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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 18
| Issue : 4 | Page : 129-135 |
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Study of clinical, hematological, and biochemical profile of under five hospitalized children with diarrhea from a tertiary care institute in Himachal Pradesh
Mohit Bajaj1, Manoj Kumar Gandhi2, Pancham Kumar3, Chiranth Gowda3, Swati Mahajan4
1 Department of Pediatrics, Dr. Rajendra Prasad Government Medical College Kangra at Tanda, Kangra, Himachal Pradesh, India
2 Department of Community Medicine, Dr. Rajendra Prasad Government Medical College Kangra at Tanda, Kangra, India
3 Department of Pediatrics, Indira Gandhi Medical College and Hospital, Shimla, India
4 Department of Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
| Date of Submission | 30-Oct-2022 |
| Date of Acceptance | 01-Feb-2023 |
| Date of Web Publication | 20-Feb-2023 |
Correspondence Address:
Dr. Manoj Kumar Gandhi
Department of Community Medicine, Dr. Rajendra Prasad Government Medical College Kangra at Tanda, Room No 104, Vivekananda Hostel, Kangra 176002, Himachal Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/AMJM.AMJM_42_22
Background: Diarrhea is still the second leading cause of death in children under 5. These deaths can be easily prevented by early recognition and appropriate intervention. Understanding of symptoms, signs, and complications of acute diarrhea is necessary in preventing these deaths. The main focus of this study was to study clinico-epidemiological and laboratory profile of under 5 hospitalized children with diarrhea. Materials and Methods: This prospective study was conducted in the Department of Pediatrics, of a tertiary care teaching hospital in North-west India from June 2016 to November 2018. Children presenting with acute watery diarrhea, between age of 1 month and 5 years, were enrolled in study. Clinical symptoms/signs along with demographic details and lab investigations of each case were studied. Results: Out of 179 admitted children, majority were males and maximum were in age group of 1–24 months. 136 (75.97%) children were exclusively breastfed till 6 months of age. Fever (88.82%), vomiting (74.30%), and oliguria (82.68%) were most common symptoms observed at admission. Depressed anterior fontanelle (63.12%), dry sunken eyes (80.45%), and/or delayed skin turgor (78.21%) were most common clinical signs observed. 140 (78.21%) children had some dehydration and 11 (6.15%) had severe dehydration. Severe features of bradycardia (2.23%), tachypnea (2.79%), and hypothermia (1.67%) were also noted. Deranged blood urea nitrogen and creatinine levels were observed in 48 (26.82%) and 15 (8.4%) children. Conclusion: Complications of diarrhea can be prevented by improving prevalent poor knowledge, attitude, and practices among parents regarding feeding and home-based interventions in diarrhea. Keywords: Clinical signs, dehydration, diarrhea, dyselectrolytemia, Himalayan region, under 5 children
How to cite this article:
Bajaj M, Gandhi MK, Kumar P, Gowda C, Mahajan S. Study of clinical, hematological, and biochemical profile of under five hospitalized children with diarrhea from a tertiary care institute in Himachal Pradesh. Amrita J Med 2022;18:129-35 |
How to cite this URL:
Bajaj M, Gandhi MK, Kumar P, Gowda C, Mahajan S. Study of clinical, hematological, and biochemical profile of under five hospitalized children with diarrhea from a tertiary care institute in Himachal Pradesh. Amrita J Med [serial online] 2022 [cited 2023 Mar 24];18:129-35. Available from: https://ajmonline.org.in/text.asp?2022/18/4/129/370008 |
| Introduction | |  |
In developing nations like India, diarrhea is still a major cause of morbidity and mortality in under 5 children. It affects 957 million children and is responsible for 9% of all deaths (mounting to 499,000 deaths) among children under 5 years each year worldwide.[1],[2]World Health Organization defined diarrhea as passage of 3 or more loose stools or liquid stools per day[3] (or more frequent passage than is normal for the individual).
