Parasitic etiology of childhood diarrhea
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《美国医学杂志》
1 Wesley Guild Hospital, Ilesa, Nigeria
2 Havana Specialist Hospital, Lagos, Nigeria
The objective was to determine the prevalence of parasitic agents among under-five children with diarrhea in Ilesa, Nigeria and the clinical correlates of diarrhea associated with parasitic infestation. All under-five children presenting with diarrhea in the hospital had stool microscopic examination. Children with parasites in diarrheic stools (cases) were compared with those without (controls) for clinical features. Out of 300 under-five children with diarrhea, 70 (23.3%) had parasites. There were 18 (6%) helminthes and 52 (17.3%) protozoas. These included the' ova of Ascaris lumbricoides (13; 18.6%), cysts and trophozoites of Entamoeba. histolytica (46; 65.7%), cysts of Entamoeba coli (1; 1.4%), Giardia Lamblia (5; 7.1%), Necator american us (1; 1.4%) and Trichuris trichiuria (4; 5.7%). As against the controls, the cases were older (t = 4.88; p = 0:0000017), more undernourished (OR = 2.04; 95% CI = 1.14 to 3.63; p = 0.009) and belonged to the lower socio-economic classes (OR = 7.15; 95% CI = 3.83 to 13.43; p=0.0000). It is concluded that parasitic infestations are commonly associated with childhood diarrhoea in Nigeria. Malnutrition and low socio-conomic status are risk factors.
Keywords: Parasitic agents; Diarrhea; Undernourished; Low socio-economic status
Diarrhea is a leading cause of childhood morbidity and mortality in the developing world.[1] A large proportion of diarrheal diseases in children are infective in origin but the etiologies, a few years ago, were largely under-determined for lack of facilities. Recently, the role of viral agents, especially the Rotavirus as the leading causes of childhood diarrhea both in the hospital and in the community was documented[2] and this has broadened the aetiological scope in childhood diarrhoea. Presently, about 60% of childhood diarrhoea in Nigeria is . attributed to viral agents.[3]
Studies had shown that intestinal parasitosis is common in the developing world[4],[5],[6] presumably because of poor enviromental and personal hygiene largely caused by poor sewage disposal and inadequate water supply. Diarrhea may be a symptom of some of these parasitic infections. Therefore, parasitic agents had also been demonstrated in diarrheic stools of Nigerian children.[7],[9] Incidentally, these children are also the most at risk of diarrheal deaths.
In Ilesa, south-western Nigeria, the role of parasitic agents in the etiology of diarrhea among under-five children has not been previously studied. Therefore, this study is important because Ilesa is a semi-urban Nigerian community where treated pipe-borne water is presently lacking and sewage disposal is poor thus creating a rich setting for the transmission of parasites. This study was aimed at determining the incidence of parasitic agents among under-five children with diarrhea as well as the clinical correlates of parasitic diarrhea.
Materials and Methods
This cross-sectional study was carried out at the pediatric Unit of the Wesley Guild Hospital, Ilesa, Nigeria between November, 2002 and July, 2003. The subjects were consecutive under-five children (except neonates) presenting with acute diarrhea. Ethical clearance and informed consent were obtained from the authority of the hospital and the parents respectively. The age, sex and anthropometry were recorded and the nutritional status classified by the Modified Wellcome system.[10] Histories of breastfeeding and bottle-feeding were obtained for children aged 24 months and below and day care attendance for those aged 36 months and below. Socio-economic classification was done by the method recommended by Oyedeji[11] in which classes I to III were grouped together as the Upper Social Class while classes IV and V were grouped together as the Lower Social Class.
Fresh stool specimens were collected directly into sterile universal bottles and examined microscopically for ova and parasites within 30 minutes of collection.
