Knowledge, attitude and practice regarding diarrhoea and its prevention and the use of oral rehydration therapy among mothers of children under the age of five visiting a tertiary care hospital in Mangalore, India

Background: Diarrheal diseases remain the second most leading cause of mortality and morbidity next to pneumonia among under-five mortality globally, contributing to 1/5th of child deaths.Methods: Cross sectional hospital based questionnaire study conducted among 200 mothers of children within the age group of 6-60 months with diarrhoea attending the paediatric outdoor or treated in the paediatric indoor (OPD) at YMCH hospital using personal interview method. Filled up questionnaires was collected and was attached along with the filled up proforma.Results: Of 200 mothers, 24.3% knew the correct meaning of diarrhoea, with 73.8% of them not knowing the correct cause of diarrhoea. Only 44.3% knew that it could be prevented. Majority 88.7% did not know to look for signs of dehydration. Less than half of the mothers had only heard of ORT. By using c2-test, preparation ORS was found to be associated with the mother's education (p=0.04) proving that knowledge is better among those mothers with formal education. No association was found between ORS preparation and age of the mother (p=0.229), religion (p=0.342), and gender of the child (p=0.061).Conclusions: The findings of this research indicate that only 73.8% of the mothers had knowledge regarding the cause of the diarrhoea and less than half 11.3% has only heard and used ORT properly.

La atención primaria de salud y la salud materno infantil

The Primary Health Care strategy introduced concepts which sought to revolutionize the way how to achieve Health for All at the global level. The Declaration of Alma Ata was a prelude to initiatives and global plans that sought compromise to States and society in achieving access to health equity. The Summit of Action for Children and the Meeting of the Millennium, which agreed health targets to achieve by year 2015 were inspired by the concepts included in Primary Health Care. While it is true that the purposes lying below the postulates in Alma Ata were not reached, there was remarkable progress in aspects related to the Mother and Child Health. The Selective Primary Healthcare inspired the so-called "Revolution for the Child Survival", which identified the main causes of the 15 million deaths in children recorded at the global level at the beginning of the Decade of the eighties of the last century, as well as the simple, low-cost interventions based on the evidence shown to be effective in the prevention of this "silent emergency" represented by the avoidable child deaths. Product of these interventions related to children health and the subsequent inclusion of interventions for the prevention of the 500 000 preventable maternal deaths recorded worldwide at the beginning of this century, has achieved remarkable progress at global level. Peru was one of the countries of the Americas that showed greater progress in reducing maternal and infant mortality. This article seeks to find an explanation of procedures and processes that allowed these achievements at the global level and in Peru, inspired by the principles proposed by the Primary Health Care strategy.

La estrategia Atención Primaria de la Salud introdujo conceptos que buscaron revolucionar la forma como se aspiraba lograr la Salud para Todos a nivel global. La declaración de Alma Ata fue un preludio de iniciativas y planes globales que buscaron comprometer a los Estados y a la sociedad en alcanzar el acceso a la salud con equidad. La Cumbre de Acción por la Infancia y la Reunión del Milenio, en la que se acordó las metas de salud a lograr el año 2015, estuvieron inspiradas en los conceptos incluidos en la Atención Primaria de la Salud. Si bien es cierto, los propósitos que subyacían a los postulados recogidos en Alma Ata no fueron alcanzados, sí hubo notables progresos en aspectos relacionados con la salud Materno Infantil. La Atención Primaria Selectiva de la Salud, inspiró la llamada ‘Revolución por la Supervivencia Infantil, que identificó las principales causas de las 15 millones muertes en niños, que se registraban a nivel global a inicios de la década de los años 80 del siglo pasado, así como las intervenciones sencillas, de bajo costo y basadas en la evidencia que habían mostrado ser efectivas en la prevención de esta ‘emergencia silenciosa que representaban las muertes infantiles evitables. Producto de estas intervenciones relacionadas con la salud infantil y la posterior inclusión de intervenciones para la prevención de las 500 000 muertes maternas evitables que registraba el mundo a inicios del presente siglo, se ha logrado notables progresos a nivel global en estos propósitos. El Perú fue uno de los países de las Américas que mostró mayores progresos en la reducción de la mortalidad materna y en la niñez. El presente artículo busca encontrar una explicación de las intervenciones y procesos que permitieron estos logros a nivel global y en el Perú, inspirados en los postulados propuestos por la estrategia de la Atención Primaria de la Salud.

