Incidence and Risk Factors for Severe Dehydration in Hospitalized Children in Ujjain, India
1
Department of Pediatrics, Gardi Medical College, Ujjain 456006, India
2
Global Health-Health Systems and Policy: Medicines, Focusing Antibiotics, Department of Global Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden
3
Department of Women and Children’s Health, International Maternal and Child Health Unit, Uppsala University, 753 27 Uppsala, Sweden
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2020, 17(2), 616; https://doi.org/10.3390/ijerph17020616
Submission received: 15 December 2019
/
Revised: 15 January 2020
/
Accepted: 16 January 2020
/
Published: 18 January 2020
(This article belongs to the Section Infectious Disease Epidemiology)
Abstract
:Diarrhoea contributes significantly to the under-five childhood morbidity and mortality worldwide. This cross-sectional study was carried out in a tertiary care hospital in Ujjain, India from July 2015 to June 2016. Consecutive children aged 1 month to 12 years having “some dehydration” and “dehydration” according to World Health Organization classification were eligible to be included in the study. Other signs and symptoms used to assess severe dehydration were capillary refill time, urine output, and abnormal respiratory pattern. A questionnaire was administered to identify risk factors for severe dehydration, which was the primary outcome. Multivariate logistic regression modeling was used to detect independent risk factors for severe dehydration. The study included 332 children, with mean ± standard deviation age of 25.62 ± 31.85 months; out of which, 70% (95% confidence interval [CI] 65 to 75) were diagnosed to have severe dehydration. The independent risk factors for severe dehydration were: child not exclusive breastfed in the first six months of life (AOR 5.67, 95%CI 2.51 to 12.78; p < 0.001), history of not receiving oral rehydration solution before hospitalization (AOR 1.34, 95%CI 1.01 to 1.78; p = 0.038), history of not receiving oral zinc before hospitalization (AOR 2.66, 95%CI 1.68 to 4.21; p < 0.001) and living in overcrowded conditions (AOR 5.52, 95%CI 2.19 to 13.93; p < 0.001). The study identified many risk factors associated with severe childhood dehydration; many of them are modifiable though known and effective public health interventions.
1. Introduction
Diarrhoea is the second leading cause of morbidity and mortality among under-5 (U-5) children worldwide [1,2,3]. Childhood diarrhoea results in the death of approximately, 700,000 U-5 children yearly, constituting almost 16% of global child death [2,3]. Apart from deaths, the grave consequence of diarrhoea in the first two years of life is its effect on growth, leading to stunting [4]. The morbidity of childhood diarrhoea is about 3 episodes per child per year, and childhood diarrhoea is concentrated in Southeast Asia and Sub Saharan Africa [1]. Controlling diarrhoeal diseases has been on the public health agenda since long. The World Health Organization (WHO)-led diarrhoeal disease control programme resulted in a steep reduction of 75% in mortality due to diarrhoea worldwide from the 1980s to 2008 [5]. However, since then, gains in the reducing mortality rates have been levelling [5]. In 2013, the WHO and the United Nations Children’s Fund (UNICEF) formulated the integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD), which outlines a framework for ending preventable child deaths due to diarrhoea and pneumonia by 2025 [1]. The GAPPD emphasises a ‘protect, prevent, and treat’ approach that integrates interventions with proven effectiveness [1].
In India, steady progress has been made in reducing deaths in U-5 children, with total deaths declining from 2.5 million in 2001 to 1.5 million in 2012, with a mean rate of fall of around 3.7% annually [1,6]. Despite this reduction, in India, diarrhoea is the third most common cause of death in U-5 children and is responsible for 13% of deaths in this age group [2,7]. Thus, in India alone diarrhoea results in the death of an estimated 300,000 children each year [2,7]. In terms of diarrhoeal episodes per year, the morbidity data from the National Family Health Survey-4 (NFHS-4) in Madhya Pradesh (M.P.) province where the current study was conducted, found that, 9.5% of all U-5 children had suffered from diarrhoea in the 2 weeks prior to survey [8]. The province of M.P. has the highest burden of infant and childhood mortality in India [8].
Despite its consequences on health and survival, the last decade has witnessed a reduction in research on childhood diarrhoea [5]. As an example, only a few studies on epidemiological and clinical risk factors in childhood diarrhoea from India, have been conducted [9,10,11,12,13], but the burden of diarrhoeal diseases remains high [14]. To achieve the goal of ending preventable deaths due to diarrhoea the WHO and UNICEF emphasise the need for more research focusing on identifying context-specific risk factors and interventions to control childhood diarrhoea [1]. Thus, the present study aimed to examine the demographic, socioeconomic, environmental, and clinical risk factors for diarrhoea in children aged less than 12 years in the city of Ujjain, M.P., India.
2. Materials and Methods
This prospective observational study was conducted from July 2015 to June 2016. This study was approved by the Institutional Ethics Committee (IEC) of RD Gardi Medical College, Ujjain (IEC reference number 459/2014).
