Management of acute gastroenteritis in healthy children in Lebanon - A national survey.

BACKGROUND: Acute gastroenteritis remains a common condition among infants and children throughout the world. In 1996, The American Academy of Pediatrics (AAP) revised its recommendations for the treatment of infants and children with acute gastroenteritis. AIM: The purpose of this survey was to determine how closely current treatment among Lebanese pediatricians compares with the AAP recommendations and to determine the impact of such management on the healthcare system. PATIENTS AND METHODS: The outline of the study was based on a telephone questionnaire that addressed the management of healthy infants and children below five years of age with acute gastroenteritis complicated by mild to moderate dehydration. In addition, the costs of medical treatment and requested laboratory studies were calculated.
RESULTS: A total of 238 pediatricians completed the questionnaire. Most pediatricians prescribed Oral Rehydration Solutions (ORS) for rehydration (92.4%), advised breastfeeding during acute gastroenteritis (81.5%), and avoided parenteral rehydration for mild to moderate dehydration (89.1%). In addition to ORS, oral fluids such as soda, juices, and rice water were allowed for rehydration by 43.7% of pediatricians. Thirty-one percent of pediatricians delayed re-feeding for more than 6 hours after initiation of rehydration. Only 32.8% of pediatricians kept their patients on regular full-strength formulas, and only 21.8% permitted full-calorie meals for their patients. 75.4% of pediatricians did not order any laboratory studies in cases of mild dehydration and 50.4% did not order any laboratory studies for moderate dehydration. Stool analysis and culture were ordered by almost half of the pediatricians surveyed. Seventy-seven percent prescribed anti-emetics, 61% prescribed probiotics, 26.3% prescribed antibiotics systematically and local antiseptic agents, 16.9% prescribed zinc supplements, and 11% percent prescribed antidiarrheal agents.
CONCLUSION: Pediatricians in Lebanon are aware of the importance of ORS and the positive role of breastfeeding in acute gastroenteritis. However, they do not follow optimal recommendations from the AAP concerning nutrition, laboratory examinations and drug prescriptions. Consequently, this poses significant financial losses and economic burden.

Introduction

Acute gastroenteritis is a common and costly clinical condition in children. Over the past two decades, pediatric acute gastroenteritis has been the subject of considerable worldwide attention. In the past, a number of laboratory studies were used to evaluate children with acute vomiting and/or diarrhea. Since oral rehydration therapy has become the preferred method of treating dehydration, routine laboratory testing is no longer necessary. However, it may be beneficial for individual patients, when oral replacement therapy was unsuccessful or for patients who are receiving parenteral hydration[1]. Treatment of acute gastroenteritis is primarily directed toward preventing or treating dehydration. When possible, age-appropriate diet and fluids should be continued[2]. Breastfeeding should not be discontinued, even during the rehydration phase. Diet should be increased as soon as it is tolerated to compensate for lost caloric intake during acute illness. Lactose restriction is usually not necessary, although it might be helpful in cases of chronic malnutrition or in children with severe enteropathy; changes in formula are usually unnecessary. Full-strength formula is typically well tolerated and allows for a more rapid return to full energy intake[3]. Antiemetic and antidiarrheal medications are generally not indicated and may contribute to complications. However, the use of antibiotics remains controversial[1].

Despite the growing body of evidence supporting the safety and efficacy of oral rehydration solutions, they remain underutilized, and the management of gastroenteritis continues to vary considerably. Common management errors include using oral rehydration solutions in children with little or no dehydration, administering intravenous rehydration therapy to children with only moderate dehydration and inappropriately withholding oral rehydration solutions or other feeding in children with vomiting[4]. For this reason, the American Academy of Pediatrics revised its recommendations concerning the treatment of acute gastroenteritis in healthy children. Therefore, the aim of our study was to determine how closely current treatment of acute gastroenteritis in children among Lebanese pediatricians compared with the AAP recommendations and to observe the impact of such management on healthcare costs.

Patients and Methods

Prior to the survey, the Institutional Review Board (IRB) committee of the Makassed General Hospital in Beirut granted ethical approval. We then conducted a telephone-based, anonymous questionnaire survey of Lebanese pediatricians concerning the management of acute gastroenteritis in healthy children between 1 month and 5 years in age with mild or moderate dehydration. Lebanese pediatricians who were registered in the Lebanese Order of Physician were included in our survey. We divided the 22-item questionnaire into two sections (Appendix 1). In the first section, we asked the pediatricians to provide their year and country of graduation as a pediatrician, and the region and type of practice (teaching hospital, community hospital, ambulatory and private practice, or a combination). The second section included 18 questions about the management of acute gastroenteritis in healthy children aged less than five years with mild or moderate dehydration. For each of these 18 questions, a score of zero was given for answers that did not concur with AAP recommendations and a 1 for answers that were compatible with the recommendations. The highest score was 18. We calculated the score for each pediatrician and then compared scores according to the year, country of graduation of the pediatrician, the region and the type of practice (Table 1). The cost of laboratory investigations requested by the pediatricians including complete blood count and differential (CBCD), serum electrolytes, stool analysis and culture was calculated. In addition, the cost of medical treatment (intravenous line or nasogastric tube insertion for hydration, oral fluids administration, special formula, antimotility agents, antiemetics, antibiotics, zinc supplements, probiotics and antiseptics) was calculated (Table 2). Table 3 shows the average cost of laboratory parameters and medical treatments.

