7. PROPUESTA DE MEJORA
7.6. Población objeto
1. Probiotics (Sacchromyces boulardii) significantly reduces the duration of diarrhoea and number of episodes of diarrhoea in young children hence reducing the risk of having persisitent diarrhoea which might ultimately lead to malnutrition.
2. There were no significant effects of the probiotic used in the relief of associated symptoms like fever, abdominal pain and vomiting.
3. Shigella sp was the most common agent identified in the stools of the subjects;
however Rotavirus which is the most common causative organism in children with diarrhoea was not checked for because of lack of adequate laboratory tools.
5.5 Reccommendations 5.5.1 Future Research
There are various types and strains of probiotics each having different properties and certain health benefits. Different strains should be well researched for different conditions which should be well defined. It is recommended that large well coordinated multicentre and community based studies should be done in Nigeria and Africa as a whole with a larger sample size because of the high incidence of diarrhoea which can contribute to malnutrition if left untreated.
5.5.2. The role of the family in managing diarrhoea
The family and the community’s role in the management of diarrhoea is mainly through prevention. The revised recommendations emphasize family and community understanding of
95
preventing, recognizing and appropriately managing diarrhoea. When they become routine practice, caretakers will act quickly at the first sign of diarrhoea, rather than wait before treating the child. Mothers and caretakers should:
1. Improve hygiene through hand washing with soap, increase use of improved sources of drinking water and sanitation services
2. Prevent dehydration through the early administration of increased amounts of appropriate fluids available in the home or ORS if at hand
3. Provide children with 20mg per day of zinc supplementation for 10 to 14 days as part of the diarrhoea treatment
4. Promote exclusive breastfeeding and increase breastfeeding and all feeding during and after the episode of acute diarrhoea6,23
5. Recognize the signs of dehydration and take the child to a health care provider for ORS or intravenous electrolyte solution as well as familiarize themselves with other symptoms requiring medical treatment (example bloody diarrhoea).
5.5.3. The role of the family physician in the prevention/treatment of diarrhoea The family physician should:
1. Counsel mothers to begin administering suitable available home fluids immediately upon onset of diarrhoea in a child
2. Treat diarrhoea in children with probiotics.
3. Treat dehydration with ORS solution or with an intravenous electrolyte solution in cases of severe dehydration and provide children with zinc 20mg/day of zinc supplementation for 10-14 days as part of the treatment
4. Emphasize continued feeding or increased breastfeeding during the diarrhoea episode and increased feeding after the diarrhoea episode
96
5. Use antibiotics only when appropriate ie in the presence of bloody diarrhoea or shigellosis and abstain from administering anti-diarrhoea drugs
6. Promote hygiene, sanitation and water
7. Promote and ensure adequate vitamin supplementation.6,23
97 References
1. Diarrhoea: Identifying serious illness and providing relief. Retrieved from www.ebmedicine.net Accessed 8th July 2012
2. Olawuyi JF, Egbewede BE, Anifalaye LA, Okochi EA. Care seeking practices on diarrhoea in a rural community. African Journal of clinical and experimental microbiology. 2004;5(1):119-125
3. Bosch-Pinto C, Lanata CF, Black RE. Global Burden of Childhood Diarrhoea. In Maternal and Child Health. Ehiri JE (editor). Springer Science and Business Media.
2009. Pages 225-243
4. Strait Times: Diarrhoea kills 3 more times. Available from
www.straitimes.com/breakingnews Posted October 15 2009. Accessed 7th June 2012
5. World Health Organization. Diarrhoea: Why children are still dying and what can be done. Retrieved from http:whqlibdoc.who.int/publications/2009/978924598415eng.pdf Accessed 2009
6. Child Health Reference Group (CHERG) of WHO and UNICEF. 2012 Briefing 7. Natahu UCM, Bhatnagar S. Diarrhoea in Children: Identifying the cause and Burden.
