Journal of Development Innovations

Vol. 2, No. 2, 2018, 1 – 9

© 2018 KarmaQuest International, Canada www.karmaquest.org/journal (ISSN: 2371-9540)

Impact of Serum Electrolyte Changes in Children with Acute Diarrhea:

Identifying the Risk Factors on Children's Health Outcomes and Its Impact in
Society

Sarita KC1, Sujeeta Bhandari2 and Babita Khanal3

ABSTRACT
This study was conducted at pediatric department of National Medical College and Teaching
Hospital, Birgunj, Nepal to identify Sodium and Potassium disturbances in acute diarrhea
and its role on children's health outcomes. Ninety one admitted patients of acute diarrhea
between the ages of 1 month to 5 years were studied and the results showed highly
significant relationship between serum electrolyte changes and dehydration. Majority of the
subjects had electrolyte abnormalities (57%) with hypokalemia in 37.4%, hyponatremia in
23.1%, hypernatremia in 7.7%, and hyperkalemia in 4.4%. Majority of cases were male
(57%) while more cases of severe dehydration appeared amongst the female (15.4%) than
male (6.6%) indicating less utilization of the health care services by female. This study
revealed that serum electrolytes should be monitored closely in patients with acute diarrhea
to minimize diarrhea induced morbidity and mortality. The study also identified the variety
of risk factors associated with high incidence of diarrhea, including drinking water without
any treatment, improper hand washing, and gender discrimination and forwarded
recommendation for wide range of prevention strategies including health education,
personal hygiene, and household sanitation.

JEL Classification: I15, I30

Keywords: Electrolyte, Acute Diarrhea, Children's Health, Household Sanitation

1 (Corresponding author) MD pediatrics, 9 Longueval lane, Broomfield, Christchurch 8042, New

Zealand, E-mail: saritakc.kc@gmail.com , Tel: +64 224767413
2
Assistant Professor, Department of Pediatrics at National Medical College and Teaching Hospital,
Kathmandu Branch, Nepal
3
Lecturer, Department of Pediatrics at Nobel Medical College, Teaching Hospital (P) LTD,
Biratnagar, Nepal
Journal of Development Innovations Vol. 2, No. 2, 2018

1. Introduction
Diarrhea is defined as passage of loose or watery stools more than 3 times a day (Ghai et
al., 2004; Shankarnaryanan, 2005). Diarrhea is also defined as daily stools with a volume
greater than 10 ml/kg in children younger than 2 years and greater than 200 gm in children
older than 2 years (Guandalini, 2018). WHO/UNICEF have defined acute diarrhea as an
attack of sudden onset, which usually lasts 3 to 7 days but may last up to 10 to 14 days (Park,
2007).
Till date, a large proportion of people suffers from diarrheal disease around the world,
especially in the developing countries (Ma et al., 2014). A majority of diarrhea occur
annually in children less than five years of age (World Health Organization, 2005). Lack of
breast feeding until 2 years of age plays a significant role in childhood diarrhea (World
Health Organization, 2005). The high incidence of diarrheal disorders in developing countries
is related to undernutrition, poor education and socioeconomic status, sanitary conditions,
trend of early breast milk substitutes, decreasing trend of exclusive breast feeding and faulty
practices of bottle feeding (Kliegman et al., 2007; Ma et al., 2014).
Electrolyte disturbances play an important role in the morbidity and mortality due to
acute diarrhea. The main cause of death in diarrhea is dehydration, which results from the
loss of fluids and electrolytes in diarrheal stools. Total body water is 60% of total body
weight in general. A 40% of total body weight is intracellular fluid (ICF) and 20% of total
body weight is extracellular fluid (ECF). The major electrolyte of ECF is sodium and ICF is
potassium, which get disturbed during diarrhea (KC et al., 2005).
The clinical manifestations of acute diarrhea are related to severity of water deficit and
pattern of electrolyte disturbances. In many parts of the world, especially in the developing
countries, laboratory facilities are not available or there is considerable time lag in obtaining
the results. Hence clinical recognition of water and electrolyte disturbances became important
(Dixit and Maskey, 2010). Timely recognition, a high index of suspicion, and thorough
understanding of common electrolyte abnormalities is necessary to ensure their correction
(Liu et al., 2012). In most cases information gained by asking detail about the illness and
observing and examining the child for specific signs is sufficient to make a diagnosis and
develop a plan for treatment (Kliegman et al., 2007).
Some of the researches conducted in diarrhea include Zulqarnain et al. (2015),
Mohammed and Tamiru (2014), Nasser (2014), Gangaraj et al. (2013), and Begum et al.
(2010). Zulqarnain et al. (2015) studied malnourished children with diarrhea to assess the
frequency of serum electrolyte disturbances. Mohammed and Tamiru (2014) studied the
burden of diarrheal diseases among children under five years of age and associated risk
factors. Nasser (2014) studied the socio-demographic, socio-economic and household
environmental characteristics associated with diarrheal disease among children under five
years of age. Gangaraj et al. (2013) studied electrolytes and blood sugar changes in severely
acute malnourished children and its association with diarrhea and vomiting. Begum et al.
(2010) studied the impact of electrolyte disturbances in the outcome of acute diarrhea in
children. These studies have provided important insights into diarrhea, its risk factors, and
complications. However, those studies have not considered hospitalized and normally
nourished children between the ages of one month to five years which is very common age
for mortality and morbidity due to diarrhea. This study was conducted in normally nourished
children admitted in hospital due to diarrhea between the age of one month to five years to
identify: (1) the incidence of various types of electrolyte imbalance in children with acute
diarrhea, (2) the incidence of age and sex distribution of acute diarrhea in children; (3) the
state of hydration in admitted cases of acute diarrhea in children; (4) the association between

