Mortality associated with acute watery diarrhea, dysentery and persistent diarrhea in rural North India

Mortality associated with diarrhea was investigated in a longitudinally followed cohort of children under six years of age in rural North India. During the follow-up, 1663 episodes of diarrhea and 23 diarrhea related deaths were recorded in 1467 children followed up for 20 months. The case fatality rate was 0.56% for acute watery diarrhea, 4.27% for dysentery and 11.94% for non-dysenteric persistent diarrhea. Most of the episodes lasted less than a week; 5.2% became persistent (duration > 14 days). The case fatality rate was similar in episodes of one and two weeks'duration (0.64% and 0.8%) and increased to 13.95% for persistent episodes. Of the total 86 persistent episodes, 22.1% were dysenteric; the case fatality rate for such dysenteric persistent episodes was 21.1% and for watery persistent diarrhea 11.4%. Diarrheal attack rates were similar among different nutritional groups, but diarrheal case fatality rates progressively increased with increasing severity of malnutrition, these were 24 times higher in children with severe malnutrition (7.48%) compared to those normally nourished (0.31%). With availability and use of oral rehydration therapy, dysentery and persistent diarrhea emerge as major causes of diarrhea related mortality, with underlying malnutrition as a key associated factor.     

Persistent diarrhea as a cause of childhood mortality in rural Bangladesh

To determine the importance of persistent diarrhea in childhood mortality a multiple-step verbal autopsy method was used to study 1934 deaths in Matlab, Bangladesh. We found that most of the deaths from acute watery diarrhea occurred in infancy, whereas the peak of non-watery diarrhea deaths was in children over 12 months of age. Children suffering from persistent diarrhea and malnutrition were at highest risk of dying during their third year of life. Children with infectious diseases have a two to four times higher risk of dying if they are malnourished, and for diarrhea the risk is 17 times as high. Forty-nine percent of the diarrheal deaths were in children with malnutrition associated with persistent diarrhea. These results imply that fluid and dietary management are key aspects in the treatment of diarrhea, particularly for those episodes which persist. We conclude that attempts to reduce diarrhoeal deaths with vertical ORT programmes will not have a major impact unless other interventions are directed to the persistent diarrhoea-malnutrition complex.     

Association of indicators of hygiene behavior with persistent diarrhea of young children

We examined the association between water and hygiene-related behaviors and persistent diarrhea (duration 14 days) among children under age three years in an indigenous rural Guatemalan community. Behavior indicators were specific aspects of the appearance of the mother, study child, other children and household that could be observed using a spot observation technique. Thirty-four percent of children had one or more episodes of persistent diarrhea during the year of study. Bivariate analyses found that a higher proportion of observations in which the anti-hygienic condition was observed was significantly associated with persistent diarrhea for 11 of 26 behavior indicators; these 11 indicators were also strongly correlated with each other. In individual logistic regression models, which included overall rate of diarrhea and other child characteristics associated with persistent diarrhea, six behavior indicators maintained significant association with persistent diarrhea: presence of toy on the ground, presence of baby bottle on the ground, the hands of the mother being dirty, presence of a fecally soiled diaper on the ground in the household compound, presence of feces in the yard, and the study child wearing a fecally soiled diaper. Three additional indicators closely approached significant association with persistent diarrhea. Excluding the three soiled diaper indicators, which might be the result rather than the cause of diarrhea, we found the six other behavior indicators to demonstrate a significant dose-response effect in increasing risk of persistent diarrhea. These findings suggest that behaviors which promote increased exposure of young children to enteric pathogens increase risk of persistent diarrhea.     

Pathology of AIDS in children

AIDS in children is a multisystem disease. The various infections, degenerative, proliferative and vascular lesions can be classified into three categories based on the known, presumed or undetermined pathogenesis. The primary lesions are due to HIV infection. The associated lesions are related to direct or indirect sequelae of HIV infection or its treatment. The third category is of lesions of undetermined pathogenesis. The pediatric pathologist plays an important role in the study and management of AIDS by demonstrating new pathologic lesions, by making the etiologic diagnosis of infection in children with AIDS, and by providing clinicopathologic correlation which leads to better understanding of the disease process and its natural history. Diagnosis of neoplastic disorders is also made by the pathologist. There is a dearth of systematic pathologic study of AIDS in children in developing countries. Although no basic differences between pathologic lesions in pediatric AIDS in Western countries, and in developing countries is expected, such a study would lead to better understanding and better management of the disorder as it affects children from the developing countries.     

