394 Journal of the College of Physicians and Surgeons Pakistan 2016, Vol. 26 (5): 394-398

INTRODUCTION

Diarrhea is still one of the leading causes of morbidity

and mortality in children around the world.

1-6

Oral

rehydration treatment has considerably reduced

complications and mortality from diarrheal diseases. Still

many children with diarrhea suffer from dehydration and

electrolyte imbalance.

Presence of different types of electrolyte disorders is

associated with significant increase in mortality rates

among children with diarrhea.

Electrolyte disorders may

remain unrecognized and result in increased morbidity

and mortality. Timely recognition, a high index of

suspicion, and a thorough understanding of common

electrolyte abnormalities is necessary to ensure their

correction. Different studies have shown different

incidences of electrolyte disorders among children with

dehydration. The present study was undertaken to

ascertain the frequency of different types of electrolyte

disorders among children with diarrhea related severe

dehydration, and to study the correlation of electrolyte,

urea and creatinine levels with age of the patients. No

study conducted previously had evaluated the

correlation of electrolyte, urea, and creatinine levels with

age of the patients. According to our research, none of

these studies evaluated chloride levels in children of

all age groups with dehydration. Previous studies

evaluated chloride levels only among children below one

year and among children with malnutrition. Parameters

of this study included checking of chloride levels among

pediatric patients with severe dehydration belonging to

all nutritional statuses and age groups and we also

studied correlation between levels of different electrolytes

and renal function tests with age of the patients.

METHODOLOGY

Appropriate sample size was calculated using World

Health Organization (WHO) sample size calculator. The

calculations of sample size were based on the given

prevalence of 6.4% for hyponatremia among children

with diarrhea in a study by Samadi et al.

At the

prevalence of 6.4%, level of confidence 95%, at required

precision of 5%, the sample size required was at least

93 cases.

All patients with acute watery diarrhea from birth to 18

years age, who presented in outdoor and emergency of

Fazle-Omar Hospital, Rabwah, Paksitan, from January

to December 2012 were assessed for the status of

hydration by a doctor in emergency and in pediatric

ward and intensive care unit. The patients with severe

ORIGINAL ARTICLE

Prevalence of Electrolyte Disorders Among Cases of Diarrhea

with Severe Dehydration and Correlation of Electrolyte

Levels with Age of the Patients

Mirza Sultan Ahmad, Abdul Wahid, Mubashra Ahmad, Nazia Mahboob and Ramlah Mehmood

ABSTRACT

Objective: To find out the prevalence of electrolyte disorders among children with severe dehydration, and to study

correlation between age and electrolyte, urea and creatinine levels.

Study Design: Prospective, analytical study.

Place and Duration of Study: Outdoor and indoor of Fazle-Omar Hospital, Rabwah, Pakistan, from January to December

2012.

Methodology: All patients from birth to 18 years age, presenting with diarrhea and severe dehydration were included in

the study. Urea, creatinine and electrolyte levels of all patients included in the study were checked and recorded in the

data form with name, age and outcome. The prevalence of electrolyte disorders were ascertained and correlation with age

was determined by Pearson's coefficient.

Results: At total of 104 patients were included in the study. None of the patients died. Hyperchloremia was the commonest

electrolyte disorder (53.8%), followed by hyperkalemia (26.9%) and hypernatremia (17.3%). Hyponatremia, hypokalemia

and hypochloremia were present in 10.6%, 7.7%, and 10.6% cases, respectively. Weak negative correlation was found

between age and chloride and potassium levels.

Conclusion: Different electrolyte disorders are common in children with diarrhea-related severe dehydration.

Key Words: Diarrhea. Dehydration. Water-Electrolyte imbalance.

Department of Pediatrics, Fazle-Omar Hospital, Rabwah,

Pakistan.

Correspondence: Dr. Mirza Sultan Ahmad, Head of the Pediatric,

Fazle-Omar Hospital, Rabwah, Pakistan.