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state of hydration and electrolyte changes, and (5) the effect on household sanitation.
The paper is organized as follows: Section 2 outlines the methodology; results are
discussed in Section 3; Section 4 discusses the socio-economic impact; and Section 5
concludes.
2. Methodology
2.1 Sample Selection and Data
The study was conducted at National Medical College and Teaching Hospital (NMCTH),
Birgunj, Nepal because diarrhea is the second common causes of hospital admission in
pediatric department at NMCTH. In addition, NMCTH is one of the well-equipped and most
referred tertiary care institutions in the southern part of Nepal. Sample was collected based on
the following criteria: one month to five years aged children, having diarrhea for less than 14
days, admitted at the NMCTH, those whose guardians agreed to give consent to the study,
those who have not taken intravenous fluids before admission at the NMCTH, and those not
having malnutrition and/or metabolic disorders.
The sample size comprised of ninety one patients who experienced acute diarrhea in order
to test the Sodium and Potassium levels and state of Hydration. The study was conducted
over the period from August 10, 2014 to August 9, 2015. The detail questionnaire used for
the survey is available in KC (2015). Four criterion as shown in Table 1 were used to classify
the state of dehydration. At least 2 out of 4 signs shown in the table must be present to define
state of hydration.
Table 1: Criterion for states of hydration

Dehydration
Signs
No Some Severe
Condition/mental status Well, alert Restless, irritable Lethargic, unconscious
Eyes Normal Sunken Very sunken
Mouth and tongue Moist Dry Very dry
Skin pinch Goes back quickly Goes back slowly Goes back very slowly
Source: Flerlage and Engorn (2015) and Paul and Bagga (2013)
To classify the normal and abnormal values of electrolytes, following criterion
suggested by Flerlage and Engorn (2015) and Paul and Bagga (2013) were used:
For Sodium
 135- 145meq/l indicate normal (Isonatremia)
 <135meq/l indicates Hyponatremia
 >145meq/l indicate Hypernatremia
For Potassium
 3.5-5.5meq/l refer normal (Isokalemia)
 <3.5meq/l refer Hypokalemia
 >5.5meq/l Hyperkalemia
2.2 Statistical Analysis
The study applied crosstab analysis to identify the association between different
categorical variables that included age (in category of different age groups), diarrhea,

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dehydration, prevalence of Serum Sodium, and the gender. The approach tested the null of no
association between the variables against the existence of association based on Chi-square
distribution. The results were obtained by using SPSS statistical software.
3. Results and Discussions
3.1 Distribution of acute diarrhea in relation to age and gender
Among 91 children studied, 52 were male (57%) whereas 39 were female (43%), a
similar distribution as found in Maharjan et al. (2007) where 60% were male and 40% were
female (Table 2). More prevalence in male over female depicts less utilization of the health
care services by female children which is routine in Nepalese society. As can be seen in the
table, acute diarrhea was more common in the age group between 6 – 23 months which might
be associated with weaning and hygiene. Shah et al. (2007) also showed majority (70%) of
patients with diarrhea were below 2 years of age.
Table 2: Distribution of acute diarrhea in relation to age and gender

Age Male Female Total

1-5 months 10 (11%) 7 (7.7%) 17 (18.7%)