2.1. Study Setting
The study was done in the pediatric ward of C.R. Gardi Hospital (CRGH), Ujjain. The CRGH is situated approximately six kilometers from Ujjain city and is a teaching hospital attached to R.D. Gardi Hospital (RDGMC). Department of Pediatrics in RDGMC has 90 beds out of the total 800 beds in CRGH. The hospital is managed by a charitable trust.
2.2. Study Participants
Consecutive patients aged between 1 month and 12 years who were admitted for acute diarrhoea (up-to 14 days) to the paediatric ward were included in the study. The WHO definition of acute diarrhoea was used: i.e., passage of three or more loose stools (liquid or watery stool) for more than one day [1]. Children having “some dehydration” and “dehydration” according to WHO classification were eligible to be included in the study [15]. Other signs and symptoms used to assess severity of dehydration included capillary refill time, urine output and abnormal respiratory pattern [16]. Children treated in the last 24 h with intravenous fluids, children with persistent diarrhoea (>14 days), children living with human immunodeficiency virus/acquired immune deficiency syndrome, bloody diarrhoea, diarrhoea due to systemic infection, and diarrhoea during a course of antibiotic therapy were excluded from this study. Figure 1 shows the patient recruitment process.
2.3. Definitions
The following definitions were used for the present study: nuclear family was defined as a family that consisted of a married couple and their children occupying the same dwelling space [17]. A joint family comprised of more than one married couple and their children who lived together in the same household and shared a common kitchen [17]. Overcrowding was defined as a situation in which more people are living within a single dwelling than there is space for, so that movement is restricted, privacy secluded, hygiene impossible, rest and sleep difficult [17]. Breastfeeding was considered exclusive if the infant has received only breast milk from his/her mother or a wet nurse, or expressed breast milk, and no other liquids or solids [18]. Severe acute malnutrition (SAM) was assessed and managed in children between the ages of 6 months to 5 years according to the consensus statement by the Indian Academy of Paediatrics (IAP) [19]. A kutcha house was one with the walls and/or roof made of material such as un-burnt bricks, bamboos, mud, grass, reeds, thatch, loosely packed stones, etc. [20]. A pucca house is one, which has walls and roof made of burnt bricks/stones packed with lime or cement [20].
2.4. Data Collection Method
The mother or caregiver accompanying the child fulfilling the inclusion criteria was interviewed by one of the research assistants using a predefined questionnaire (online supplementary data). Information was collected on demographics of the child and mother, relevant medical history, history of treatment received before hospitalisation, and environmental and personal hygiene-related risk factors for diarrhoea. Signs and symptoms of children included in the study was recorded at time of admission. Apart from the first author, two independent paediatric consultants assessed each admitted child and decided the management of the child.
2.5. Clinical Management of Diarrhoea
2.6. Data Management and Statistical Analysis
Data were entered into EpiData Entry (Version 3.1, EpiData Software Association, Odense, Denmark) and were analysed using Stata (Version 13.0, Statacorp. Texas, TX, USA). The Pearson chi-square test was used to evaluate the association of each risk factor with severe dehydration, and the results are reported as unadjusted odd ratios (OR). Stepwise multivariate logistic regression models, with backward elimination of predictor variables having a p value of more than 0.1 were used to develop the final model. In the final model, the p value of all predictor variables was less than 0.1, except for age and sex. Adjusted OR (AOR) and their 95% confidence intervals (CI) were then calculated. A p value of <0.05 was considered significant. Model discrimination was conducted using the C-statistics-receiver-operating-characteristics (ROC) curve, and model calibration was performed using Hosmer–Lemeshow ‘goodness-of-fit’ test [22].
3. Results
During the study period, 332 children (54% boys and 46% girls) with diarrhoea were enrolled. The mean age of children was 25.62 months (SD ± 31.85). Of the 332 children admitted with diarrhoea, 232 children were diagnosed to have severe dehydration and the remaining had “some dehydration” according to WHO classification. The prevalence of severe dehydration was thus 70% (95% CI 65 to 75). The signs and symptoms at the time of admission are shown in Table 1. None of the children included in the study died during the hospital stay.
Although slightly more boys were admitted then girls there was no statistically significant difference in the prevalence of severe dehydration among the boys and girls. Most (74%) children belonged to younger age group of 1 month to 24 months. Children of illiterate mothers compared to children of literate mothers and children of working mothers compared to non-working mothers, had increased risk for severe dehydration (Table 2).
Association severe dehydration with feeding-related factors, other factors in past one month-Vitamin A supplementation, measles and diarrhea are shown in Table 3. Presence of SAM, and if the child received vaccination on schedule were also associated with severe h = dehydration. Treatment-related factors like antibiotics, ORS and zinc, and home treatment for the present episode of diarrohea were significantly associated with severe dehydration (Table 3).
The environmental and household sanitation conditions identified as risk factors are shown in Table 4.
