Home Based Diarrhea Case Management and the Risk of Dehydration and All- Cause Child Mortality in the Kenya GEMS Site
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Background :Modeling studies suggest that oral rehydration solution (ORS), pre-packed oral rehydration salts based on the formulation recommended by the World Health Organization, may prevent most diarrheal deaths if universal coverage is achieved. Globally, only one-third of children with diarrhea receive ORS, the form of rehydration for diarrhea recommended in the Integrated Management of Childhood Illness guidelines. Achieving universal ORS use will require substantial financial input and behavior change efforts. To strengthen the case for promoting appropriate diarrhea case management at home, of which ORS administration is a key component, we evaluated whether home-based diarrhea treatment methods reduced the risk of dehydration and death in children with moderate to severe diarrhea (MSD). Methods :At the GEMS Kenya field site, we enrolled children <5 years of age with MSD. Enrolling clinicians asked caretakers about diarrhea case management at home during the time preceding enrollment. Survival status was determined at follow-up 50-90 days after enrollment. We calculated adjusted risk ratios (aRR) and 95% confidence intervals (CI) to describe associations between the following methods of home-based diarrhea treatment methods, and dehydration and death: oral rehydration therapy (ORT) consisting of ORS, recommended home-fluids, or increasing fluids; ORS with or without other fluids; and continued feeding. Results :During 2008-11, 1,476 MSD cases were enrolled; 1,419 (96%) were followed up. At home, 65% of children received one or more forms of ORT, 14% received ORS with or without other fluids, and 19% were offered continued feeding. Between enrollment and follow-up, 52 deaths occurred (case fatality rate 3.7%), 35% of which reportedly occurred ≤ 7 days after enrollment. Children with MSD who later died were more likely to present with a slow return skin pinch and restless/irritable mental status at enrollment, and to require intravenous hydration and hospitalization during treatment than those who survived (P<.0001 for all). When adjusted for age of child, socioeconomic status and hospitalization, provision of ORT was found to have a negligible effect against dehydration as indicated by a slow skin pinch (aRR=1.01 [CI 0.84-1.21]), and a small protective effect against altered mental status (aRR=0.93 [CI 0.87-1.01]). ORS however was found to be protective against both slow skin pinch: aRR=0.79 [CI 0.63-1.00]) and altered mental status: aRR=0.87 [CI 0.77-0.98]). In contrast to the findings on protection against dehydration, home-based diarrhea case management strategies were not associated with mortality risk (ORT: aRR=0.89 [CI 0.51-1.54], ORS: aRR=1.15 [CI 0.60-2.19], and continued feeding: RR=0.58 [CI 0.23-1.44]. Conclusion :In Kenya, children with MSD experienced a high case fatality rate, but few were offered ORS and continued feeding at home. ORS was shown to reduce the risk of dehydration in children with MSD as much as 21%; forms of ORT other than ORS were not found to have any dehydration prevention benefits. Therapies that should, and to some extent did, prevent dehydration however did not prevent mortality. A small number of deaths and low usage of ORS and continued feeding reduced our ability to identify protective effects of ORT, ORS, and continued feeding among children with moderate-to-severe diarrhea. Our findings underscore the importance and need for improving home-based diarrhea case management with a specific focus on ORS and continued feeding.