Original Articles

Original Articles

Indian Pediatrics 2000;37: 37-43

Neonatal diarrhea in a diarrhea treatment center in bangladesh: clinical presentation, breastfeeding management and outcome

Rukhsana Haider, Iqbal Kabir, George J. Fuchs and Demissie Habte

From the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B), GPO Box 128, Dhaka 1000, Bangladesh.
Reprint requests: Rukhsana Haider, Associate Scientist, ICDDR, B, GPO Box 128, Dhaka 1000, Bangladesh.
E-mail: [email protected]
Manuscript received: May 3, 1999; Initial review completed: June 16, 1999; Revision accepted: August 9, 1999.

Objective: To study the clinical presentation and outcome of neonates admitted with diarrhea, and effect of counseling their mothers for exclusive breastfeeding. Design: Prospective study. Setting: Inpatient unit. Results: Two hundred and forty-four neonates were studied during 1994-95. Their mean (SD) age was 18 (6.2) days, and body weight and length were 2.18 (0.52) kg and 47.5 (3.2) cm, respectively. More neonates had some dehydration than severe dehydration (78% vs. 11%), with mean (SD) serum bicarbonate values 9.6 (5.1) mmol/1. V. cholerae was isolated from 25 (12%), Shigella spp. from 8 (3%), and Salmonella spp. from 3 (1%) of the patients who had rectal swab cultures. Mean (SD) hospital stay was 3.6 (2.1) days, during which the majority (80%) recovered fully, but 29 (13%) left earlier. Eleven (4%) of the neonates had to be referred elsewhere for treatment of other problems and 7 (3%) died. None of the neonates were exclusively breastfed on admission. Excluding mothers of adopted neonates, breastfeeding counseling enabled 64% of the mothers to convert to exclusive breastfeeding during the hospital stay. Conclusions: Most of the neonates admitted with diarrhea were small and underweight, and had poor feeding practices. The majority of neonates recovered soon, and were exclusively breastfeeding when discharged from the hospital. Breastfeeding counseling should be included as an integral part of case management at all health facilities.

Key words: Breastfeeding counseling, Diarrhea, Neonate.

Although substantial data is available on diarrheal diseases in infants and older children(1), information on diarrhea in neonates from developing countries is scarce(2,3). The Dhaka hospital of the International Center for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) treats more than 100,000 patients each year. Apart from 30 neonates included in a study on shigellosis in infants(4), there are no reports on neonatal diarrhea from Bangladesh. Perhaps because of the greater prevalence of breastfeeding in most developing countries, infectious diarrhea has not been described as a major cause of neonatal morbidity and mortality. This pattern may be changing however, as urbanization predisposes to early introduction of other milk and decreases the prevalence of breastfeeding(5). It has been reported earlier that the median age of introduction of complementary foods in infants aged 0-6 months admitted with diarrhea at ICDDR,B was 27 days(6). The number of neonatal admissions has also increased over the years. We therefore carried out a prospective study to obtain further information on neonatal diarrhea in our hospital. Considering that exclusive breastfeeding provides substantial protection against infectious diarrhea, and that counseling of mothers of infants below 3 months of age (without complications) could help them revert to exclusive breastfeeding(7), the mothers of these neonates (with suspected complications) were also counseled during the hospital stay.

Patients and Methods

All neonates aged 0 to 28 days with diarrhea, admitted to the inpatient unit (general ward and special care unit) during March 1994 to July 1995 were enrolled in the study. On admission, a clinical history was obtained and the neonatal patients examined by the duty physician. Socioeconomic data and feeding practices of the neonates prior to the diarrheal episode were collected carefully by trained breastfeeding counselors on the same or following day, using a pre-coded questionnaire. Neonates were said to be exclusively breastfed if fed only breastmilk, predominantly breastfed if water/juices/oral rehydration solution were also given, and partially breastfed if other milk or gruel was fed in addition to breastmilk(8). Dehydration was assessed according to the WHO guidelines provided by the Programme for the Control of Diarrheal Disease in Bangladesh(9). Body weights of the neonates were taken on admission and after rehydration, and lengths measured before discharge. Routine investigations in most cases included a complete blood cell count, serum electrolytes and rectal swab cultures. Concentrations of serum sodium, chloride, potassium and total carbon dioxide were determined with ion-selective electrode methods (Synchron EL-ISE, Beckmann, USA). Rectal swabs were taken and plated on Monsur's media, Shigella-Salmonella agar and MacConkey's agar for isolation of V. cholerae, Shigella and Salmonella spp. Other investiga-tions such as blood culture, chest X-ray, stool microscopy, urine examination, liver function tests and lumbar puncture were done if indicated. Septicemia was clinically suspected if two or more of the following criteria were met, namely; (i) fever or hypothermia; (ii) tachycardia; (iii) tachypnea; (iv) abnormal white blood cell count(10).

