Acta Paediatr Suppl 381: 121-3. 1992
Clinical aspects of acute vs persistent diarrhea in Ho Chi Minh City, Vietnam Pham N Thanh, Dao-T-Ly, Pham-T-Dung and Pham-D Le Diarrheal Training Unit. Pediatric Hospital No. I , Ho Chi Minh City, Vietnam
Thanh PN, Ly DT, Dung PT, Le PD. Clinical aspects of acute vs persistent diarrhea in Ho Chi Minh City, Vietnam. Acta Paediatr 1992;(suppl 381): 121-3. Stockholm. ISSN 0803-5326 A retrospective clinical study of acute and persistent diarrhea in children younger than three years of age was conducted for 12 months (October 1989 to September 1990) in a Pediatric Hospital in H o Chi Minh City, South Vietnam. Most of the 3833 episodes of diarrhea identified were of short duration, with 77.7% lasting only 1-7 days. Only 5.3% of episodes lasted more than 14 days. Episodes of longer duration were associated with young age (0-5 months). Bloody stool was present in more than 40% of persistent episodes. Severe malnutrition was associated with persistent episodes that lasted 14-21 days (33%) or more than 22 days (59%). It is important that all patients with diarrhea have appropriate dietary management in addition to fluid therapy, and that future analysis examines etiologic factors to determine the optimal treatment of bloody diarrhea. PN Thanh. Diarrheal Training Unit, Pediatric Hospital No. I Ho Chi Minh City, Vietnam ~
Diarrheal diseases are well recognized as important vomiting, swollen abdomen, dehydration, fever, and causes of morbidity and mortality among children severe malnutrition. under three years of age in developing countries (1, 2). Diarrhea was defined as three or more liquid stools The majority of episodes are of relatively short duration (taking the shape of a container) within 24 h. A diarrheal (i.e. less than seven days) and can be treated easily and episode was considered as beginning with the first 24 h effectively with oral rehydration therapy (ORT) and period when stools meeting the definition of diarrhea continued feeding with an appropriate diet (3). Anti- were passed; an episode was considered to have ended biotics are necessary only when dysentery is recognized on the last day of diarrhea that was followed by at least or cholera is likely. This simple treatment regimen has two consecutive days not meeting the definition of reduced childhood mortality due to diarrhea worldwide. diarrhea. Duration of diarrhea represented the number In some instances, however, diarrhea lasts longer than of days of illness for an episode. For analysis of clinical usual. Such episodes of “persistent” diarrhea are often characteristics, episodes were classified by duration into associated with a deterioration in nutritional status and four groups: 1-7 days, 8-14 days, 15-21 days, and 22 or a substantial risk of death (4). In such cases, since more days. Persistent diarrhea was defined as an acute persistent diarrhea is a major cause of malnutrition and episode lasting more than 14 days. Dehydration was death, the clinical characteristics of the illness must be based on the three grades of the World Health Organizaunderstood so that appropriate treatment can be insti- tion (WHO) classification: no dehydration, some dehydtuted. This report summarizes the clinical aspects of ration, and severe dehydration. Nutritional status was based on weight (kg) for height acute vs persistent diarrhea in children hospitalized in a Pediatric Hospital of Ho Chi Minh City, Vietnam. (cm) expressed as a percentage of the expected median weight-for-height of the US National Center for Health Statistics (NCHS) reference population ( 5 ) . Diagnosis of severe malnutrition was based on weight-for-height below 70% of the median or the presence of edema. Methods This retrospective study was conducted in a Diarrheal Training Unit from October 1989 to September 1990. All children under three years of age who were hospitalized with diarrhea were included in the study. Cases of diarrhea associated with other non-diarrheal illness (i.e. respiratory infection, otitis media) were dropped from the studv. Clinical information recorded included Characteristics of stool (watery or bloody), anorexia,
Results During the study, 3833 episodes of diarrhea were identified. Most episodes of diarrhea were of short duration, 77.7% lasted 1-7 days. Only 5.3% of episodes lasted more than 14 davs. and 2.4%lasted more than 21 days. The proportion Gfepisodes lasting more than 14
122
Pham N Thanh el al.
ACTA PRDIATR SUPPL 381 (1992)
Table I . Percentage distribution of diarrheal episode by duration and age, Ho Chi Minh City, Vietnam, October 1989 to September 1990. Episode duration (days) Age group (months)
Diarrheal episodes
1-7
8-14
15-21
22+
0-5 6-1 1 12-23 24-36
564 985 1,683 60 I
74.7 77.2 78.6 80.2
19.2 20.3 18.6 9.7
5.7 2.5 I .8 I .6
3.2 I .8 2.4 2.2
Total
3,833
77.7
17.0
2.9
2.4
days was higher ( p < O . O O l ) in infants aged zero to 5 months (8.9%) than in older children (3.8%) (Table I). The clinical characteristics of diarrheal episodes of various durations are compared in Table 2. Severe malnutrition was associated with persistent episodes lasting more than 14 days (33%) or more than 21 days (59%). Bloody stool was also associated with more than 60% of episodes of persistent diarrhea.