E-mail: ahmadmirzasultan@gmail.com

Received: June 02, 2015; Accepted: February 06, 2016.

dehydration were included in the study. WHO criteria

was used to assess the status of hydration. Following

signs were taken as signs of severe dehydration:

(i) lethargy or loss of consciousness, (ii) sunken eyes,

(iii) drinks poorly or not able to drink, (iv) After skin pinch,

skin goes back very slowly. If at least 2 of these signs

were present, it was labelled as severe dehydration. The

patients who had other diagnoses besides acute watery

diarrhea were included in the study. History was taken to

assess whether the participants had taken oral

rehydration salts (ORS) or not; and if it was taken,

whether or not its volume given after each loose motion,

since the commencement of diarrhea was according to

WHO recommendations. The patients with blood in

stools and those who were given intravenous fluids

within 6 hours before presentation or before taking of

blood samples were excluded from the study. Blood

samples were collected before giving intravenous fluids.

SPSS version 20 was used for data analysis. Urea,

creatinine, sodium, potassium, and chloride levels were

checked by ISE method (Prolyte machine). Name, age,

urea, creatinine, electrolyte levels, and outcomes were

recorded on a proforma and data sheet of SPSS version

20 by doctors conducting the study.

Potassium levels below 3.5 mmol/l and above 5 mmol/l

were categorized as hypokalemia and hyperkalemia,

respectively. Sodium levels below 130 mmol/l and above

150 mmol/l were taken as hyponatremia and hyper-

natremia, respectively. Chloride level below 98 mmol/l

and above 108 mmol/l were categorized as hypo-

chloremia and hyperchloremia, respectively. Urea

and creatinine levels higher than 6.7 mmol/l and

125 ummol/l, were considered higher than normal.

Patients were divided in to 4 groups according to age

(i) below 1 month, (ii) 1 month to 11 months, (iii) 1 year

to 4 years 11 months, (iv) above 5 years. All cases were

admitted and rehydrated with Ringer's Lactate and other

appropriate treatments.

Ethical Committee of Fazle-Omar Hospital approved

the study.

RESULTS

A total of 104 patients were included in the study. None

of the patients died. According to age, 11 (10.6%)

patients were below one month, 48 (46.1%) were

between 1 month and 11 months, 32 (30.8%) were

between 1 year and 4 years and 11 months, and

13 (12.5%) were ≥ 5 years. Eighteen (17.1%) patients

had taken ORS. None of them took quantity of ORS after

loose motions, according to WHO recommendations.

Urea level was high in 88 (84.6%) patients. Creatinine

level was high in 36 (34.6%) patients. Hyperchloremia

was the commonest electrolyte abnormality (53.8%),

followed by hyperkalemia (26.9%) and hypernatremia

(17.3%) [Table I].

Minimum and maximum sodium levels were 124 mmol/l

and 190 mmol/l, respectively. Median value was 142

mmol/l. Minimum and maximum potassium levels were

2.19 mmol/l and 6.8 mmol/l, respectively. Median value

was 4.78 mmol/l. Minimum and maximum chloride levels

were 85 mmol/l and 150 mmol/l, respectively. Median

level was 107 mmol/l. Correlation of the electrolyte, urea

and creatinine levels with age of the patients were

checked. Urea, potassium, and chloride levels had weak

negative correlation with age of the patients (Table II).

Median sodium levels of patients with age < 1 month,

1 month to 11 months, 1 year to 60 months, and > 5

years were 146 mmol/l, 142 mmol/l, 140 mmol/l, and 143

mmol/l, respectively. Median chloride levels in these 4

age groups were 112 mmol/l, 108.5 mmol/l, 103.5

mmol/l, and 106 mmol/l, respectively. Median potassium

levels in these age groups were, 4.3 mmol/l, 5.150

mmol/l, 4.40 mmol/l, and 4.20 mmol/l, respectively.

Table III shows mean ranks of electrolytes in different

groups according to age, along with pairwise comparisons.

Spearman's coefficient was used to check correlation

between continuous variables. Spearman's coefficient (rs)

of 0.0 - 0.19 was taken as very week, 0.20 - 0.39 as

Electrolyte levels in severe dehydration

Table I: Prevalence of electrolyte abnormalities among pediatric

cases of severe dehydration.

Electrolyte Low Normal High Total

Sodium 11 (10.6%) 75 (72.1%) 18 (17.3%) 104

Potassium 8 (7.7%) 68 (65.4%) 28 (26.9%) 104

Chloride 11 (10.6%) 37 (35.6%) 56 (53.8%) 104

Table II: Correlation of age with electrolyte levels and renal function tests.

