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ORIGINAL ARTICLE
Year : 2022  |  Volume : 13  |  Issue : 1  |  Page : 8-12

Prescribing pattern for acute diarrhea in children: A survey of pediatricians from Maharashtra, India


Department of Pediatrics, MGM Medical College and Hospital, Navi Mumbai, Maharashtra, India

Date of Submission17-Jan-2022
Date of Acceptance16-Feb-2022
Date of Web Publication02-Sep-2022

Correspondence Address:
Dr. Jeetendra B Gavhane
Department of Pediatrics, MGM Medical College and Hospital, Plot No. 1 and 2, Sector-1, NH-4 Junction, Mumbai - Pune Highway, Kamothe, Navi Mumbai - 410 209, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjmsr.mjmsr_4_22

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  Abstract 


Context: Irrational use of medications for acute diarrhea in children is rampant. We conducted this survey to analyze prescription practices among pediatricians for acute diarrhea and their deviation from standard treatment guidelines. Subjects and Methods: A self-administered online questionnaire regarding prescription practices was circulated among pediatricians in Maharashtra, India, through various academic groups on WhatsApp, during the World Oral Rehydration Salt (ORS) Week, 2021. The questionnaire was anonymous and consisted of 15 compulsory close-ended multiple-choice questions. Results: Two hundred and eighty-seven pediatricians participated. Among which, 88.9% of the participants said that they prescribed ORS in acute diarrhea, 26.8% preferred zinc supplementation only in the case of watery diarrhea, 62% used probiotics or probiotics plus zinc combinations, and 60% said that they prescribe antisecretory drugs such as racecadotril. Forty percentage of the participants admitted that they occasionally use antibiotics for the management of acute diarrhea, while 5% said that they frequently do so. Most pediatricians advise appropriate ORS substitutes. Large number of pediatricians perceived probiotics (51.2%), dietary restriction (15.7%), racecadotril (10.5%), and antibiotics (6.3%) to be an important part in managing acute diarrhea. Only 25.4% of the pediatricians answered correctly and said parental counseling along with zinc and ORS work best as treatment. Conclusions: This study demonstrates low adherence by pediatricians to standard treatment guidelines for the management of acute diarrhea. Misuse of antibiotics and unscientific use of drugs were evidenced from this study. Awareness regarding the advantages of ORS among pediatricians is high. At present, there is a need to focus on appropriate feeding practices, emphasizing on the role of zinc and discouraging use of antibiotics, probiotics, antisecretory drugs, and irrational combinations.

Keywords: Acute diarrhea, oral rehydration salt, pediatric, prescription practice


How to cite this article:
Patra VS, Gavhane JB, Amonkar PS. Prescribing pattern for acute diarrhea in children: A survey of pediatricians from Maharashtra, India. Muller J Med Sci Res 2022;13:8-12

How to cite this URL:
Patra VS, Gavhane JB, Amonkar PS. Prescribing pattern for acute diarrhea in children: A survey of pediatricians from Maharashtra, India. Muller J Med Sci Res [serial online] 2022 [cited 2022 Oct 6];13:8-12. Available from: https://www.mjmsr.net/text.asp?2022/13/1/8/355296




  Introduction Top


Diarrheal diseases are responsible for 1 in 9 child deaths worldwide and are the second leading cause of death among children under the age of 5 years in India.[1],[2],[3] Diarrhea is thus one of the most common illnesses encountered in outpatient clinics and is managed by health-care professionals with varied levels of expertise. Given the enormous burden of this disease, detailed guidelines for the management of acute diarrheal disease in resource-poor settings have been outlined by the WHO (2005) and Indian Academy of Pediatrics (IAP) (2006)[4],[5] Despite the efforts made by the Government of India and IAP to increase awareness among physicians regarding appropriate management of this illness, irrational use of medications is rampant. We conducted this survey to analyze prescription practices for acute diarrhea and their deviation from standard treatment guidelines. Since the reach of awareness campaigns is highest in pediatricians, this survey was targeted toward them.