Terapia de rehidratacion oral en pacientes deshidratados por diarrea aguda infantil / Oral rehydration therapy in children with acute diarrhea and dehydration

La Terapia de Rehidratación Oral (TRO) se ha convertido en las últimas décadas en la piedra angular del tratamiento de las enfermedades diarreicas, constituyendo un gran avance para tratar en forma segura y eficaz la deshidratación producida por diarrea de diversas etiologías en todas las edades, excepto cuando la deshidratación es grave. La composición de las soluciones de rehidratación oral (SRO) ha sido objeto de controversias relacionadas con el contenido de electrolitos, bicarbonato, osmolaridad, transportadores, y micronutrientes. Sin embargo, los resultados de investigaciones promovidas por la Organización Mundial de la Salud (OMS) y el Fondo para la Infancia de las Naciones Unidas (UNICEF) en el año 2001, recomiendan el uso de las SRO de Osmolaridad Reducida (SROOR) ya que estas muestran superioridad significativa, en los resultados clínicos, sobre las SRO estándar (SRO-S). En el texto, a continuación, se describen las bases fisiológicas de la terapia de la rehidratación oral, la composición y características de las SRO, la evaluación clínica de la deshidratación, los planes de hidratación en casos de diarrea, y la terapia de rehidratación oral en el niño desnutrido.

Oral rehydration therapy (ORT) has been in the last decades the corner stone of the therapy for diarrheic diseases, this type of treatment produced a great improvement in safety and efficiency in the therapy of diarrheas of diverse etiologies, in all ages, with the only exception of serious dehydration. The therapy of diarrheas with oral rehydration solutions (ORS) has triggered numerous controversies related to the composition of the solutions on the basis of electrolytes content, sodium bicarbonate, osmolality, transporters, and micronutrients. However, the results of the research conducted, in 2001, by the World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF), recommend the use of the ORS of reduced osmolality (ORS-R), because this kind of therapy shows a meaningful superiority in the clinical outcome of the patients, when compared with the ORS of standard osmolality (ORS-S). In the text, we describe the physiological basis for oral therapy rehydration, the composition and characteristics of ORS, the clinical evaluation of dehydration, different therapy treatments for hydration in diarrheic disease, and the use of therapy of oral rehydration in malnourished infant.

Promoting Appropriate Management of Diarrhea: A Systematic Review of Literature for Advocacy and Action: UNICEF-PHFI Series on Newborn and Child Health, India.

Background: Scaling up of evidence-based management and prevention of childhood diarrhea is a public health priority in India, and necessitates robust literature review, for advocacy and action. Objective: To identify, synthesize and summarize current evidence to guide scaling up of management of diarrhea among under-five children in India, and identify existing knowledge gaps. Methods: A set of questions pertaining to the management (prevention, treatment, and control) of childhood diarrhea was identified through a consultative process. A modified systematic review process developed a priori was used to identify, synthesize and summarize, research evidence and operational information, pertaining to the problem in India. Areas with limited or no evidence were identified as knowledge gaps. Results: Childhood diarrhea is a significant public health problem in India; the point (two-weeks) prevalence is 9-20%. Diarrhea accounts for 14% of the total deaths in under-five children in India. Infants aged 6-24 months are at the highest risk of diarrhea. There is a lack of robust nation-wide data on etiology; rotavirus and diarrheogenic E.coli are the most common organisms identified. The current National Guidelines are sufficient for case-management of childhood diarrhea. Exclusive breastfeeding, handwashing and point-of-use water treatment are effective strategies for prevention of all-cause diarrhea; rotavirus vaccines are efficacious to prevent rotavirus specific diarrhea. ORS and zinc are the mainstay of management during an episode of childhood diarrhea but have low coverage in India due to policy and programmatic barriers, whereas indiscriminate use of antibiotics and other drugs is common. Zinc therapy given during diarrhea can be upscaled through existing infrastructure is introducing the training component and information, education and communication activities. Conclusion: This systematic review summarizes current evidence on childhood diarrhea and provides evidence to inform child health programs in India.