Variables Spearman’s coefficient ( rs) p-value

Sodium -.080 .422

Potassium -.304 .002

Chloride -.304 .002

Urea -.291 .003

Creatinine -.049 .620

Table III: Mean ranks of electrolytes in different groups according to age.

Electrolyte < 1 month 1 - 11 months 1 - 5 years > 5 years p-value Pairwise comparisons

a b c d ab ac ad bc bd cd

Sodium 62.3 52.9 46.1 58.3 .379

Chloride 64.4 60.2 39.8 45.3 .001 .70 .02 .10 .003 .12 .34

Potassium 48.9 62.8 44.8 36.7 .010 .30 .99 .64 .006 .005 .35

Kruskal-Wallis test was done to evaluate difference between different age groups. If Kruskal-Wallis test was significant Mann-Whitney U test was applied for pairwise comparison.

Journal of the College of Physicians and Surgeons Pakistan 2016, Vol. 26 (5): 394-398 395

weak, 0.40 - 0.59 as moderate, 0.60 - 0.79 as strong,

and 0.80 - 1.0 as very strong correlation.

Kruskal-Wallis test was used to assess significant

difference on a continuous dependant variable by a

grouping independent variable, if the groups were 3 or

more. If the result of Kruskal-Wallis test was found to be

significant, pairwise comparison was conducted by

Mann-Whitney U test. P-value of 0.05 or less was taken

as significant.

DISCUSSION

Majority of children with dehydration suffer from different

electrolyte abnormalities.

As shown in Table I, hyper-

chloremia was the commonest electrolyte disorder in

this study. Chloride ion is distributed exclusively within

the extracellular fluid (ECF), which comprises the blood

and the interstitial fluid compartments. It is the major

anion associated with sodium in the ECF. Conditions

causing elevation of the serum chloride concentration

and a concomitant elevation of the serum sodium

concentration result primarily from disorders associated

with loss of hypotonic fluids. Causes of hypochloremia

include loss of chloride ion from gastrointestinal tract by

diarrhea, vomiting, and through nasogastric tube.

Severe vomiting may lead to the most disproportionate

loss of chloride compared to sodium since gastric

chloride content is greater than 100 mEq/L and gastric

sodium content is relatively low (20 - 30 mEq/L).

Relatively few studies have analyzed chloride among

cases of diarrhea. A study by Weizman et al. showed

that among 74% cases of infants with some and severe

dehydration presented with normal anion gap and

hyperchloremia (115.8 ±4.2 mmol/L).

In this study,

53.8% cases had hyperchloremia.

Disorders of sodium levels among cases diarrhea

related dehydration can constitute a medical emergency

requiring a prompt and adequate diagnosis and

management.

Different studies have shown different

prevalences of hyponatremia and hypernatremia among

children with dehydration. According to a study by

Chouchane et al., hypernatremia was present in 11.51%

cases of all kinds of dehydration.

A study by Samadi

et al. included children admitted with diarrhea. This

showed that hyponatremia and hypernatremia were

present in 20.8% and 6.4% cases, respectively.

The

study by Shah et al. showed that 56% of cases admitted

with diarrhea and dehydration had hyponatremia,

while hypernatremia was present in 10% cases.

Hypernatremic dehydration is also a serious problem in

neonatal age. Neonates with weight loss are at

increased risk of developing hypernatremia. Some of

these cases suffer from long-term neurological

consequences.

12-16

Unlike the studies by Samadi et al. and Shah et al., this

study showed that hypernatremia was more common

than hyponatremia, and majority had normal sodium

levels.

Different factors can alter the prevalence of electrolyte

disorders among children with diarrhea. Malnutrition is

one of these factors. It has been shown to be significant

factor that alters the prevalence of electrolyte disorders

among children with diarrhea. A study by Memon

et al.

showed that hyponatremia and hypokalemia were

significantly more common in children with malnutrtition

among children from age of 6 months to 5 years.

Another factor that can alter the amount of electrolyte

loss in stools is the causative pathogen. Diarrhea due to

different pathogens can lead to significantly different

amount of electrolyte loss in the stool. It can also

increase significantly because of electrolyte transport

into fecal water due to exogenous substances and

toxins, e.g. cholera toxin. A study by Molla

et al., showed

that the mean stool sodium concentration in cholera was

88.9 mmol/L, in enterotoxigenic

Eschericia coli 53.7

mmol/L, and in rotavirus infection, 37.2 mmol/L.