For the purpose of comparison, children with identified parasitic agents in stool were classified as the cases while those with no identifiable parasites were the controls. The cases and controls were compared for the known risk factors for diarrhea and the clinical features using student's t test, chi-square test and Odds Ratio (OR) and 95% Confidence Interval (CI). Data analysis was done using the SPSS and the Computer Package for Epidemiologists.
Results
General characteristics and distribution of parasites
Over the period of 9 months, the 300 under-five children who presented with acute diarrhea in authors hospital were studied. Parasitic agents were identified in 70 (23.3%) stool samples while the remaining 230 (76.7%) had no identifiable parasitic agent. There were 18 (6%) helminthic and 52 (17.3%) protozoan agents. The parasites isolated were the ova of Ascaris lumbricoides (13; 18.6%), Entamoeba histolytica (46; 65.7%), cysts of Entamoeba coli (l; 1.4%), Giardia lamblia (5; 7.1%), Necator american us (I; 1.4%) and Trichuris trichiuria (4; 5.7%) respectively. E. histolytica was found in the amoeboid (40; 86.9%) and cystic (6; 13.1%) forms.
There was a male preponderance among the cases (40 : 30) and the controls (140 : 90). [Table - 1] shows the age distribution of the cases and the controls. The former were concentrated in the second year of life {(39/ 70 vs 83/230); OR = 2.23; CI = 1.25 to 3.98; p = 0.003} compared to the latter who were mostly infants {(126/230 vs 16/70); OR = 0.24; CI = 0.13 to 0.47; p = 0.0000}. The mean age ± SD of the cases was 20.7 ± 13.7 months compared with 13.8 ± 9.1 months for the controls and this difference was statistically significant (t = 4.88; p=0.0000017).
Thirty (42.9%) of the cases had normal nutritional status while the remaining 40 (57.1%) were undernourished according to the Modified Wellcome system of classification. The undernourished cases 'comprised underweight (36; 90%), marasmus (3; 7.5%) and marasmic kwashiorkor (1; 2.5%). A significantly higher proportion of the cases were undernourished compared with the controls {(40/70 vs 91/230); OR = 0.49; CI = 0.28 - 0.87; p = 0.009}.
The parasites identified in these 40 malnourished cases included Entamoeba histolytica (28; 70%), Ascaris lumbricoides (6; 15%), Trichuris trichiura (3; 7.5%) and Giardia lamblia (3; 7.5%). The parasites identified in the 30 cases without malnutrition included Entamoeba Histolytica (18; 60%), Ascaris lumbricoides (7; 23.3%), Giardia lamblia (2; 6.7%), Trichuris trichiura (1; 3.3%), Entamoeba coli (1; 3.3%) and Necator american us (1; 3.3%).
[Table - 2] shows the distribution of the children in both groups by socio-economic classes. A significantly higher proportion of cases belonged to the lower socio-economic classes compared with the controls (OR = 7.15; CI = 3.83 to 13.43; p = 0.0000).
Risk factors for diarrhoea
In [Table - 3] the sources of water were not significantly different in both groups. Attendance of day care centres was higher in the controls but without significance {(43/227 vs 8/59); OR = 1.49; CI = 0.62 to 3.68; p = 0.335}. On the other hand, a higher but non-significant proportion of the cases were bottle-fed compared to the controls {(27/57 vs 78/207); OR = 1.49; CI = 0.79 to 2.80; p = 0.186}. In addition, a significantly higher proportion of the cases had -stopped breastfeeding before the age of 24 months compared to the controls {(34/57 vs 46/207); OR = 0.19; CI = 0.10 to 0.38; p = 0.0000}.
