Alimentary tract and
pancreas
Alimentarni trakt i pankreas
ARCH GASTROENTEROHEPATOL
2002; 21 ( No 1 – 2 )
Management of acute gastroenteritis in Yugoslavia:
Compliance with ESPGHAN recommendations
Lecenje akutnog
gastroenteritisa u Jugoslaviji: Saglasnost
sa peporukama ESPGHANa
1Tamara Vukavić, 1M. Stojšić, 2Ljiljana Savić, 2Ivica
Stanković, 3M. Perošević, 4K. Ajdžanović, 5Lj.
Stolić, 6B. Kažić.
( accepted February 28th, 2002 )
1Institute of Child and Youth Health Care, Novi Sad; 2Institute of Mother and Child Health Care, Novi Beograd;
3 Clinical Centre, Podgorica; 4Health
Centre, Ruma; 5General Hospital, Vršac; 6General
Hospital, Vrbas
Acknowledgements:
The authors
wish to thank all participating, 113 physicians from Yugoslavia.
Address
correspondence to:
Dr
Tamara Vukavic
Institute
of Child and Youth Health Care
Paediatric Clinic
10, Hajduk Veljkova Str
YU - 21 000 Novi Sad
Serbia,
Yugoslavia
………………..
………………………….
Acute
gastroenteritis management in children
Gastroenteroloska sekcija
SLD-
01729, 2002
ABSTRACT
Oral
rehydration is a mainstay of treatment for acute diarrhoea, both, in developing
and in industrialized countries. ESPGHAN (European Society for Paediatric
Gastroenterology, Hepatology and Nutrition) Working Group on Acute Diarrhoea
initiated European multicentre survey covering main aspects of the management
of water and electrolyte losses and refeeding. Yugoslavia was one of 29
countries participating from Europe. The results showed that physicians often
advice oral rehydration solution – ORS (Yugoslavia 70%, others 84%), less frequently ORS with 60 mmol/L sodium
(Yugoslavia 62%, others 66%), and seldom practice fast rehydration over 3-4h
(Yugoslavia 15%, others 16%). Advice for
continued supplementation with ORS for watery stools after initial fast
rehydration varies among physicians (Yugoslavia 93%, others 37%).
Reintroduction of normal diet after fast rehydration is not in a frequent
practice (Yugoslavia 6%, others 21%). Contrary to ESPGHAN recommendations,
lactose-free or lactose-free cow's milk protein-free formula is recommend often
(Yugoslavia 51% and 24%, others 35% and
19%, respectively). However, breast-feeding is continued at high rate
(Yugoslavia 96%, others 77%).
Physicians
also advise antidiarrhoeal drugs (Yugoslavia 47%, others 25%), antibiotics and
probiotics (Yugoslavia 79.6% and 60%).
Key words:
acute gastroenteritis, treatment, infant, Yugoslavia.
SAŽETAK
Oralna rehidracija čini
osnovu terapije kod akutne dijareje u nerazvijenim i u razvijenim zemljama.
Radna grupa za akutnu dijareju Evropskog udruženja za dečiju gastroentrologiju,
hepatologiju i ishranu (ESPGHAN), pokrenula je multicentričnu evropsku studiju
za primenu prepopruka za nadoknadu vode i
elektrolita i realimentaciju nakon
inicijalne rehidracije, u kojoj je Jugoslavija bila jedna 29 zemalja učesnica
zapadne, centralne i istočne Evrope. Ispitivanje je pokazalo da lekari često
ordiniraju oralnu rehidracionu soluciju – ORS (Jugoslavija 70%, ostali 84%),
manje često ORS sa 60 mmol/L natrijuma (Jugoslavia 62%, ostali 66%), a retko
retko primenjuju brzu rehidraciju (Jugoslavija 15%, ostali 16%). Nastavljanje
nadoknade ORS pri perzistiranju tečnih stolica, posle početne rehidracije,
različito se praktikuje (Jugoslavija 93%, ostali 37%). Uvođenje normalne dijete
posle početne rehidracije primenjuje se retko (Jugoslavija 6%, ostali 21%).