6-23 months 35 (38.4%) 21 (23.1%) 56 (61.5%)

24-60 months 7 (7.7%) 11 (12.1%) 18 (19.8%)
Total 52 (57.1%) 39 (42.9%) 91 (100%)
3.2 State of dehydration in relation to gender
Large proportion of children covered by the study had some dehydration (62.6%)
followed by severe dehydration (22%) and no dehydration (15.4%) (Table 3). Severe
dehydration was more common in female patients while some dehydration and no
dehydration were more common in male patients. The test of association also justified this by
showing a significant relationship between state of dehydration and the gender as shown by
p-value.
Table 1: Association between state of dehydration and gender

Chi-square Test
Dehydration Male Female Total
(p-value)
No 12 (13.2%) 2 (2.2%) 14 (15.4%)

Some 34 (37.3%) 23 (25.3%) 57 (62.6%) 0.004

Severe 6(6.6%) 14(15.4%) 20 (22%)
Total 52 (57.1%) 39 (42.9%) 91 (100%)
3.3 Sources of drinking water, treatment of drinking water and place of defecation
Table 4 shows different sources of drinking water, ways of treatment of drinking water,
and place of defecation. Majority of the interviewee informed that they drink water without
any treatment (84%) which could be one of the contributing factors for diarrhea. Majority of
the children used toilet facility (84%), but they used only water and no soap to wash their
hands. It may also have contributed to the incidence of diarrhea.

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Table 4: Source of drinking water, treatment of drinking water, and place of defecation

Numbers of
Description Percentage
interviewee
Bore well 73 80%
Sources of drinking water Tap 16 18%
Open well 2 2%
No treatment 76 84%
Boiling 5 5%
Treatment of drinking water
Filtration 8 9%
Chlorination 2 2%
Toilet 76 84%
Place of defecation
Open field 15 16%
3.4 Distribution of Serum Sodium in relation to state of hydration
Table 5 shows the relationship between states of hydration and Serum Sodium status in
the children under study. Normal Sodium level was noted in 63 children (69.2%),
Hyponatremia was noted in 21 children (23.1%) and Hypernatremia was noted in 7 children
(7.7%). Statistical analysis showed highly significant association between distributions of
Serum Sodium and States of Hydration.
Table 5: Distribution of Serum Sodium in relation to state of Hydration

States of hydration
Chi-square
Sodium No Some Severe Total Test (p-
dehydration dehydration dehydration value)
Isonatremia 12 (13.2%) 43 (47.2%) 8 (8.8%) 63 (69.2%)
Hyponatremia 1 (1.1%) 13 (14.3%) 7 (7.7%) 21 (23.1%) 0.009
Hypernatremia 1 (1.1%) 1 (1.1%) 5 (5.5%) 7 (7.7%)

Sodium levels obtained in this study was consistent with various previous studies as shown in
Table 6. All the studies included in Table 6 indicated that Hyponatremia is more common
than Hypernatremia. This implies that loss of Sodium ratio is greater than loss of water
during diarrhea. Therefore, close monitoring of serum sodium level and sodium replacement
is essential for the Hyponatremic children.
Table 6: Comparison of Sodium levels in prior studies

Sodium levels (Bhutta et al., 2013) (Farthing et al., 2013) This study
Normal 72.8% 54.5% 69.2%
Hyponatremia 20.8% 39% 23.1%
Hypernatremia 6.4% 6.5% 7.7%
3.5 Distribution of Serum Potassium in relation to state of hydration
Table 7 shows the relationship between States of Hydration and Serum Potassium levels
for children under study. Normal Potassium level was noted in 53 (58.2%), Hypokalemia was
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noted in 34 (37.4%) and Hyperkalemia was noted in 4 (4.4%) children. Crosstab analysis
depicted a significant relationship (p<0.01) between distributions of Serum Potassium and
States of Hydration.
Table 7: Distribution of Serum Potassium in relation to states of hydration

Potassium States of hydration Total Chi-square

No Some Severe Test (p-
dehydration dehydration dehydration value)

Isokalemia 11 (12.1%) 33 (36.2%) 9 (9.9%) 53 (58.2%)

Hypokalemia 3 (3.3%) 24 (26.4%) 7 (7.7%) 34 (37.4%) 0.002
Hyperkalemia 0 0 4 (4.4%) 4 (4.4%)
Potassium levels obtained in this study was also consistent with prior studies as shown in
Table 8. All the studies included in Table 8 indicated that Hypokalemia is more common than
Hyperkalemia which implies that loss of potassium ratio is greater than loss of water during
diarrhea. Therefore, Hypokalemic children are required to have close monitoring of Serum
Potassium level, and potassium replacement is necessary to correct Hypokalemia.
Table 8: Comparison of Potassium levels in various studies