Diarrheal disease morbidity has great negative impact on growth and development of infants and young children.[4] Inappropriate feeding practices, lack of clean water, poor hand washing, limited sanitary disposal of waste, poor housing conditions, poor knowledge about use of ORS/oral rehydration therapy (ORT), and lack of access to adequate and affordable health care are main factors that aggravate under 5 diarrheal disease.[5],[6],[7] Diarrhea is easily treatable at an early stage, but improper knowledge, poor practice, and negative attitudes of parents and society lead to severe dehydration, complications, and lastly death.[8],[9]
Guidelines classify dehydration as none, some, and severe dehydration as per Integrated Management of Childhood Illnesses guidelines.[10] The individual signs that best predict dehydration are prolonged capillary refill time >2 s, abnormal skin turgor, hyperpnea (deep, rapid breathing suggesting acidosis), dry mucous membranes, absent tears, and general appearance (including activity level and thirst). As the number of signs increases, so does the likelihood of dehydration. Tachycardia, altered level of consciousness, and cold extremities with or without hypotension suggest severe dehydration.[10]
About 80% of deaths occurring in first 2 years of life is caused by dehydration and electrolyte imbalance. Only 20% of children receive appropriate ORT.[11] Serum sodium and potassium levels in a dehydrated patient may be normal, low, or high. Untreated electrolyte disturbances are associated with higher mortality.[11],[12] Thus, timely recognition, high index of suspicion, and thorough understanding of common electrolyte abnormalities are necessary to ensure their correction. Similarly blood urea nitrogen (BUN) and creatinine values show good specificity in differentiating various levels of dehydration.[13]Understanding and knowledge of magnitude of abovementioned aspects of acute diarrhea are of utmost importance for advocating various strategies and interventions at individual and community level. So the clinical, demographical, hematological, and biochemical and treatment profile amongst under 5 diarrheal children from sub-Himalayan region were studied.
| Materials and Methods | | |
Study area, design, and duration
This prospective observational cross-sectional study was conducted in tertiary referral care hospital providing general and specialized medical care, located in North-west India. It caters to health needs of majority of population of state of Himachal Pradesh, India and some areas of adjoining state and migrant population.
Patient enrollment
The study was conducted over a period of 30 months from June 2016 to November 2018. 383 children were admitted with acute watery diarrhea in study age group of 1 month to 5 years during study period. Out of these, 179 children meeting the requisite criteria were enrolled in study after obtaining informed consent from their caretakers. The criteria were
- Children aged <5 years and above 1 month of age admitted in children ward for treatment of acute diarrhea (<14 days duration).
- Caretakers involved in care of child consenting to take part in the study.
Parents unwilling to give consent to participate in study, children with diarrhea more than 14 days, history of prior admission in any other hospital or having developed diarrhea during hospital stay for some other cause and. Children suffering from malnutrition or immunodeficiency were excluded from the study.
Demographic details thorough history, clinical examination, and treatment details were recorded using a uniform structured Performa by trained medical officer under supervision of senior pediatrician. WHO laid guidelines and definitions were used in Performa, wherever necessary. Before starting any treatment 5 mL of venous blood was withdrawn to estimate values of random blood sugar, complete blood counts, serum electrolytes, and BUN and creatinine. Based on age specific reference values,[14] various lab investigations were analyzed, classified, and treated.
Statistical analysis
The data were entered into Microsoft Excel, and statistical analysis was performed by statistical software Epi-Info version 7.1, Centers for Disease Control and Prevention (CDC), Altanta, USA. Chi-square test was applied for comparing the categorical data (frequency). The P-value was considered to be significant when <0.05.
| Results | | |
The study was conducted over a period of 30 months from June 2016 to November 2018. Out of total admitted 4917 children, 383 children were admitted with acute watery diarrhea. Only 179 children met our study criteria and after caretakers consent, these children constituted our study group.