  Subjects and Methods Top


A cross-sectional survey was conducted in collaboration with the local branch of IAP, an academic body for pediatricians. Participation in the survey was anonymous and voluntary. A self-administered online questionnaire regarding prescription practices for children presenting with acute diarrhea was circulated among pediatricians in the state of Maharashtra, India, through various academic groups on WhatsApp, during the World Oral Rehydration Salt (ORS) Week, in July 2021. A total of 287 pediatricians participated. The questionnaire consisted of 15 compulsory close-ended multiple-choice questions. Most questions were single answer-only type, while few had the option of multiple answers. The questionnaire was designed to include questions related to all the possible medications that are given for acute diarrhea to children, their dosage, problems faced in prescribing, and perceptions on what modality works the best.

The data were entered into Microsoft Excel (2016, Microsoft Corporation, Redmond, WA, USA). Descriptive statistics in the form of frequencies and percentages were used to summarize answers to all the 15 questions. The study was approved by the institutional ethics Committee. Informed consent was obtained electronically from the pediatricians before inclusion in the study.


  Results Top


A total of 287 pediatricians voluntarily participated in this online survey. Questions regarding frequency of use of medications commonly prescribed for acute diarrhea by pediatricians on outpatient basis were asked [Figure 1]. We found that ORS was prescribed almost unanimously by all pediatricians. View on other medications, however, was widely divided and in many cases, in contrast to standard recommendations. Nearly 26.8% of the practitioners preferred zinc supplementation only in the case of watery diarrhea, whereas 62% used probiotics or probiotics plus zinc combinations. Sixty percentage of the pediatricians said that they prescribe antisecretory drugs such as racecadotril. Forty percentage of the pediatricians said that they occasionally use antibiotics for the management of acute diarrhea even when there was no blood in stools, while 5% said they frequently do so.
Figure 1: Medications prescribed in acute diarrhea by pediatricians across Maharashtra

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Various practical problems faced by pediatricians in ensuring the use of ORS by parents were enquired [Figure 2]. Pediatricians noticed that the taste of ORS was the main restrictive reason (87.5%). Most pediatricians advise appropriate ORS substitutes. Energy drink, which is a poor substitute for use in acute diarrhea, is advised by only 2.1% of the pediatricians.
Figure 2: Problems faced by pediatricians while prescribing oral rehydration salt and alternatives advised

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Other prescribing practices followed by pediatricians across Maharashtra are summarized in [Figure 3]. On choice of antibiotic in bloody diarrhea, 61.3% answered cefixime, which is the recommended antibiotic in acute dysentery. Interestingly, 15% of the pediatricians go for wait and watch policy rather than prescribing antibiotics. Up to 20% of the pediatricians use ofloxacin/ofloxacin plus ornidazole, which is not recommended. Use of colistin was also reported in our study.
Figure 3: Other prescribing practices in acute diarrhea

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Advice regarding quantity of ORS to be given varied. Some pediatricians advise adlib, frequent consumption, whereas others prefer to advise exact quantity that should be given. It is not recommended to stop lactose diet in acute diarrhea, so switching to soya milk is not advisable. In our study, 77% of the pediatricians adhere to this guideline of not recommending soya-based formula in acute diarrhea. Considering the availability of irrational combination medicines such as ORS plus zinc combinations, we asked questions on their usage. Majority of the participants (84.7%) answered that they have never used it.