Health care and its costs for children with perinatally acquired HIV infection

Objective : To describe survival patterns, use of health services and related costs for Australian children with perinatally acquired human immunodeficiency virus (HIV) infection.
Methodology : A retrospective cross-sectional survey was made of 20 children with HIV infection (91% of those diagnosed) and 13 children with maternal antibodies who subsequently seroreverted, treated at 10 medical centres. Details of disease progression and use of health services were obtained from hospital medical records. Monthly costs for three phases of infection were estimated by linking service usage rates with estimates of the unit cost of each service. The average lifetime cost was estimated by combining monthly costs and phase duration estimates from the literature.
Results : Patterns of disease progression were similar to those reported internationally, with a median survival of 8 years. Use, of health services increased with severity of illness. Mean monthly costs were $120 per month (1992 Australian dollars) for children with maternal antibodies who subsequently seroreverted, $320 per month for children with HIV infection but no acquired immunodeficiency syndrome (AIDS)-defining illness, and $1830 per month for children with AIDS. The present value of total lifetime cost for a child with HIV infection was $48174,46% of which was for treatment of AIDS.
Discussion : The mean lifetime cost for a perinatally infected child was just over half that for a man with HIV in Australia. Health service usage and costs were lower for Australian than American children with HIV.     

小儿迁延性、慢性腹泻病83例临床分析

目的 分析小儿迁延性、慢性腹泻病的病因、临床特点及治疗现状.方法 对2002年10月-2007年10月住院并诊断为迁延性、慢性腹泻病83例患儿的临床资料进行回顾性分析.结果 主要病因包括食物过敏29例(85.3%),乳糖不耐受61例(73.5%),免疫功能低下55例(66.3%),感染35例(42.2%)等.长时间腹泻患儿多伴有营养不良,不同程度的离子紊乱、微量元素缺乏、肠道菌群失调等,部分患儿合并其他脏器受累(如心肌、肝脏等).针对病因治疗,同时辅以支持疗法和对症治疗,取得了良好的效果.结论 迁延性、慢性腹泻的病因并不都是感染;其临床表现多样,并发症多;经不同途径联合治疗,可从各个不同环节阻断病情发展,减少并发症,从而缩短病程,提高治愈率.[临床儿科杂志,2009,27(10):930-934]     

Household behaviors in the management of diarrhea and their relevance for persistent diarrhea

There has been a great deal of research in recent years on household behaviors related to diarrhea management. Most of the available data on household diarrhea management, however, pertains to acute diarrheal episodes. There is a dearth of knowledge concerning household and caretaker behaviors when the diarrhea is of longer duration. This paper briefly reviews some of what has been learned about household behaviors in the management of acute diarrhea and discusses its relevance for persistent diarrhea. Based upon what has been learned from anthropological studies of acute diarrhea and the little that is known about caretaker behavior during persistent diarrhea, a hypothetical model of the interactions among household behavior and characteristics of diarrheal episodes is presented. The model argues that maternal (or caretaker) concern increases with diarrheal duration, and that changes in behavior, both adaptive and maladaptive, are more likely to occur during an episode of persistent diarrhea, compared to acute. In some cases, these actions may directly influence the outcome of the episode. There is a need to better understand household case management behaviors through the continuum of diarrheal duration and the effect of these behavioral factors on episode outcome. This information is necessary in order to communicate effective messages to caretakers about what they should know and what they should do when persistent diarrhea occurs.     

Epidemiology of persistent diarrhea and etiologic agents in Mirzapur, Bangladesh

To determine the epidemiology and etiologic agents of persistent diarrhea we carried out an intensive diarrhea surveillance on children less than six years old in rural Bangladesh. From March 1987 to February 1989 we examined 363 children through diarrhea recall interviews and analyzed stool samples of all diarrhea cases for potential pathogens. Results showed that children had an average of two episodes per year and the incidence rate of diarrheal episodes denned as acute (<14 d) and persistent (14 d) varied similarly with age. The peak incidence (episodes/child/year) of acute diarrhea (2.8) and persistent diarrhea (0.8) occurred in the 6-11 months age group. The data showed that an episode tended to be prolonged if the stool was loose/mucoid or bloody at onset. Aggregative adherent Escherichia coli was found significantly more often at onset in persistent than in acute episodes, whereas Shigella, Aeromonas, Giardia and toxigenic E. coli were isolated with less frequency in persistent than acute episodes. This suggests that other factors might be more important in the development of persistent diarrhea than specific pathogens.     