From Cholera to Burns: A Role for Oral Rehydration Therapy.

According to the practice guidelines of the American Burn Association on burn shock resuscitation, intravenous (IV) fluid therapy is the standard of care for the replacement of fluid and electrolyte losses in burn injury of ≥20% of the total body surface area. However, in mass burn casualties, IV fluid resuscitation may be delayed or unavailable. Oral rehydration therapy (ORT), which has been shown to be highly effective in the treatment of dehydration in epidemics of cholera, could be an alternate way to replace fluid losses in burns. A prospective case series of three patients was carried out as an initial step to establish whether oral Ceralyte®90 could replace fluid losses requiring IV fluid therapy in thermal injury. The requirement of the continuing IV fluid therapy was reduced by an average of 58% in the first 24 hours after the injury (range 37-78%). ORT may be a feasible alternative to IV fluid therapy in the resuscitation of burns. It could also potentially save many lives in mass casualty situations or in resource-poor settings where IV fluid therapy is not immediately available. Further studies are needed to assess the efficacy of this treatment and to determine whether the present formulations of ORT for cholera need modification.

The 2008 Cholera Epidemic in Zimbabwe: Experience of the icddr,b Team in the Field.

During August 2008–June 2009, an estimated 95,531 suspected cases of cholera and 4,282 deaths due to cholera were reported during the 2008 cholera outbreak in Zimbabwe. Despite the efforts by local and international organizations supported by the Zimbabwean Ministry of Health and Child Welfare in the establishment of cholera treatment centres throughout the country, the case-fatality rate (CFR) was much higher than expected. Over two-thirds of the deaths occurred in areas without access to treatment facilities, with the highest CFRs (>5%) reported from Masvingo, Manicaland, Mashonaland West, Mashonaland East, Midland, and Matabeleland North provinces. Some factors attributing to this high CFR included inappropriate cholera case management with inadequate use of oral rehydration therapy, inappropriate use of antibiotics, and a shortage of experienced healthcare professionals. The breakdown of both potable water and sanitation systems and the widespread contamination of available drinking-water sources were also considered responsible for the rapid and widespread distribution of the epidemic throughout the country. Training of healthcare professionals on appropriate cholera case management and implementation of recommended strategies to reduce the environmental contamination of drinking-water sources could have contributed to the progressive reduction in number of cases and deaths as observed at the end of February 2009.

National Scale-up of Zinc Promotion in Nepal: Results from a Post-project Population-based Survey.

The World Health Organization and the United Nations Children’s Fund recommend using a new oral rehydration solution (ORS) plus zinc supplementation for 10-14 days for the treatment of diarrhoea in children aged less than five years. The Social Marketing Plus for Diarrhoeal Disease Control: Point of Use Water Disinfection and Zinc Treatment (POUZN) project in Nepal was one of the first zinc-promotion projects to move beyond pilot efforts into a scaled-up programme with national-level reach. This study used data from a survey conducted in 26 districts in Nepal in 2008 to examine zinc-use behaviour, knowledge, and beliefs of caregivers of children aged less than six years, other diarrhoea-treatment practices, and recollection of project communication messages. The results of the survey indicated that, by six months following the onset of a zinc-promotion campaign, the majority (67.5%) of children (n=289), aged less than six years, with diarrhoea were treated with ORS, and 15.4% were treated with zinc. Over half (53.1%) of all caregivers (n=3,550) interviewed had heard about zinc products; most (97.1%) of those who had heard of zinc knew that zinc should be used for the treatment of diarrhoea. Zinc-related knowledge and behaviours were positively associated with recall of communication messages. Children whose caregivers recalled the mass-media message that zinc should be used for 10 days [odds ratio (OR)=2.02, 95% confidence interval (CI) 1.85-2.19] and whose caregivers perceived that zinc is easy to obtain (OR=1.76, 95% CI 1.49-2.09) were more likely to be treated with zinc for 10 days, along with ORS. The findings demonstrated that mass media play an important role in increasing caregivers’ knowledge about zinc and encouraging trial and correct use. Future efforts should also focus on understanding the factors that motivate providers to continue recommending antibiotics and antidiarrhoeals instead of zinc. These findings are being used for informing the design and implementation of zinc programmes in other developing countries with a high prevalence of diarrhoea.