Nasuprot ESPGHAN preporukama, preparati kravljeg mleka bez laktoze ili
preparati bez laktoze i belačevina kravljeg mleka često se daju (Jugoslavija
51%, odnosno 24%, ostali 35% odnosno 19%). Međutim, dojenje se nastavlja u
visokom procentu (Jugoslavija 96%, ostali 77%). Lekari takođe ordiniraju
antidijaroične lekove (Jugoslavija 47%, ostali 25%), antibiotike i probiotike
(Jugoslavija 79.6% i 60%).
Ključne reči: akutni gastroenteritis, lečenje, odojče, Jugoslavija..
INTRODUCTION
Gastroenteritis
in children is not only one of the leading causes of morbidity worldwide with
around billion episodes of illness, but also of mortality in developing
countries with 3-5 millions of deaths annually (1). In industrialized
countries, morbidity and mortality from acute diarrhoea are much lower, but
still significant. In Europe, they declined sharply over the last decades of
the past century - from mid ‘70 till mid ’80, death rates dropped by 20-25% (2,
3).
In early
’80, acute infectious diarrhoea, was the cause of infant death in of West
European countries within the range of
2.3 (Germany) to 72.9 (Portugal) per 100.000 (3). In the USA, a quarter
of a million of children, age less than 5 years, are admitted to hospital for acute
gastroenteritis, anually. The death rates from diarrhoea and dehydration are
between 300 and 500 each year (4, 5). Management of water and electrolyte
losses and refeeding is the mainstay of the therapy for diarrhoea. Oral
rehydration generally is the treatment of choice for mild to moderate
dehydration and also a major approach in preventing complications. Through the
activities of the World Health Organization (who)
and UN Children’s Fund, oral rehydration solution (ORS) dramatically reduced
mortality from diarrhoeal diseases and became a major weapon in child survival
programs. The latest estimated death rate from acute diarrhoea in children and
adults, for 1999, fell to 2.2 million annually, as a result of the use of oral rehydration solution (ORS) (6).
Working
group of the European Society for Paediatric Gastroenterology, Hepatology and
Nutrition (ESPGHAN) have issued two sets of recommendations on the treatment of
infants with acute gastroenteritis complicated by mild to moderate dehydration.
The first one, published in 1992 presented the guidelines for optimal
composition of ORS for the use in children of Europe (7). It recommended a
glucose based,
60 mmol/L sodium solution,
which is hypoosmolar, as more suitable than WHO 90 mmol/L solution designed for
treatment of children with cholera diarrhoea in developing countries (8). The
second one, published in 1997, as the report of ESPGHAN Working Group on Acute
Diarrhoea, recommended that the optimal management of mild to moderately dehydrated children in Europe should consist
of oral rehydration over 3-4h and rapid reintroduction of normal feeding
thereafter (9). Breast-feeding is to be continued if it is possible. Also, ORS
has been recommended after initial rehydration, for replacement of ongoing
abnormal losses of water and electrolytes. The Working Group concluded that the
use of lactose-free formulae does not appear to be justified in the vast
majority of children. Also in most cases the normal diet can be resumed without
restriction of lactose intake. However, if diarrhoea does worsen on the
reintroduction of milk, stool pH and/or reducing substances should be checked.
Lactose content should be reduced only if the stool is acid and contains >
0,5% reducing substances, suggesting lactose intolerance.
Although
recommendations on the use of antidiarrhoeal and antimicrobial drugs were not
published by the ESPGHAN, there is a general agreement among paediatric
gastroenterologists that pharmacological agents should not be used to treat
acute gastroenteritis, with only few exceptions (infection with certain
pathogenic microorganisms, patients with immune deficiency and some other,
specific clinical settings) (10). The
recommendations of the ESPGHAN Working Group are in accordance with the
recommendations issued by the WHO and American Academy of Pediatrics (AAP)
(7,911).
In
1992 an analysis was carried out in the USA to assess how their physicians
treat infants with acute gastroenteritis (12). It showed that very few primary
care physicians followed all aspects of the AAP treatment guidelines for
infants with acute diarrhoea complicated by mild to moderate dehydration.