The Laancet.2013;382(9888):184-186
8. PHYSORG. Probiotics shorten diarrhoea episodes. Retrieved from Phys.org/news/2010-11-probiotics-shorten-diarrhoea-episodes.html Posted November 10 2010. Accessed 4th May 2012
9. Dans L, Martinez E. Amoebic dysentery. Clinical Evidence. 2006;1(15): 1007-13 10. Schrezenmeir J, De Vrese M. Probiotics, Prebiotics and Symbiotics- approaching a
definition. Am J Clin Nutr. 2001;73(2):361s-364s
98
11. WHO Media Centre: Diarrhoea disease. www.whoint/mediacentre/factsheets/fs330/en/
Accessed 20th July 2013
12. Wazny K, Ziporsky A, Black R, Cortis V, Duggan C. Setting research priorities to reduce mortality and morbidity of childhood diarrhoea disease in the next 15 years. Plos Med 2013;10 (5):e1001446. Doi:10.1371/Journal.pmed.1001446
13. Waduha N, Natchu UC, Sommerfelt H, Stand TA, Kapor V. ORS and Zinc does not reduce duration or stool volume of acute diarrhoea in children. J Pediatr Gastroenterol Nutr. 2011;53(2):161-7
14. Othero DM, Orago SSA, Groenewegen T, Kaseje DO, Otengah PA. Home Management of Diarrhoea among under fives in a rural community in Kenya:
Household perceptions and practices. East African Journal of Public Health.
2008;5(3):142-146
15. Goldin BR, Gorbach SL. Clinical indications for probiotics: An overview. Clin Infect Dis. 2008; suppl 2: s96-100;s144-51 doi:10.1086152333
16. Charles Boelen. The 5 star Doctor: An asset to health care reform. WHO report.
Retrieved from www.who.int/entity/hrh/en/ Accessed 04/04/2012
17. Digestive Disorders Health Centre. The basics of Diarrhoea. Retrieved from www.webmd.com/digestive-disorders/digestive-diseases-diarrhoea. Accessed 04/04/2012
18. Medical Education. Teaching Medical Students about Diarrhoea Diseases. Unit 1; The Epidemiology and Etiology of Diarrhoea. Retrieved from
http://www.who.int/child.adolesent.health Publications/child health/meded/med.htm Accessed 04/04/2012
19. Excerpts from the Goodwill message by Dr Robert Limlim during the national launch of Hand washing Campaign held at Sheraton Hotels and Towers, Abuja. May 22, 2008
99
20. Kung’u WN, Musar PM, Ochieng A, Wachira GG, Omol RTA, Rakwar J, et al.
Diarrhoea prevalence and risk factors in slums. J Natl Inst Public Health.
2002;51(1):73-76
21. O’Reilly CE, Jaron P, Ochieng B, Nyaguara A, Tate JE, Parsons MB. Risk factors for death among children less than five years old hospitalized with diarrhoea in rural western Kenya: A cohort study. PLoS Med. 2005;9(7):e1001256 doi;10.7371/journal.pmed.1001256
22. Chatterjel BD, Thowani G, Sanyal SN. Aetiology of acute childhood diarrhoea in Calcutta. Trop Gastroenterol. 2009;10(1)158-66
23. Souza EC, Martinez MB, Taddei CR, Mulai L. Aetiological profile of acute diarrhoea in children in Sao Paulo. J Pediatr (Rio). 2002;78:31-8
24. Saelzer E, Munil P, Pena A. Bacterial isolation in infants hospitalized for acute diarrhoea. Rev Chil Pediatr. 2009;60: 328-33
25. Ogbu O, Agumadu N, Uneke CJ, Amadi ES. Aetiology of acute infantile diarrhoea in South-Eastern Nigeria: An assessment of microbiological and antibiotic sensitivity profile. The internet Journal of Third World Medicine. 2008; 7(1) DOI:10.5580/599 26. Greenberg HB, Estes MK. Rotavirus from pathogenesis to vaccination.