Clinical features
The duration of the illness prior to presentation in the hospital was significantly longer among the cases compared to the controls (3.9 ± 3.5 days vs 3.0 ± 2.4 days; t = 2.45, p = 0.015). The frequency of diarrhea was also significantly higher among the cases compared to the controls (7.0 ± 2.3 per day vs 6.3 ± 1.7 per day; t = 2.76, p = 0.006). A higher pyroportion of the controls had vomiting but this was not statistically significant {(114/230 vs 30/70); OR = 0.76; Cl = 0.43 to 1.35; p = 0.325}. Fever was also more significantly associated with diarrhea in the controls {(181/230 vs 36/70) OR = 0.29; CI = 0.16 to 0.52; p = 0.0000}. A significantly higher proportion of the controls had moderate to severe dehydration compared to the cases {( 152/230 vs 25/70); OR = 0.21; CI = 0.16 to 0.52; p = 0.0000}.
Discussion
The prevalence of parasitic agents associated with under-five diarrhea in this study was lower than 32.5% reported from Ilorin,[8] 30.7% reported from Jos,[9] both in Nigeria and 46.5% and 70% from Delhi[12] and Addis Ababa[13] respectively. Helminthes were uncommonly identified in this study compared to protozoans. The prominence of the protozoans over the helminthes in this study seemed unusual.[14] The authors found in this study that Ascaris lumbricoides was the commonest helminth found in childhood diarrhea. However, protozoans were commoner in the previous reports from Jos, Nigeria and Delhi, India.[9],[12] In contrast to a previous Lagos, Nigeria study,[15] where parasites accounted for about 2.3% of the etiology of childhood diarrhea, authors findings may be explained in terms of patients' selection. The patients were from rural and semi-urban areas unlike Lagos which is an urban setting where the risk of transmission of parasites may not be very high because of the likelihood of relatively better hygiene. Cryptosporidium was not found in this study for unknown reasons in agreement with previous report from Lagos.[15]
The low prevalence of helminthes in childhood diarrhea in Ilesa was most likely due to the 'culture' of rampant medication of children with anti-helminthics by most mothers at the slightest indication of ill health (unpublished data). This is due to the widespread unrestricted access to drugs in Nigeria, like most other developing countries and increased awareness about helminthiases since the people of Ilesa had been in contact with a district hospital - turned tertiary hospital, for close to a century.
Although, parasitic diarrhea had been reported to affect all ages,[7] it is often found after infancy in concordance with authors findings. Perhaps, the increased explorative tendencies at this age heighten the risks of feco-oral transmission of the ova and cysts of parasites. Also, authors' observation that many more children in the control group were infants may not be surprising as viral agents, particularly the Rotavirus, have been reported to affect infants more than other age groups.[16]
While the 'lack of relationship between the sources of water and the two groups of children attests to their similar home situation, it was remarkable that early cessation of breastfeeding was associated with parasitic diarrhea. Although there was no such association with bottle feeding and day care centre attendance, it is plausible to infer that early cessation of breastfeeding deprived these children of the protective effects of breast milk. It also exposed them to alternative methods of feeding which encouraged contact with the parasites which are endemic in this environment. This has a direct bearing with the standard of living of the people, hence, the association of parasitic diarrhea with malnutrition and low socio-economic status as observed in this study. Interestingly, diarrheal diseases generally had earlier been shown at the same centre to be worse among children of popr background.[17] These children are usually undernourished and prone to pica, hence, the ingestion of the ova and cysts of parasites.
Likewise, the strong association between the controls and more severe degrees of dehydration is typical of viral diarrhea which is renowned for being the leading causes of dehydrating diarrhea requiring hospitalisation.[18] The prominence of none to mild dehydration among the cases may conceivably be due to the fact that most parasitic agents cause exudative rather than secretory diarrhea.[10] This may also explain the relatively earlier presentation of the controls in the hospital since they had more significant dehydration. The latter is seemingly a major reason for bringing diarrheic children to the hospital. The reason for the rdatively lower frequency of stooling among the controls was not very obvious.
Conclusion
Parasitic agents are significantly associated with childhood diarrhea in this community. Thus, it is conceivable that intestinal parasitic infestation and the attendant diarrheal illnesses can be reduced by improving the level of hygiene (personal and environmental), and nutrition including breastfeeding practices.[19]
Acknowledgements
The assistance of the Nurses at the General Pediatric Out-Patient Clinic and the Children's Emergency Room at the Wesley Guild Hospital, Ilesa, Nigeria is hereby acknowledged.
