Harmful practices in the management of childhood diarrhea in low- and middle-income countries: a systematic review

The publication dates of the 114 studies included in the review were relatively evenly distributed over the period from 1990 to 2013, with publications clustering slightly in the early 1990s and late 2000s/early 2010s. The majority of studies were conducted in South Asia and sub-Saharan Africa (Fig. 2). The number of publications reporting on the prevalence of each of the four practices varied, with the highest proportion reporting on inappropriate medication use (70 %), followed in order of frequency by food restriction (56 %), curtailment of fluids other than breast milk (53 %), and breastfeeding restriction (37 %).

Respondents in the majority of prevalence studies were caregivers of children under 5 years of age, although some studies interviewed mothers exclusively. The age of children referenced for the practice also varied, with the majority of studies referencing children under 5 years of age. The definition of the diarrhea reference episode also varied, ranging from diarrhea in the past 24 h to the most recent diarrhea event, although the most common reference period was the previous two weeks.

The measurement of fluid intake, and prevalence estimates, varied widely across studies (Table 1, Column 4). Many studies differed in their definition or failed to specify if fluid restriction included or excluded breastfeeding or assessed amount of fluid offered versus consumed. The reported practice of curtailing fluids during a recent episode of diarrhea ranged from as low as 11 % of caregivers in Mirzapur, Bangladesh [7] to over 80 % of caregivers in Kenya’s Nyanza province [8]. Where specified by the study authors, the practice of stopping all fluids was uncommon, generally reported in fewer than 10 % of episodes.

Multiple studies explored variations in fluid curtailment by characteristics of the diarrhea episode, child, caregiver, and household (Table 2). Fluid curtailment was associated with diarrhea severity and vomiting in two studies [9, 10], whereas increase in fluid was associated with long illness duration and poor appetite [11]. Studies in Pakistan, Bangladesh, and Saudi Arabia found no clear association between fluid restriction and the age of the child [12‐14]. However, a study in Mozambique reported that less fluid was given to infants relative to older children [15]. Younger mothers and mothers who did not work outside the home [12] and less educated mothers [16] were more likely to curtail fluids.

Multiple studies have attributed the practice of fluid curtailment to caregiver beliefs about the impact of fluid intake on a child’s diarrhea episode (Table 3). Multiple studies reported that caregivers often stated that more or specific fluids would increase the severity of the illness [17‐19] or could not be digested [20‐22]. Two studies suggested these beliefs were informed by caregivers’ observations that reduced fluids decreased stool output and diarrhea intensity [7, 23]. One study reported that certain types of diarrhea are perceived to be manageable by adjusting fluid intake, while others require traditional or spiritual methods, or no treatment at all [24]. The beliefs of family and community members, particularly elderly relatives, have also been reported as influential in determining caregiver practices related to fluids and feeding during childhood diarrhea episodes [22, 24, 25]. In three studies caregivers reported reduced fluid intake due to child refusal, child crying, or decreased thirst [22, 26, 27]. In one study, mothers reported they did not encourage increased fluids because they were inexperienced in how to do this [27].

Many studies reported the practice of breastfeeding reduction or cessation during diarrhea episodes (Table 1, Column 5). Most studies found that among mothers breastfeeding their child prior to the onset of diarrhea, fewer than 10 % of mothers stopped breastfeeding during the episode. The practice of breastfeeding cessation ranged from no mothers reporting breastfeeding cessation in a surveillance study in northeast Thailand to 62 % of mothers reporting stopping breast or milk feeding in a hospital-based study in Saudi Arabia [20, 28]. The practice of breastfeeding cessation was higher in hospital samples compared to samples from the general population. Where breastfeeding reduction was reported, on average one quarter of mothers reported reducing breastfeeding, although there was significant variation in the practice.

Multiple studies assessed variance in breastfeeding restriction by factors including characteristics of the diarrhea episode, child, caregiver, and household (Table 2). One study found younger and less educated mothers were more likely to reduce breastfeeding during episodes of diarrhea [12].

Mothers reported ceasing or reducing breastfeeding when their child had diarrhea for various reasons (Table 3). Mothers reported stopping or reducing breastfeeding because of beliefs that breastmilk was too fatty to be digested [20]. Others reported continued breastfeeding would not reduce the duration of diarrhea [20, 29] or could cause or worsen the diarrhea [18, 19, 29]. Caregivers in two studies believed specific types of diarrhea must be treated with breastfeeding cessation [29, 30]. In multiple cultures, “dirty” breast milk or secretion of ingested food through breast milk was thought to cause certain types of diarrhea. Mothers received treatment or a modified diet to improve the quality of their breast milk [31‐34] or children were weaned [35]. Some caregivers stated they were following the advice of healthcare providers by restricting breastfeeding [20, 36]. Older relatives were also important sources of information on feeding practices during diarrhea episodes [25, 31]. In some studies, mothers continued feeding but diluted milk or formula [29], switched to powdered or goat’s milk [37], or only gave water [38].

The measurement of food restriction, and prevalence estimates, varied widely across studies (Table 1, Column 6). Many studies differed in their definition or failed to specify if food restriction was measured only among those eating solid foods prior to illness, whether breastfeeding was included or excluded, and whether amount of food offered versus consumed was measured. Findings on restriction of specific foods have been included for context but not in prevalence estimates of overall food restriction (Table 1). The practice of stopping all food ranged from as low as 3 % of mothers stating they stopped giving solid or semi-solid foods during the episode in Oyo State, Nigeria [26] to as high as 53 % of mothers reporting they stopped feeding in Kenya [39]. As expected, measures that included the reduction of feeding in addition to complete restriction of feeding showed higher rates of food restriction, mostly within the range of 30–60 % of episodes.