Demographic profiles showed that majority of children were males in all age groups and were in first 2 years of life. Male:female ratio was 1.7:1. Maximum duration of hospital stay was 1–3 days [Table 1]. Most of parents belonged to classes 3 and 4 as per Kuppuswami classification. Feeding practices were reasonably good. 148 (82.68%) of newborns were started on breastfeeds within 2 h of delivery. Out of these, 136 (75.97%) continued breastfeeding thereafter. 43 (24.03%) babies were on top feeds after birth, and all were given bottle feeds. 30 of top fed babies were on cow or buffalo milk. 24 of them received diluted milk and 19 received undiluted cow milk. 5 of top fed were on formula feeds with proper dilution. 122 (68%) withheld feeding while 58 (32%) continued feeding during diarrhea episode [Table 2]. | Table 1: Age and gender wise distribution of enrolled children (n = 179)
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 | Table 2: Socioeconomic and feeding practices profile of enrolled children (n = 179)
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Fever (88.83%), vomiting (74.30%), oliguria (82.68%), and lethargy (53.07%) were usual main symptoms observed. However, few 13(7.26%) presented with seizures. Vomiting (74.3%) was observed mostly on day 1 of admission with maximum of 3–4 episodes. 4–6 loose stools were observed most frequently with maximum incidence on day 1 of admission (64.2%). Depressed anterior fontanelle (63.12%), prolonged capillary refill time (19.56%), dry sunken eyes (80.45), inability to drink milk (6.15%), and delayed skin turgor (78.21%) were observed in children and based on these children were classified as having no dehydration (15.64%), some dehydration (78.21), and severe dehydration (6.15%) after evaluation. 151 (84.35%) received intravenous fluids along with oral rehydration solution mostly for 4 h [Table 3] and [Table 4].
Bradycardia (2.23%), tachypnea (2.79%), and hypothermia (1.67%) were observed in sick children. Hypoglycemia was observed in 12 (6.70%) at admission; however, it improved after treatment. About half of enrolled children (47.5%) had anemia. Serum sodium levels revealed hyponatremia and hypernatremia. Serum potassium levels revealed hypokalemia and hyperkalemia both. Elevated BUN and creatinine levels were observed in 48 (26.82%) and 15 (8.4%) children [Table 5][Table 6][Table 7].  | Table 6: Hematological profile observed at admission of admitted children
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 | Table 7: Deranged renal function tests in diarrhea as per degree of dehydration
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| Discussion | | |
General prevalence
The prevalence of diarrhea in this study was 7.78%, which is slightly higher to study done by Khanduja and Bhargava[15] (5.5%). Our study showed that highest burden of diarrhea (83.24%) and hospital stay (1–7 days) was seen in 1–12 months and under 2 years of age group which is similar to other studies.[16],[17]The high incidence of diarrheal disease in the first 2 years of life can be explained by faulty weaning, unhygienic handling and storage of milk and food products, higher incidence of parental infection, malnutrition, development of mouthing habits, and immaturity of immune system.
Gender distribution
Males (63.12%) were more affected than females (37.88%), and this difference was seen in all the age groups as shown in [Table 1]. This observation is in concordance with study done by Jarman et al.[18] (56.2% and 43.8%, respectively).
Demographical profile
In this study, 82.6% of newborns were started on breastfeeds within 2 h of delivery which is less than studies conducted by Onsa and Ahmed[19] (92.8%) and Eldoom et al.[20] (98.6%), respectively. Out of these, about 2/3rd (75.9%) were exclusively breastfed for 6 months, which is high as compared to other Indian studies.[21],[22]In remaining 1/3rd, bottle feeding was given, and mostly children (1/3rd) were given cow’s milk in improper dilution. Most of parents in our study group belonged to low socioeconomic group, which highlights importance of education of parents and society regarding breastfeeding practices, complementary feeding, role of sanitation, and malnutrition.