References
1.World Health Organization. WHO Fact Sheet. Number 180; 1997.
2.Youseff M, Shurman A, Bougnoux M, Rawashdeh M, Bretagne S, Strockbine N. Bacterial, viral and parasitic enteric pathogens associated with acute diarrhea in hospitalized children from northern Jordan. FEMS Immunol Med Microbiol 2000; 28: 257-265.
3.Akinbami FO. Diarrhoea in Children. In Azubuike JC and Nkanginieme KEO, eds. Paediatrics and Child Health in a Tropical Region. Owerri, Nigeria; African Educational Services, lst Edition. 1999; 141-145.
4.Awogun IA. The prevalence of Intestinal parasitic infections in children living in Ilorin, Kwara State. Nigerian Medical Practitioner 1984; 7: 176-178.
5.Fagbenro-Beyioku AF, Oyerinde JPO. Parasitic intestinal infections of children in Lagos. Nig J Paediatr 1987 ; 14 : 89-86.
6.Magambo JK, Zeyhle E, Wachira TM. Prevalence of intestinal parasites among children in southern Sudan. East Afr Med J 1998; 75: 288-290. [PUBMED]
7.Odugbemi TO, Oyerinde JPO, Isaac-Sodeye JO, Roberts JIK. Parasitic and bacterial aetiology of childhood enteritis in Under-5. West Afr J Med 1982; 1: 19-24.
8.Adedoyin MA, Awogun lA, Juergensen T. Prevalence of Intestinal Parasitoses in relationship to diarrhoea among children in Ilorin. West Air J Med 1990; 9: 83-88.
9.Ighogboja IS, Ikeh EI. Parasitic agents in childhood diarrhoea and malnutrition. West Afr J Med 1997; 16: 36-39. [PUBMED]
10.Hendrickse RG. Protein Energy Malnutrition. In Hendrickse RG, Barr DGD, Mathews TS, eds. Paediatrics in the Tropics. 1st Edition. Oxford; Blackwel1 Scientific Publications, 1991; 119-131.
11.Oyedeji GA. Socioeconomic and cultural background of hospitalized children in Ilesa. Nig J Paediatr 1985; 12: 111; 117.
12.Kaur R, Rawat D, Kakkar M, Uppal B, Sharma VK. Intestinal parasites in children with diarrhea in Delhi, India. Southeastern Asian J Trop Med Public Health 2002; 33: 725-729.
13.Throen A, Stintzing G, Walder M, Habte D. Aetiology and clinical features of severe infantile diarrhoea in 'Addis Ababa, Ethiopia. J Trop Paediatr 1982; 28: 127-131.
14.Kebede A, Polderman AM, Okeke IN, Ojo O, Lamikanra A, Kaper JB. Etiology of acute diarhhoea in adults in south-western Nigeria. J Clin Microbiol 2004; 42: 3909-3910.
15.Ogunsanya TI, Rotimi VO, Adenuga A. A study of the aetiological agents of childhood diarrhoea in Lagos, Nigeria. J Med Microbiol 1994; 40: 10-14.
16.Abiodun PO. Incidence of Rotavirus in acute diarrhoea in the University of Benin Teaching of Hospital, Benin. Nig J Plediatr 1989; 16: 31-34.
17.Oyedeji GA. The effect of socio-economic factors on the incidence and severity of gastroenteritis in Nigerian chidren. Nigerian Medical Journal 1987; 4 : 229-232.
18.World Health Organisation. The treatment of diarrhoea. A manual for Physicians and Other Senior Health Workers. WHO/CDD 95.3: 1995.
