In this study, only one in six of the children (15.9%) who visited the study hospitals received appropriate diarrhea management. This is a bothersome practice that underscores the critical need for prescribers to adhere to the recommended WHO protocols. This finding is lower than results from studies conducted in Ethiopia (Hawassa City (43.3%) [18], Addis Ababa (45.6%) [17], and Oromia region (79%) [19]), Bangladesh (27%) [20] and Italy (20.6%) [21]. The variation in results could be due to differences in study design, study area and the criteria used to assess the appropriateness of diarrhea management.
In a significant number of children, diarrhea was inappropriately classified (with stool characteristics not documented and the duration of diarrhea unspecified), inconsistently diagnosed, and inadequately assessed. These shortcomings in assessment, classification, and diagnosis can lead to treatments that do not adequately address underlying issues, resulting in inappropriate diarrhea management. Such deficiencies highlight challenges in adhering to established guidelines and maintaining comprehensive clinical documentation. To address these issues, it is essential to enhance healthcare professionals’ adherence to protocols through improved awareness programs and to ensure meticulous documentation practices.
One in five caregivers of the children with diarrhea received counseling on diarrhea management, which contradicts WHO guidelines. The WHO recommends counseling on providing extra fluids, continuing feeding, and scheduling follow-up appointments (particularly for children with dysentery and other danger signs) as integral component of diarrhea management [9]. This finding is inconsistent with studies from Hawassa city, Ethiopia, where most mothers (96%) were advised to provide ORS [18] and Addis Ababa where over half caretakers received advice on extra fluids and continued feeding, and immediate return if the child was unable to drink/breastfeed or if the child’s condition worsened [17]. To further improve counseling practices, targeted awareness-raising programs for prescribers should be enhanced.
ORS was prescribed to 84.7% of the children with diarrhea in this study. However, ORS was not prescribed for 12.3% of children who needed it, and its use was incorrect in one case. WHO guidelines endorse ORS therapy as the gold standard for clinically efficacious and cost-effective management of diarrhea. Unless a patient is comatose or severely dehydrated, ORS is recommended regardless of the causative agent or patient age as it is less expensive, often equally effective, and more practical than intravenous fluid [13, 14]. The prescription of ORS in the current study is higher than reported in Iraq (15%) [22], Addis Ababa, Ethiopia (66.7%) [17], Northern Tanzania (68.4%) [22], Ujjain, India (80%) [12], and a multicenter study in Indian hospitals (82%) [23]. However, it lower than studies conducted in Lebanon (92.4%) [24], Bahrain (89.3%) [13], India (86.9%) [25], and Kenya (90%) [26].
In this study, all but four children with severe dehydration received intravenous fluids, consistent with WHO recommendations and a study conducted in South Sudan [27]. The main problem identified was that the unnecessary and improperly scheduled of use of intravenous fluids in children with all forms of dehydration. While the selection of intravenous fluids for children with some dehydration was appropriate, their administration protocol did not align with WHO guidelines. Furthermore, there was an excessive and unnecessary use of intravenous fluids in children who could have been effectively managed with ORS, contributing to inappropriate diarrhea management.
The prescription rate of zinc supplementation in this study was found to be 48.3%, which contradicts WHO recommendations. According to the WHO guideline and supported by a meta-analysis of 17 randomized controlled trials of zinc supplementation and other recent systematic reviews, zinc supplementation for children under-five reduces the duration and severity of diarrheal episodes and lowers the incidence of diarrhea in the subsequent 2–3 months. Therefore, all children with diarrhea should receive zinc supplements as early as possible after diarrhea has started as part of first-line treatment [9, 28,29,30]. The current study’s finding is higher than studies conducted in Ethiopia (45.3%) [18] and (43.7%) [17], India (38.7%) [31], Tanzania 28% [32] Iraq (1.25%) [22] and Uganda (0%) [33].
Additionally, in the current study, the dose, route, frequency, and duration of antibiotics, zinc, and other medicines were often incorrect and/or undocumented in a substantial number of children. The low prescription rate of zinc and incorrect prescriptions in this study may indicate that prescribers’ low awareness on its importance or inadequate documentation of treatments, necessitating intervention from the policy makers and program managers.
Notably, there was no documented use of anti-diarrheal and anti-emetic medicines in this study which is in line with the WHO recommendations. These medicines are not recommended for management of acute diarrhea as they can reduce intestinal motility, prolong the disease course, extend pathogen contact with the intestinal mucosa, and potentially worsen systemic symptoms [34]. Such medicines offer no benefit in diarrhea management and may pose serious, even life-threatening side effects in children. This finding differs from a study in Iraq where anti-diarrheal and anti-emetics medicines were used in 12.8% and 33.2% of the cases, respectively [32]. Similar studies reported prescription rates for anti-diarrheal and anti-emetics in diarrhea management as 0% and 7% [17], and 0% and 3.4% [18], respectively.
The presence of vomiting, some dehydration, and prescriber qualification were identified as determinants of appropriate diarrhea management. This finding contrasts with studies conducted in Ethiopia, where diarrhea management appropriateness was significantly associated with children’s age and stool characteristics [17, 18].
The odds of treating diarrhea cases according to guidelines were about four times higher among the medical intern than among GPs. This finding, however, requires careful interpretation. One plausible explanation is that medical interns, operating under the close supervision of senior pediatric physicians, are held to a higher standard of meticulous documentation. This structured environment ensures that all aspects of guideline adherence are meticulously recorded, which may not always be the case for GPs facing high patient volumes and time constraints in a less supervised setting. Consequently, the observed difference may, in part, reflect a disparity in documentation practices rather than a fundamental difference in clinical competence. This is supported by the non-significant findings for “correct dose/route/frequency/duration of treatment” and “correct antibiotic prescription”. Conversely, degree nurse prescribers were 68% less likely to adhere to guidelines for appropriate diarrhea management compared to GPs, which could be due to differences in knowledge among the prescribers.
The study has several limitations that warrant caution when interpreting its findings. As the results were derived from a secondary data, patient medical records may have been incomplete or contained unreadable information, potentially leading to an underestimation or overestimation of certain findings. Specifically, most diagnoses and conclusions regarding signs of infection were based solely on physician documentation rather than objective interpretation, which could introduce bias. Furthermore, the lack of documentation for any criteria used in the assessment of appropriateness was considered to indicate inappropriate diarrhea management. This methodological approach may have resulted in an overestimation of inadequate diarrhea management, even in cases where treatment was performed correctly. Furthermore, data on the outcomes of diarrhea management were not collected. The findings of this study may also lack generalizability to the entire country, as it was conducted only in national and regional referral hospitals. Therefore, the authors recommend broader future studies that include lower health facilities, utilize primary sources, and employ qualitative methods, to gain a more comprehensive understanding of the subject, including outcomes in diarrheal cases.
Conclusions and recommendations
Inappropriate diarrhea management was prevalent among children under five years of age. Key determinants of management appropriateness included the presence of vomiting, dehydration status, and prescriber qualifications. Identified issues included inadequate documentation, lack of proper counseling, underutilization of zinc supplementation, and excessive use of intravenous fluids., It is crucial to strengthen awareness programs for healthcare professionals and ensure strict adherence to guidelines and protocols by relevant authorities to improve diarrhea management in this age group.
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