Interventions to reduce post-acute consequences of diarrheal disease in children: a systematic review

Abstract

BackgroundAlthough acute diarrhea often leads to acute dehydration and electrolyte imbalance, children with diarrhea also suffer long term morbidity, including recurrent or prolonged diarrhea, loss of weight, and linear growth faltering. They are also at increased risk of post-acute mortality. The objective of this systematic review was to identify interventions that address these longer term consequences of diarrhea.MethodsWe searched Medline for randomized controlled trials (RCTs) of interventions conducted in low- and middle-income countries, published between 1980 and 2016 that included children under 15 years of age with diarrhea and follow-up of at least 7 days. Effect measures were summarized by intervention. PRISMA guidelines were followed.ResultsAmong 314 otherwise eligible RCTs, 65% were excluded because follow-up did not extend beyond 7 days. Forty-six trials were included, the majority of which (59%) were conducted in Southeast Asia (41% in Bangladesh alone). Most studies were small, 76% included less than 200 participants. Interventions included: therapeutic zinc alone (28.3%) or in combination with vitamin A (4.3%), high protein diets (19.6%), probiotics (10.9%), lactose free diets (10.9%), oral rehydration solution (ORS) formulations (8.7%), dietary supplements (6.5%), other dietary interventions (6.5%), and antimicrobials (4.3%). Prolonged or recurrent diarrhea was the most commonly reported outcome, and was assessed in ORS, probiotic, vitamin A, and zinc trials with no consistent benefit observed. Seven trials evaluated mortality, with follow-up times ranging from 8 days to 2 years. Only a single trial found a mortality benefit (therapeutic zinc). There were mixed results for dietary interventions affecting growth and diarrhea outcomes in the post-acute period.ConclusionDespite the significant post-acute mortality and morbidity associated with diarrheal episodes, there is sparse evidence evaluating the effects of interventions to decrease these sequelae. Adequately powered trials with extended follow-up are needed to identify effective interventions to prevent post-acute diarrhea outcomes.Electronic supplementary materialThe online version of this article (10.1186/s12889-018-5092-7) contains supplementary material, which is available to authorized users.

Derivation and external validation of clinical prediction rules identifying children at risk of linear growth faltering

“…While effective interventions exist for treating acute malnutrition (e.g., exclusive breastfeeding for the first 6 months of life, inpatient- and community-based management of acute malnutrition using corn-soy blend or ready-to-use therapeutic food; WHO, 2013 ; Bergeron and Castleman, 2012 ; Keats et al, 2021 ), there are few evidence-based guidance on how to reverse the effects of chronic malnutrition once a child is stunted ( Bergeron and Castleman, 2012 ; Leroy et al, 2015 ; Reinhardt and Fanzo, 2014 ; Pavlinac et al, 2018 ; WHO, 2015 ). We found that approximately one in five children experience severe growth faltering subsequent to acute diarrhea, that is, an additional ≥0.5 decrease in HAZ in the 2–3 months after acute diarrhea.…”

Factors Associated With Child Stunting, Wasting, and Underweight in 35 Low- and Middle-Income Countries

“…Inconsistent findings on the association of oral rehydration therapy for diarrhea with outcomes may be because of the differential prevalence of children very close to the anthropometric failure cutoffs given that only they would be substantially affected by the occurrence of diarrhea and oral rehydration treatment. 49,50 The heterogeneous association between sanitation facility and child undernutrition may be attributed to differences in complementarity of toilet maintenance, including other water and hygiene practices. 51,52 Limitations There are several limitations to this study.…”

Determinants of linear growth faltering among children with moderate-to-severe diarrhea in the Global Enteric Multicenter Study

“…However, it is unclear which groups of children are at highest risk. In addition, few interventions have been successful at mitigating the nutritional consequences of diarrhea [10]. Identifying risk factors for post-MSD linear growth faltering can inform which groups of children should be prioritized for inclusion in trials of potential interventions, and, once an effective intervention has been identified, to optimize the effectiveness of intervention delivery within programs by targeting children at high risk of growth faltering.…”