19.Chauliac M. Diarrhoeal diseases. Children in the Tropics 1985; 158 : 11-19.(Tinuade Ogunlesi, John Okeniyi, Saheed O)
2 Havana Specialist Hospital, Lagos, Nigeria
The objective was to determine the prevalence of parasitic agents among under-five children with diarrhea in Ilesa, Nigeria and the clinical correlates of diarrhea associated with parasitic infestation. All under-five children presenting with diarrhea in the hospital had stool microscopic examination. Children with parasites in diarrheic stools (cases) were compared with those without (controls) for clinical features. Out of 300 under-five children with diarrhea, 70 (23.3%) had parasites. There were 18 (6%) helminthes and 52 (17.3%) protozoas. These included the' ova of Ascaris lumbricoides (13; 18.6%), cysts and trophozoites of Entamoeba. histolytica (46; 65.7%), cysts of Entamoeba coli (1; 1.4%), Giardia Lamblia (5; 7.1%), Necator american us (1; 1.4%) and Trichuris trichiuria (4; 5.7%). As against the controls, the cases were older (t = 4.88; p = 0:0000017), more undernourished (OR = 2.04; 95% CI = 1.14 to 3.63; p = 0.009) and belonged to the lower socio-economic classes (OR = 7.15; 95% CI = 3.83 to 13.43; p=0.0000). It is concluded that parasitic infestations are commonly associated with childhood diarrhoea in Nigeria. Malnutrition and low socio-conomic status are risk factors.
Keywords: Parasitic agents; Diarrhea; Undernourished; Low socio-economic status
Diarrhea is a leading cause of childhood morbidity and mortality in the developing world.[1] A large proportion of diarrheal diseases in children are infective in origin but the etiologies, a few years ago, were largely under-determined for lack of facilities. Recently, the role of viral agents, especially the Rotavirus as the leading causes of childhood diarrhea both in the hospital and in the community was documented[2] and this has broadened the aetiological scope in childhood diarrhoea. Presently, about 60% of childhood diarrhoea in Nigeria is . attributed to viral agents.[3]
Studies had shown that intestinal parasitosis is common in the developing world[4],[5],[6] presumably because of poor enviromental and personal hygiene largely caused by poor sewage disposal and inadequate water supply. Diarrhea may be a symptom of some of these parasitic infections. Therefore, parasitic agents had also been demonstrated in diarrheic stools of Nigerian children.[7],[9] Incidentally, these children are also the most at risk of diarrheal deaths.
In Ilesa, south-western Nigeria, the role of parasitic agents in the etiology of diarrhea among under-five children has not been previously studied. Therefore, this study is important because Ilesa is a semi-urban Nigerian community where treated pipe-borne water is presently lacking and sewage disposal is poor thus creating a rich setting for the transmission of parasites. This study was aimed at determining the incidence of parasitic agents among under-five children with diarrhea as well as the clinical correlates of parasitic diarrhea.
Materials and Methods
This cross-sectional study was carried out at the pediatric Unit of the Wesley Guild Hospital, Ilesa, Nigeria between November, 2002 and July, 2003. The subjects were consecutive under-five children (except neonates) presenting with acute diarrhea. Ethical clearance and informed consent were obtained from the authority of the hospital and the parents respectively. The age, sex and anthropometry were recorded and the nutritional status classified by the Modified Wellcome system.[10] Histories of breastfeeding and bottle-feeding were obtained for children aged 24 months and below and day care attendance for those aged 36 months and below. Socio-economic classification was done by the method recommended by Oyedeji[11] in which classes I to III were grouped together as the Upper Social Class while classes IV and V were grouped together as the Lower Social Class.
Fresh stool specimens were collected directly into sterile universal bottles and examined microscopically for ova and parasites within 30 minutes of collection.
For the purpose of comparison, children with identified parasitic agents in stool were classified as the cases while those with no identifiable parasites were the controls. The cases and controls were compared for the known risk factors for diarrhea and the clinical features using student's t test, chi-square test and Odds Ratio (OR) and 95% Confidence Interval (CI). Data analysis was done using the SPSS and the Computer Package for Epidemiologists.