3.1. Multivariate Analysis
The independent risk factors for severe dehydration were: lack of exclusive breastfeeding in first six months of life, history of measles in the last one month, excessive crying, presence of malnutrition, receiving antibiotic in last 7 days, not receiving oral rehydration solution before hospitalization, not receiving oral Zinc before hospitalization, and living in overcrowded conditions (details in Table 5).
3.2. Model Performance
4. Discussion
This is the first study from central India and from the province of Madhya Pradesh to define risk factors for severe dehydration in children with acute watery diarrhoea. Despite measures to control the disease at national level in India the disease burden remains high [14].
In our study, bivariate analysis revealed that children living in urban areas had a lower risk of severe dehydration than children living in rural areas. This may be due to presence of greater number of risk factors associated with diarrhoea among children living in urban areas [23,24]. However, increased risk of acute diarrhoea in rural areas has also been reported [25]. The most important underlying factors in both urban and rural areas are water, sanitation and hygiene (WASH)-related an include the faecal contamination of drinking water, the lack of personal hygiene especially during water handling, and inadequate hand washing after defecation [9,10,26,27]. The children of illiterate mothers have a nearly two-fold increased risk of severe dehydration in our study. Similar increased risk of diarrhoea has been reported in children born to illiterate mothers [5,28].
It has been well documented that the morbidity of diarrhoea is the lowest in exclusively breastfed children, due to the protective effects of breast milk [1,29,30]. Bottle-feeding has been shown to be associated with diarrhoea in India as well as in other low-income countries [24,31]. In the present study, 84% of children received vitamin A supplementation. In our study, the association of vitamin A supplementation with severe dehydration was not statistically significant. However, evidence shows that vitamin A supplementation reduces diarrhoea mortality by 12% and significantly reduces morbidity due to diarrhoea and measles [32]. In our study, bivariate analysis results support that post-measles diarrhoea is an important complication of measles, and children with measles have a 1.29 times increased risk of severe dehydration. Acute diarrhoea has been reported in more than 50% of cases of complicated measles [33]. In our study, SAM was present in 33% of children; of these children, 79% had severe dehydration (p < 0.05). The presence of SAM, as defined by IAP’s weight-for-age classification, increases the risk of severe dehydration (Table 5). SAM can increase the severity of diarrhoea, particularly in wasted children, which may be due to the diminished immune response to infection [24]. In our study, according to bivariate analysis, the odds of severe dehydration increased when an antibiotic was prescribed to a child for the present episode of diarrhoea in the last 7 days. Moreover, patients who did not receive ORS and zinc had a higher risk of diarrhoea. Antibiotics are indicated only for a fraction of cases of acute diarrhoea but are prescribed to up to 70% of children with diarrhoea [34]. According to the NFHS-4 data for Ujjain district, 64% and 52% of U-5 children with diarrhoea received ORS in urban and rural areas, respectively. Compared with the NFHS-4 data, the ORS use rates in our study were 32% and 37% in rural and urban areas, respectively [8]. Moreover, according to the NFHS-4 data, 20% of U-5 children received zinc, which is comparable to the rate of 19% reported in our study [8].
In our study, we explored the association of the type of household sanitation with severe dehydration. The absence of a toilet in the house, non-use of toilet, and practice of open-air defecation increased the risk of severe dehydration. In our study, 86% of households had a toilet facility. An increase in the number of toilets constructed at households and the use of toilets can be linked to the Swachh Bharat campaign initiated by the Government of India from 2nd October 2014 onwards [33]. The association of overcrowding with severe dehydration found in our study is probably a proxy for poor sanitation, lack of access to clean water, and inadequate personal hygiene, which are responsible for approximately 88% of childhood diarrhoea in India [24]. Moreover, in many places in India, child faeces are not disposed of safely [10,24,26]. Similar WASH-related environmental risk factors for diarrhoea have been reported recently from Mozambique, Tanzania and Nepal [9,35,36]. Environmental enteric dysfunction is now considered the most important causes of stunting in children with diarrhoea in low-middle-income countries [4,37]. The lack of hand hygiene is a universal risk factor for diarrhoea [38]. It has been estimated that proper hand washing practices can reduce the number of diarrhoeal episodes by more than one-third [38]. However, the best approach to promote hand hygiene among children remains elusive [39].
Strengths and Limitations
The main strength of this cross-sectional study is that we collected both epidemiological and clinical data for risk assessment of severe dehydration in childhood admitted with acute diarrhoea, which is rare. The study also identified many modifiable risk factors for childhood diarrhoea, which can be used for planning community interventions. However, the study has certain limitations: the study did not ascertain the aetiology of diarrhoeal diseases in children, because it was not the primary study objective and also because of limited laboratory on-site capacity and the lack of affordable point-of-care diagnostics. A home visit to the children with diarrhoea could have helped us identify the contamination of household drinking water, but this was not thought to be feasible.
5. Conclusions
Our study identified a multitude of risk factors for childhood diarrhoea, and many of them are modifiable. Promotion of breastfeeding, early identification and treatment of severe acute malnutrition, and treatment of diarrhoea with ORS and zinc in the household and community can reduce the risk for severe dehydration. Research should be conducted to identify effective interventions that can modify the identified risk factors. The implementation of such effective interventions may substantially reduce the morbidity and mortality of diarrhoea in this and similar resource-constrained settings.