These

factors explain why different studies show different

incidence of electrolyte abnormalities.

Timely detection and correction of electrolyte disorders

is important. Various studies have shown that disorder in

sodium levels leads to adverse effect on outcome. A

study by Molat et al. showed that increasing severity of

hypernatremia leads to increase in mortality rate and is

associated with significant difference in Denver

Developmental Screening II test results.

Similarly,

study by Molaschi et al. conducted in elderly population

showed that mortality was positively related to sodium

levels.

A study by Corona et al. showed that among

cases suffering from hyponatremia, correction of sodium

level leads to improvement in mortality rate.

The study

by Samadi et al., showed that among children under 3,

with diarrhea and dehydration, the case fatality rates

were 10.1% in hyponatremia, 3.8% in isonatremia, and

1.2% in hypernatremia.

As none of the case included

in this study died, effect of sodium abnormality on

mortality rate cannot be studied.

Many studies have been conducted in the past to study

the prevalence of different electrolyte disorders among

children. These studies show that disorders of sodium

levels are common among children with severe

dehydration. Studies from South Asia show that

hyponatremia is more common as compared with

hypernatremia in pediatric age group. This study shows

that now among children with severe dehydration,

hypernatremia is more common as compared to

hyponatremia. Above mentioned information can help us

decide the electrolyte constituents of the intravenous

Mirza Sultan Ahmad, Abdul Wahid, Mubashra Ahmad, Nazia Mahboob and Ramlah Mehmood

396 Journal of the College of Physicians and Surgeons Pakistan 2016, Vol. 26 (5): 394-398

and oral rehydration fluids used to correct severe

dehydration.

Disorders of potassium levels are common among

children with diarrhea and also among critically ill

pediatric patients suffering from other ailments.

Hypokalemia is a common complication among children

admitted in intensive care. It can have profound effects

on electrical activity in cardiac, skeletal and smooth

muscle. If severe, these may result in life threatening

conditions like cardiac arrhythmias, cardiac arrest,

respiratory failure, muscular paralysis and paralytic

ileus. A study by Singhi

et al. showed that 14.8% cases

in pediatric intensive care unit had hypokalemia, and

mortality rate among these patients was significantly

higher (25.6%) as compared with other patients

admitted in the same unit (10.9%).

Hypokalemia is a

common problem among children with diarrhea and

dehydration. In the study by Shah

et al., among the

children with diarrhea and severe dehydration 46%

cases had hypokalemia.

Total body potassium is decreased as much as 25% in

malnourished children, due to decreased intake and

reduced muscle mass. Study by Odey

et al. showed

among children of protein energy malnutrition with

diarrhea, hypokalemia was the commonest (23.4%)

electrolyte disorder.

In this study, the prevalence of hyperkalemia (26.9%)

was higher as compared to the prevalence of

hypokalemia (7.7%). One reason for higher prevalence

of hyperkalemia in this study can be that only children

with severe dehydration were included in this study. In

severe dehydration, metabolic acidosis is present that

causes intracellular potassium to shift to extracellular

compartment.

We used Pearson's coefficient to study the strength of

association between electrolyte levels, urea, creatinine,

and age of the patient. There was weak negative

correlation between age of the patients and urea,

potassium, and chloride levels.

This study is the first study which has ascertained

chloride levels in the pediatric patients of all age groups

with severe dehydration, regardless of their nutritional

status. And this shows that hyperchloremia is the

commonest electrolyte disorder among these cases. No

previous study had evaluated the correlation between

age of the patients and levels of electrolytes, urea and

creatinine.

CONCLUSION

Among patients with diarrhea-related severe dehydration,

hyperchloremia, hypernatremia, and hyperkalemia are

common electrolyte abnormalities. None of the patients

with severe dehydration, included in this study, had

taken ORS according to WHO recommendations. It is

necessary to keep watch over signs and symptoms of

electrolyte disorders among patients having severe

dehydration. If such clinical manifestations are present,

electrolyte levels should be checked. Proper use of

ORS, according to WHO recommendations, should be

promoted.

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