Authors: Sabrina Chambuso, Bernard Okamo, Vitus Silago, Martha Fidelis Mushi, Erasmus Kamugisha
Institution: Catholic University of Health and Allied Sciences
Dehydration from diarrhea leads to a loss of vital electrolytes in the body. The prevalence of electrolytes deficiency and its outcomes due to diarrhea among children under five in Mwanza, Tanzania was not clearly known, thus this study was performed to determine this statistic. A cohort study was conducted among 66 children less than five years old suffering from diarrhea attended and admitted to health centers in Mwanza, Tanzania. Vein puncture was performed to obtain peripheral blood, processed, and analyzed for two major electrolytes, Potassium and Sodium. This study was conducted because the loss of vital electrolytes (sodium and potassium) from diarrhea can be fatal if poorly treated. The median age of study participants was 1 year, ranged from 0.6 to 3 years. The prevalence of electrolytes deficiency in the cohort was determined to be 54.5%. Sodium deficiency (Hyponatremia) was the most prevalent (37.9%). After medication and oral rehydration therapy, all of the diarrheagenic children recovered, and those with electrolytes deficiency had their electrolytes balanced. Proper medication with oral rehydration therapy ensures complete recovery from diarrhea and electrolytes balance.
Diarrhea is the passage of three or more loose or liquid stools per day; it may be a result of eating contaminated food and water or from food poisoning and is a common symptom of gastrointestinal infections caused by a wide range of pathogens, including bacteria, viruses and protozoa (Black et al., 1980; Kothari VR, & Thakur NA, 2014). Dehydration can be identified by experiencing dizziness, thirst, fatigue, infrequent urination and dark colored urine, nausea and headaches can leave the body without the electrolytes necessary for survival (Hirschhorn, 1980; Mackenzie, Barnes, & Shann, 1989). The electrolytes found in the body are potassium, calcium, sodium, magnesium, bicarbonate and chloride for cells functioning and signaling. According to WHO estimates; diarrheal disease is the leading cause of under-five mortality and is responsible for killing around 760,000 children every year (Kothari VR, & Thakur NA, 2014).
Epidemiological studies have shown that in developing countries, there are an estimated 1.3 billion episodes and 3.2 million deathsof those under age five each year due to diarrhea (Rahman, 2014). Overall, these children experience an average of 3.3 episodes of diarrhea per year, but in some areas, primarily in developing countries, the average exceeds 9 episodes per year (Rahman, 2014). Where episodes are frequent, children may spend more than 15% of their days with diarrhea and about 80% of deaths that occur in the first two years of life are due to the condition. In developing countries 50% of pediatric hospitalizationsare due to acute diarrhea (Rahman, 2014).
A study carried outby the BP Koirala Institute of Health Sciences in Dharan, Nepal that examined acid, base, and electrolyte disturbance in diarrhea showed 56% sodiumdeficiency (hyponatremia), 46% potassium deficiency (hypokalemia) and 26% combined (hyponatremia and hypokalemia) (Shah, Das, Kumar, Singh, & Bhandari, 2007). The same study reported five children out of 57 had died due to electrolytes loss from diarrhea (Shah et al., 2007).
Statistical information about the prevalence of electrolyte deficiency and the outcomes among children under five years old with diarrhea that attended or was admitted to healthcare centers in Mwanza, Tanzania was not clearly known. We hypothesized that, vital electrolytes (sodium and potassium) are lost together with water due to excessive diarrhea among children under five years old. The outcome of vital electrolytes lost can be fatal, so this study was designed to guide management of children under five years old with diarrhea for early and complete recovery.
MATERIALS AND METHODS
A cohort study was conducted between July and August 2016. All children less than five years old suffering from diarrhea who was admitted at the pediatric wards in Mwanza Healthcare centers and whose parents or guardians gave their consent to take part in this study were used in the study. A serial sampling method was used to determine eligibility of these study participants. About 2.5 to 5ml of two blood samples were collected from each participant and placed in a plain vacutainer tubes whereby the serum was extracted for electrolytes (sodium and potassium) analysis. Blood sample A was collected on the first day of participant admission or visit and sample B, as a follow up to sample A, was collected three days after administering oral rehydration solution (ORS) or antibiotics to all participants with electrolyte(s) [sodium and/or potassium] deficiency results.