The impact of HIV/AIDS on children in developing countries

HIV infection and AIDS among children continues to be a significant problem in developing countries despite the progress that has been made in HIV prevention and AIDS treatment elsewhere during the past two decades. The reasons for this difference are complex and multifactorial. They include the higher background prevalence of infection among adults in some communities in developing countries, the slow implementation in many countries of prenatal HIV screening programs and prophylaxis which can reduce the transmission to infants during labor and delivery, the social and health consequences of not breastfeeding, and the economic realities associated with expensive diagnostic testing and antiretroviral treatment. While the world waits for an effective HIV/AIDS vaccine, to reduce the prevalence of HIV in the community, public health programs need to continue to emphasize proven methods of HIV transmission prevention among groups with a high-risk of HIV acquisition, as well as provide counselling for the general population about personal protection and the provision of compassionate care for those affected.     

Epidemiology of persistent diarrhea among Guatemalan rural children

A prospective, longitudinal two-year study to determine the epidemiology of persistent ( 14 days'duration) diarrhea in rural children of Guatemala was undertaken. Three-hundred and twenty-one children aged 0-35 months were kept under surveillance by twice-a-week home visits. The overall incidence of diarrhea was 0.147 per child-week; the incidence of persistent diarrhea was 0.014 per child-week. The peak of persistent diarrhea was observed in infants below six months of age, with a continuous decline thereafter. This trend in incidence of persistent diarrhea was associated with a higher proportion (16%) of illnesses persisting for more than 13 days in children younger than six months of age as compared to children 30-35 months old (4%). Males had more diarrhea (0.156 per child-week) than females (0.139 per child week). Among children above 18 months of age, the proportion of episodes that lasted for more than 13 days was lower in females than in males.     

血清降钙素原在儿童急性病毒性腹泻病中的临床价值探讨

目的：探讨急性病毒性腹泻病患儿血清降钙素原( PCT)的表达水平及临床意义。方法回顾性分析2013年9月至2015年9月在我院住院治疗的186例急性病毒性腹泻患儿,男107例,女79例,其中轮状病毒感染171例,诺如病毒感染15例。平均年龄(1.29±0.89)岁。所有患儿血培养、粪培养均阴性。按照患儿脱水程度和是否伴有器官功能障碍分为重症组(包括重度脱水、休克、多器官功能障碍)33例、轻-中度脱水组68例和无脱水组85例。8例死亡。选取35例健康同龄儿童作为健康对照组。腹泻患儿入院后2 h内分别留取血标本检测血清PCT水平,同时检查血常规、超敏CRP。结果急性病毒性腹泻患儿血清 PCT水平升高73例,其中>100 ng/ml 8例,5~100 ng/ml 21例,0.5~5.0 ng/ml 44例。急性病毒性腹泻患儿血清PCT(ng/ml)[0.36(0.14,1.67)]、超敏CRP(mg/L)[3.50(0.70,14.83)]、WBC(×109/L)[9.06(6.79,12.50)]水平均较健康对照组儿童[0.09(0.05,0.13);1.00(0.40,2.50);6.90(5.90,8.20)]升高(P<0.05)。合并脱水者PCT水平较无脱水者升高[0.54(0.19,7.83)vs.0.26(0.11,0.55)](P<0.05);重症组患儿PCT水平[13.69(3.41,60.30)]较轻-中度脱水组[0.33(0.13,0.89)]和无脱水组[0.26(0.11,0.55)]升高(均P<0.017),超敏CRP、WBC水平各组无差异(P>0.05)。结论急性病毒性腹泻患儿血清PCT也可以升高,尤其是合并重度脱水、休克及多器官功能障碍者更高。持续较高的PCT水平提示病情危重,预后差。 PCT可以指导评估急性病毒性腹泻病患儿病情的严重程度及预后。     

