CHAPTER ONE

1.1       BACKGROUND OF THE STUDY

Diarrheal disease is highly preventable, yet accounts for nine percent of all deaths among children under age five worldwide [Liu, 2013]. In 2013, this translated into about 580,000 child deaths, or, on average, 1,600 children dying each day due to preventable diarrhea [WHO, 2014].

Diarrhoea is the disturbance of the gastrointestinal tract comprising of changes in intestinal motility and absorption, leading to increase in the volume of stools and in their consistency [Ballabriga, et al 2000]. In diarrhoea, stool contains more water than normal stool and is often called loose or watery stool. In certain cases, they may contain blood in which case the diarrhoea is called dysentery [Obionu, 2007]. Any passage of three or more watery stools within a day [24 hours] is referred to as diarrhoea [Cairncross et al, 2010].

Diarrhoea accounts for high levels of mortality in young children in developing countries like Nigeria, despite worldwide efforts to improve overall child health levels. Each year,third world countries of Asia, Africa and Latin America, record approximately five million deaths of children under five years of age from acute diarrhoea. About 80 per cent of these deaths are in the first two years of life [Lucas & Gilles, 2009]. In the developing world as a whole, about one-third of infant and child deaths are due to diarrhoea and approximately 70 per cent of diarrhoeal deaths are caused by dehydration – the loss of large quantity of water and salts from the body, which needs water to maintain blood volume and other fluids to function properly [Gupta & Mahajan, 2005]. UNICEF [2002] summated that in Nigeria, infant mortality rates are twice as high in rural settings as they are in urban ones due to poor hygiene and poor sanitation. About three million infant births in Nigeria, approximately 170,000 result in deaths that are mainly due to poor knowledge and management practices of childhood diarrhoea. Several factors are likely to contribute to the high rate of diarrhoea morbidity and mortality in children under-five years these include poverty, female illiteracy, poor water supply and sanitation, poor hygiene practices and inadequate health services [Park, 2009]. Malnutrition is another established risk factor for mortality among children with diarrhoea disease. This may be due to inadequate case management. In 2004, WHO and UNICEF issued a joint statement on clinical treatment of acute diarrhea, recommending the use of low-osmolarity oral rehydration salts [ORS], zinc supplementation, increased amounts of appropriate fluids, and continued feeding [WHO; 2014]. Treatment of diarrhea with ORS is a simple, proven, high-impact intervention that can be provided in home settings by caretakers or by health care providers at community and facility levels to prevent dehydration due to diarrhea and decrease related deaths. The first line of management of diarrhoea is therefore, the prevention of dehydration. This can also be achieved at home using Oral Rehydration Therapy [ORT].

The consistency and the volume of stool constitute how to classify diarrhoea. World Health Organization – WHO [2014] classified diarrhoea as acute or persistent based on its duration. An episode of diarrhoea that lasts less than two weeks is acute diarrhoea, while diarrhoea that lasts more than two weeks is persistent. Calogero et al[2000] further classified diarrhoea according to its typology: Secretary Diarrhoea, osmotic diarrhoea and exudative diarrhoea. Secretary diarrhoea results from active process in the intestinal epithelium stimulated by the presence of toxin, chemical or nutritional product in the intestinal linning. Osmotic diarrhoea is caused by the presence in the intestinal linning of osmotically active solutes that are poorly absorbed by the injection of laxatives such as magnesium sulphate or magnesium hydroxide. Exudative diarrhoea is associated with damage to the mucosa lining leading to outpouring of mucus, blood and plasma protein among other substances. However, it is important to note that the classification of diarrhoea does not influence the cause.

Diarrhoea is a symptom of infection caused by a host of bacterial, viral and parasitic organisms most of which can be spread by contaminated water. Diarrhoea in most cases is caused by three major groups of micro-organisms namely; Viruses, bacteria and protozoa or parasites [Lucas & Gilles, 2009]. The main agents of diarrhoea are enteroviruses [e.g. rotavirus, escherichia coli, campylobacter spp, shigella, vibrio cholera, salmonella [non typhoid], entamoeba histolytica, giardia lamblia, cryptosporidium]. These are further grouped in the following ways: Viruses

; Bacteria [e.g. shigella, escherichia coli, vibrio cholerae, salmonella non typhoid, campylobacter spp]. Parasites [e.g. entamoeba histolytica, crytosporidium and giardia lamblia]. All over the world, viruses especially rotavirus has been identified as the major cause of acute diarrhoea in children. Studies in Nigeria also found viruses as the major causes of diarrhoea in 60 per cent of cases with bacteria responsible for about only 3-20 per cent. Most of these pathogens are transmitted by faeco-oral route. Childhood diarrhoea within the context of this study refers to any type of loose, watery stool that occurs more frequently than usual in a child. The various causative agents vary according to the signs and symptoms manifesting from the disease.

The main consequence of diarrhoea are frequent loose or watery stools, the risk of dehydration, damage to intestine [especially when there is bloody diarrhoea] and loss of appetite with or without vomiting. However, Victoria, Bryce, Fountaine and Monasch [2000] asserted that signs of dehydration are not evident until there is acute fluid loss of approximately 4-5 per cent of body weight. The signs and symptoms of dehydration include sunken fontanels, dry mouth and throat, fast and weak pulse, loss of skin elasticity and reduced amount of urine. This loss leads to shock and untimely death of under-five. Werner [2001] noted that dehydration takes its heaviest toll on infants and children under-five. The signs and symptoms according to Longmach, Wilkinson and Rajagopalan [2004] are passage of frequent loose watery stools, abdominal cramps or pain, fever particularly if there is an infectious cause and bleeding. Bacteria and parasites often can produce bloody diarrhoea [dysentary]. In addition, inflammatory bowel disease, polyps and colorectal cancer can cause blood and mucus in the stools, nausea and vomiting may also be present in the case of infection.