{"id":58664,"date":"2024-06-25T10:24:41","date_gmt":"2024-06-25T10:24:41","guid":{"rendered":"https:\/\/biomedpharmajournal.org\/?p=58664"},"modified":"2024-07-03T17:53:32","modified_gmt":"2024-07-03T17:53:32","slug":"acute-diarrhoea-in-children-aged-up-to-2-years-age-group-assessment-of-therapeutic-strategies-and-hospital-stay-variance-in-tertiary-care-rural-hospital-an-observational-study","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol17no2\/acute-diarrhoea-in-children-aged-up-to-2-years-age-group-assessment-of-therapeutic-strategies-and-hospital-stay-variance-in-tertiary-care-rural-hospital-an-observational-study\/","title":{"rendered":"Acute Diarrhoea in Children Aged Up to 2 Years Age Group: Assessment of Therapeutic Strategies and Hospital Stay Variance, in Tertiary Care Rural Hospital \u2013 An Observational Study"},"content":{"rendered":"\n

Introduction<\/strong><\/p>\n\n\n\n

According to World Health Organization \u201cDiarrhoea is the passage of unusually loose or watery stools, usually at least three times in a 24-hour period\u201d.1<\/sup> Diarrhoeal diseases are one of the leading cause of children morbidity and mortality in developing countries, and an important cause of mal nutrition. Severely malnourished patients have higher mortality rates and more frequent hospital admissions. Malnutrition adversely affects the immune system hence, considered to be the most common cause of immunodeficiency throughout the world.2<\/sup> It has been abstracted that the diarrhoea can be considered as low (1-5 stools\/day), medium (6-9 stools\/day), and high (\u2265 10 stools\/day), according to the number of stool passed per day.3<\/sup> Diarrhoea may be due to an infection of the intestinal tract, which is caused by a variety of bacterial, viral and parasitic organisms. This infection can be spread through contaminated water and food& from person-to-person due to the result of poor hygiene. Other than this, it can be said that zinc deficiency may be a cause of diarrhoea or can say diarrhoea is consistently found in children with severe zinc deficiency.4<\/sup> Rotavirus is the most common cause of gastroenteritis in childhood, both in the developed and still developing countries. Viruses can cause almost 70% of infectious diarrhoeal diseases in children.5<\/sup> It is also the main important cause of diarrhoeal mortality.6<\/sup> So, antimicrobials have no role in such type of diarrhoeas. According to WHO, antimicrobials are helpful only for children suffering from bloody diarrhoea and suspected case of cholera with severe dehydration.1<\/sup> Now a days, antimicrobial resistance is a major problemworldwide.7<\/sup> Oral Zinc supplement can decrease the severity of the diarrhoea episode, amount of stool per day and the number of stools per day8<\/sup>. It has direct effect on intestinal villus, brush border disaccharidase activity and intestinal transport of water and electrolytes. Zinc also causes early normalization of stool consistency, early recovery and decreases total duration of hospital stay.9<\/sup> Still, a major number of clinicians prefer to prescribe antimicrobials for all of the acute diarrhoea cases and it is prescribed in a large number.10,11<\/sup><\/p>\n\n\n\n

There are some utilization studies\nof diarrhoea cases\navailable but very few was done in under 2 years age group. So, we have decided to observe the utilization pattern\nof Zinc and antimicrobials\nin our setup in under 2 years age group in acute moderate diarrhoea cases and to observe the hospital\nstay difference between\ngroups received Zinc and antimicrobials.<\/p>\n\n\n\n

Aim<\/strong><\/p>\n\n\n\n

Assess the use of Zinc and Antimicrobials and hospital stay variance in the treatment of acute Diarrhoeal diseases in up to 2 years age group.<\/p>\n\n\n\n

Objectives<\/strong><\/p>\n\n\n\n

Overall average use of Zinc and Antimicrobials alone and combined in treatment of acute Diarrhoea.<\/p>\n\n\n\n

Assessment of hospital stay variance between patients getting Zinc and Antimicrobials alone in acute moderate diarrhoea cases<\/p>\n\n\n\n

Materials and Methods<\/strong><\/p>\n\n\n\n

This observational study was conducted in the dept. of Pharmacology in collaboration with department of Paediatrics of Mahatma Gandhi Institute of Medical Sciences, Sewagram starting from January 2016 to June 2016. All the patients admitted in indoor of dept. of Paediatrics under 2 years of age with acute moderate diarrhoea in the given period was included in the study.<\/p>\n\n\n\n