The patients were rehydrated with standard oral rehydration solution (sodium chloride 3.5 g, potassium chloride 1.5 g, trisodium citrate dihydrate 2.5 g, and glucose 20g) or intravenous fluids, usually cholera saline (with 133 mmol of sodium, 13 mmol of potassium, 98 mmol of chloride, and 48 mmol of acetate/liter), depending on the degree of dehydration, and were given antibiotics when indicated. Invasive diarrhea was defined as the presence of blood and/or mucus in the stools. Case management in the hospital also included breastfeeding management and counseling for the neonates' mothers to initiate exclusive breastfeeding during the hospital stay and to continue it at home until the infants were 5 months old, in accordance with present WHO/UNICEF recommendations(11). During the individual counseling sessions, the reasons for the additional fluids/foods were first determined, and then the counselors explained why the mothers should breastfeed exclusively (namely, that breastfeeding helps recovery from diarrhea, would prevent further attacks of diarrhea, frequent breastfeeding makes more milk, and that breastmilk alone is sufficient for a baby's growth in the first 5 months of life). Mothers were encouraged to eat adequately. Also, the necessity of family support to enable the mothers to continue exclusive breastfeeding at home was explained to the family members during their visits to the hospital.

Data Analysis

Data were entered into a personal computer using StatPac Gold (Walonick Associates, Minneapolis, USA) and analyzed with the statistical package SPSS/PC+ (SPSS Inc., Chicago, USA). Anthropometric status of the infants was assessed using the National Center for Health Statistics (NCHS) standards(12).

Results

A total of 244 neonates were enrolled into the study, of which 161 (66%) were boys and 83 (34%) were girls. These neonates comprised 2.4% of the total (10,029) patients admitted in the inpatient unit during the study period (1994-95). Fifty three per cent mothers were illiterate, and only 8% had completed five years of schooling. The average monthly income of the fathers was Taka 3700 (Taka 42 = 1 US $). According to the mother's reporting of gesta-tional age, 43 (19%) of the babies were born before 37 weeks of gestation, and 32 (13%) had been adopted after birth. Most of the neonates 195 (79%) were delivered at home by untrained traditional birth attendants, relatives or neigh-bors, 36 (15%) in hospitals and 12 (5%) in private clinics. The duration of diarrhea before hospitalization was 4.4 (2.8) days, and 28 (12%) were severly dehydrated. The neonates' mean (SD) body weight was 2.18 (0.52) kg and length 47.5 (3.2) cm. The mean (SD) weight-for-age (%) of the neonates was 56.4 (12.7), with 66% <_2SD. Seventy-eight per cent of the neonates had weight-for-length < _2SD and 49% had length-for-age <_2SD.

Ninety per cent of the neonates had some dehydration which required fluid therapy, but only 70% had received some ORS before coming to the hospital. The cases who presented with specific types of electrolyte imbalance are shown in Table I. Pathogens were isolated from 44 (19%) of the rectal swab cultures. Although blood cultures were drawn from 161 patients in whom septicemia was suspected, they were positive in only 5 (3%) patients (E. coli in 3 cases and Acinetobacter spp in 2 cases).

Table I^__ Laboratory Parameters of Neonates with Diarrhea

Hematocrit and white blood cell count (n=237)

Hematocrit (%) 52.8 (10.6)

Total white blood cells(per cu mm) 18,497 (9667)

Serum electrolytes (n=184)

Hypokalemia (K < 3.0 mmol/l) 11 (6)

Hyponatremia (Na < 130 mmol/) 36 (19)

Hypernatremia (Na > 150 mmol/L) 22 (12)

Acidosis (TCO₂ < 10 mmol/l) 85 (46)

Blood glucose (n=78)

*Hypoglycemia < 2.2 mmol/l 17 (22)

Rectal swab culture (n=205)

No growth 161 (78)

V. cholerae O1 25 (12)

Shigella spp. 8 (4)

Salmonella spp. 3 (1)

Others 8 (4)

* Blood glucose estimated only when neonates were clinically suspected to be hypoglycemic.
Values are mean�SD and No. (%)

None of the neonates were exclusively breastfed on admission. Excluding the adopted neonates (n = 31), 163 (77%) were breastfed. Among the latter, 42 (20%) were predominantly breastfed, and 121 (57%) partially breastfed. For the majority of mothers (47%), the main reason for feeding additional milk/gruel was a per-ception of having insufficient amount of breast-milk. Forty-eight (23%) among this group of neonates were non-breastfed.