Immunological background in children with persistent diarrhea in Ghana

BACKGROUND: Persistent diarrheal diseases have become one of the most serious medical problems in developing countries, but few studies have been conducted to determine the risk factors. In the present study, we investigated the nutritional and immunological background in children with persistent diarrhea in comparison with those with acute diarrhea. METHODS: Children with diarrhea who were brought to the Oral Rehydration Salt Clinic of Princess Marie Louise Children's Hospital in Accra were evaluated from an immunological and nutritional aspect. In the follow-up visit, the cases whose diarrhea stopped within 2 weeks after onset were classified into the acute diarrhea group; those with diarrhea lasting more than 2 weeks were classed in the persistent group. Nutritional and immunological data at the initial visit were compared between these two groups. RESULTS: In general, the diarrhea cases had a tendency to undernutrition and impaired cellular immunity compared with healthy control. Persistent cases had lower values for longer half-life, rapid turn-over proteins. Persistent cases had a higher percentage of CD8+ cells and lower CD4/CD8 ratio. CD25 expression in CD4+ cells stimulated by anti-CD3 antibody was lower in the persistent diarrhea group. CONCLUSION: These results appear to support the hypothesis that more severe nutritional status and impairment of cellular immunity is related to the persistence of diarrhea.     

The Treatment of Persistent Diarrhoea and Malnutrition: Long-term Effects of In-patient Rehabilitation

ABSTRACT. This study aimed to characterise the clinical condition of Gambian children presenting with persistent diarrhoea and severe protein energy malnutrition and to evaluate the effects of short term in-patient treatment in terms of long-term outcome. Twenty-two children (aged 6 to 36 months) with persistent diarrhoea (≥ four loose stools/day for more than two weeks) and severe malnutrition (weight-for-height <75% of the National Center for Health Statistics median value) were assessed prior to in-patient treatment for three weeks with antibiotics and high nutrient-density milk. Initial assessment included biochemical and immunological status together with stool microbiology. Criteria for discharge—cessation of diarrhoea for five consecutive days and steady weight gain—were met in all subjects within four weeks. Progress was assessed clinically and anthropometrically at weekly intervals and 6 and 12 months following discharge. Results showed a steady improvement in growth during the period of in-patient treatment. Continuing improvement in weight-for-age and mid-upper arm circumference was observed after 6 and 12 months and weight-for-height continued to improve up to 6 months but fell back by 12 months. This study has demonstrated that, in the treatment of persistent diarrhoea in the tropics, relatively short periods of in-patient rehabilitation, whilst leading to a resolution of diarrhoea1 symptoms and weight gain in the short term, do not lead to complete recovery. Persistent diarrhoea and malnutrition are likely to recur when the child returns to his village. It is necessary to establish in a prospective study the minimum period of supervised feeding required to ensure the 'critical level' of weight gain necessary for linear growth to return to normal.     

Maternal beliefs regarding diet during acute diarrhea

Amongst 800 rural and urban mothers harmful beliefs regarding diet during diarrhea included restriction of foods (98%) and lack of recognition of dehydration (83%). Foods like chapattis (bread), pulses, certain fruits and vegetables, meat and eggs were often excluded. Milk administration was restricted by 70.8% of mothers. The mothers placed reliance on khichari, moong dal, banana and wheat porridge. Fluids like herbal tea (31.5%), mint water (16.6%) and butter milk (13.2%) were considered appropriate.     

Ataxia Telangiectasia with Persistent Epstein-Barr Virus Infection and Malignant Lymphome

Ataxia telangiectasia is agenetically determined immunodeficiency with predisposition to malignancy. Herein we report a case of ataxia telangiectasis in a child who had showed high antibody titers to viral capsid antigen (VCA), presence of antibodies to Epstein-Barr virus (EBV) induced early antigen (EA), low titers of antibodies to EBV associated nuclear antigen (EBNA), and a high incidence of EBNA-positive cells in the peripheral blood without symptoms of infectious mononucleosis before succumbing to malignant lymphoma five years later. We hypothesize the association betwen some cytogenetic defects and persistent EBV infection on the development of the malignant lymphoma in this patient.     