Discussion This study showed that the rate of persistent diarrhea was highest among the children under six months old; community-based studies in Lima, Peru (6), and northern India (7) have also shown the highest incidence among the youngest children. However, in northeastern Brazil, the peak incidence included those in the second year of life, and the risk of developing persistent diarrhea was not related to age for children under three years (8, 9). This study also found that most episodes were less than one week in duration, only 5.3% of all episodes lasted longer than 14 days. Other studies have
found that 3-20% of episodes of diarrhea persist for this duration (4, 7, 8). Children with persistent diarrhea in our series were often severely malnourished, suggesting that this may be a risk factor for prolonged illness, as has been postulated previously (4). However, from case series such as this study, one cannot distinguish cause from effect. Episodes of long duration have particularly adverse effects on the growth of children. Marasmus (and less frequently, kwashiorkor) may develop rapidly during such episodes. For surviving children, however, the longterm effect on growth is likely to be stunting rather than wasting ( 1 0). Diarrheal episodes of longer duration (i.e. more than 14 d) were more often dysenteric, with blood observed in the stools. In a prospective community-based study in Lima, Peru, reports of blood or mucus in the stool during the first seven days were significant in predicting episodes that would persist beyond seven days; however, stool examination for leukocytes or blood early in the illness did not distinguish the episodes of shorter duration from those that were longer (6). These findings suggest that reported observation of blood in the stools may be a better predictor than a single laboratory examination for blood or leukocytes and could be used to predict dysentery and persistent diarrhea. Studies have shown that of the common enterpathogens, Shigella species cause diarrheal episodes of longer average duration than those due to other enteropathogens (1 I), and usually result in dysenteric illnesses. In conclusion, all episodes of diarrhea should have not only appropriate fluid therapy, but also good dietary management. The more severe episodes should be followed up to detect adverse effects on growth and permit more intensive nutritional intervention (12, 13). More attention should be given to appropriate treat-
Tuble 2. Percentage distribution of diarrheal episodes by clinical characteristics of the illness and duration, Ho Chi Minh City, Vietnam. October 1989 to September 1990. Episode duration (days) 1-7 (n= 2979) Clinical charateristics Watery or mucusa Bloodb Anorexia Vomitingb Swollen abdomenb Dehydration some severe Severe malnutritionb Feverh Chi square for episodes p
Clinical aspects of acute vs persistent diarrhea in Ho Chi Minh City, Vietnam Pham N Thanh, Dao-T-Ly, Pham-T-Dung and Pham-D Le Diarrheal Training Unit. Pediatric Hospital No. I , Ho Chi Minh City, Vietnam
Thanh PN, Ly DT, Dung PT, Le PD. Clinical aspects of acute vs persistent diarrhea in Ho Chi Minh City, Vietnam. Acta Paediatr 1992;(suppl 381): 121-3. Stockholm. ISSN 0803-5326 A retrospective clinical study of acute and persistent diarrhea in children younger than three years of age was conducted for 12 months (October 1989 to September 1990) in a Pediatric Hospital in H o Chi Minh City, South Vietnam. Most of the 3833 episodes of diarrhea identified were of short duration, with 77.7% lasting only 1-7 days. Only 5.3% of episodes lasted more than 14 days. Episodes of longer duration were associated with young age (0-5 months). Bloody stool was present in more than 40% of persistent episodes. Severe malnutrition was associated with persistent episodes that lasted 14-21 days (33%) or more than 22 days (59%). It is important that all patients with diarrhea have appropriate dietary management in addition to fluid therapy, and that future analysis examines etiologic factors to determine the optimal treatment of bloody diarrhea. PN Thanh. Diarrheal Training Unit, Pediatric Hospital No. I Ho Chi Minh City, Vietnam ~
Diarrheal diseases are well recognized as important vomiting, swollen abdomen, dehydration, fever, and causes of morbidity and mortality among children severe malnutrition. under three years of age in developing countries (1, 2). Diarrhea was defined as three or more liquid stools The majority of episodes are of relatively short duration (taking the shape of a container) within 24 h. A diarrheal (i.e. less than seven days) and can be treated easily and episode was considered as beginning with the first 24 h effectively with oral rehydration therapy (ORT) and period when stools meeting the definition of diarrhea continued feeding with an appropriate diet (3). Anti- were passed; an episode was considered to have ended biotics are necessary only when dysentery is recognized on the last day of diarrhea that was followed by at least or cholera is likely. This simple treatment regimen has two consecutive days not meeting the definition of reduced childhood mortality due to diarrhea worldwide. diarrhea. Duration of diarrhea represented the number In some instances, however, diarrhea lasts longer than of days of illness for an episode. For analysis of clinical usual. Such episodes of “persistent” diarrhea are often characteristics, episodes were classified by duration into