Table II^__ Clinical Diagnosis and Outcome of Neonates Admitted with Diarrhea

Feature Number (%)

(n=244)

*Diagnosis

Acute watery diarrhea 218 (89)

Invasive diarhea 14 (6)

Persistent diarrhea 5 (2)

Electrolyte imbalance 184 (75)

Clinically suspected septicemia 161 (66)

Upper respiratory tract infection 22 (9)

Bronchopneumonia 51 (21)

Jaundice 40 (16)

Oral thrush 21 (9)

Outcome

Recovered and discharged 196 (80)

Died 7 (3)

Referred to other hospital 11 (4)

Left against medical advice 29 (13)

* More than 2 diagnoses in most cases.

The majority of the neonates recovered during the hospital stay (Table II), but 11 (4%) were referred to other hospitals after their diarrhea stopped for the following conditions: management of recurrent hypoglycemia, jaun-dice, acute renal failure, congenital dislocation of hip, intestinal obstruction and apneic spells with clinical septicemia. Six of the 7 neonates who died during their hospital stay had weight-for-age and weight-for-length <_2SD of the NCHS median. Excluding the mothers of neonates who were adopted, died, or were referred when given nothing per oral (NPO), 131/204 (64%) of the mothers converted to exclusive breastfeeding as compared to none on admission (p <0.001). Mothers of twins (7 pairs), pre-term, very low birth weight sick babies who could not suckle effectively, with nipple problems and other illness, were the ones who could not achieve exclusive breastfeeding before discharge. Only 5 of the mothers who were partially breastfeeding could not be motivated to try exclusive breastfeeding in hospital. Mothers who had never breastfed (n = 10) and those who had stopped breast-feeding (n = 38) were encouraged and helped to relactate, and were successful (also 2 of those with adopted babies).

To evaluate the effects of breastfeeding on the clinical presentation and outcome, the neonates who were non-breastfed were com-pared with those who were presently breastfed. The former had lower mean (SD) weight-for-age compared to the latter [55.2% (13.1) versus 56.9% (12.5)], but the difference was not significant. With regard to outcome, signifi-cantly more neonates in the presently breastfed group recovered from diarrhea during their hospital stay, compared to those who were non-breastfed or had stopped breastfeeding (85% versus 72%, p <0.02).

Discussion

This paper reports the findings of a large number of neonates who were hospitalized specifically for treatment of diarrhea. The socioeconomic status of their families and the feeding practices of the neonates was similar to those of young infants reported earlier(6). The neonates' weights were below _2SD of the median expected birth weight, indicating that they were severely underweight. In developing countries, most low birth weight (LBW) infants are born as a result of intrauterine growth retardation rather than due to prematurity delivery(13) the causes of which are differ-ent(14). As incidence of LBW in Bangladesh is 30-50%(15), it is very likely that most of the neonates in our study were born in this category. The large proportion of adopted neonates (13%) also merits comment, as it demonstrates that being non-breastfed, they were especially prone to diarrhea.

The large proportion of neonates who presented with some dehydration and electrolyte imbalance, demonstrates that if ORS had been used appropriately at home, the need for hospitalization at such an early age might have been prevented. Current guidelines/criteria for assessment of dehydration are the same as those for infants and children(9), but this assessment may be difficult in neonates, especially those with LBW and reduced subcutaneous fat. Acidosis was common, as has been reported previously(16). Acidosis may also have contributed to the neonate's lethargic state, leading to a clinical suspicion of sepsis. Diarrhea, however, is not a common clinical manifestation of sepsis(17). Studies have reported hypernatremia in neonates following administration of standard ORS(18,19) and although this was seen initially in some of the cases in our study, they recovered uneventfully during their hospital stay. No bacterial patho-gens were isolated from rectal swab cultures of 78% of our neonates. It is possible that they were infected with other diarrheal pathogens such as rotavirus, enteropathogenic E. coli, enterotoxigenic E. coli as shown in India(3) and Nairobi(20). Surprisingly, V. cholerae, which is less frequently seen in children below 2 years of age(21), was isolated from 12% of our patients probably because they were given large amounts of water or other milk diluted/prepared with water, depriving them of the protective effects of breastfeeding(22).