Appendix 1

Management of acute gastroenteritis in healthy children aged 1 month - 5 years with mild to moderate dehydration - A national survey

Table 1

Demographic data of pediatricians and their mean scores of practice.

Table 2

Estimated costs of the most commonly prescribed medications and laboratory investigations in acute gastroenteritis.

Table 3

Mean Cost of Treatment of Acute Gastroenteritis in Children with Acute Gastroenteritis with Mild to Moderate Dehydration.

Statistical Analysis

Data were collected and statistically evaluated with the analysis of variance test using the SPSS version 16 statistical software package.

Results

A total of 863 pediatricians were registered in the 2010 logbook of the Lebanese Order of Physicians. From this logbook, 440 pediatricians were randomly chosen by the computer and contacted for the survey. However, only 238 pediatricians answered our questionnaire (27.6%). Therefore, data from the participating 238 pediatricians were analyzed.

The majority of the pediatricians surveyed graduated in the 1990s (39.5%) and 2000s (37%). Among them, 38.7% graduated from Lebanese university hospitals, 24% from West Europe excluding France, 22% from France and 11% from East Europe. Fifty-four pediatricians (22.7%) worked in teaching hospitals, while 40 practiced in private clinics (16.8%). Of the 238 pediatricians, 152 were employed in urban areas and major cities while 82 pediatricians worked in rural areas (64.7% versus 35.3%, respectively). The highest score among surveyed pediatricians was 17/18 and the lowest was 6/18. Table 1 summarizes the mean score in the different groups of pediatricians and Figure 1 shows the percentages of irrational medical acts.

Fig. 1

Percentages of irrational medical acts.

(a) Oral fluids besides ORS including juices, soda, rice water, mineral water, (b) Intravenous hydration, (c) Nasogastric hydration, and (d) Laboratory studies for mild and moderate dehydration include complete blood count and differential in addition to serum sodium, potassium, chloride and bicarbonate.

Concerning rehydration, oral rehydration solutions (ORS) were prescribed alone by 49% of pediatricians and in combination with other fluids such as juice, soda, water and/or rice water by 43%. Among all pediatricians surveyed, 89% avoided parenteral hydration for mild and moderate dehydration as compared to all of the pediatricians who worked in teaching hospitals. Sixty-nine percent of pediatricians resumed early feeding as recommended by the AAP; 33% of teaching hospital practitioners did not follow this practice, while the practitioners who worked in rural areas tended to allow early feeding more often (73.8%). Eighteen percent of pediatricians still discontinued breastfeeding during acute gastroenteritis, with higher rates among community hospitals practitioners (20.8%). Seventy-eight of the 238 pediatricians (32.8%) continued human or regular-strength formula; while 52.8% prescribed lactose-free formula, 13.4% a diluted one, and 1% a hydrolyzed formula.

Laboratory studies for mild dehydration, including CBCD, and serum electrolytes, were requested by 24.6% of pediatricians; whereas these studies were ordered by 49.6% in patients with moderate dehydration. Fifty-eight percent of pediatricians requested microscopic stool analysis and fifty percent ordered a stool culture.

Eleven percent of Lebanese pediatricians prescribed antimotility medications. On the other hand, 77% of pediatricians prescribed antiemetic agents. In regard to antibiotic prescription, more than 26% of pediatricians preferred to treat acute gastroenteritis with antimicrobial agents. The rate of antibiotic use was higher in pediatricians working in rural areas or in an ambulatory setting(45.2% versus 40% respectively). Zinc supplements were prescribed by 16.8% of pediatricians and probiotics by 60%.

The estimated mean cost of irrational management was 63,872 Lebanese Pound (L.P.), which was equal to USD 42.58, for each patient. Table 3 summarizes the mean cost of treatment in relation to the different groups of pediatricians.

Discussion

The results of our questionnaire revealed that two thirds of the pediatricians in Lebanon usually followed the AAP recommendations with a mean score of 11/18. Pediatricians who graduated in the last two decades and those working in teaching hospitals and/or in urban areas were more likely to adhere to the AAP guidelines than the other groups. A similar study done in Israel in 1998 showed that 60% of pediatricians followed these guidelines[6].