Author Contributions
A.S.; A.M.; C.S.L.; and A.P. participated in the conception and design of the study. A.S. and A.M. collected the data. A.M. and A.P. did data management. A.P. supervised the data collection. A.S.; A.M. and A.P. performed the statistical analysis. A.S. and A.P. drafted the manuscript. A.S.; A.M.; C.S.L. and A.P. revised the paper critically for substantial intellectual content. All authors read and approved the final version. All authors have read and agreed to the published version of the manuscript.
Funding
This study is funded by Uppsala Universitet’s L R Åkerhams post-doctoral scholarship in clinical research, obtained by Ashish Pathak. The funders had no role in study design, data collection, data analysis, decision to publish, or preparation of the manuscript.
Acknowledgments
We are thankful to all the study participants for taking part in the study. We would also like to thank the Dean, M. K. Rathore, and Medical Director, V. K. Mahadik, R. D. Gardi Medical College, Ujjain for the support that was provided us in undertaking the study.
Conflicts of Interest
The authors declare no conflict of interest.
References
- UNICEF; WHO. End Preventable Deaths: Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea; World Health Organization: Geneva, Switzerland, 2013; Available online: http://apps.who.int/iris/bitstream/handle/10665/79200/9789241505239_eng.pdf;jsessionid=837AEC1288C76D2368F1E8F8DAB86B55?sequence=1 (accessed on 7 December 2019).
- Liu, L.; Oza, S.; Hogan, D.; Perin, J.; Rudan, I.; Lawn, J.E.; Cousens, S.; Mathers, C.; Black, R.E. Global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: An updated systematic analysis. Lancet 2015, 385, 430–440. [Google Scholar] [CrossRef]
- Walker, C.L.; Rudan, I.; Liu, L.; Nair, H.; Theodoratou, E.; Bhutta, Z.A.; O’Brien, K.L.; Campbell, H.; Black, R.E. Global burden of childhood pneumonia and diarrhoea. Lancet 2013, 381, 1405–1416. [Google Scholar] [CrossRef]
- Troeger, C.; Colombara, D.V.; Rao, P.C.; Khalil, I.A.; Brown, A.; Brewer, T.G.; Guerrant, R.L.; Houpt, E.R.; Kotloff, K.L.; Misra, K.; et al. Global disability-adjusted life-year estimates of long-term health burden and undernutrition attributable to diarrhoeal diseases in children younger than 5 years. Lancet Glob. Health 2018, 6, e255–e269. [Google Scholar] [CrossRef] [Green Version]
- Santosham, M.; Chandran, A.; Fitzwater, S.; Fischer-Walker, C.; Baqui, A.H.; Black, R. Progress and barriers for the control of diarrhoeal disease. Lancet 2010, 376, 63–67. [Google Scholar] [CrossRef]
- Ram, U.; Jha, P.; Ram, F.; Kumar, K.; Awasthi, S.; Shet, A.; Pader, J.; Nansukusa, S.; Kumar, R. Neonatal, 1-59 month, and under-5 mortality in 597 indian districts, 2001 to 2012: Estimates from national demographic and mortality surveys. Lancet Glob. Health 2013, 1, e219–e226. [Google Scholar] [CrossRef] [Green Version]
- Liu, L.; Johnson, H.L.; Cousens, S.; Perin, J.; Scott, S.; Lawn, J.E.; Rudan, I.; Campbell, H.; Cibulskis, R.; Li, M.; et al. Global, regional, and national causes of child mortality: An updated systematic analysis for 2010 with time trends since 2000. Lancet 2012, 379, 2151–2161. [Google Scholar] [CrossRef]
- National Family Health Survey-4; Ministry of Health and Family Welfare, Government of India: New Delhi, India, 2016; pp. 105–116. Available online: http://rchiips.org/nfhs/NFHS-4Reports/India.pdf (accessed on 7 December 2019).
- Acharya, D.; Singh, J.K.; Adhikari, M.; Gautam, S.; Pandey, P.; Dayal, V. Association of water handling and child feeding practice with childhood diarrhoea in rural community of southern Nepal. J. Infect Public Health 2018, 11, 69–74. [Google Scholar] [CrossRef] [PubMed]
- Bawankule, R.; Singh, A.; Kumar, K.; Pedgaonkar, S. Disposal of children’s stools and its association with childhood diarrhea in india. BMC Public Health 2017, 17, 12. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Gupta, S.; Singh, K.P.; Jain, A.; Srivastava, S.; Kumar, V.; Singh, M. Aetiology of childhood viral gastroenteritis in lucknow, north india. Indian J. Med. Res. 2015, 141, 469–472. [Google Scholar] [PubMed] [Green Version]
- Lakshminarayanan, S.; Jayalakshmy, R. Diarrheal diseases among children in india: Current scenario and future perspectives. J. Nat. Sci. Biol. Med. 2015, 6, 24–28. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Sur, D.; Manna, B.; Deb, A.K.; Deen, J.L.; Danovaro-Holliday, M.C.; von Seidlein, L.; Clemens, J.D.; Bhattacharya, S.K. Factors associated with reported diarrhoea episodes and treatment-seeking in an urban slum of kolkata, india. J. Health Popul. Nutr. 2004, 22, 130–138. [Google Scholar] [PubMed]
- Nilima; Kamath, A.; Shetty, K.; Unnikrishnan, B.; Kaushik, S.; Rai, S.N. Prevalence, patterns, and predictors of diarrhea: A spatial-temporal comprehensive evaluation in india. BMC Public Health 2018, 18, 1288. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- The Treatment of Diarrhoea: A Manual for Physicians and Other Senior Health Workers. Geneva: World Health Organization. Available online: https://www.who.int/maternal_child_adolescent/documents/9241593180/en/ (accessed on 7 December 2019).