associated with a deterioration in nutritional status and four groups: 1-7 days, 8-14 days, 15-21 days, and 22 or a substantial risk of death (4). In such cases, since more days. Persistent diarrhea was defined as an acute persistent diarrhea is a major cause of malnutrition and episode lasting more than 14 days. Dehydration was death, the clinical characteristics of the illness must be based on the three grades of the World Health Organizaunderstood so that appropriate treatment can be insti- tion (WHO) classification: no dehydration, some dehydtuted. This report summarizes the clinical aspects of ration, and severe dehydration. Nutritional status was based on weight (kg) for height acute vs persistent diarrhea in children hospitalized in a Pediatric Hospital of Ho Chi Minh City, Vietnam. (cm) expressed as a percentage of the expected median weight-for-height of the US National Center for Health Statistics (NCHS) reference population ( 5 ) . Diagnosis of severe malnutrition was based on weight-for-height below 70% of the median or the presence of edema. Methods This retrospective study was conducted in a Diarrheal Training Unit from October 1989 to September 1990. All children under three years of age who were hospitalized with diarrhea were included in the study. Cases of diarrhea associated with other non-diarrheal illness (i.e. respiratory infection, otitis media) were dropped from the studv. Clinical information recorded included Characteristics of stool (watery or bloody), anorexia,
Results During the study, 3833 episodes of diarrhea were identified. Most episodes of diarrhea were of short duration, 77.7% lasted 1-7 days. Only 5.3% of episodes lasted more than 14 davs. and 2.4%lasted more than 21 days. The proportion Gfepisodes lasting more than 14
122
Pham N Thanh el al.
ACTA PRDIATR SUPPL 381 (1992)
Table I . Percentage distribution of diarrheal episode by duration and age, Ho Chi Minh City, Vietnam, October 1989 to September 1990. Episode duration (days) Age group (months)
Diarrheal episodes
1-7
8-14
15-21
22+
0-5 6-1 1 12-23 24-36
564 985 1,683 60 I
74.7 77.2 78.6 80.2
19.2 20.3 18.6 9.7
5.7 2.5 I .8 I .6
3.2 I .8 2.4 2.2
Total
3,833
77.7
17.0
2.9
2.4
days was higher ( p < O . O O l ) in infants aged zero to 5 months (8.9%) than in older children (3.8%) (Table I). The clinical characteristics of diarrheal episodes of various durations are compared in Table 2. Severe malnutrition was associated with persistent episodes lasting more than 14 days (33%) or more than 21 days (59%). Bloody stool was also associated with more than 60% of episodes of persistent diarrhea.
Discussion This study showed that the rate of persistent diarrhea was highest among the children under six months old; community-based studies in Lima, Peru (6), and northern India (7) have also shown the highest incidence among the youngest children. However, in northeastern Brazil, the peak incidence included those in the second year of life, and the risk of developing persistent diarrhea was not related to age for children under three years (8, 9). This study also found that most episodes were less than one week in duration, only 5.3% of all episodes lasted longer than 14 days. Other studies have
found that 3-20% of episodes of diarrhea persist for this duration (4, 7, 8). Children with persistent diarrhea in our series were often severely malnourished, suggesting that this may be a risk factor for prolonged illness, as has been postulated previously (4). However, from case series such as this study, one cannot distinguish cause from effect. Episodes of long duration have particularly adverse effects on the growth of children. Marasmus (and less frequently, kwashiorkor) may develop rapidly during such episodes. For surviving children, however, the longterm effect on growth is likely to be stunting rather than wasting ( 1 0). Diarrheal episodes of longer duration (i.e. more than 14 d) were more often dysenteric, with blood observed in the stools. In a prospective community-based study in Lima, Peru, reports of blood or mucus in the stool during the first seven days were significant in predicting episodes that would persist beyond seven days; however, stool examination for leukocytes or blood early in the illness did not distinguish the episodes of shorter duration from those that were longer (6). These findings suggest that reported observation of blood in the stools may be a better predictor than a single laboratory examination for blood or leukocytes and could be used to predict dysentery and persistent diarrhea. Studies have shown that of the common enterpathogens, Shigella species cause diarrheal episodes of longer average duration than those due to other enteropathogens (1 I), and usually result in dysenteric illnesses. In conclusion, all episodes of diarrhea should have not only appropriate fluid therapy, but also good dietary management. The more severe episodes should be followed up to detect adverse effects on growth and permit more intensive nutritional intervention (12, 13). More attention should be given to appropriate treat-
Tuble 2. Percentage distribution of diarrheal episodes by clinical characteristics of the illness and duration, Ho Chi Minh City, Vietnam. October 1989 to September 1990. Episode duration (days) 1-7 (n= 2979) Clinical charateristics Watery or mucusa Bloodb Anorexia Vomitingb Swollen abdomenb Dehydration some severe Severe malnutritionb Feverh Chi square for episodes p