Mothers were not confident about their capability to produce sufficient breastmilk, and this was the primary cause for starting other milk in the first month, as has been reported for later months(6,7). It could also be that the very low birth weight babies were unable to suckle effectively at the breast and so their mothers resorted to spoon or bottle feeding. It is likely that early complementation reduces the frequency of breastfeeding and ultimately may decrease the production of breastmilk. For LBW infants, the goal is to achieve a postnatal growth that approximates the in-utero growth of a fetus at the same postconception age(23). It has been shown that weight gain in LBW infants fed their own mother's milk was similar to that reported for fetuses of similar postconceptional age(24).

Additionally, appropriate counseling increased the confidence of mothers of hospitalized babies so that they could breastfeed exclusively(7,25). Even with a short hospital stay, most of the mothers of sick and small neonates in this study could be helped to stop other feeds and begin exclusive breastfeeding. Mothers who were not breastfeeding on admission, were successfully helped to relactate. This demonstrates again, that mothers are very receptive to counseling which helps them to change their feeding practices so that it has a positive effect on their babies health and nutritional status, and that opportunities for doing so should not be overlooked.

Most of the breastfed neonates recovered fully during their hospital stay compared to the non-breastfed, probably because breastfeeding facilitated their recovery. The case fatality rate of neonates during the study was lower as compared to an earlier report of 10% mortality in neonates with shigellosis(4) and of 27% neonatal deaths in India(3). The lower number of deaths in our study may have been partly due to early diagnosis and prompt treatment with appropriate fluids and antibiotics, and partly due to more interaction with the mothers for ensuring breastfeeding.

As this study reports the findings of neonates who were admitted for treatment of diarrhea in a hospital setting, and not in a separately funded research project, there were certain obvious limitations. The etiology of diarrhea could not be studied for all the diarrheal pathogens, only for those requiring antibiotic therapy. The number of laboratory investiga-tions for each neonate differed because these were done only when clinically indicated (to minimize costs). Again because of the absence of a budgetary provision, the counseled mothers could not be followed-up, and although they were requested to come to the hospital after a week, very few did so. Thus we do not know what proportion of the mothers continued exclusive breastfeeding at home, but expect that the majority could sustain this practice, as had been our earlier experience(7).

Malnutrition and non-breastfeeding are major risk factors for death in children below 5 years of age admitted with diarrhea at ICDDR,B(26). As the neonates in our study were probably born as LBW babies, ensuring that they continued breastfeeding, preferably exclusive breastfeeding, was a vital pre-requisite for preventing further diarrhea and improving their chances of survival. Guidelines for management of sick neonates and young infants have been developed(27), but if breastfeeding counseling is to be effective at all health facilities, it should be carried out by motivated personnel especially trained for this purpose.

Acknowledgements

This research was supported by the International Centre for Diarrheal Disease Research, Bangladesh (ICDDR, B). ICDDR,B is supported by countries and agencies which share its concern for the health problems of developing countries. Current donors include: the aid agencies of the Governments of Australia, Bangladesh, Belgium, Canada, China, Germany, Japan, the Netherlands, Norway, Republic of Korea, Saudi Arabia, Sri Lanka, Sweden, Switzerland, the United Kingdom and the United States; international organizations including the Arab Gulf Fund, Asian Development Bank, European Union, International Atomic Energy Agency, the United Nations Children's Fund (UNICEF), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA) and the World Health Organization (WHO); private foundations including the Child Health Foundation, Ford Foundation, Popula-tion Council, Rockefeller Foundation and the Sasakawa Foundation; and private organizations including American Express Bank, Bayer A.G., CARE, Family Health International, Helen Keller International, the Johns Hopkins Univer-sity, Procter and Gamble, RAND Corporation, SANDOZ, Swiss Red Cross, the University of California Davis, and others.

We acknowledge with thanks, the breastfeeding counselors Tanzila and Kona, and our colleagues and dieticians at the hospital who fully supported our efforts to help these mothers breastfeed exclusively. We also thank Drs T. Teka and N.H. Alam for their suggestions and careful review of an earlier version of this manuscript and Mr M.A.R. Patwary for secretarial assistance.

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