- Steiner, M.J.; DeWalt, D.A.; Byerley, J.S. Is this child dehydrated? JAMA 2004, 291, 2746–2754. [Google Scholar] [CrossRef] [PubMed]
- Park, K. Park’s Textbook of Preventive and Social Medicine, 23th ed.; Banarsidas Bhanot Publication: Jabalpur, India, 2015. [Google Scholar]
- WHO. Global Strategy on Infant and Young Child Feeding Geneva, 2002. Available online: https://apps.who.int/iris/bitstream/handle/10665/42590/9241562218.pdf?sequence=1 (accessed on 7 December 2019).
- Dalwai, S.; Choudhury, P.; Bavdekar, S.B.; Dalal, R.; Kapil, U.; Dubey, A.P.; Ugra, D.; Agnani, M.; Sachdev, H.P.S. Consensus statement of the indian academy of pediatrics on integrated management of severe acute malnutrition. Indian Pediatr. 2013, 50, 399–404. [Google Scholar] [CrossRef] [PubMed]
- Ministry of Statistics and Programme Implementation (MSPI). Concepts and Definitions Used in NSS; Ministry of Statistics and Programme Implementation: New Delhi, India, 2001.
- Dekate, P.; Jayashree, M.; Singhi, S.C. Management of acute diarrhea in emergency room. Indian J. Pediatr. 2013, 80, 235–246. [Google Scholar] [CrossRef] [PubMed]
- Steyerberg, E.W.; Vickers, A.J.; Cook, N.R.; Gerds, T.; Gonen, M.; Obuchowski, N.; Pencina, M.J.; Kattan, M.W. Assessing the performance of prediction models: A framework for traditional and novel measures. Epidemiology 2010, 21, 128–138. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Alnawajha, S.K.; Bakry, G.A.; Aljeesh, Y.I. Predictors of acute diarrhoea among hospitalized children in gaza governorates: A case-control study. J. Health Popul. Nutr. 2015, 33, 1–8. [Google Scholar]
- Ganguly, E.; Sharma, P.K.; Bunker, C.H. Prevalence and risk factors of diarrhea morbidity among under-five children in india: A systematic review and meta-analysis. Indian J. Child Health 2015, 2, 152–160. [Google Scholar]
- Siziya, S.; Muula, A.S.; Rudatsikira, E. Correlates of diarrhoea among children below the age of 5 years in sudan. Afr. Health Sci. 2013, 13, 376–383. [Google Scholar] [CrossRef] [Green Version]
- Das, J.K.; Bhutta, Z.A. 3.6 reducing the burden of acute and prolonged childhood diarrhea. World Rev. Nutr. Diet 2015, 113, 168–172. [Google Scholar]
- Dos Santos, S.; Ouedraogo Fde, C.; Soura, A.B. Water-related factors and childhood diarrhoea in african informal settlements. A cross-sectional study in ouagadougou (burkina faso). J. Water Health 2015, 13, 562–574. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Sinmegn Mihrete, T.; Asres Alemie, G.; Shimeka Teferra, A. Determinants of childhood diarrhea among underfive children in benishangul gumuz regional state, north west ethiopia. BMC Pediatr. 2014, 14, 102. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Bhutta, Z.A.; Das, J.K.; Walker, N.; Rizvi, A.; Campbell, H.; Rudan, I.; Black, R.E.; Lancet Diarrhoea and Pneumonia Interventions Study Group. Interventions to address deaths from childhood pneumonia and diarrhoea equitably: What works and at what cost? Lancet 2013, 381, 1417–1429. [Google Scholar] [CrossRef]
- Das, J.; Das, S.K.; Ahmed, S.; Ferdous, F.; Farzana, F.D.; Sarker, M.H.; Ahmed, A.M.; Chisti, M.J.; Malek, M.A.; Rahman, A.; et al. Determinants of percent expenditure of household income due to childhood diarrhoea in rural bangladesh. Epidemiol. Infect. 2015, 143, 2700–2706. [Google Scholar] [CrossRef]
- Mahmood, D.A.; Feachem, R.G.; Huttly, S.R. Infant feeding and risk of severe diarrhoea in basrah city, iraq: A case-control study. Bull. World Health Organ. 1989, 67, 701–706. [Google Scholar]