Extracted sera were analyzed within two hours after specimen collection for sodium and potassium following the internal standard operating procedures, and as per reagents manufacturer guidelines for the SP Twin Electrolytes Test Kit (ARKRAY Healthcare Pvt. Ltd, India) in the Corolimeter manual analyzer (CL 157 Colorimeter).
Demographic and Clinical Characteristics of Participants
During this study, a total of 66 children were enrolled. Out of those, 53.0% (35/66) were females. The median age of study participant was 1 (IQR: 0.6-3) year (Table 1).
Electrolyte Deficiency Results
The overall prevalence of electrolytes deficiency in diarrheagenic under-five children was 54.5% (36/66). Hyponatremia, hypokalemia and both (hyponatremia and hypokalemia) electrolytes deficiency were observed in 37.9% (25/66), 16.7% (11/66) and 15.2% (10/66) of the cohort respectively.
Factors Associated with Electrolytes Deficiency
Factors found to be connected with electrolytes deficiency among diarrheagenic under-five children in the bivariate analysis were 1) Present of symptoms like fever, vomiting and dehydration, 2) Duration of diarrhea, and 3) Diarrhea treatment. Children with symptoms such as fever, vomiting and dehydration showed electrolyte deficiency; 20/58 (34.5%) had hyponatremia, 10/58 (17.2%) had hypokalemia, and 8/58 (13.8%) had both (p = .707) (Table 2).
Considering the duration of diarrhea, most of children showed electrolyte deficiency during the early three up to seven days of diarrhea; 13/36 (36.1%) had hyponatremia, 6/36 (16.7%) had hypokalemia, and 8/36 (22.2%) had both hypokalemia and hyponatremia (p = .651).
Following diarrhea treatment with ORS, antibiotics or both, for those who did not received any treatment; 12/34 (35.3%) had hyponatremia, 4/34 (11.8%) had hypokalemia and 9/34 (26.5%) had both hypokalemia and hyponatremia (p = .031) (Table 2).
Electrolyte Deficiency Outcomes
Out of 66 diarrheagenic children, 40 recovered completely, 18 were still suffering from diarrhea and 8 were lost prior to follow-up (discharged or did not attend next visit) with no record of death. Among the cohort, 32 received management with antibiotics, ORS or both, whereby 62.5% (20/32) recovered completely from diarrhea (p = .0069). All diarrheagenic children who had recovered after treatment, 20/20 (100%) had balanced electrolytes from day three of follow up (Table 3).
In this study, the prevalence of electrolytes deficiency among under-five diarrheagenic children was 54.5%, with the most prevalent depleted electrolyte being sodium (hyponatremia), 37.9% followed by potassium depletion (hypokalemia), 16.7%. This is comparable to another study done in Dharan, Nepal which found that the most prevalent depleted electrolyte among children with diarrhea was sodium (hyponatremia), 56% (Shah et al., 2007). Another study done in Nigeria in 2015 on serum electrolyte profiles in children admitted with dehydration due to diarrhea showed that hyponatremia and hypokalemia ranked first and second by 60.5% and 44.3% respectively (Onyiriuka, & Iheagwara, 2015). Sodium and potassium are the major lost electrolytes in diarrhea because they form intracellular and extracellular fluids respectively at the sodium-potassium pump (Skou, 1989).
The current study found that, electrolytes deficiency among diarrheagenic children to be associated with clinical symptoms like fever, duration of diarrhea and treatment type as previously reported (Bahl et al., 2002; Donowitz, Kokke, & Saidi, 1995; Thapar, & Sanderson, 2004; Weiner, & Epstein, 1970). The more episodes of diarrhea a child experiences, the greater amount of water and electrolytes are lost (Thapar, & Sanderson, 2004). Lack of treatment therapy to replace water and electrolytes resultsin a high level of deficiency (Thapar, & Sanderson, 2004).