In
1998, ESPGHAN Working group on acute diarrhoea initiated a similar study in 29
European countries (13). The purpose of this multicentre study was to determine
how closely, physicians treating infants with acute gastroenteritis,
complicated by mild to moderate dehydration, follow ESPGHAN recommendations,
regarding :
1.
type of ORS used (if any)
2. start of
oral rehydration (time from diarrhoea onset)
3. duration
of oral rehydration
4. timing
of refeeding
5. use of
cow’s milk (CM) protein-free and/or lactose-free formulas
6. use of
antidiarrhoeal drugs
7. use of
antimicrobial drugs
8. use of
other drugs
METHODS
The
study was based on questionnaire dealing with the management of hypothetical
6-month old infant with a 3-day history of mild to moderate diarrhoea, who was
5% dehydrated, had no fever or vomiting and was fed on cow's milk based
lactose-containing formula and solids. The child has not been breast-fed. By
all given information the parents of the infant were considered reliable. There
were no special indications for hospitalization of this child (13).
National
coordinators in 29 European countries - Austria, Belgium, Croatia, Cyprus,
Czech, Denmark, Estonia, Finland, France, Georgia, Greece, Hungary, Iceland,
Ireland, Israel, Italy, Latvia, Lithuania, Netherlands, Norway, Poland,
Portugal, Romania, Russia, Slovakia, Slovenia, Sweden, United Kingdom and
Yugoslavia, circulated the questionnaires to randomly selected primary care
physicians as well as hospital based registrars and paediatricians. A minimum
of 50 completed questionnaires were required from each country. The
national data obtained from the
questionnaires were collected and analyzed by the coordinators of the working
group (13).
The
study started on October 1, 1998 and was completed by March 31, 1999 (13).
All
data quoted in the tables and the text, extracted from the reference 13 for
easier comparison, represent a
percentage of total response rate of physicians (numbers outside parentheses).
Data within parentheses (percentage and actual numbers, concerning Yugoslavia
only), represent a percentage of the response rate to individual questions.
The
response rate in Yugoslavia, participating with 113/150 returned questionnaires
or 3.8% out of total returned from 29 European countries, was 75%. The number
of responding physicians varied among cities/towns: Beograd - 60, Herceg Novi -
7, Inđija - 4, Nova Pazova - 3, Novi Sad - 20, Podgorica - 6, Ruma - 5, Vladičin Han - 4, Vršac –
4.
The
majority of responding physicians, 70% (70.5% - 79/112) followed ESPGHAN
recommendations for the use of ORS. Table
1. The remaining physicians started rehydration with clear fluids such
as tea, Coca-Cola, fruit juice, chicken broth or home made ORS.
The
60 mmol/L sodium ORS was used by 56% (62.4% - 63/101) of physicians. Table 1.
ESPGHAN guidelines for the use of oral
rehydration over 3-4 h was strictly followed by only 14% (14.4% - 15/104)
of physicians, while majority (49.5% -
50/101) rehydrated their patients over
6-12 h. Not insignificant proportion of physicians - 24% (19.8% - 20/101), stated much longer
exclusive oral rehydration. Table 1.
Supplementary
ORS for replacement of ongoing losses from watery diarrhoea after initial
rehydration, as recommended by ESPGHAN, was followed by 56% (92.6% - 63/68) of
physicians. Table 1.
ESPGHAN
recommendation to reintroduce rapidly normal diet with solids after initial 3-4
h of oral rehydration was followed by only 12% (5.5% - 6/109), and contrary to
guidelines, after 12-24 h (21.1% - 23/109) and even as late as 48 h after fast
rehydration, by 36% (37.6% - 41/109) of physicians.
TABLE 2.
Lactose containing formula was adviced after successful
oral rehydration by 23% (24.3% - 26/107) of physicians. Contrary to ESPGHAN
guidelines, lactose free formula was prescribed by high 49% (51.4% - 55/107)
and lactose-free and CM protein-free formula by 23% (24.3% - 26/107). Table 2.