Results
General characteristics and distribution of parasites
Over the period of 9 months, the 300 under-five children who presented with acute diarrhea in authors hospital were studied. Parasitic agents were identified in 70 (23.3%) stool samples while the remaining 230 (76.7%) had no identifiable parasitic agent. There were 18 (6%) helminthic and 52 (17.3%) protozoan agents. The parasites isolated were the ova of Ascaris lumbricoides (13; 18.6%), Entamoeba histolytica (46; 65.7%), cysts of Entamoeba coli (l; 1.4%), Giardia lamblia (5; 7.1%), Necator american us (I; 1.4%) and Trichuris trichiuria (4; 5.7%) respectively. E. histolytica was found in the amoeboid (40; 86.9%) and cystic (6; 13.1%) forms.
There was a male preponderance among the cases (40 : 30) and the controls (140 : 90). [Table - 1] shows the age distribution of the cases and the controls. The former were concentrated in the second year of life {(39/ 70 vs 83/230); OR = 2.23; CI = 1.25 to 3.98; p = 0.003} compared to the latter who were mostly infants {(126/230 vs 16/70); OR = 0.24; CI = 0.13 to 0.47; p = 0.0000}. The mean age ± SD of the cases was 20.7 ± 13.7 months compared with 13.8 ± 9.1 months for the controls and this difference was statistically significant (t = 4.88; p=0.0000017).
Thirty (42.9%) of the cases had normal nutritional status while the remaining 40 (57.1%) were undernourished according to the Modified Wellcome system of classification. The undernourished cases 'comprised underweight (36; 90%), marasmus (3; 7.5%) and marasmic kwashiorkor (1; 2.5%). A significantly higher proportion of the cases were undernourished compared with the controls {(40/70 vs 91/230); OR = 0.49; CI = 0.28 - 0.87; p = 0.009}.
The parasites identified in these 40 malnourished cases included Entamoeba histolytica (28; 70%), Ascaris lumbricoides (6; 15%), Trichuris trichiura (3; 7.5%) and Giardia lamblia (3; 7.5%). The parasites identified in the 30 cases without malnutrition included Entamoeba Histolytica (18; 60%), Ascaris lumbricoides (7; 23.3%), Giardia lamblia (2; 6.7%), Trichuris trichiura (1; 3.3%), Entamoeba coli (1; 3.3%) and Necator american us (1; 3.3%).
[Table - 2] shows the distribution of the children in both groups by socio-economic classes. A significantly higher proportion of cases belonged to the lower socio-economic classes compared with the controls (OR = 7.15; CI = 3.83 to 13.43; p = 0.0000).
Risk factors for diarrhoea
In [Table - 3] the sources of water were not significantly different in both groups. Attendance of day care centres was higher in the controls but without significance {(43/227 vs 8/59); OR = 1.49; CI = 0.62 to 3.68; p = 0.335}. On the other hand, a higher but non-significant proportion of the cases were bottle-fed compared to the controls {(27/57 vs 78/207); OR = 1.49; CI = 0.79 to 2.80; p = 0.186}. In addition, a significantly higher proportion of the cases had -stopped breastfeeding before the age of 24 months compared to the controls {(34/57 vs 46/207); OR = 0.19; CI = 0.10 to 0.38; p = 0.0000}.
Clinical features
The duration of the illness prior to presentation in the hospital was significantly longer among the cases compared to the controls (3.9 ± 3.5 days vs 3.0 ± 2.4 days; t = 2.45, p = 0.015). The frequency of diarrhea was also significantly higher among the cases compared to the controls (7.0 ± 2.3 per day vs 6.3 ± 1.7 per day; t = 2.76, p = 0.006). A higher pyroportion of the controls had vomiting but this was not statistically significant {(114/230 vs 30/70); OR = 0.76; Cl = 0.43 to 1.35; p = 0.325}. Fever was also more significantly associated with diarrhea in the controls {(181/230 vs 36/70) OR = 0.29; CI = 0.16 to 0.52; p = 0.0000}. A significantly higher proportion of the controls had moderate to severe dehydration compared to the cases {( 152/230 vs 25/70); OR = 0.21; CI = 0.16 to 0.52; p = 0.0000}.