- Imdad, A.; Mayo-Wilson, E.; Herzer, K.; Bhutta, Z.A. Vitamin a supplementation for preventing morbidity and mortality in children from six months to five years of age. Cochrane Database Syst. Rev. 2017, 3, CD008524. [Google Scholar] [CrossRef]
- Marufu, T.; Siziya, S.; Tshimanga, M.; Murugasampillay, S.; Mason, E.; Manyame, B. Factors associated with measles complications in gweru, zimbabwe. East Afr. Med. J. 2001, 78, 135–138. [Google Scholar] [CrossRef]
- Pathak, D.; Pathak, A.; Marrone, G.; Diwan, V.; Lundborg, C.S. Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in ujjain, india--a cross-sectional prescription analysis. BMC Infect. Dis. 2011, 11, 32. [Google Scholar] [CrossRef] [Green Version]
- Knee, J.; Sumner, T.; Adriano, Z.; Berendes, D.; de Bruijn, E.; Schmidt, W.P.; Nala, R.; Cumming, O.; Brown, J. Risk factors for childhood enteric infection in urban maputo, mozambique: A cross-sectional study. PLoS Negl. Trop. Dis. 2018, 12, e0006956. [Google Scholar] [CrossRef]
- Kabhele, S.; New-Aaron, M.; Kibusi, S.M.; Gesase, A.P. Prevalence and factors associated with diarrhoea among children between 6 and 59 months of age in mwanza city tanzania. J. Trop. Pediatr. 2018, 64, 523–530. [Google Scholar] [CrossRef]
- Tickell, K.D.; Atlas, H.E.; Walson, J.L. Environmental enteric dysfunction: A review of potential mechanisms, consequences and management strategies. BMC Med. 2019, 17, 181. [Google Scholar] [CrossRef] [PubMed]
- Ejemot-Nwadiaro, R.I.; Ehiri, J.E.; Arikpo, D.; Meremikwu, M.M.; Critchley, J.A. Hand washing promotion for preventing diarrhoea. Cochrane Database Syst. Rev. 2015, 9, CD004265. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Watson, J.A.; Ensink, J.H.J.; Ramos, M.; Benelli, P.; Holdsworth, E.; Dreibelbis, R.; Cumming, O. Does targeting children with hygiene promotion messages work? The effect of handwashing promotion targeted at children, on diarrhoea, soil-transmitted helminth infections and behaviour change, in low- and middle-income countries. Trop. Med. Int. Health 2017, 22, 526–538. [Google Scholar] [CrossRef] [PubMed] [Green Version]
Figure 1.
Flow chart of the patient recruitment process.
Table 1.
Signs and symptoms of the 332 children admitted with severe dehydration included in the study in Ujjain, India.
Table 1.
Signs and symptoms of the 332 children admitted with severe dehydration included in the study in Ujjain, India.
| Variable | Total (n = 332) (%) | Variable | Total (n = 332) (%) |
|---|---|---|---|
| Eye-ball appearance a | Abnormal respiratory pattern b | ||
| Sunken | 270 (81) | Yes | 89 (27) |
| Normal | 62 (19) | No | 243 (73) |
| Ability to drink a | Poor oral intake | ||
| Normal | 9 (3) | Yes | 291 (88) |
| Eagerly | 300 (90) | No | 41 (12) |
| Poorly | 23 (7) | Normal | 13 (4) |
| Irritability/Restlessness a | Sunken anterior fontanelle c | ||
| Yes | 64 (19) | Yes | 37 (11) |
| No | 268 (80) | No | 295 (89) |
| Lethargic/Unconscious a | Fever | ||
| Yes | 179 (54) | Yes | 289 (87) |
| No | 153 (46) | No | 43 (13) |
| Skin Pinch a | Vomiting | ||
| Normal | 9 (3) | Yes | 235 (71) |
| Slow | 300 (90) | No | 97 (29) |
| Very Slow | 23 (7) | Tenesmus | |
| Capillary refill time b | Yes | 95 (29) | |
| Delayed/prolonged | 298 (90) | No | 237 (71) |
| Normal | 34 (10) | ||
| Urine output b | |||
| Decreased | 301 (91) | ||
| Normal | 31(9) |
Table 2.
Association of socio-demographic and birth-related risk factors with severe dehydration in 332 children hospitalized with diarrhoea.
Table 2.