Multiple studies addressed the variance of food restriction by other factors, including characteristics of the diarrhea episode, child, caregiver, and household (Table 2). Food curtailment was associated with dehydration and more severe disease [40], seeking care outside of the home, and ORS use [41]. In one study, caregivers were more likely to withhold food if a child had fever or a low appetite [11]. Another study found children less than 2 years of age were more likely to receive continued feeding compared to older children [42]. Two studies found that less educated mothers were more likely to restrict foods [12, 16].

Motivation for food restriction differed (Table 3). Some caregivers reported that a child’s diet should be restricted because of beliefs that a child cannot eat or digest as much during a diarrhea episode [22, 43] and feeding can exacerbate or prolong diarrhea episodes [19, 22, 29, 44‐46]. Belief that only certain foods should be restricted because they can aggravate diarrhea was common across countries and included a range of foods such as meat, milk, sweet food, greasy food, high carbohydrate and high protein foods [29, 37, 38, 43, 47‐54]. Alternatively, in two studies some caregivers reported that specific foods were customary and should be given during a diarrhea episode to strengthen the bowel or soothe the stomach [36, 52]. Some caregivers reported that restriction of certain foods was based on long held folk tradition [29, 47]. Others reported that diet alteration is based on the type or perceived cause of the diarrhea [18, 29, 55]. Elderly relatives, neighbors, and health care providers were reported to influence mothers’ feeding practices in many contexts [22, 23, 25, 27, 29, 36, 53, 56, 57]. Some caregivers reported that a child’s diet was not restricted during diarrhea because it was already limited [27, 44, 58]. One study reported mothers coaxed their child to eat more [36], but others reported some mothers of children with decreased appetite were unfamiliar with encouraging children to eat [22, 44] or had little time to prepare additional food because they were caring for the child [22]. One study suggested caregivers felt continued feeding was less important if they had been given some treatment at a health facility [31].

Many studies reported the use of drugs to treat diarrhea in children under five (Table 1, Column 7). The most commonly reported measures were the use of an antibiotic or antimicrobial, followed by use of any medicine, and the use of an antidiarrheal or antimotility agent. While antibiotics are recommended for treatment of dysentery or cholera, most studies did not differentiate between simple and dysenteric diarrhea when reporting on antibiotic use. The Lives Saved Tool (LiST) attributes 7 % of diarrhea cases in children under 5 to dysentery [59], therefor it may be inferred that high antibiotic use rates are inclusive of inappropriate antibiotic use. A hospital-based study in Enugu, Nigeria highlights the difficultly of collecting information on the type of medicine used to treat diarrhea. The study reported that 70 % of mothers misclassified antibiotics and analgesics as antimotility agents when self-reporting drugs used in diarrhea treatment [60]. Multiple studies outside of this review have shown that the accuracy of drug recall varies by questionnaire design and method of assessment [61].

Reported use of antidiarrheal and antimotility agents was generally lower than reported use of antibiotics. Use of antibiotics at any point in an episode ranged from 10-77 %. Antidiarrheal use ranged from 3–45 % of diarrhea episodes, with the exception of very high reported use (74 %) in Egypt in 2002 [62]. Use of any drug for a diarrhea episode occurring in the previous 2 weeks ranged from 26–76 %. Studies that used a shorter reference period limited to the previous 24 h reported lower rates of drug use at around 20 %.

Multiple studies addressed variance in inappropriate medication use by factors including characteristics of the diarrhea episode, child, caregiver, and household (Table 2). A hospital-based study in Nigeria found children who had received an antibacterial or antidiarrheal at home presented to the hospital with more severe dehydration than those children who did not receive these drugs [60]. Antibiotic and/or antidiarrheal use were associated with seeking care outside of the home [11, 41] and use of ORT [60, 63]. Two studies in Enugu, Nigeria reported conflicting associations between maternal education and antibiotic use [60, 64].

Caregivers reported using antibiotics and other drugs to treat diarrhea because they were accessible and believed to be efficacious (Table 3). Multiple studies reported caregiver beliefs that modern medicines are powerful [64‐67], and more effective in treating diarrhea than ORS [65, 68]. Multiple studies reported drugs were widely available and affordable in the public and private sector, typically without prescription [35, 38, 40, 44, 49, 52, 64, 69]. In many contexts, caregivers stocked drugs at home, purchasing them in advance or saving leftover medication from previous illnesses [33, 37, 38, 52, 70]. Caregivers perceived drugs to be cheaper and more accessible than ORS, particularly given the flexibility to purchase a few tablets for little money [64, 65, 71]. Use of antibiotics in the treatment of pediatric diarrhea has become routine for both health care providers and caregivers in some contexts [18, 40, 66]. Caregivers may have also influenced provider behavior as caregivers’ preference for drug therapies creates pressure on providers to give medications in addition or instead of ORS [28, 33, 65, 72]. Drugs were given in sub-clinical doses in multiple studies [67, 69, 73]. It was common in studies for children to receive multiple drugs for a single episode of diarrhea, often from the same source [67, 74‐77]. A study in Brazil found drugs were used more commonly to treat episodes of longer duration [63], although initial treatment of diarrhea at home with drugs was common in a study in Mali [78]. Multiple studies suggested treatment with modern medicines may be related to the perceived cause or type of diarrhea [18, 52, 60, 79‐81]. Treatment seeking was often related to inappropriate use of medicine for diarrhea management [33, 57, 62, 82].