iarrhea remains as one of the leading causes of
under-five child mortality in India. ‘ZODIAC’ is an acronym that I have
been using in my lectures to simplify learning the management of
diarrhea. ZODIAC stands for:
Z – Zinc (gives Z security to the gut)
O – Oral Rehydration Solution (ORS)
D – Diet (including continuation of
breastfeeding)
I – Immunization (Measles vaccine and Rotavirus
vaccine)
A – Antibiotics and Adjuncts (low down in the
list; limited indications)
C – Cleanliness (Personal and public) and Common
sense
Let us see the rationale behind ZODIAC.
Zinc
Diarrhea leads to excessive loss of zinc – an
essential nutrient that has a direct impact on the intestinal villus,
brush border disaccharidase activity, and the intestinal transport of
water and electrolytes in the body. The World Health Organization (WHO)
and United Nations Children’s Fund (UNICEF) recommend zinc for the
treatment of diarrhea [1]. Zinc supplementation given for 14 days during
an episode of acute diarrhea not only reduces the duration and severity
of the episode, but also reduces the likelihood of subsequent episodes
in the following 2-3 months.
ORS
Dehydration is almost always the immediate cause of
death in children with diarrhea. The prevention of dehydration should,
therefore, be the first line of action in the treatment of diarrhea [2].
ORS is absorbed in the small intestine, replacing the water and
electrolytes lost during diarrhea. In 1970s, owing to terrible suffering
from acute dehydrating diarrhea and diarrhea-related diseases in the
children from socioeconomically poor countries, the international health
community joined in a global strategy to develop ORS. This development
has saved thousands of infants and children from death [3]. The WHO and
UNICEF currently recommends new reduced osmolarity ORS solution contains
75 mmol/L of sodium, 65 mmol/L of chloride, 75 mmol/L of glucose, 20
mmol/L of potassium and 110 mmol/L of citrate [4]. Low osmolarity ORS
is the Only Rehydrating Solution for prevention of
dehydration. Physicians treating diarrhea must give topmost priority to
ORS in the prescription and must spend extra time or depute someone to
explain the proper way of preparing ORS solution.
Diet
Everyone needs to remember and spread the message
that the child should not be kept nil-by-mouth during diarrhea. All
guidelines recommend that breastfeeding should be continued throughout
the rehydration process. Infants over 6 months should be given cereals,
vegetables and other foods. The food must be well cooked, and mashed or
ground to enable easy digestion; fermented foods may be easier to
digest. In addition, foods with higher potassium content, including
bananas and green coconut water, are beneficial. During persistent
diarrhea, animal milk is replaced with yoghurt (if available), as it
contains less lactose and is better tolerated. If yoghurt is
unavailable, animal milk is restricted to 50 mL/kg/day as greater
amounts can exacerbate diarrhea. The milk must not be diluted. To break
the vicious cycle of diarrhea and malnutrition, the WHO guidelines
suggest continuing the nutrient-rich foods during and after diarrhea
[4].
Immunization
Vaccination is an effective strategy to prevent the
occurrence or reduce the severity of diarrheal diseases, which in turn
help in reducing the risk of malnutrition and developmental delay
associated with severe and prolonged diarrhea in children. Rotavirus is
the most common cause of severe dehydrating diarrhea in young children –
globally accounting for an estimated 527 thousand deaths each year in
children aged <2 years [5]. Measles is known to predispose to diarrheal
disease secondary to measles-induced immune deficiency, and a high
proportion of measles cases get complicated by diarrhea [6].
The decision to include a vaccine in the national
immunization schedule depends on ‘NESCAFE’ – Need, Efficacy,
Safety, Cost-effectiveness, Affordability, Flexibility
and Ethical issues. The decision to introduce the rotavirus
vaccine into India’s routine immunization schedule is a welcome move. In
2011, the Indian Academy of Paediatrics (IAP) included the rotavirus
vaccine in its recommended immunization schedule, recognizing that the
vaccine gives us a very real shot at reducing the morbidity and
mortality of the disease. Every child is vulnerable to rotavirus
diarrhea, regardless of where they live, and for those in places without
accessible healthcare, it can be a death sentence. A single episode of
moderate-to-severe diarrhea in young children disproportionately
increases susceptibility to death by other causes. Being exposed to
disease at an early age intensifies the risk of malnutrition, which, in
turn, leads to poor physical, cognitive and emotional growth. A child
protected by the rotavirus vaccine averts weakness and disease, and is
better placed to perform.