Inclusion criteria<\/strong><\/p>\n\n\n\n

All the admitted and diagnosed cases\nof acute moderate diarrhoea within the study period Under the age up to 2 years<\/p>\n\n\n\n

Passed watery stool less than 10 times on the day of admission Willing to give consent<\/p>\n\n\n\n

Exclusion criteria<\/strong><\/p>\n\n\n\n

Chronic\nDiarrhoea cases (duration more than 14 days)\nBloody Diarrhoea<\/p>\n\n\n\n

Patients\nhaving other diseases, acute or chronic Seriously ill patients<\/p>\n\n\n\n

Taking any medication other than prescribed for Diarrhoea<\/p>\n\n\n\n

Total 93 patients were admitted during the study period\nand among them 76 cases were included in the study and total 17 cases\nwere excluded from the study according to the inclusion and exclusion criteria.\nAmong the 17 patients Pneumonia\n3 cases, URTI 6 cases, Hydronephrosis 1 case, LRTI 3 cases,\nMiliary TB 1 case, Meningitis 1 case, Febrile\nconvulsion 1 case, Seizure disorder 1 case.<\/p>\n\n\n\n

The diagnosis was made by the paediatrician and average\nstool output was 5 to 9 times on the day of admission which may be considered as medium or moderate diarrhoea3<\/sup>.<\/p>\n\n\n\n

Institutional Ethical Committee (IEC) approval was taken prior to the study.<\/p>\n\n\n\n

Data collection<\/strong><\/p>\n\n\n\n

Prior written informed consent was taken from every patient\u2019s guardian. Single time enrolment of the patients was maintained throughout the study. The data was recorded in the case record form (CRF).<\/p>\n\n\n\n

Statistical analysis<\/strong><\/p>\n\n\n\n

The data was entered into GraphPad software and mean, standard deviation (SD) and p value was calculated. p value was calculated by using Unpaired t test and p value < 0.05 considered to be significant.<\/p>\n\n\n\n

Results and Discussion<\/strong><\/p>\n\n\n\n

Total 76 patients were enrolled in the study according to inclusion and exclusion criteria. Among 76 patients, it was found that 50 patients (65.79%) were from 6 – 11 months age group and 23 patients (30.26%) were from 1- 2 years and 3 patients (3.95%) were from 0- 6 months age group. Among the 76 patients, 56 patients (73.68%) were male and 20 patients (26.31%) were female. Among them, 64 patients (84.21%) were culture negative and 12 patients (15.79%) were culture positive. (Table 1a, 1b & 1c)<\/p>\n\n\n\n

Table 1(a): Demographic Data (Age wise distribution)<\/strong>.<\/p>\n\n\n\n\n\n\n\n\n
\n

Age<\/strong><\/p>\n<\/td>\n

\n

Total patients
<\/strong>(n = 76)<\/p>\n<\/td>\n

\n

Percentage<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

0 – 6 months<\/p>\n<\/td>\n

\n

3<\/p>\n<\/td>\n

\n

3.95%<\/p>\n<\/td>\n<\/tr>\n

\n

6 -11 months<\/p>\n<\/td>\n

\n

50<\/p>\n<\/td>\n

\n

65.79%<\/p>\n<\/td>\n<\/tr>\n

\n

1 \u2013 2 years<\/p>\n<\/td>\n

\n

23<\/p>\n<\/td>\n

\n

30.26%<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

Table 1(b): Demographic Data (Gender wise distribution)<\/strong>.<\/p>\n\n\n\n\n\n\n\n
\n

Gender<\/strong><\/p>\n<\/td>\n

\n

Total patients
<\/strong>n = 76<\/p>\n<\/td>\n

\n

Percentage<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Male<\/p>\n<\/td>\n

\n

56<\/p>\n<\/td>\n

\n

73.68%<\/p>\n<\/td>\n<\/tr>\n

\n

Female<\/p>\n<\/td>\n

\n

20<\/p>\n<\/td>\n

\n

26.31%<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

Table 1(c): Culture report wise distribution of patients<\/strong><\/p>\n\n\n\n\n\n\n\n
\n

Culture<\/strong><\/p>\n<\/td>\n

\n

Total patients
<\/strong>n = 76<\/p>\n<\/td>\n

\n

Percentage<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Positive<\/p>\n<\/td>\n