Clinical profile and hydration status
Fever (88.83%), vomiting (74.30%), oliguria (82.68%), and lethargy (53.07%) were usual main symptoms observed. However, some had unusual symptoms like seizures 13 (7.26%) and anuria 7 (3.91%). Vomiting was observed in 105 (58.7%) children on day 1of stay with maximum frequency of 3–4 episodes. 4–6 loose stools were observed most frequently in 100 (55.9%) children with maximum incidence on day 1 of admission 115 (64.2%). This study aligns with observations made by similar studies regarding clinical picture characteristics of gastroenteritis among under 5 children.[16],[23],[24]
Evaluation of the individual signs of dehydration revealed presence of dry sunken eyes (80.45%) to be most significantly correlated with degree of dehydration followed by decreased skin turgor (78.21%), depressed anterior fontanelle (63.12%), and prolonged capillary refill time (capillary refill time >2 s) 19.56%. These findings were consistent with earlier studies done[25],[26],[27] and highlight the fact that when considered together dry sunken eyes, delayed skin turgor, and prolonged capillary refill time are best predictors of degree of dehydration.
After assessment of these signs, children were classified as having no dehydration 28 (15.64%), some dehydration 140 (78.21), and severe dehydration 11 (6.15%). Our findings were similar to earlier studies.[16],[26] The main reason for some dehydration being seen in majority of cases following no dehydration in our study may be because of the lack of knowledge among most of parents about the use of ORS/ORT in diarrhea.
Hematological profile
Hypoglycemia was observed in 12 (6.70%) children. Anemia was observed in 85 (47.5%) children. Electrolyte disturbances were seen in 54 (30.16%) cases. Isonatremic dehydration was commonest 150 (83.8%), followed by hyponatremic dehydration 16 (8.9%) and hypernatremic dehydration 9 (5.0%). Our findings were similar to studies done by Daral et al.[30] and Kumar et al.[31] who reported isonatremic dehydration in 79%, hyponatremic in 12.3%, and hypernatremic in 8.6% cases.
Most common electrolyte disturbance seen was hypokalemia 18 (10.1%) followed by hyponatremia 16 (8.9%), hypernatremia 9 (5%), and hyperkalemia 11 (6.1%). Findings of our study showed less incidence of electrolyte abnormalities as compared to other studies[28],[29] showing benefit of early use of ORS/ORT in diarrhea by mothers. This can also be explained by low losses of stool electrolytes in early infancy.[32] Majority of study population was isonatremic and normokalemic 150 (83.8%). Mixed electrolyte disturbances were seen in 18 (10.1%) cases out of which most common was hyponatremia and hyponatremia 16 (8.9%). Similar electrolyte disturbances were seen in study done earlier.[13],[23] Also levels of sodium and potassium decreased with severity of dehydration.
Out of 179 cases, increased BUN and creatinine levels were seen in 48 (26.82%) and 15 (8.4%) children overall. Elevated BUN levels were found in 9/11 (81.81%) of severe dehydration, 35/140 (25%) in moderate dehydration and 4/28 (14.28%) in no dehydration as shown in [Table 5]. These findings were similar to study by Ukarpol et al.[29] where 24% of children had elevated BUN and BUN correlated statistically with degree of dehydration. Further high creatinine levels were seen in 7/11 (63.63%) in severe dehydration, 8/140 (5.71%) in moderate dehydration, and none in mild dehydration. Thus, our study highlighted fact that BUN and creatinine levels were significantly high in severe dehydration as compared to some dehydration and no dehydration.
| Conclusion | | |
Incidence of diarrhea peaks before 2 years of age. Dry sunken eyes, decreased skin turgor, prolonged capillary refill time, and general appearance combined are best indicators to assess severity of dehydration. Acute diarrhea mostly presents as isonatremic dehydration; however, in severe dehydration, hyponatremia and hypokalemia can also be present. With increase in dehydration severity, derangement of renal function tests was observed.
It can be concluded from this study that to reduce morbidity and mortality associated with diarrhea, timely recognition of dehydration by parents is needed that need to be increased by promotion of health education, awareness, and practices regarding breastfeeding and diarrhea among parents
Author contributions
All authors helped in collection and analysis of data.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
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