Antibiotics
Viral pathogens, including rotavirus, account for
most of the diarrheal episodes in under-five children. The WHO
recommends the use of antibiotics only for cases with acute bloody
diarrhea/dysentery. Overuse of antibiotics can lead to development of
antimicrobial resistance (AMR), particularly in developing countries,
where the incidence of infectious diseases is high. Rational usage of
antimicrobials limits the development of AMR. Antibiotics are being
misused in children with diarrhea and thus, caregivers need to be
educated against this urgently [7,8].
Cleanliness
The primary sources of exposure to a diarrheogenic
microbe are contaminated water, poor sanitation, and unhygienic
conditions. Practicing open defecation or sharing sanitation facilities
increases the burden of diarrheal disease, malnutrition, and
diarrhea-related mortality. Currently, only 68% of the world’s
population and 38% of those living in the least developed countries meet
the criteria for access to an improved sanitation facility [9].
Interventions supporting increased access to clean water and private
household sanitation facilities may reduce exposure to enteric pathogens
and thereby reduce the incidence of diarrhea among young children [9].
Washing hands with soap and clean water, using clean and safe methods of
preparing and storing food. washing fruits and vegetables or cooking
them well before eating, using a toilet for defecation, and covering
food are important cleanliness practices to prevent diarrhea.
Epilogue
Diarrhea in children continues to pose a major public
health challenge despite significant advances in interventions. Reducing
mortality rates largely depends on life-saving treatment with ORS and
zinc to all the children suffering with diarrhea, whereas main tools of
prevention are cleanliness and vaccination. As pediatricians, we endorse
the move to introduce the rotavirus vaccine into the national
immunization schedule of India. The vaccine is a cost-effective
intervention poised to make a much needed positive impact on public
health in India. It will go a long way to ensure that Indian infants and
children are protected against diarrhea, the second largest killer of
Indian children.
I hope that the prescription rates of ORS and zinc
improve, children continue to get breastfeeding and usual diet during
diarrhea, children are routinely administered the measles and rotavirus
vaccines, antibiotic abuse is avoided, and parents observe cleanliness
and apply common sense while bringing up children.
References
1. UNICEF. Clinical Management of Acute Diarrhea.
WHO/UNICEF Joint Statement 2004. Available from:
http://www.unicef.org/publications/files/ENAcute_Diarrhea_ reprint.pdf.
Accessed May 04, 2016.
2. Munos, MK, Walker CL, Black RE. The effect of oral
rehy-dration solution and recommended home fluids on diarrhea mortality.
Int J Epidemiol. 2010; 39(Suppl 1):i75-87.
3. Oral Rehydration Therapy: A Revolution in Child
Survival. Available from: http://pdf.usaid.gov/pdf_docs/PNAAZ606.pdf.
Accessed April 29, 2016.
4. WHO. The Treatment of Diarrhea: A Manual for
Physicians and Other Senior Health Workers. 2005. Available from:
http://apps.who.int/iris/bitstream/10665/43209/ 1/9241593180.pdf.
Accessed May 04, 2016.
5. Das JK, Tripathi A, Ali A, Hassan A, Dojosoeandy
C, Bhutta ZA. Vaccines for the prevention of diarrhea due to cholera,
shigella, ETEC and rotavirus. BMC Public Health. 2013;13(Suppl 3):S11.
6. Perry RT, Halsey NA. The clinical significance of
measles: A review. J Infect Dis. 2004;189(Suppl 1):S4-16.
7. Kotwani A, Chaudhury RR, Holloway K.
Antibiotic-prescribing practices of primary care prescribers for acute
diarrhea in New Delhi, India. Value Health. 2012;15(Suppl 1):S116-9.
8. Ekwochi U, Chinawa JM, Obi I, Obu HA, Agwu S. Use
and/or misuse of antibiotics in management of diarrhea among children in
Enugu, Southeast Nigeria. J Trop Pediatr. 2013;59:314-6.
9. Baker KK, O’Reilly CE, Levine MM, Kotloff KL,
Nataro JP, Ayers TL, et al. Sanitation and hygiene-specific risk
factors for moderate-to-severe diarrhea in young children in the Global
Enteric Multicenter Study, 2007-2011: Case-control study. PLoS Med.
2016;13:e1002010.