Potassium levels KC et al. (2005) Shah et al. Begum et al. This study
(2007) (2010)
Normal 64.70% 51% 67.40% 58.20%
Hypokalemia 26.50% 46% 31.40% 37.40%
Hyperkalemia 9% 3% 1.20% 4.40%
3.6 Isolated and mixed Electrolyte disturbances
Table 9 shows the combined status of Hyponatremia and Hypokalemia amongst the studied
cases. Identification of the most common electrolyte imbalance is a key to prioritize treatment
schedule to avoid potential casualties. As can be seen in the table, 52 (57.1%) children had
electrolyte imbalance and 39 (42.9%) had normal electrolytes in their serum. The most
common electrolyte abnormality was Isolated Hypokalemia (24.2%) and the least common
electrolyte abnormality was Hyperkalemia (2.2%).
Table 9: Frequency of isolated and mixed Electrolyte disturbances

Electrolyte disturbances Frequency Percentage

Isolated Hyponatremia 11 12.1
Hyponatremia + Hypokalemia 8 8.8
Hyponatremia + Hyperkalemia 2 2.2
Isolated Hypernatremia 3 3.3
Hypernatremia + Hypokalemia 4 4.4
Hypernatremia + Hyperkalemia 0 0
Isolated Hypokalemia 22 24.2
Isolated Hyperkalemia 2 2.2
Total abnormal 52 57.1
Normal electrolyte 39 42.9
Among the children under study, majority of electrolyte imbalance was Hypokalemia

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37.4% (Isolated Hypokalemia 24.2% plus mixed Hypokalemia 13.2%) followed by

Hyponatremia 23.1%, Hypernatremia 7.7% and Hyperkalemia 4.4% (see table 5 and 7).
4. Socio-Economic Impact
Severe complications of diarrhea are dehydration and electrolyte abnormalities which
cause morbidity and mortality if proper treatment is not administered in time. Acute diarrhea
is one of the common causes of morbidity and mortality in children under 5 years throughout
the world especially in the developing countries (Ma et al., 2014). Acute diarrhea is common
in Asian and African countries. For example, in Busia town of Kenya 16.7% of children were
suffered from diarrhea which was comparable to 14% children suffered in Nepal (Ministry of
Health and Population (MOHP), 2012; Muasya, 2013). More than 4000 children lose their
lives each day due to diarrhea worldwide (Woldu et al., 2016). According to Patwari (1999),
there is a marked negative relationship between diarrhea and physical growth & development
of a child. There are notable social and economic costs induced by the incidence of diarrheal
diseases (Ma et al., 2014).
This study identified a variety of risk factors associated with high incidence of diarrhea,
including drinking water without any treatment and improper hand washing. In addition,
gender discrimination has caused more severe dehydration due to diarrhea in girls. It is
believed that the findings of this study will help concerning agency to take necessary steps to
ensure children's healthy life and reduce morbidity and mortality due to diarrhea among them.
To diminish the diarrhea induced child death, implementation of wide range of prevention
strategies including health education, personal hygiene, and household sanitation are essential.
Since close monitoring of dehydration and serum electrolytes is very essential for proper
treatment, such preventive measures will not only save lives of children and ensure sanity in
the society but also save a huge financial burden to the nation that may arise from unhealthy
population.
5. Conclusion
This study was based on 91 children with acute diarrhea between the ages of one month to
five years admitted at paediatrics department of National Medical College & Teaching
Hospital, Birgunj, Nepal. The results showed a higher incidence of acute diarrhea in male
(57.1%) compared to female (42.9%). However, severe dehydration was common in female
(15.4%) compared to male (6.6%) with highly significant association between state of
hydration and gender as suggested by crosstab analysis. Maximum incidence was found
amongst the age group of 6 to 23 months (61.5%). Electrolyte imbalance was common
(57.1%) than normal electrolytes level (42.9%). Most common electrolyte imbalance was
Hypokalemia (37.4%) followed by Hyponatremia (23.1%), Hypernatremia (7.7%), and
Hyperkalemia (4.4%). There was highly significant association between Sodium and
Potassium changes and states of hydration in the studied children as shown by significance
test of association. The results warrant for prevention strategies such as health education,
personal hygiene, and household sanitation to be pursued to reduce the morbidity and
mortality among children.
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