Association of socio-demographic and birth-related risk factors with severe dehydration in 332 children hospitalized with diarrhoea.
| Variable | Severe Dehydration | ||||||
|---|---|---|---|---|---|---|---|
| Total (%) a (n = 332) | Yes (%) b (n = 232) | No (%) b (n = 100) | OR | 95% CI | p Value | ||
| Lower | Upper | ||||||
| Gender | |||||||
| Boys | 179 (54) | 123 (69) | 56 (31) | R | |||
| Girls | 153 (46) | 109 (71) | 44 (29) | 1.03 | 0.90 | 1.19 | 0.616 |
| Age | |||||||
| 1 to 24 months | 246 (74) | 177 (72) | 69 (28) | R | |||
| >2yr to 12yr | 86 (26) | 55 (64) | 31 (36) | 0.88 | 0.74 | 1.06 | 0.792 |
| Resident | |||||||
| Urban | 243 (73) | 160 (66) | 83 (34) | R | |||
| Rural | 89 (27) | 72 (81) | 17 (19) | 1.22 | 1.07 | 1.40 | 0.003 |
| Prematurity | |||||||
| Yes | 321 (97) | 224 (70) | 97 (30) | R | |||
| No | 11 (3) | 8 (73) | 3 (27) | 1.04 | 0.72 | 1.50 | 0.826 |
| Term low birth weight | |||||||
| Yes | 45 (14) | 28 (62) | 17 (38) | R | |||
| No | 287 (86) | 204 (71) | 83 (29) | 1.14 | 0.89 | 1.45 | 0.276 |
| Mother’s education | |||||||
| Literate | 252 (76) | 167 (66) | 85 (34) | R | |||
| Illiterate | 80 (24) | 65 (81) | 15 (19) | 1.22 | 1.06 | 1.40 | 0.004 |
| Mother’s occupation | |||||||
| Housewife | 281 (85) | 190 (68) | 91 (32) | R | |||
| Working | 51 (15) | 42 (82) | 9 (18) | 1.21 | 1.04 | 1.41 | 0.010 |
a = column percentage, b = row percentage, R-reference
Table 3.
Association of feeding, other past history and past treatment-related risk factors with severe dehydration in 332 hospitalized children.
Table 3.
Association of feeding, other past history and past treatment-related risk factors with severe dehydration in 332 hospitalized children.
| Variable | Severe Dehydration | ||||||
|---|---|---|---|---|---|---|---|
| Total (%)a (n = 332) | Yes (%)b (n = 232) | No (%)b (n = 100) | OR | 95%CI | p Value | ||
| Lower | Upper | ||||||
| Exclusive breastfeeding (first 6 months) | |||||||
| Yes | 228 (69) | 143 (63) | 85 (37) | R | |||
| No | 104 (31) | 89 (86) | 15 (14) | 1.36 | 1.20 | 1.54 | <0.001 |
| Bottle feeding (at present) | |||||||
| No | 253 (76) | 169 (67) | 84 (33) | R | |||
| Yes | 79 (24) | 63 (80) | 16 (20) | 1.91 | 1.03 | 1.37 | 0.014 |
| Vitamin A supplementation (past 1 month) | |||||||
| Yes | 280 (84) | 195 (70) | 85 (30) | R | |||
| No | 52 (16) | 37 (71) | 15 (29) | 1.02 | 0.84 | 1.23 | 0.824 |
| History of measles (past 1 month) | |||||||
| No | 299 (90) | 203 (68) | 96 (32) | R | |||
| Yes | 33 (10) | 29 (88) | 4 (12) | 1.29 | 1.11 | 1.50 | 0.001 |
| History of diarrhoea (past 1 month) | |||||||
| No | 140 (42) | 88 (63) | 52 (37) | R | |||
| Yes | 19 2(58) | 144 (75) | 48 (25) | 1.19 | 1.02 | 1.38 | 0.022 |
| SAM (diagnosed on admission) | |||||||
| No | 221 (67) | 144 (65) | 77 (35) | R | |||
| Yes | 111 (33) | 88 (79) | 23 (21) | 1.21 | 1.06 | 1.39 | 0.005 |
| Vaccination on schedule | |||||||
| Yes | 316 (95) | 218 (69) | 98 (31) | R | |||
| No | 16 (5) | 14 (88) | 2 (12) | 1.26 | 1.03 | 1.54 | 0.019 |
| Antibiotic received for present episode | |||||||
| No | 209 (67) | 123 (59) | 86 (41) | R | |||
| Yes | 123 (37) | 109 (89) | 14 (11) | 1.50 | 1.32 | 1.71 | <0.001 |
| ORS received for present episode | |||||||
| Yes | 111 (33) | 98 (88) | 13 (12) | R | |||
| No | 221 (67) | 134 (61) | 87 (39) | 1.47 | 1.29 | 1.66 | <0.001 |
| Oral Zinc received for present episode | |||||||
| Yes | 64 (19) | 21 (33) | 43 (67) | R | |||
| No | 268 (81) | 211 (79) | 57 (21) | 2.23 | 1.68 | 3.42 | <0.001 |
| Home treatment given for present episode | |||||||
| Yes | 67 (20) | 58 (87) | 9 (13) | R | |||
| No | 265 (80) | 174 (66) | 91 (34) | 1.31 | 1.15 | 1.49 | <0.001 |
a = column percentage, b = row percentage, SAM = Severe acute malnutrition, ORS = Oral rehydration solution.
Table 4.