\n

12<\/p>\n<\/td>\n

\n

15.79%<\/p>\n<\/td>\n<\/tr>\n

\n

Negative<\/p>\n<\/td>\n

\n

64<\/p>\n<\/td>\n

\n

84.21%<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

Among the 76 patients,31 patients (40.79%) were treated with Zinc alone, 25 patients (32.89%) were treated with antimicrobial alone and (Zinc+ antimicrobial) treated were11 patients (14.47%) and 9 patients (11.84%) were treated with others (prebiotics, H2 blockers, Proton pump inhibitors). (Table 2).<\/p>\n\n\n\n

Table 2: Distribution of Treatment<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n
\n

Treatment<\/strong><\/p>\n<\/td>\n

\n

Total patients
(n = 76)<\/strong><\/p>\n<\/td>\n

\n

Percentage<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Zinc only<\/p>\n<\/td>\n

\n

31<\/p>\n<\/td>\n

\n

40.79%<\/p>\n<\/td>\n<\/tr>\n

\n

Antimicrobial only<\/p>\n<\/td>\n

\n

25<\/p>\n<\/td>\n

\n

32.89%<\/p>\n<\/td>\n<\/tr>\n

\n

(Zinc +antimicrobial)<\/p>\n<\/td>\n

\n

11<\/p>\n<\/td>\n

\n

14.47%<\/p>\n<\/td>\n<\/tr>\n

\n

Others<\/p>\n<\/td>\n

\n

9<\/p>\n<\/td>\n

\n

11.84%<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n

In culture positive (12) cases 3 patients (25%) were treated by Zinc alone, 5 patients (41.67%) were treated by antimicrobial alone and 4 patients (33.33%) were treated by (Zinc + antimicrobial). (Table 3a).<\/p>\n\n\n\n

In culture negative (64) cases 28 patients (43.75%) were treated by Zinc alone, 20 patients (31.25%) were treated by antimicrobial alone and 7 patients (10.94%) were treated by (Zinc +antimicrobial) and 9 patients (14.06%) were treated by others. (Table 3b).<\/p>\n\n\n\n

Table 3(a): Treatment pattern in Culture positive cases<\/strong><\/p>\n\n\n\n\n\n\n\n\n
\n

Treatment<\/strong><\/p>\n<\/td>\n

\n

Treated patient
n = 12<\/strong><\/p>\n<\/td>\n

\n

Percentage<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Zinc<\/p>\n<\/td>\n

\n

3<\/p>\n<\/td>\n

\n

25%<\/p>\n<\/td>\n<\/tr>\n

\n

Antimicrobial<\/p>\n<\/td>\n

\n

5<\/p>\n<\/td>\n

\n

41.67%<\/p>\n<\/td>\n<\/tr>\n

\n

Zinc+ Antimicrobial<\/p>\n<\/td>\n

\n

4<\/p>\n<\/td>\n

\n

33.33%<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

Table 3(b): Treatment pattern in Culture negative cases<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n
\n

Treatment<\/strong><\/p>\n<\/td>\n

\n

Treated patient
n= 64<\/strong><\/p>\n<\/td>\n

\n

Percentage<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Zinc<\/p>\n<\/td>\n

\n

28<\/p>\n<\/td>\n

\n

43.75%<\/p>\n<\/td>\n<\/tr>\n

\n

Antimicrobial<\/p>\n<\/td>\n

\n

20<\/p>\n<\/td>\n

\n

31.25%<\/p>\n<\/td>\n<\/tr>\n

\n

Zinc + Antimicrobial<\/p>\n<\/td>\n

\n

7<\/p>\n<\/td>\n

\n

10.94%<\/p>\n<\/td>\n<\/tr>\n

\n

Others<\/p>\n<\/td>\n

\n

9<\/p>\n<\/td>\n

\n

14.06%<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

Hospital stays difference in between Zinc alone treated and antimicrobial alone treated group in culture positive diarrhoea cases is statistically significant (p \u2013 0.03*) but it is not statistically significant (p \u2013 0.08) in between Zinc alone treated and antimicrobial alone treated group in culture negative diarrhoea cases. The hospital stays difference in between Zinc alone treated and combined (Zinc+ antimicrobial) treated group is not statistically significant (p- 0.2) in culture negative cases but significant (p – 0.03*) in culture positive cases. While comparing between antimicrobial alone and combined (Zinc+ antimicrobial) treated group is found that hospital stay difference is highly significant (p \u2013 0.0007**) in culture positive cases but it is not significant in culture negative cases. (Table 4a, 4b &4c)<\/p>\n\n\n\n

