DOI 10.1007/s12098-011-0561-3
ORIGINAL ARTICLE
Received: 19 October 2010 / Accepted: 12 September 2011 / Published online: 24 September 2011
# Dr. K C Chaudhuri Foundation 2011
Abstract
Objective To identify baseline risk factors for prolonged
diarrheal duration and subsequent complications in children
aged 6 to 59 mo with acute diarrhea who participated in a
micronutrient clinical trial in a tertiary care hospital.
Methods The adjusted odds ratio or incidence risk ratios (IRR)
of the baseline variables for prolongation of diarrheal duration
(cox proportional hazard model), diarrhea >7 d (multiple
logistic regressions), severe dehydration experienced after
hospitalization (poisson regression models) was estimated.
Results Fever (OR 1.10, 95% CI 1.021.19, p=0.02), dehydration (OR 1.32, 95% CI 1.101.59, p=0.003), dysentery
(OR 1.41 95% CI 1.091.82, p=0.008), those who received
medications (OR 1.19, 95% CI 1.031.39, p=0.02), and
A. B. Patel
Department of Pediatrics,
Indira Gandhi Government Medical College,
Nagpur, India
A. B. Patel : N. B. Badhoniya
Lata Medical Research Foundation,
Nagpur, India
R. Ovung
Indira Gandhi Government Medical College,
Nagpur, India
N. B. Badhoniya
Department of Biostatistics, Public Health Foundation of India,
New Delhi, India
M. J. Dibley
The Sydney School of Public Health, University of Sydney,
Sydney, Australia
A. B. Patel (*)
125, Raj Nagar, Opposite Tidke Vidyalay, Katol Road,
Nagpur 440 013, MS, India
e-mail: dr_apatel@yahoo.com
Introduction
Diarrheal disease causes an estimated 1.8 million deaths per
year [1]. Despite evidence of reduction in mortality over the
473
474
n=808
17.9 (11.1)
477 (59.03)
7 (4.249967
549 (68)
453 (56.1)
35.4 (20.4)
8.5 (4.2)
20.3 (20.8)
98.8 (1)
Dehydration N (%)
Dysentery N (%)
174 (21.5)
78 (9.6)
169 (21.1)
365 (45.2)
426 (52.7)
0.0001 (1)
1.8 (0.93)
1.2 (1.04)
71.2 (32.5)
123.5 (36.4)
9.7 (1.9)
Baseline variables
Unadjusted
Adjusted
OR (95% CI)
Zinc
Zinc and Copper
Age (mo)
Female Gender
1.05
1.02
0.98
1.07
(0.90, 1.22)
(0.88, 1.18)
(0.98,0.99)
(0.92,1.23)
0.57
0.81
<0.001
0.39
0.99
1.00
1.32
1.00
1.01
(0.97,1.00)
(0.86,1.16)
(1.15,1.53)
(1.00,1.01)
(1.00,1.03)
0.1
0.97
<0.001
0.01
0.11
1.00
1.13
1.31
1.26
1.21
1.31
1.14
0.91
1.10
1.01
1.00
1.00
0.96
(1.00,1.01)
(1.04,1.22)
(1.10,1.58)
(0.98,1.61)
(1.02,1.44)
(1.13,1.51)
(0.99,1.32)
(0.84,0.98)
(1.02,1.19)
(0.94,1.07)
(1.00,1.00)
(1.00,1.00)
(0.92,0.99)
0.16
<0.001
<0.001
0.07
0.03
<0.001
0.07
0.01
0.01
0.88
0.81
0.02
0.02
OR (95% CI)
0.98(0.97, 0.99)
1.14(0.98,1.32)
<0.001
0.09
0.99 (0.97,1.01)
1.10 (0.95,1.28)
0.15
0.25
1.00 (1.00,1.01)
0.05
1.10 (1.02,1.19)
1.32 (1.10,1.59)
1.41 (1.09,1.82)
0.02
<0.001
0.01
1.19
1.25
0.92
1.06
0.02
<0.001
0.06
0.13
(1.03,1.39)
(1.07,1.46)
(0.85,1.00)
(0.98,1.15)
1.00 (1.00,1.00)
0.08
475
significantly more likely to experience severe dehydration. Children dehydrated at admission were also at
increased risk of complications (OR 5.25, 95% CI 2.4011.4,
p<0.001).