Only
19% (20.2% - 22/109) of physicians adviced refeeding with full strength formula
or cow's milk. TABLE 2. Others adviced diluted milk for 2 or 3 days (32.7% -
33/101 or 14.9% - 15/101). High 25% (12.9% - 13/101) of physicians, adviced it
for more than 3 days.
ESPGHAN
recommendation to continue breast-feeding was followed by 50% (96.4% - 107/111)
of responding physicians. TABBLE 2.
Antidiarrhoeal drugs were prescribed by 45% (46.8% -
51/109) of physicians. TABLE 3. Antibacterial drugs were prescribed often
(79.6% - 90/113). Probiotics were also prescribed often (60% - 39/65). Smectite
is prescribed by 7%, alone (12.3% – 8/65) or combined with probiotic (15.4% -
10/65). Homeopathic remedies were prescribed by 5% (3.1% - 2/65). TABLE 3. With
the exception of only few physicians, greatest majority did not report any use
of opiates, loperamide, chlorpromazine or bismuth subsalicylate.
Only
18% (18.2% - 20/110) of physicians, usually would not recommend antimicrobial
drugs in suggested situation.
DISCUSSION
The survey on the management of acute
gastroenteritis in Europe, like any other study based on mailed questionnaires,
was in the risk of poor response. However, in Yugoslavia, a good response rate
of 75% was achieved, better than in 15 WE, and in 10 CEE countries (13). The
response rate was better in only 2 CEE countries - Romania (100%) and Slovakia
(82%). The reason for low response rate could be either a mere unwillingness to
spend time responding in writing or reluctance of physicians to release information
on the compliance with ESPGHAN recommendations in their own practice. On the
other hand, high response rate, in Yugoslavia, Romania and Slovakia could be
the result of good contacts of national survey coordinators with local doctors.
The
cornerstone in the management of acute gastroenteritis - oral rehydration, is
applied in Europe on the whole, by majority of physicians (84%). However, in
Yugoslavia, recommendation for the use of ORS is followed by 70% of physicians
vs 79% in CEE and 88% in WE. The use of
ORS, as shown in this study, is the only ESPGHAN recommendation on the
management of acute gastroenteritis generally complied with. This is probably
the consequence of its unquestioned success, mirrored in a spectacular fall of
mortality from diarrhoea after the introduction of this therapy in developing
countries over the past fifteen years.
Considering
the results on the use of ORS with low sodium concentration Yugoslavia showed a
lower score (56%) than CEE (65%) and WE (67%) (13). However, when calculated as
a response rate to this particular question, and not on the number of responded
questionnaires, this score for Yugoslavia, increased to 62.4%, which is a true
result.
When
duration of exclusive oral rehydration over 3-4h; 3-6h and >12-24h is
analyzed, total response rate of yugoslav physicians are in better accordance
with their colleagues in WE than in CEE
The true result for Yugoslavia, calculated from the response rate to
this particular question, was only half that one calculated from the total
response rate of physicians (14.9% vs 31%). It appears that CEE physicians are
better followers of the recommendation for fast initial rehydration than
others. Still, overall practice of fast initial rehydration is far from
routinely practiced, and it is not possible to make any reasonably accurate
judgement in this regard about any country, unless the response rate to this
particular question was available.
The use of
ORS for continuing watery stools, advised by only 56% (92.6% - 63/68) of
doctors in Yugoslavia, 46% in CEE and 30% in WE
are a surprising result. However, it could be the consequence of applied
methodology, presenting all results as a percentage of total response rate of
physicians and not by the response rate to this particular question, which may
give significantly different picture of local practice, as it is obvious from
yugoslav data.
Eight
questions considering refeeding after acute gastroenteritis Revealed even
greater differences, not only between European countries, but particularly
compared with ESPGHAN recommendations. TABLE 2.