Dietary management of acute diarrhea with local foods in a Guatemalan rural community

A community-based, randomized trial was conducted to evaluate a locally available diet for the management of acute diarrhea ( n = 99 episodes) in 90 Guatemalan children, 4–42 months of age. The Test Diet (TD), a combination of a semi-solid pap (maize flour, black beans, oil) and a liquid gruel, Incaparina (maize flour, cotton seed flour, sugar), in addition to breast-milk and other home foods (group TD, n = 45 episodes) was offered for 14 d and compared to usual home feeding (group HF, n = 54 episodes). Diarrhea episodes after admission were significantly shorter for group TD (median 2. 0 d) than group HF (median 4. 4 d, p = 0. 003) after adjusting for potential confounders. Weight gains did not differ significantly between groups. We conclude that community-based dietary management of acute childhood diarrhea using energy-dense, locally available foods is feasible and may shorten diarrhea duration. This may encourage mothers to follow recommendations for continued feeding during diarrhea in developing country environments.     

Cryptosporidium causing chronic diarrhea

The authors report a case of a child with chronic diarrhea due to Cryptosporidium. The child had also hemolytic uraemic syndrome. Cryptosporidium oocysts were identified by the modified Ziehl-Neelsen technique.     

Children and adolescents living with HIV and AIDS: a review

Worldwide, more than one million children are infected with human immunodeficiency virus (HIV) and in the United States it has become the sixth leading cause of death among 15-24-year-olds. Despite the trend of increasing rates of infection, advances in therapies have led to survival past 5 years of age for more than 65% of infected children. This global health threat will therefore continue to have a significant impact on child and adolescent psychiatry and psychology. This paper reviews current studies and reports on the consequences of the acquired immunodeficiency syndrome (AIDS) epidemic in the psychiatric care and development of children and adolescents infected by HIV. From a search of all the English-language-based literature on pediatric AIDS, 140 studies are reviewed which address HIV infection and its psychological and social implications. Several topics of mental health significance are examined: (1) the epidemiology of HIV, (2) neurocognitive development among those infected, (3) psychological impact of infection, and (4) the family and social context of HIV. The transition of HIV from an acute, lethal disease to a subacute, chronic disease has enormous implications for the neurocognitive and psychosocial development of children and families. As children and adolescents infected with HIV continue to live longer, normal developmental milestones and educational needs will take on new significance. Many children will continue to be adversely impacted by non-HIV factors such as poverty, inadequate medical services, and a lack of social support. This review outlines recent developments that hold promise to effectively reduce the treatment burden on the infected, their families, and health care providers and to decrease the incidence of transmission to the uninfected.     

Is small bowel bacterial overgrowth of pathogenic significance in persistent diarrhea?

Bacterial overgrowth in the upper small intestine is postulated to cause persistent diarrhea. We compared the fecal and upper intestinal flora in 82 patients with persistent diarrhea aged 36 months and weight-for-length 90% of National Center for Health Statistics standards (NCHS) and 39 non-diarrheal children with age 36 months, nutritionally matched with the patients and residing in the same environment. In the age groups 12 months and Ygt;12 months the duodenal fluid bacterial counts 10⁵/ml were found with similar frequency in patients and controls for aerobic ( p =0.33; p =0.1) and anaerobic ( p =1.0; p =1.0) bacteria. However, the duodenal isolation rates of any aerobic bacteria ( p <0.05) without regard to counts and Enterobacteriaceae ( p = 0.06) were higher in patients than in controls. Colonization with Enterobacteriaceae was directly correlated with increased stool weight over a 7-day observation period ( p <0.05; p <0.01). One or more pathogens were isolated in the feces of 58% of the patients and 43.8% of the controls. Enteroadherent E. coli of the localized [EAEC-L] ( p <0.01) and aggregative [EAggEC] ( p =0.22) phenotypes were isolated more commonly from the feces of patients. The duodenal fluid detection rates for Klebsiella were significantly greater ( p <0.01) in patients, while Giardia lamblia was detected more commonly in the duodenal fluid of controls ( p <0.01). The presence of specific pathogens in the feces did not seem to be related to the extent of small bowel colonization. Thus small bowel overgrowth with aerobes or anaerobes is common in malnourished children with or without diarrhea. However, specific pathogens such as EAEC-L, EAggEC and Klebsiella may be associated with persistent diarrhea.