Association of environmental and personal hygiene-related risk factors with presence or absence of severe dehydration in 332 hospitalized children.
Table 4.
Association of environmental and personal hygiene-related risk factors with presence or absence of severe dehydration in 332 hospitalized children.
| Variables | Severe Dehydration | ||||||
|---|---|---|---|---|---|---|---|
| Total (%) a (n = 332) | Yes (%) b (n = 232) | No (%) b (n = 100) | OR | 95% CI | p Value | ||
| Lower | Upper | ||||||
| Type of family | |||||||
| Nuclear | 147 (44) | 106 (72) | 41 (28) | R | |||
| Joint | 185 (56) | 126 (68) | 59 (32) | 0.94 | 0.82 | 1.08 | 0.427 |
| Type of home | |||||||
| Pacca | 235 (71) | 157 (67) | 78 (33) | R | |||
| Kutcha | 97 (29) | 75 (77) | 22 (23) | 1.15 | 1.00 | 1.33 | 0.042 |
| Over-crowding | |||||||
| No | 50 (15) | 27 (54) | 23 (46) | R | |||
| Yes | 282 (85) | 205 (73) | 77 (27) | 1.34 | 1.30 | 1.75 | 0.028 |
| Toilet present | |||||||
| Yes | 285 (86) | 193 (68) | 92 (32) | R | |||
| No | 46 (14) | 38 (82) | 8 (18) | 1.21 | 1.04 | 1.42 | 0.012 |
| Use of toilet | |||||||
| Yes | 283 (85) | 191 (67) | 92 (33) | R | |||
| No | 49 (15) | 41 (83) | 8 (17) | 1.23 | 1.06 | 1.43 | 0.004 |
| Open air defecation | |||||||
| No | 284 (86) | 192 (68) | 92 (32) | R | |||
| Yes | 47 (14) | 39 (83) | 8 (17) | 1.22 | 1.05 | 1.42 | 0.008 |
| Hand washing after going to toilet | |||||||
| Yes | 298 (90) | 202 (68) | 86 (32) | R | |||
| No | 34 (10) | 30 (88) | 4 (12) | 1.30 | 1.12 | 1.50 | <0.001 |
| Finger nail trimmed | |||||||
| Yes | 277 (83) | 188 (68) | 89 (32) | R | |||
| No | 55 (17) | 44 (80) | 11 (20) | 1.71 | 1.00 | 1.37 | 0.038 |
| Eating open/stale food | |||||||
| No | 161 (49) | 114 (71) | 47 (29) | R | |||
| Yes | 171 (51) | 118 (69) | 53 (31) | 0.97 | 0.84 | 1.12 | 0.720 |
a = column percentage, b = row percentage.
Table 5.
Multivariate analyses of socio-demographic, past treatment-related, environmental and sign and symptom-related risk factors for severe dehydration in 332 children hospitalized with diarrhoea.
Table 5.
Multivariate analyses of socio-demographic, past treatment-related, environmental and sign and symptom-related risk factors for severe dehydration in 332 children hospitalized with diarrhoea.
| Variable | Adjusted OR | 95% CI | p Value | |
|---|---|---|---|---|
| Lower | Upper | |||
| Age in months * (continuous variable) | 1.26 | 0.65 | 2.46 | 0.483 |
| Sex * (boys vs. girls) | 0.99 | 0.98 | 1.01 | 0.980 |
| Lack of exclusive breastfeeding in first 6 months of life | 5.67 | 2.51 | 12.78 | <0.001 |
| SAM (yes vs. no) | 2.05 | 1.10 | 5.32 | 0.027 |
| History of not receiving ORS before hospitalization | 1.34 | 1.01 | 1.78 | 0.038 |
| History of not receiving oral zinc | 2.66 | 1.68 | 4.21 | <0.001 |
| Living in overcrowded house (yes vs. no) | 5.52 | 2.19 | 13.93 | <0.001 |
* Adjusted for age and sex, SAM = Severe Acute Malnutrition, ORS = Oral rehydration solution.
© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
MDPI and ACS Style
Sharma, A.; Mathur, A.; Stålsby Lundborg, C.; Pathak, A. Incidence and Risk Factors for Severe Dehydration in Hospitalized Children in Ujjain, India. Int. J. Environ. Res. Public Health 2020, 17, 616. https://doi.org/10.3390/ijerph17020616
AMA Style
Sharma A, Mathur A, Stålsby Lundborg C, Pathak A. Incidence and Risk Factors for Severe Dehydration in Hospitalized Children in Ujjain, India. International Journal of Environmental Research and Public Health. 2020; 17(2):616. https://doi.org/10.3390/ijerph17020616
Chicago/Turabian StyleSharma, Abhishek, Aditya Mathur, Cecilia Stålsby Lundborg, and Ashish Pathak. 2020. "Incidence and Risk Factors for Severe Dehydration in Hospitalized Children in Ujjain, India" International Journal of Environmental Research and Public Health 17, no. 2: 616. https://doi.org/10.3390/ijerph17020616
Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.