Table 4 (a): Hospital stay comparison between Zinc and Antimicrobial treated group<\/strong><\/p>\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Zinc treated group (Hospital stays) Mean \u00b1 SD<\/strong><\/p>\n<\/td>\n

\n

Antimicrobial treated group <\/strong>(Hospital stays)
<\/strong>Mean \u00b1 SD<\/strong><\/p>\n<\/td>\n

\n

p value<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Culture positive case<\/p>\n<\/td>\n

\n

4.1\u00b11.79<\/p>\n<\/td>\n

\n

2.68\u00b11.16<\/p>\n<\/td>\n

\n

0.03\u20f0<\/p>\n<\/td>\n<\/tr>\n

\n

Culture negative case<\/p>\n<\/td>\n

\n

2.68\u00b11.22<\/p>\n<\/td>\n

\n

3.4\u00b11.6<\/p>\n<\/td>\n

\n

0.08(NS)<\/p>\n<\/td>\n<\/tr>\n

\n

Unpaired t test was used. p value \u02c2 0.05 considered significant. NS \u2013 not significant<\/p>\n

\u20f0 – statistically significant<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n

Table 4(b): Hospital stay comparison between Zinc and (Zinc +Antimicrobial) treated group<\/strong><\/p>\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Zinc treated group (Hospital stays)<\/strong><\/p>\n

Mean \u00b1 SD<\/strong><\/p>\n<\/td>\n

\n

(Zinc + Antimicrobial) treated group (Hospital stays)<\/strong><\/p>\n

Mean \u00b1 SD<\/strong><\/p>\n<\/td>\n

\n

p value<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Culture positive case<\/p>\n<\/td>\n

\n

4.1\u00b11.79<\/p>\n<\/td>\n

\n

7.75\u00b11.5<\/p>\n<\/td>\n

\n

0.03\u20f0<\/p>\n<\/td>\n<\/tr>\n

\n

Culture negative case<\/p>\n<\/td>\n

\n

2.68\u00b11.22<\/p>\n<\/td>\n

\n

3.28\u00b11.38<\/p>\n<\/td>\n

\n

0.2(NS)<\/p>\n<\/td>\n<\/tr>\n

\n

Unpaired t test was used. p value \u02c2 0.05 considered significant. NS \u2013 not significant<\/p>\n

\u20f0 – statistically significant<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n

Table 4(c): Hospital stay comparison between Zinc and (Zinc+ Antimicrobial) treated group<\/strong>.<\/p>\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Antimicrobial treated group (Hospital stays)<\/strong><\/p>\n

Mean \u00b1 SD<\/strong><\/p>\n<\/td>\n

\n

(Zinc + Antimicrobial) treated group<\/strong><\/p>\n

(Hospital stays)<\/strong><\/p>\n

Mean \u00b1 SD<\/strong><\/p>\n<\/td>\n

\n

p value<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Culture positive case<\/p>\n<\/td>\n

\n

2.68\u00b11.16<\/p>\n<\/td>\n

\n

7.75\u00b11.5<\/p>\n<\/td>\n

\n

0.0007**<\/p>\n<\/td>\n<\/tr>\n

\n

Culture negative case<\/p>\n<\/td>\n

\n

3.4\u00b11.6<\/p>\n<\/td>\n

\n

3.28\u00b11.38<\/p>\n<\/td>\n

\n

0.8(NS)<\/p>\n<\/td>\n<\/tr>\n

\n

Unpaired t test was used. p value \u02c2 0.05 considered significant. NS \u2013 not significant<\/p>\n

\u20f0 – statistically significant, ** – highly significant<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n

The time period was selected from January to June, as diarrhoeal disease prevalence is more in summer in India,12,13<\/sup>because in hot and humid weather, the growth of pathogenic organisms in the food and other material is increased. Summer is also the breeding season for flies that act as mechanical vectors carrying pathogens to food and water. In tropical areas of India, rotavirus diarrhoea occurs throughout the year.13<\/sup> In this study, 6 \u2013 11 months age group (65.79%) was mostly affected by diarrhoea which is like studies done by Sazawal et al14<\/sup>, Fatima et al15<\/sup>, Ahmed et al13<\/sup> and contrast to studies done by Sontakke et al16<\/sup>. Possible cause of this maybe it is the age when weaning is started in India. Male preponderance (73.68%) was found in this study which is like the studies done by Fatima et al15<\/sup>, Rizwan et al10<\/sup>, Desai et al17<\/sup>, Gupta et al18<\/sup> but contrast to Sontakke et al16<\/sup> where they found female preponderance. Male preponderance may be described by the study done by Walker et al6<\/sup> and Siziya et al19<\/sup> which also described the possible mechanism behind this.<\/p>\n\n\n\n