Early
refeeding with full strength formula, introduced immediately after fast initial
oral rehydration (<4h) is
practiced at a low rate Rapid
reintroduction of previously used normal diet, after initial oral rehydration,
was obviously practiced by a minority of interviewed physicians. In 8 European
countries (2 WE and 6 CEE), this practice was even less frequent than in
Yugoslavia which is sharing the position number 9 with Ireland, also showing 12%
rate, calculated from the total response rate of physicians (13 ). However, the true result for
Yugoslavia, calculated from the response rate to this particular question, was
half that rate (5.5%). The results of very late refeeding (>48h) showed that
in Yugoslavia, it is practiced more
frequently, than in CEE and in WE (13). It is obvious that more than 60% of
doctors in Europe practice refeeding of infants between a wide range of <4h and 48h. Additional
questions in the original questionnaire might have revealed true and detailed
practice of refeeding.
Recent
ESPGHAN recommendations, did not persuade clear majority of doctors in Europe
that they should not worry too much about secondary lactase intolerance, which
may occur in 1-4% of children with acute gastroenteritis (14, 15). This is best
mirrored in the answer of physicians on refeeding practice with
lactose-containing formula. TABLE 3. When advising lactose-free formula, the
rate in Yugoslavia was higher and CEE than in WE. Physicians in WE, with 30%
positive answers to this question showed, to some extent, a better practice
than their colleagues in CEE. When CM proteins are considered, there is still a
significant caution in the attitudes of physicians in relation to CM protein
intolerance. It is greater in CEE than in WE. Lactose-free and CM protein-free
formula is advised often in Yugoslavia and CEE and less often in WE. Full
strength formula is practiced more in WE (46%) than in other parts of Europe .
The practice of the use of lacose-free and lactose-free, CM proteins-free
formula in Yugoslavia, certainly was not infrequent and should be abolished,
except for selected cases.
Prolonged
refeeding with diluted formula (>72h) was rather high in Yugoslavia,
reaching twice the frequency of CEE and WE (13). This is the sequel of earlier
long standing practice of very restrictive diets during and after acute
gastroenteritis. But, the true result for Yugoslavia, calculated from the
response rate to this particular question was half (12.9%) the one calculated
from total response rate of physicians (25%).
The practice of continued breast-feeding during acute gastroenteritis, was reported as low 50% for Yugoslavia vs higher 75% in CEE and 78% in WE (13). This is contrary, to all published recommendations. However, the true result for Yugoslavia, calculated from the response rate to this particular question was excellent (96.4% - 107/111), and it revealed how false impresion could emerge when applying certain methodology, i.e. percentage based on total response rate of physicians and not by the response rate to this particular question. In other participating countries, this response rate could maybe represent the percentage of all breast-fed 6-months old infants physicians met in the every-day practice.
Nearly one half (47%) of responding physicians in Yugoslavia, reported prescribing antidiarrhoeal drugs, compared with lower rate in CEE and WE. In other 22 European countries, these medications were prescribed by 25% of physicians, and in 6 WEE countries were not at all prescribed. In 5 WEE and 1 CEE, antidiarrhoeal drugs were prescribed by less than 5% of physicians. The answer of physicians to the question whether they use antimicrobial drugs for patients of this age group stated "ALMOST NEVER" was low in Yugoslavia, acceptable in CEE and good in WE.
Since the significant number of physicians in Yugoslavia reported
prescribing probiotics (60% - 39/65) and 18% stated that almost never
prescribed antidiarrhoeal drugs, the assumption would be that a good prescribing
practice for acute gastroenteritis in infants run nearly 80%. But, taking into
account that the percentage of those who prescribed antibacterial drugs was
high (79.6% - 90/113), the conclusion would be that in a clear majority of cases antibacterial
drugs were prescribed together with probiotics, as could be judged by the
statement that 18% of them would almost never prescribe antidiarrhoeal
drugs.
Toxin adsorbing drug - dioctahedral
smectite, mostly held a high position in CEE. The only WE country where it was
prescribed often was France (44%) (13).
Homeopathic
drugs are very seldom prescribed in Yugoslavia, CEE and WE. Surprisingly maybe,
in Great Britain and in France, where homeopathy is well accepted and
practiced, these drugs are not advised (0%) for acute gastroenteritis in
infants (13). The suvey, interviewing parents would maybe reveal some different
data.