Discussion
The prevalence of parasitic agents associated with under-five diarrhea in this study was lower than 32.5% reported from Ilorin,[8] 30.7% reported from Jos,[9] both in Nigeria and 46.5% and 70% from Delhi[12] and Addis Ababa[13] respectively. Helminthes were uncommonly identified in this study compared to protozoans. The prominence of the protozoans over the helminthes in this study seemed unusual.[14] The authors found in this study that Ascaris lumbricoides was the commonest helminth found in childhood diarrhea. However, protozoans were commoner in the previous reports from Jos, Nigeria and Delhi, India.[9],[12] In contrast to a previous Lagos, Nigeria study,[15] where parasites accounted for about 2.3% of the etiology of childhood diarrhea, authors findings may be explained in terms of patients' selection. The patients were from rural and semi-urban areas unlike Lagos which is an urban setting where the risk of transmission of parasites may not be very high because of the likelihood of relatively better hygiene. Cryptosporidium was not found in this study for unknown reasons in agreement with previous report from Lagos.[15]
The low prevalence of helminthes in childhood diarrhea in Ilesa was most likely due to the 'culture' of rampant medication of children with anti-helminthics by most mothers at the slightest indication of ill health (unpublished data). This is due to the widespread unrestricted access to drugs in Nigeria, like most other developing countries and increased awareness about helminthiases since the people of Ilesa had been in contact with a district hospital - turned tertiary hospital, for close to a century.
Although, parasitic diarrhea had been reported to affect all ages,[7] it is often found after infancy in concordance with authors findings. Perhaps, the increased explorative tendencies at this age heighten the risks of feco-oral transmission of the ova and cysts of parasites. Also, authors' observation that many more children in the control group were infants may not be surprising as viral agents, particularly the Rotavirus, have been reported to affect infants more than other age groups.[16]
While the 'lack of relationship between the sources of water and the two groups of children attests to their similar home situation, it was remarkable that early cessation of breastfeeding was associated with parasitic diarrhea. Although there was no such association with bottle feeding and day care centre attendance, it is plausible to infer that early cessation of breastfeeding deprived these children of the protective effects of breast milk. It also exposed them to alternative methods of feeding which encouraged contact with the parasites which are endemic in this environment. This has a direct bearing with the standard of living of the people, hence, the association of parasitic diarrhea with malnutrition and low socio-economic status as observed in this study. Interestingly, diarrheal diseases generally had earlier been shown at the same centre to be worse among children of popr background.[17] These children are usually undernourished and prone to pica, hence, the ingestion of the ova and cysts of parasites.
Likewise, the strong association between the controls and more severe degrees of dehydration is typical of viral diarrhea which is renowned for being the leading causes of dehydrating diarrhea requiring hospitalisation.[18] The prominence of none to mild dehydration among the cases may conceivably be due to the fact that most parasitic agents cause exudative rather than secretory diarrhea.[10] This may also explain the relatively earlier presentation of the controls in the hospital since they had more significant dehydration. The latter is seemingly a major reason for bringing diarrheic children to the hospital. The reason for the rdatively lower frequency of stooling among the controls was not very obvious.
Conclusion
Parasitic agents are significantly associated with childhood diarrhea in this community. Thus, it is conceivable that intestinal parasitic infestation and the attendant diarrheal illnesses can be reduced by improving the level of hygiene (personal and environmental), and nutrition including breastfeeding practices.[19]
Acknowledgements
The assistance of the Nurses at the General Pediatric Out-Patient Clinic and the Children's Emergency Room at the Wesley Guild Hospital, Ilesa, Nigeria is hereby acknowledged.