In our study culture positivity rate was higher than the studies done by Koplan et (2.4%) al20<\/sup> and Rohner et al (12.6%)21<\/sup>. Comparatively high stool cultures positivity rate in our study may be due to the seriousness of diarrhoea21<\/sup> as it is the only tertiary health care centre and the main referral unit of this area. Various positivity rates in different studies could be due to many factors like different screening panels and evaluation methods, nature of diarrhoeal cases (community vs. hospital), several dietary factors22<\/sup> and of course hygiene.<\/p>\n\n\n\n

In our study, highest number\nof patients were treated with Zinc only (40.79%) which\nis greater than the studies done by Desai et al\n(12.6%)17<\/sup>, Sontakke et al (5%)16<\/sup> which indicates towards the adherence to the WHO guideline in our setup. 32.89% patients\nwere treated with antimicrobials\nwhich is lower than the studies done by Devi et al (71%)11<\/sup>, Rizwan\net al (87.5%)10<\/sup> but higher\nthan the studies done by Desai et al (25.5%)17<\/sup>, and Sontakke et al (23.74%)16<\/sup>. Only one antimicrobial agent was given to\neach patient which indicates toward the\nrationality of prescription and to avoid antimicrobial resistance. But the\npercentage of patients treated with\nantimicrobials in this study is a bit high though culture positivity rate is low, may be because of a single negative stool culture report may not be enough to completely rule out the presence of bacterial infection.21<\/sup> Sometimes, if the patient\u2019s symptom is indicating towards any infectious cause the clinicians started early\nantimicrobial therapy to reduce the morbidity\nand mortality, which may lead to the existence of antimicrobial agents in\nspecimen which may cause false-negative stool culture report\nas it may inhibit the growth of susceptible bacteria.21<\/sup><\/p>\n\n\n\n

In this study, among the culture positive diarrhoea\ncases 41.67% patients were treated with antimicrobials\nand 33.33% patients were treated with antimicrobials and Zinc supplement combinedly justifies the treatment for\ninfectious diarrhoea. Only 3 patients were treated with Zinc supplement only, possible cause may be as this is a\nreferral hospital, so patient may have got any antimicrobial in previous hospital\nand he\/she was symptomatically better when reaches\nhere.<\/p>\n\n\n\n

In culture negative cases, maximum cases (43.75%) were treated with Zinc supplement only and 14.06% patients were treated with other measures which justifies the treatment protocol for non-infectious\/viral diarrhoea. Here also 31.25% and 10.94% patients received antimicrobial alone and antimicrobial with Zinc consecutively. This may be due to these patients were false negative cases or symptomatically worse.<\/p>\n\n\n\n

In our study, when we compared the hospital stay between\nthe groups, we have found that hospital stay difference is statistically significant (p = 0.03)\nin between Zinc and antimicrobial treated group in culture positive cases. But in culture\nnegative cases when we compared the hospital\nstay between Zinc treated and Antimicrobial treated & also between Zinc\ntreated and combinedly Zinc and antimicrobial treated, we observed\nthat it is statistically not significant in both\nthe cases. So, it may be taken into consideration that use of antimicrobials\ndoes not have any beneficiary effect\nin reducing hospital stay in culture negative diarrhoea cases. Hospital stay difference is also statistically significant (p – 0.03) in between culture\npositive cases treated\nwith zinc alone and (zinc+ antimicrobial) combinedly, which is obvious.\nWhile comparing hospital stay between antimicrobial alone and zinc and antimicrobial combinedly treated group\nit is found to be statistically highly significant(p-0.0007) may be due\nto the reason that zinc directly\naffect intestinal villus and brush border disaccharides activity and affect intestinal water and electrolytes transportation. So, when zinc is used in treatment, it can bring down the severity and duration of diarrhoeal disease and thus cut down the\nhospital stay effectively 8,9<\/sup>.<\/p>\n\n\n\n