Methodology applied in this survey, in calculating results from total response rate of physicians, resulted in false conclusions about physician’s practice in Yugoslavia for: 3-6h exclusive rehydration with ORS, ORS supplementation for continuing losses, early refeeding, prolonged refeeding with diluted milk and continuation of breast-feeding in particular (13). The same might also be true for some other participating countries.
It is
obvious from the survey that a clear majority of responding physicians in
Yugoslavia and the rest of Europe do not comply with all ESPGHAN
recommendations on the management of acute diarrhoea (13). This survey also
imply that additional educational efforts are required in most european
countries, including Yugoslavia, in order to introduce fully all ESPGHAN
recommendations for the management of acute gastroenteritis in every-day
practice. The treatment of acute gastroenteritis and average, true attitudes of
physicians in Yugoslavia were not much different from those in the rest of
Europe, with few exceptions, some better, others worse, of which the concerning
one is a high prescribing rate of antimicrobial drugs.
CONCLUSIONS
1. The use of ORS as the treatment of choice for dehydration is
frequently, but still not sufficiently,
followed ESPGHAN recommendation.
2.
Continuation of breast feeding throughout the whole episode of acute diarrhoea
and ORS supplementation for continuing watery stools, are highly followed
ESPGHAN recommendations.
3. Fast
rehydration over 3-4 hours, with rapid reintroduction of normal feeding are
seldom practiced.
4. Very
high rate of prescribing antimicrobial drugs call for more re-education of
physicians.
5. Frequent
use of lactose-free formula, are in discordance with ESPGHAN recommendation.
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Table 1. The practice of oral rehydration in Yugoslavia (YU), Central and Eastern Europe (CEE) and Western Europe (WE).
Questions
|
YU
|
CEE |
WE |
WE+ CEE |
|
1. Rehydration with ORS |
70% (70.5%-79/112) |
79% |
88% |
84% |
|
2. Use of 60 mmol sodium ORS |
56% (62.4%-63/101) |
65% |
67% |
66% |
|
3. 3-4h exclusive rehydration with ORS |
14% (14.9%-15/101) |
19% |
15% |
16% |
|
4. 3-6h exclusive rehydration with ORS |
31% (14.4%-15/101) |
60% |
35% |
45% |
|
5. >12-24h exclusive rehydration with ORS |
24% (19.8%-20/101) |
9% |
23% |
17% |
|
6. ORS for continuing watery stools |
56% (92.6%-63/68) |
46% |
30% |
37% |
( ) response rate to individual question
Questions
|
YU |
CEE |
WE |
WE+ CEE |
|
1. Early refeeding (<4h) |
12% (5.5%-6/109) |
19% |
22% |
21% |
|
2. Late refeeding (>48h) |
36% (37.6%-41/109) |
26% |
17% |
21% |
|
3. Refeeding with lactose-containing formula |
23% (24.3%-26/107) |
23% |
45% |
36% |
|
4. Refeeding with lactose-free formula |
49% (51.4%-55/107) |
42% |
30% |
35% |
|
5. Refeeding with lactose-free and CM protein-free formula |
23% (24.3%-26/107) |
28% |
12% |
19% |
|
6. Refeeding with full strength formula |
19% (20.2%-22/109) |
38% |
46% |
43% |
|
7. Prolonged refeeding (>72h) with diluted formula |
25% (12.9%-13/101) |
14% |
12% |
12% |
|
8. Continuation of breast-feeding |
50% (96.4%-107/111) |
75% |
78% |
77% |
Questions
|
YU |
CEE |
WE |
WE+ CEE |
|
1. Use of antidiarrhoeal drugs |
45% (46.8%-51/109) |
33% |
19% |
25% |
|
2. Use of smectite |
7% (12.3%-8/65) |
41% |
9% |
22% |
|
3. Use of homeopathic remedies |
5% (3.1%-2/65) |
5% |
1% |
3% |
|
4. Almost no use of antimicrobial drugs |
18% (18.2%-20/110) |
32% |
72% |
56% |