This study found that most of the children experienced electrolyte deficiency after suffering from diarrhea during the early three to seven days. This may be because during the early days they had not yet received treatment; thus, the results showed electrolytes had decreased. However, as the days went on they underwent treatment and their levels began to rise as ORS replaced the lost electrolytes. Diarrhea treatment either with ORS or antibiotics ensures recovery and a rise in electrolytelevels (Hirschhorn, 1980). But for those children who received antibiotic treatment and ORS, still in diarrhea may be the exact aetiological cause of diarrhea was not bacteria (Black et al., 1980; Hirschhorn, 1980).
Most patients with electrolyte deficiency recovered completely after receiving treatment; those who had not received any treatment but recovered may have been affected by a bacterial toxin, in which case the diarrhea usually stops itself after some time (self-limiting) (Challapalli, Tess, Cunningham, Chopra, & Houston, 1988).
The current study found high prevalence of electrolytes deficiency, 54.5% among children under five years old with diarrhea. Electrolytes deficiency was connected with fever, vomiting and dehydration. The use of ORS as part of diarrhea management to replace water and the lost electrolytes is recommended. This study was unable to determine the aetiological causative agent of diarrhea among children under five years old. Further studies should attempt to determine the aetiological causative agent of diarrhea cases.
Bahl, R., Bhandari, N., Saksena, M., Strand, T., Kumar, G. T., Bhan, M. K., &
Sommerfelt, H. (2002). Efficacy of zinc-fortified oral rehydration solution in 6-to 35-month-old children with acute diarrhea. The Journal of Pediatrics, 141(5), 677-682.
Black, R. E., Merson, M., Rahman, A. M., Yunus, M., Alim, A. A., Huq, I., Curlin,
G. (1980). A two-year study of bacterial, viral, and parasitic agents associated with diarrhea in rural Bangladesh. Journal of Infectious Diseases, 142(5), 660-664.
Challapalli, M., Tess, B. R., Cunningham, D. G., Chopra, A. K., & Houston, C. W.
(1988). Aeromonas-associated diarrhea in children. The Pediatric Infectious Disease Journal, 7(10), 693-697.
Donowitz, M., Kokke, F. T., & Saidi, R. (1995). Evaluation of patients with chronic
diarrhea. New England Journal of Medicine, 332(11), 725-729.
Hirschhorn, N. (1980). The treatment of acute diarrhea in children. An historical
and physiological perspective. The American Journal of Clinical Nutrition, 33(3), 637-663.
Hsiao, A. L., & Baker, M. D. (2005). Fever in the new millennium: a review of
recent studies of markers of serious bacterial infection in febrile children. Current Opinion in Pediatrics, 17(1), 56-61.
Mackenzie, A., Barnes, G., & Shann, F. (1989). Clinical signs of dehydration in
children. The Lancet, 334(8663), 605-607.
Onyiriuka, A., & Iheagwara, E. (2015). Serum electrolyte profiles of under-five
Nigerian children admitted for severe dehydration due to acute diarrhea. Nigerian Journal of Health Sciences, 15(1), 14.
Rahman, H. (2014). Molecular characterization of Necrotoxigenic Escherichia Coli
NTEC of man and animals.
Shah, G., Das, B., Kumar, S., Singh, M., & Bhandari, G. (2007). Acid base and
electrolyte disturbance in diarrhoea.
Skou, J. C. (1989). Sodium-potassium pump Membrane transport (pp. 155-185):
Thapar, N., & Sanderson, I. R. (2004). Diarrhoea in children: an interface between
developing and developed countries. The Lancet, 363(9409), 641-653.
VR, Kothari., & NA, Thakur. (2014). A Cross Sectional Study of Risk Factors for
Development of Dehydration in Children under 5 Years Having Acute Watery Diarrhea.
Weiner, M., & Epstein, F. (1970). Signs and symptoms of electrolyte disorders. The
Yale Journal of bBology and Medicine, 43(2), 76.