Study on incidences of electrolyte disorders among children with dehydration

Background: Electrolyte abnormalities are common in children with diarrhoea. It may remain unrecognized and result in mortality and morbidity. Timely recognition, a high index of suspicion and thorough understanding of common electrolyte abnormalities is necessary to ensure their correction. The present work was undertaken to determine the incidence and clinical importance of Hypokalemia, hypernatraemia, Hyponatremia and Hypernatremia in children with acute diarrheal diseases with dehydration. Method: The present prospective study was conducted at Department of Paediatrics, GSL Medical College & General Hospital, Rajahmundry from 2015 to 2017.Consecutive Patients attending OPD and inpatients in view of acute diarrhea between 1month and 5years of age were included in the study. A detailed history from the patients with acute gastroenteritis of age 1 month to 5 years was taken. Result: The incidence of Acute diarrhoea was greater in males (54.6%%) compared to females (45.4%). Severe Dehydration was present in 39.1% cases and some dehydration was present in 60.8% cases. Hyponatremic dehydration was present in 33% cases, Isonatremic dehydration in 59.8% and hypernatremic dehydration in 7.2% cases. Mean sodium levels being 134.97 mmol/l. Hypokalemia was present in 44.3% cases, normal levels in 51.6% and Hyperkalemia in 4.2% cases. Mean potassium levels being 3.62 mmol/l. Conclusion: Like any other electrolyte abnormalities, which occurs in conditions other than diarhoea, are basically asymptomatic & does not require aggressive correction of electrolytes. They do very well with ORS & fluid correction as recommended by W.H.O.


Introduction
Almost 1.731 billion episodes of diarrhoea occurred in 2010 in children younger than 5 yr. of age in developing countries, with more than 80% of the episodes occurring in Africa and South Asia (50.5% and 32.5%, respectively) and 36 million of the total episodes progress to severe episodes [1].
Global mortality may be declining rapidly, but the overall incidence of diarrhoea has only declined from 3.4 to approximately 2.9 episodes per child-year in the past 2 decades, and it is estimated to account for 23 million childhood disability-adjusted life year [1]. Of India's more than 2.3 million annual deaths among children, about 334 000 are attributable to diarrhoeal diseases [2].
In India, acute diarrhoeal disease accounts for about 8% of deaths in under-5 years age group. During the year 2014, about 11.6 million cases with 1,323 deaths were reported in India [3]. The high incidence of diarrhoeal diseases in developing countries is related to undernutrition, increased vulnerability to infections, poor education, socio-economic status and the unfortunate trend of early breast milk substitutes. Decreasing trend of exclusive breast feeding and faulty practices of bottle-feeding plays an important role. The main cause of death in acute diarrhoea is dehydration, which results from the loss of fluid and electrolytes in diarrheal stools.
The clinical manifestations of acute diarrhoea are related to the severity of water deficit and the type of electrolyte disturbances. Often laboratory facilities are not available or, even if available; there is a A study conducted in 2010 in Dhaka Shishu hospital showed that electrolyte disturbances in Acute Gastroenteritis was associated with increased morbidity, with hyponatremic dehy-dration in 15% cases [4].
A study by Molat et al. showed that increasing severity of hypernatremia leads to increase in mortality rate and is associated with significant difference in Denver Developmental Screening II test results [5].
Electrolyte abnormalities are common in children with diarrhoea. It mayremain unrecognized and result in mortality and morbidity. Timely recognition, a high index of suspicion and thorough understanding of common electrolyte abnormalities is necessary to ensure their correction.
Different studies have shown different incidences of electrolyte disorders among children with dehydration. The present work was undertaken to study the common electrolyte abnormalities in diarrhoea and its impact on the mortality.

Objectives:
To determine the incidence and clinical importance of Hypokalemia, hypernatraemia, Hyponatremia and Hypernatremia in children with acute diarrheal diseases with dehydration.

Method of collection:
A detailed history from the patients with acute gastroenteritis of age 1 month to 5 years was taken. The procedure of the study was explained & required consent for the study was taken.
Detailed clinical examination was done to look for thirsty, irritability, pinched look, sunken eyes, dry inner side of cheeks, abdominal distention, deep and rapid breathing, weak and thready pulse, falling blood pressure, reduced quantity of urine according to WHO dehydration assessment scale.

Basal Hematological and Biochemical investigations
were done in all patients, including hemoglobin, total and differential white cell counts, platelets & peripheral smear examination 2. Basal blood urea nitrogen and basal random blood sugar was done in all patients.
Statistical analysis: Descriptive statistics such as mean, SD and percentage was used to present the data. Data was analysed by using software SPSS v20.0. Microsoft excel was used to construct tables and graphs.
In the present study, the incidence of hyponatermic dehydration is almost all similar in both age groups (in< 1 year and 3-5 years). M M Okposio et.al study shows correlation with present study, Dehydration was hyponatraemic in 112 (60.5%) children, hypernatraemic in 8 (4.3%) and isonatraemic in 65 (35.1%) [6].
Pizzoti et al [18] study, found hyponatremia 34% of admitted patients and 5.7% in Habibullah Barbar et.al study [8]. Isolated hypernatremia was 2.9%, in a study of Jenkins and Ansari study found it <1% of their cases [19]. It is because of most fluid in diarrhoea lost with a lower sodium concentration.
The incidence of hypernatremia was 15.7% in a study by Subba Gangaraj et al. [20], Shah GS et al study showed that, major electrolyte disturbances noted were hyponatremia (56%), which was either isolated (26%) or associated with hypokalemia (26%) and about 10% patient had hypernatremia [11] The study by Shah et al showed that 56% of cases admitted with diarrhea and dehydration had hyponatremia, while hypernatremia was present in 10% cases [11].
A clinical and biochemical study by K. R. Purohit  However, statistically significant mortality was observed in patients presenting with either hyponatremia or hypokalemia as compared to the group with normal electrolytes.

Limitation:
The present study was based on a small sample size. A larger study group is recommended to come to a very definite conclusion.

Conclusion
Hypokalemia is the most common electrolyte abnormality noted, followed by hyponatremia. What the present study adds to existing knowledge?
Literature on the incidences of electrolyte disorders among children with dehydration has shown different incidences rates which make a meaningful adding in existing literature by conducting the present study in the present study area to timely recognition and understanding of common electrolyte abnormalities.