Although 97.6% of the pediatricians correctly answered the most common cause of acute diarrhea in children as viral [Figure 4], almost 75% of the pediatricians gave answers that deviate from recommended guidelines when asked what works best in acute diarrhea. Large number of pediatricians perceived probiotics (51.2%), dietary restriction (15.7%), racecadotril (10.5%), and antibiotics (6.3%) to be an important part in managing acute diarrhea. Only 25.4% of the pediatricians answered correctly and said parental counseling along with zinc and ORS work best in acute diarrhea. Another 27.17% of the pediatricians answered probiotics in addition to parental counseling, zinc, and ORS work best. 6.2% of the pediatricians answered that parental counseling alone works best in management.
Figure 4: Perceptions of pediatricians regarding management of acute diarrhea

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  Discussion Top


According to the recommendations of the IAP National Task Force (2006),[5] low osmolarity ORS should be prescribed for all ages in all types of diarrhea along with zinc supplementation (20 mg/day for >6 months and 10 mg/day for younger than 6 months) for 14 days. The group does not recommend the use of probiotics, antisecretory drugs such as racecadotril, or marketing of ORS with additives (probiotics, minerals) due to insufficient evidence on their safety and efficacy. Multiple mass media campaigns on the management of diarrhea have been carried out by the Government of India and IAP so far, for sensitization of physicians and pediatricians. Various educational activities are also undertaken during the ORS week in July each year. However, despite these efforts, the gap between recommendation and actual practice is wide. The purpose of this study was, thus, to analyze current outpatient prescription practices of pediatricians and their perceptions regarding management of acute diarrhea.

Our survey shows that ORS has gained the confidence of pediatricians and its acceptance in clinical practice has increased significantly. Previous studies show low percentages of diarrhea prescriptions containing ORS.[6],[7],[8] The use of ORS has been increasing progressively over the years from 22% (1995)[6] 19% (1997)[7] and 58% (2011)[8] to as high as 70.5% (2019)[9] and 89% in the current study. Knowledge regarding ORS substitutes also seemed to be at par with recommendations and pediatricians are well aware of the instructions that need to be conveyed to parents to ensure its use. Improvement in the proportion of pediatricians who prescribe ORS may be an indicator of the success of educational campaigns promoting its use.

Twenty-three percentage of the pediatricians in our survey had misconceptions regarding feeding during diarrhea and advise use of soya-based formulae to avoid lactose. Although majority of participating pediatricians answered correctly regarding duration of zinc treatment, over one-forth pediatricians believed that zinc should be prescribed only if stools are watery. Studies show zinc prescription rates as low as 13.5%.[10] More than half of the pediatricians in our study prefer to use probiotics, antibiotics, antisecretory drugs, and irrational combinations despite lack of scientific evidence of their efficacy. The reason for this, we believe, is aggressive incentive-based marketing campaigns by pharmaceutical companies targeting practitioners and parental pressure for quick resolution of symptoms. Neither ORS nor zinc has dramatic effects on the reduction of stool quantity or frequency. Doctors, too, are now bearing the brunt of the increasingly consumer driven society and are giving in to parental demands for quick solution. Eighty percentage of general practitioners and 37% of pediatricians in a study from Karachi cited parental pressure for an effective drug to stop diarrhea, to be the reason for prescribing nonrecommended drugs.[11] Similar reasons have been cited by others.[12],[13],[14]

The use of antibiotics is only indicated in acute bloody diarrhea. However, in our study, 40% of pediatricians admitted to using antibiotics occasionally and 5% frequently, even when not indicated. Since we did not examine prescriptions in our study, the actual use of antibiotics may be far more rampant than what is demonstrated here. Studies show that antibiotics are the second most common drug prescribed for diarrhea after ORS.[15] Parental demands for prescribing antibiotics may be a contributing factor to this. On the contrary, 15% of the pediatricians in our study said they choose not to give antibiotics even if indicated. We also found the choice of antibiotic to be inappropriate in 25% replies. Use of colistin, which is a higher broad-spectrum antibiotic, for outpatient management of viral diarrhea is an eye-opening example of antibiotic abuse by practitioners and is a contributor to rising antimicrobial resistance. A study of diarrhea prescriptions from Ujjain showed that antibiotics were prescribed in 71% of diarrhea prescriptions and ofloxacin with ornidazole was the most frequent oral antibiotic prescribed.[8] Physicians with high-volume practices and those who are in practice longer are more likely to prescribe antibiotics inappropriately.[16]