Oral rehydration therapy using a commercial pediatric oral rehydration solution was the preferred approach to mild or moderate dehydration and was accepted as the standard of care for the clinically efficacious and cost-effective management of acute gastroenteritis[2]. The French survey of pediatricians in 2004 showed that 63% allowed rehydration using ORS as compared to 16% of pediatricians in a multi-center European study conducted in 2000, 87% of Israeli pediatricians in 1998, and 30% of US pediatricians in 1991[6-9]. In our survey, 92% of Lebanese pediatricians recommended ORS at the beginning of treatment for rehydration. The results were similar to those obtained in 2001 that involved Hungarian pediatricians[10]. However, almost half of the pediatricians in our survey used ORS in combination with other oral fluids such as soda, juices, mineral water or rice water. This practice, by far, tended to increase the severity of diarrheal illness by increasing the intraluminal osmolarity of the intestines when using soda or juices and, therefore, exacerbating the course of the disease. Conversely, mineral and rice water do not contain the sufficient amount of electrolytes required to compensate their fecal losses.

Breastfeeding should be continued at all times, even during the initial rehydration phase in children with acute gastroenteritis[3]. In our survey, 82% of pediatricians continued breastfeeding compared to 84% in the Hungarian and 77% in the European surveys, respectively[810].The AAP recommended continuing a non-restrictive diet promptly after an episode of gastroenteritis in children to compensate for lost caloric intake during acute illness[2]. It was unfavorable that three quarters of the pediatricians in our survey prescribed an antidiarrheal diet and one third delayed the introduction of feeding until 24 hours after the oral rehydration. Noted that this practice remains frequent worldwide; 66% of French pediatricians prescribed a dietary regimen and only 10% of Hungarian pediatricians suggested early reintroduction of normal feeding after oral rehydration[710]. Lactose-free or lactose-reduced formulas usually are unnecessary. A meta-analysis of clinical trials indicated no advantage of lactose-free formulas over lactose-containing formulas for the majority of infants, although certain infants with malnutrition or severe dehydration recovered more quickly when given lactose-free formulas[11]. In our survey, more than 32% of pediatricians used a lactose-containing formula after successful rehydration. This result was comparable to that of a European survey[8]. Although medical practice has often favored beginning feeding with diluted (e.g. half or quarter-strength) formula, controlled clinical trials have demonstrated that this practice is unnecessary and is associated with prolonged symptoms and delayed nutritional recovery[1213]. However, 13.4% of Lebanese pediatricians still preferred to dilute the formula.

Supplementary laboratory studies, including serum electrolytes to assess patients with acute diarrhea usually are unnecessary[1415]. Stool cultures are indicated in cases of dysentery but are not usually indicated in acute watery diarrhea for the immune-competent patient[3]. However, certain laboratory studies might be important when the underlying diagnosis is unclear or when diagnoses other than acute gastroenteritis are possible. Laboratory studies such as CBCD and serum electrolytes were largely requested by pediatricians in our survey. More than half of pediatricians working in rural areas tended to request stool analysis and culture; this may be due to the higher prevalence of parasitic and/or bacterial gastrointestinal infections in these areas.

Since viruses are the predominant cause of acute gastroenteritis in developed countries[16], the routine use of antibiotics may lead to increased antimicrobial resistance. Even when a bacterial cause is suspected in an outpatient setting, antimicrobial treatment usually should not be initiated because the majority of cases are self-limited. An exception may be for immune-compromised children and those with an underlying disease[3]. However, the pediatricians worldwide variably prescribed antimicrobials. Two percent of pediatricians in Bahrain prescribed an antibiotic for patients with acute gastroenteritis[17] as compared to 81% in a French population after performing a stool culture[7]. In our survey, more than 26% of pediatricians considered acute gastroenteritis in our country to be parasitic or bacterial in origin and, therefore, prescribed antibiotics systematically as a part of treatment. In addition, pediatricians working in rural areas tended to prescribe antibiotics more often. Nonspecific antidiarrheal agents (e.g. adsorbents such as kaolin-pectin), antimotility agents (e.g. loperamide), antisecretory drugs, and toxin binders (e.g. cholestyramine) are commonly used among older children and adults, however, data are limited regarding their efficacy. Side effects of these drugs are well-known, in particular among the antimotility agents, including opiate-induced ileus, drowsiness, and nausea caused by the atropine effects and binding of nutrients and other drugs[3]. Almost all French pediatricians prescribed at least one drug in managing children with acute gastroenteritis[7]. In our survey, antiemetics were the most commonly used medication by three-quarters of pediatricians, followed by probiotics, which were prescribed by 60% of pediatricians. Their efficacy has not been proven in the literature.

To our knowledge, this is the first survey that evaluated the impact of management of patients with acute gastroenteritis on the healthcare system. The costs resulting from irrational management of acute gastroenteritis in our survey was surprisingly elevated for each patient. Therefore, this might contribute to the increased financial burden on the healthcare system.

Conclusion

The results from our survey suggested that, with the exception of recommending ORS for rehydration and continuation of breastfeeding during acute diarrhea, only a minority of pediatricians followed AAP recommendations for optimal management of acute gastroenteritis. Consequently, significant financial losses and economic burden may ensue. These findings suggested that effective healthcare policies are needed to implement the recommendations and to reduce the unnecessary medical costs on the healthcare system in our country.