased risk of in-hospital death. Akech and colleagues have shown that at hospital level, the vast majority of children (in Kenya) with diarrhoea and dehydration have additional diagnoses, with significant implications for fluid management. While correct fluid prescriptions (type, volume, and rate) at the time of admission were present for only 3760 (47%) of 8562 patients, with 3569 (45%) of 8025 receiving some intravenous fluids, administration of the correct fluids was associated with lower mortality. As the investigators note, it is possible that the correct fluid prescription on admission is an association with improved overall care rather than a specific benefit, but it seems that current recommendations have some validity. Ideally future research would consider the fluids prescribed and administered throughout the admission. Akech and colleagues have shown the substantial benefits associated with their clinical information network. They have highlighted the gap between recommendations and implementation of policy even within a relatively well-developed network. As priorities for diarrhoea related research are re-evaluated, the researchers have shown the need to consider patient presentations at the hospital level; the potential complexity of multiple diagnoses; and the need to consider a much wider range of pathogens than those typically associated with diarrhoea.13Kotloff KL Nataro JP Blackwelder WC et al.Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study.Lancet. 2013; 382: 209-222Summary Full Text Full Text PDF PubMed Scopus (2261) Google Scholar I declare no competing interests. Risk factors for mortality and effect of correct fluid prescription in children with diarrhoea and dehydration without severe acute malnutrition admitted to Kenyan hospitals: an observational, association studyChildren at risk of in-hospital death are those with complex presentations rather than uncomplicated dehydration, and the prescription of recommended rehydration guidelines reduces risk of death. Strategies to optimise the delivery of recommended guidance should be accompanied by studies on the management of dehydration in children with comorbidities, the vulnerability of young girls, and the delivery of immediate care. Full-Text PDF Open Access