Our survey demonstrates that pediatricians perceive a number of nonrecommended medications to be an important part of managing diarrhea. Similar perceptions regarding antibiotics, probiotics, and racecadotril were self-reported by doctors in a study from Bahrain.[17] It has been found that adherence to treatment guidelines for the management of diarrhea is low not only in India, but worldwide.[6],[18],[19],[20],[21] Antibiotics were prescribed during 16% GP consultations and 36% hospital admissions in a study from Poland.[22] It is even lower if the prescriptions by general physicians and practitioners of alternative medicine are examined. In a study of 843 diarrhea prescriptions, only six prescriptions for acute diarrhea were found to include both ORS and zinc, without probiotics, antibiotics, racecadotril, or antiemetics.[8] The use of irrational combinations and unnecessary drugs hampers proper management of acute diarrhea and also adds on to the cost of treatment.

It was observed in a study that the highest number of prescriptions that contained ORS and zinc with low antibiotic use came from medical colleges, where interference by pharmaceutical companies is least and awareness of recommendations is high.[8] A retrospective study carried out in a private tertiary care hospital of Chennai, India, showed that education of health-care workers on the use of zinc had resulted in an increase in its use to 75% and a decline in the use of antibiotics to below 30%, over a 3-year period.[23] Thus, there is an unmet need for education on the benefits of using zinc and appropriate antibiotic and drug use in acute diarrhea.


  Conclusions Top


This study demonstrates low adherence by pediatricians to standard treatment guidelines for the management of acute diarrhea and the wide gap between recommendations and actual practice. Misuse of antibiotics and unscientific use of drugs is evidenced from this study. Awareness regarding advantages of ORS among pediatricians is high. At present, there is a need to focus on appropriate feeding practices and discouraging use of antibiotics, probiotics, antisecretory drugs, and irrational combinations. Role of zinc also needs to be emphasized further. Inclusion of practitioners of all systems of medicine is necessary for worthwhile impact.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
CDC: Global Diarrhea Burden. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Foodborne, Waterborne, and Environmental Diseases at CDC; 2015. Available from: https://www.cdc.gov/healthywater/global/diarrhea-burden.html. [Last accessed on 2022 Jan 05].  Back to cited text no. 1
    
2.
WHO. Diarrhoeal Disease. Geneva: World Health Organization; 2017. Available from: https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease. [Last accessed on 2022 Jan 02].  Back to cited text no. 2
    
3.
Million Death Study Collaborators; Bassani DG, Kumar R, Awasthi S, Morris SK, Paul VK, et al. Causes of neonatal and child mortality in India: A nationally representative mortality survey. Lancet 2010;376:1853-60.  Back to cited text no. 3
    
4.
WHO. The Treatment of Diarrhoea: A Manual for Physicians and Other Senior Health Workers. Geneva: World Health Organization; 2005. Available from: http://www.who.int/child_adolescent_health/documents/9241593180/en/index.html. [Last accessed on 2022 Jan 05].  Back to cited text no. 4
    
5.
Bhatnagar S, Lodha R, Choudhury P, Sachdev HP, Shah N, Narayan S, et al. IAP Guidelines 2006 on management of acute diarrhea. Indian Pediatr 2007;44:380-9.  Back to cited text no. 5
    
6.
Singh J, Bora D, Sachdeva V, Sharma RS, Verghese T. Prescribing pattern by doctors for acute diarrhoea in children in Delhi, India. J Diarrhoeal Dis Res 1995;13:229-31.  Back to cited text no. 6
    
7.
Choudhry AJ, Mubasher M. Factors influencing the prescribing patterns in acute watery diarrhoea. J Pak Med Assoc 1997;47:32-5.  Back to cited text no. 7
    