The epidemiology of childhood diarrhoea and pneumonia, both of them are important causes of childhood morbidity and mortality, share same risk factors like undernutrition, measles , inadequate water and sanitation, poor handwashing, indoor air pollution and crowding, and can be prevented by scheduled infant vaccination, breastfeeding and good childhood nutrition, proper care at home and appropriate case management.6<\/sup> So, diarrhoeal diseases and also morbidity and mortality can be minimised significantly by providing safe drinking water and proper sanitation and hygiene.<\/p>\n\n\n\n

Conclusion<\/strong><\/p>\n\n\n\n

Zinc alone was prescribed over antimicrobials in acute moderate diarrhoea cases. Use of antimicrobials in culture negative acute diarrhoea cases cannot reduce hospital stay. Zinc can reduce hospital stay in culture positive and negative moderate diarrhoea cases.<\/p>\n\n\n\n

Limitations<\/strong><\/p>\n\n\n\n

Further studies are required with large sample size and longer duration of study for better interpretation of result. <\/p>\n\n\n\n

Acknowledgement<\/strong><\/p>\n\n\n\n

None <\/strong><\/p>\n\n\n\n

Conflict of Interest<\/strong><\/p>\n\n\n\n

There is no conflict of interest.<\/p>\n\n\n\n

Funding Sources<\/strong><\/p>\n\n\n\n

There is no funding Sources<\/p>\n\n\n\n

References<\/strong><\/p>\n\n\n\n

  1. World Health Organization. The Treatment of Diarrhoea. 2005. https:\/\/apps.who.int\/iris\/handle\/10665\/43209<\/li>
  2. Das SK, Hossain MI, Chisti MJ, Islam MM. Childhood Diarrhea and Severe Malnutrition. In: Epidemiology of Childhood Diarrhea and Malnutrition. 2014. page 235\u201356.<\/li>
  3. Lamberti LM, Walker CLF, Black RE. Systematic review of diarrhea duration and severity in children and adults in low- and middle-income countries. BMC Public Health 2012;12(276):1\u201311. doi:10.1186\/1471-2458-12-832
    CrossRef <\/a><\/li>
  4. Skrovanek S, Diguilio K, Bailey R, Huntington W, Urbas R, Mayilvaganan, et al. Zinc and gastrointestinal disease. World J Gastrointest Pathophysiol 2014;5(4):496\u2013513. doi:10.4291\/wjgp.v5.i4.496
     CrossRef <\/a><\/li>
  5. Revelas A. Acute gastroenteritis among children in the developing world Acute gastroenteritis among children in the developing world. South African J Epidemiol Infect 2012;27(4):156\u201362. doi:10.1080\/10158782.2012.11441503
     CrossRef <\/a><\/li>
  6. Fischer Walker CL, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, et al. Global burden of childhood pneumonia and diarrhoea. Lancet2013;381(9875):1405\u201316. doi:10.1016\/S0140-6736(13)60222-6
     CrossRef <\/a><\/li>
  7. Nema P, Totade S, Gupta C, Patel JR. An Assessment of Factors Affecting Antibiotic Prescription in Pediatric Department of Rural Tertiary Care Teaching Hospital , Wardha District ,Maharashtra. Res J Pharm , Biol Chem Sci 2012;3(3):921\u20138.<\/li>
  8. Fischer Walker CL, Bhutta ZA, Bhandari N, Teka T, Shahid F, Taneja S, et al. Zinc supplementation for the treatment of diarrhea in infants in Pakistan, India and Ethiopia. J Pediatr Gastroenterol Nutr [Internet] 2006 [cited 2022 Apr 25];43(3):357\u201363. Available from: https:\/\/pubmed.ncbi.nlm.nih.gov\/16954960\/
     CrossRef <\/a><\/li>
  9. Trivedi SS, Chudasama RK, Patel N. Effect of Zinc Supplementation in Children with Acute Diarrhea\u202f: Randomized Double Blind Controlled Trial. Gastroenterol Res 2009;2(3):168\u201374.doi:10.4021\/gr2009.06.1298
    CrossRef <\/a><\/li>
  10. Rizwan F, Monjur F, Tanjia N, Ghosh NK. A Comparative Study Between Infant and Neonate Patients Suffering From Diarrhea In Dhaka City of Bangladesh. Asian J Biomed Pharm Sci 2015;5(50):20\u20133.doi:10.15272\/ajbps.v5i50.747<\/li>
  11. Devi G, Rai J, Singh A, Singh K. Prescription audit for acute diarrhoea in children under five in tertiary ,secondary and private care hospitals in Amritsar,Punjab. J Evol Med Dent Sci 2015;4(50):8753\u20138.doi:10.14260\/jemds\/2015\/1268