References
1.World Health Organization. WHO Fact Sheet. Number 180; 1997.
2.Youseff M, Shurman A, Bougnoux M, Rawashdeh M, Bretagne S, Strockbine N. Bacterial, viral and parasitic enteric pathogens associated with acute diarrhea in hospitalized children from northern Jordan. FEMS Immunol Med Microbiol 2000; 28: 257-265.
3.Akinbami FO. Diarrhoea in Children. In Azubuike JC and Nkanginieme KEO, eds. Paediatrics and Child Health in a Tropical Region. Owerri, Nigeria; African Educational Services, lst Edition. 1999; 141-145.
4.Awogun IA. The prevalence of Intestinal parasitic infections in children living in Ilorin, Kwara State. Nigerian Medical Practitioner 1984; 7: 176-178.
5.Fagbenro-Beyioku AF, Oyerinde JPO. Parasitic intestinal infections of children in Lagos. Nig J Paediatr 1987 ; 14 : 89-86.
6.Magambo JK, Zeyhle E, Wachira TM. Prevalence of intestinal parasites among children in southern Sudan. East Afr Med J 1998; 75: 288-290. [PUBMED]
7.Odugbemi TO, Oyerinde JPO, Isaac-Sodeye JO, Roberts JIK. Parasitic and bacterial aetiology of childhood enteritis in Under-5. West Afr J Med 1982; 1: 19-24.
8.Adedoyin MA, Awogun lA, Juergensen T. Prevalence of Intestinal Parasitoses in relationship to diarrhoea among children in Ilorin. West Air J Med 1990; 9: 83-88.
9.Ighogboja IS, Ikeh EI. Parasitic agents in childhood diarrhoea and malnutrition. West Afr J Med 1997; 16: 36-39. [PUBMED]
10.Hendrickse RG. Protein Energy Malnutrition. In Hendrickse RG, Barr DGD, Mathews TS, eds. Paediatrics in the Tropics. 1st Edition. Oxford; Blackwel1 Scientific Publications, 1991; 119-131.
11.Oyedeji GA. Socioeconomic and cultural background of hospitalized children in Ilesa. Nig J Paediatr 1985; 12: 111; 117.
12.Kaur R, Rawat D, Kakkar M, Uppal B, Sharma VK. Intestinal parasites in children with diarrhea in Delhi, India. Southeastern Asian J Trop Med Public Health 2002; 33: 725-729.
13.Throen A, Stintzing G, Walder M, Habte D. Aetiology and clinical features of severe infantile diarrhoea in 'Addis Ababa, Ethiopia. J Trop Paediatr 1982; 28: 127-131.
14.Kebede A, Polderman AM, Okeke IN, Ojo O, Lamikanra A, Kaper JB. Etiology of acute diarhhoea in adults in south-western Nigeria. J Clin Microbiol 2004; 42: 3909-3910.
15.Ogunsanya TI, Rotimi VO, Adenuga A. A study of the aetiological agents of childhood diarrhoea in Lagos, Nigeria. J Med Microbiol 1994; 40: 10-14.
16.Abiodun PO. Incidence of Rotavirus in acute diarrhoea in the University of Benin Teaching of Hospital, Benin. Nig J Plediatr 1989; 16: 31-34.
17.Oyedeji GA. The effect of socio-economic factors on the incidence and severity of gastroenteritis in Nigerian chidren. Nigerian Medical Journal 1987; 4 : 229-232.
18.World Health Organisation. The treatment of diarrhoea. A manual for Physicians and Other Senior Health Workers. WHO/CDD 95.3: 1995.
19.Chauliac M. Diarrhoeal diseases. Children in the Tropics 1985; 158 : 11-19.(Tinuade Ogunlesi, John Okeniyi, Saheed O)