8.
Pathak D, Pathak A, Marrone G, Diwan V, Lundborg CS. Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in Ujjain, India – A cross-sectional prescription analysis. BMC Infect Dis 2011;11:32.  Back to cited text no. 8
    
9.
Kesavan A, Vincent N, Jose R. Prescription pattern for acute diarrheal disease in children between 6 months to 5 years. Indian J Trauma Emerg Pediatr 2019;11:33-6.  Back to cited text no. 9
    
10.
Sontakke S, Khadse V, Bokade C, Motghare V. Medication prescribing pattern in pediatric diarrhea with focus on zinc supplements. Int J Nutr Pharmacol Neurol Dis 2016;6:152-6.  Back to cited text no. 10
  [Full text]  
11.
Nizami SQ, Khan IA, Bhutta ZA. Self-reported concepts about oral rehydration solution, drug prescribing and reasons for prescribing antidiarrhoeals for acute watery diarrhea in children. Trop Doct 1996;26:180-3.  Back to cited text no. 11
    
12.
Bhan MK. Current and future management of childhood diarrhoea. Int J Antimicrob Agents 2000;14:71-3.  Back to cited text no. 12
    
13.
Howteerakul N, Higginbotham N, Freeman S, Dibley MJ. ORS is never enough: Physician rationales for altering standard treatment guidelines when managing childhood diarrhoea in Thailand. Soc Sci Med 2003;57:1031-44.  Back to cited text no. 13
    
14.
Mittal SK, Mathew JL. Regulating the use of drugs in diarrhea. J Pediatr Gastroenterol Nutr 2001;33 Suppl 2:S26-30.  Back to cited text no. 14
    
15.
Panchal J, Desai C, Iyer G, Patel P, Dikshit R. Prescribing pattern and appropriateness of drug treatment of diarrhea in hospitalized children at a tertiary care hospital in India. Int J Med Public Health 2013;3:123-30.  Back to cited text no. 15
    
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Cadieux G, Tamblyn R, Dauphinee D, Libman M. Predictors of inappropriate antibiotic prescribing among primary care physicians. CMAJ 2007;177:877-83.  Back to cited text no. 16
    
17.
Ismaeel AY, Al Khaja KA, Damanhori AH, Sequeira RP, Botta GA. Management of acute diarrhoea in primary care in Bahrain: Self-reported practices of doctors. J Health Popul Nutr 2007;25:205-11.  Back to cited text no. 17
    
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Uhlen S, Toursel F, Gottrand F; Francaise de Pediatrie Ambulatoire (French Association of Ambulatory Pediatrics). Treatment of acute diarrhea: Prescription patterns by private practice pediatricians. Arch Pediatr 2004;11:903-7.  Back to cited text no. 18
    
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Cheraghali AM, Idries AM. Availability, affordability, and prescribing pattern of medicines in Sudan. Pharm World Sci 2009;31:209-15.  Back to cited text no. 19
    
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Hoekstra JH; European Society of Paediatric Gastroenterology; Hepatology and Nutrition Working Group on Acute Diarrhoea. Acute gastroenteritis in industrialized countries: Compliance with guidelines for treatment. J Pediatr Gastroenterol Nutr 2001;33 Suppl 2:S31-5.  Back to cited text no. 20
    
21.
Okubo Y, Miyairi I, Michihata N, Morisaki N, Kinoshita N, Urayama KY, et al. Recent prescription patterns for children with acute infectious diarrhea. J Pediatr Gastroenterol Nutr 2019;68:13-6.  Back to cited text no. 21
    
22.
Stefanoff P, Rogalska J, Czech M, Staszewska E, Rosinska M. Antibacterial prescriptions for acute gastrointestinal infections: Uncovering the iceberg. Epidemiol Infect 2013;141:859-67.  Back to cited text no. 22
    
23.
Balasubramanian S, Ganesh R. Prescribing pattern of zinc and antimicrobials in acute diarrhea. Indian Pediatr 2008;45:701.  Back to cited text no. 23
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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