Oral rehydration therapy: New insights on an old remedy

Oral Rehydration Therapy (ORT) has been the cornerstone of diarrheal management since the late 1960s. It is a cheap but effective treatment and has significantly decreased the morbidity worldwide from diarrhea-associated dehydration. The road leading to the discovery of ORT and the modifications that were done after 25 years of use are discussed in the present review.

Indicação da Terapia de Reidratação Oral no setor de emergência: decisão baseada na clínica: [revisão] / Use of Oral Rehydration Therapy in the emergency unit: a clinical-based decision: [review]

OBJETIVO: Revisar a literatura acerca da indicação da terapia de reidratação oral (TRO) no contexto do Setor de Emergência, buscando fatores inerentes à formação do médico, à atitude do cuidador e, finalmente, à dinâmica do próprio serviço como determinantes à sua aplicação. FONTES DE DADOS: Revisão não-sistemática da literatura incluindo artigos originais e meta-análises, nos idiomas inglês, português e espanhol, a partir das bases de dados Pubmed/Medline, Cochrane Collaboration, Lilacs e SciELO, no período de 1990 a 2008. Foram utilizados os termos "oral rehydration therapy", "diarrhea case management", "emergency department" e palavras relacionadas. SÍNTESE DOS DADOS: Realizada em local apropriado, a TRO mostrou eficácia semelhante à terapia venosa no restabelecimento do nível de hidratação em crianças com diarreia aguda no Setor de Emergência. O tempo de formado e a experiência profissional, o conhecimento e o treinamento no manejo da diarreia aguda mostraram associação à utilização da TRO. Entretanto, relatos de inconveniência de sua administração no Setor de Emergência incluem falta de espaço físico e pressão assistencial, sugerindo, ao mesmo tempo, inadequação estrutural e uso inapropriado do serviço nesses casos. A relação com o cuidador também influencia na decisão médica, com o relato de desconfiança deste quanto à eficácia da terapia sendo citado como barreira à sua indicação. CONCLUSÕES: A subutilização da TRO no Setor de Emergência está associada a fatores extrínsecos à formação médica, como questões estruturais e fatores inerentes à relação com o cuidador diante das suas expectativas quanto à terapia.

OBJECTIVE: To review the literature about indication of oral rehydration therapy (ORT) for children in the emergency unit, seeking factors related to medical training, caregiver's attitude and units' conditions as determinants for that practice. DATA SOURCES: Non-systematic literature review including original articles and meta-analysis in English, Portuguese and Spanish, identified via Pubmed/Medline, Cochrane Collaboration, Lilacs and SciELO, published between 1990 and 2008, using the terms "oral rehydration therapy", "diarrhea case management", "emergency department" and related words. DATA SYNTHESIS: When carried out in appropriate rooms, ORT treatment is as effective as intravenous therapy in restoring the level of hydration in children with acute diarrhea in the emergency unit. Time of graduation and professional experience, knowledge and training on acute diarrhea case management showed an association with ORT use. However, reports of inconvenience of its administration in the emergency unit include lack of physical space and pressure care, while simultaneously suggesting structural inadequacy and improper use of the service in these cases. Reports of caregivers' suspicion about the effectiveness of this therapy are cited as a barrier for prescription. CONCLUSIONS: Subuse of ORT in the emergency unit is associated with factors beyond medical training and expertise, such as structural problems and caregivers' expectations about the therapy.

Management of Acute Infectious Diarrhea

Acute infectious diarrhea is a mostly self-limiting disease, but in some clinical situations such as infants, elderly, and immunocompromised patients, diarrheal illnesses might cause ominous results. Appropriate therapy could ameliorate symptoms and improve the prognosis. The mainstay of therapy consists of fluids and electrolytes, diet, symptomatic drugs, and antimicrobial agents. Rehydration is always the first goal of therapy by using oral rehydration solutions or intravenous fluids according to the patient's clinical condition. Antimicrobial therapy could be effective in the treatment of infectious diarrhea such as shigellosis, traveler's diarrhea, and C. difficile-associated colitis but also cause some adverse reactions such as worsening Shiga-toxin producing E. coli infection and increasing cost. So it is advisable to use antimicrobial agents properly and, first of all, preventive measures should be underscored.