Results
The baseline characteristics of the study population are
shown in Table 1. The univariate and multivariate hazard
ratios of baseline variables associated with continuation of
diarrhea are shown in Table 2 and that for diarrhea >7 d is
shown in Table 3. Clinical indicators such as younger age
(increased risk for continuation of diarrhea by 24% for age
reduction by each year), fever, blood in stools, weight for
age Z-score 2, duration of diarrhea at enrolment were
common risk factors for continuation of diarrhea and for
diarrhea >7 d. It is important to note that receiving zinc
supplement, lower sanitation (water safety and hand
washing) score, baseline zinc and anemia had no impact
on duration of diarrhea. Those children who were dehydrated (6.69, 95% CI 2 3.01, 14.85, p<0.001) at baseline
were more likely to experience severe dehydration even
after admission. Incompletely immunized children (OR
3.33, 95% CI 1.57.69, p<0.001) and those receiving
medications (OR 3.03, 95% CI 1.267.14, P 0.01) were
Discussion
This is a prospective study in 808 children with mean age
17.9+11.1 mo at the government hospital. The mean
maternal literacy was low with an average of 7 y of
education and over half the children had weight for age Zscore 2 (52.7%). Prolongation in duration of acute
diarrhea was associated with the following clinical indicators: younger age, fever, dehydration, blood in stools, those
who received any medication, duration of diarrhea at
enrolment and weight for age Z-score 2 (Table 2). There
was also a tendency towards prolonged diarrhea in children
with lower wealth index. Studies have shown that diarrheal
incidence is high in toddlers, however, this study shows
that even the diarrheal duration is longer in younger
children [13, 14]. The reason for their susceptibility for
prolongation could be their poorly challenged immune
system. A study from Hong Kong that retrospectively
Table 3 Risk factor associated with diarrheal duration >7 d from onset
Factors influencing diarrheal duration >7 d from onset
Unadjusted
OR (95% CI)
Adjusted
P
OR (95% CI)
1.77 (0.89,3.50)
Zinc
0.215
0.102
0.795
0.005
0.93 (0.88,0.97)
0.003
Male gender
0.52 (0.29,0.94)
0.03
0.43 (0.22,0.84)
0.013
0.990.92,1.06)
1.18 (0.62, 2.24)
0.62 (0.33,1.15)
1.05 (1.04,1.07)
1.00 (0.93,1.07)
1.01 (0.99,1.02)
1.25 (0.95,1.65)
1.08 (0.53,2.23)
2.40 (1.11,5.18)
1.23 (0.62,2.41)
2.44 (1.33,4.49)
2.08 (1.11,3.90)
0.87 (0.63,1.19)
1.36 (1.01,1.83)
0.91 (0.68,1.22)
1.00 (1.00,1.00)
1.00 (1.00,1.00)
0.803
0.611
0.126
<0.001
0.973
0.389
0.114
0.828
0.026
0.557
0.004
0.022
0.379
0.04
0.522
0.087
0.093
1.56 (0.76,3.21)
0.223
Hemoglobin% g/dl
0.95 (0.81,1.11)
0.527
1.06
0.95
0.99
1.75
(1.04,1.09)
(0.87,1.03)
(0.97,1.00)
(1.23,2.49)
<0.001
0.216
0.106
0.002
2.50
1.84
1.72
4.32
(0.99,6.29)
(0.82,4.14)
(0.86,3.45)
(2.03,9.16)
0.052
0.138
0.125
<0.001
1.29 (0.90,1.85)
0.171
1.00 (1.00,1.00)
0.241
476
Conclusions
Few prospective studies have identified baseline clinical
risk factors that predict morbidity in a cohort of children
with acute diarrhea for better monitoring of these children.
It was observed that clinical indicators such as younger
children, those malnourished, having fever, diarrhea with
blood, received no medications, longer duration of diarrhea
at admission and those with dehydration at the time of
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