     CrossRef <\/a><\/li>
  12. Lakshminarayanan S, Jayalakshmy R. Diarrheal diseases among children in India: Current scenario and future perspectives. J Nat Sci Biol Med 2015;6(1):24\u20138. doi:10.4103\/0976-9668.149073
    CrossRef <\/a><\/li>
  13. Ahmed SF, Farheen A, Muzaffar A, Mattoo GM. Prevalence of Diarrhoeal Disease, its Seasonal and Age Variation in under- fives in Kashmir, India. Int J Health Sci (Qassim) [Internet] 2008;2(2):126\u201333. Available from: http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/ 21475494%0A http:\/\/www.pubmedcentral.nih.g ov\/articlerender.fcgi?artid=PMC3068726<\/li>
  14. Sazawal S, Black RE, Bhan MK, Bhandari N, Sinha A, Jalla S. Zinc supplementation in young children with acute diarrhea in india. N Engl J Med 1995;333(13):839\u201344.
     CrossRef <\/a><\/li>
  15. Fatima S, Irfana N, Mushtaq SM, Mohammed Q, Masood R, Parveen J, et al. A Cross- Sectional Study to Assess Prevalence and Management of Acute Gastroenteritis in Pediatric Inpatients of A Large Teaching Hospital. J Pharm 2014;4(12):12\u201326.<\/li>
  16. Sontakke SD, Khadse V, Bokade CM, Motghare VM. Medication prescribing pattern in pediatric diarrhea with focus on zinc supplements. Int J Nutr Dis 2016;6(4):152\u20136.
     CrossRef <\/a><\/li>
  17. Desai CK, Iyer GS. Prescribing pattern and appropriateness of drug treatment of diarrhoea in hospitalised children at a tertiary care hospital in India. Int J Med Public Heal 2013;3(4):335\u201341.doi:10.4103\/2230-8598.123522
    CrossRef <\/a><\/li>
  18. Gupta DA. Prevalence of Diarrhoea and its association with Wasting, Age, and Gender in Children below the Age of Five years. Int J Med Res Rev 2014;2(4):291\u20135. doi:10.17511\/ijmrr.2014.i04.04
     CrossRef <\/a><\/li>
  19. Siziya S, Muula AS, Rudatsikira E. Correlates of diarrhoea among children below the age of 5 years in Sudan. Afr Health Sci 2013;13(2):376\u201383. doi:10.4314\/ahs.v13i2.26
     CrossRef <\/a><\/li>
  20. Koplan JP, Jane Benfari Ferraro M, Fineberg H V., Rosenberg ML. Value of stool cultures. Lancet 1980;316(8191):413\u20136. doi:10.1016\/S0140-6736(80)90453-5
     CrossRef <\/a><\/li>
  21. Rohner P, Pittet D, Pepey B, Nije-Kinge T, Auckenthaler R. Etiological agents of infectious diarrhea: Implications for requests for microbial culture. J Clin Microbiol 1997;35(6):1427\u201332. doi:10.1128\/jcm.35.6.1427-1432.1997
     CrossRef <\/a><\/li>
  22. Chau ML, Hartantyo SHP, Yap M, Kang JSL, Aung KT, Guti\u00e9rrez RA, et al. Diarrheagenic pathogens in adults attending a hospital in Singapore. BMC Infect Dis 2016;16(1):1\u20139. doi:10.1186\/s12879-016-1354-0
     CrossRef <\/a><\/li><\/ol>\n","protected":false},"excerpt":{"rendered":"

    Introduction According to World Health Organization \u201cDiarrhoea is the passage […]<\/p>\n","protected":false},"author":15,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[115],"tags":[],"class_list":["post-58664","post","type-post","status-publish","format-standard","hentry","category-vol17no2"],"_links":{"self":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/58664","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/users\/15"}],"replies":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/comments?post=58664"}],"version-history":[{"count":5,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/58664\/revisions"}],"predecessor-version":[{"id":59673,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/58664\/revisions\/59673"}],"wp:attachment":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/media?parent=58664"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/categories?post=58664"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/tags?post=58664"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}