Gastroenterology. 2009;136(6):1939-51
27. Ali MB, Ghengesh IW, Aissa RB, Abuhelfaia I, Dufam M. Aetiology of childhood diarrhoea in Zliten-Libya. Saudi Med J. 2005;26:1759-65
28. Olesen B, Numann J, Botiger B, Ethelberg S. Aetiology of diarrhoea in young children in Denmark: a case control study. J Clin Microbiol. 2005;43:3636-41
29. Ethelberg S, Olesen B, Numann J. Risk factors for diarrhoea among children in an industrialized country. Epidemiology. 2006;17:24-30
100
30. Zurawska-Olszewska J, Krzeslowska I, Dlugosz G, Krasiukiazis A. Aetiology of acute diarrhoeas in children from the Lodz region. Occurrence of aetiological agents. Med Dosw Mikrobiol. 2002;54:129-36
31. Valentiner-Branth P, Streisland H, Fisher TK. Cohort study of Guinean children:
incidence, pathogenicity, conferred protection and attributable risk for enteropathogenesis during the first 2 years of life. J Clin Microbiol. 2003;41:4238-45 32. Ansanzzaman M, Kuhn I. Clonal groups of enteropathogenic e coli isolated in
case-control studies of diarrhoea in Bangladesh. J Med Microbiol. 2002(49):177-85
33. Gomes TA, Rassi V, McDonald KL, Ramos SR, Trabulsi LR. Enteropathogens associated with acute diarrhoea disease in urban infants in Sao Paulo, Brazil. J Infant Dis. 2002;164:331-7
34. Notario R, Borda N, Gambande T. Sutich E. Species and serovars of enteropathogenic agents associated with acute diarrhoea disease in Rosario, Argentina. Rev Inst Med Trop Sao Paulo. 2006;38:5-7
35. Hodges K, Gill R. Infectious diarrhoea: cellular and molecular mechanisms. Gut Microbes. 2010;(1):4-21
36. Sanchez TH, Brooks JT, Sulivan PS, Juhasz M, Mutze E, Dworkin MS, et al. Bacterial diarrhoea in persons with HIV infection, United States, 1992-2002. Clin Infect Dis.
2005;41(11):1621-1627
37. Subramanya SB, Rajendran VM, Srinivasan P, Nanda Kumar NS, Ramakrishna BS, Binder HJ. Differential regulation of cholera toxin-inhibited Na-H exchange isoforms by butyrate in rat ileum. Am J Physiol Gastrointest Liver Physiol. 2007;293:857–863 38. Gopalakrishnan S, Pandey N, Tamiz AP, Vere J, Carrasco R, Somerville R, et al.
Mechanism of action of ZOT-derived peptide AT-1002, a tight junction regulator and absorption enhancer. Int J Pharm. 2009;365:121–130
101
39. Deneve C, Janoir C, Poilane I, Fantinato C, Collignon A. New trends in Clostridium difficile virulence and pathogenesis. Int J Antimicrob Agents. 2009;33:24–28
40. Bercion R, Njuimo SP, Boudjeka PM, Manirakiza A. Distribution and antibiotic susceptibility of shigella isolates in Bangui, Central African Republic. Tropical Medicine and international health. 2008;13(4):468-471
41. Schroeder GN, Hilbi H. Molecular pathogenesis of Shigella spp.: controlling host cell signaling, invasion and death by type III secretion. Clin Microbiol Rev. 2008;21:134–
156
42. Kaper JB, Nataro JP, Mobley HL. Pathogenic Escherichia coli. Nat Rev Microbiol.
2004;2:123–140
43. Gill RK, Borthakur A, Hodges K, Turner JR, Clayburgh DR, Saksena S, et al.
Mechanism underlying inhibition of intestinal apical Cl/OH exchange following infection with enteropathogenic E. coli. J Clin Invest. 2007;117:428–437
44. Hecht G, Hodges K, Gill RK, Kear F, Tyagi S, Malakooti J, et al. Differential regulation of Na+/H+ exchange isoform activities by enteropathogenic E. coli in human intestinal epithelial cells. Am J Physiol Gastrointest Liver Physiol. 2004;287:370–378
45. Dean P, Maresca M, Schuller S, Phillips AD, Kenny B. Potent diarrheagenic mechanism mediated by the cooperative action of three enteropathogenic Escherichia coli-injected effector proteins. Proc Natl Acad Sci USA. 2006;103:1876–1881.
46. Hodges K, Alto NM, Ramaswamy K, Dudeja PK, Hecht G. The enteropathogenic Escherichia coli effector protein EspF decreases sodium hydrogen exchanger 3 activity.
Cell Microbiol. 2008;10:1735–1745
47. Creydt VP, Miyakawa MF, Martin F, Zotta E, Silberstein C, Ibarra C. The Shiga toxin 2 B subunit inhibits net fluid absorption in human colon and elicits fluid accumulation in rat colon loops. Braz J Med Biol Res. 2004;37:799–808
102
48. Musher DM, Musher BL. Contagious acute gastrointestinal infections. N Engl J Med.
2004;351:2417–2427
49. Buret AG. Mechanisms of epithelial dysfunction in giardiasis. Gut. 2007;56:316–317 50. Bracha R, Nuchamowitz Y, Mirelman D. Transcriptional silencing of an amoebapore
gene in Entamoeba histolytica: molecular analysis and effect on pathogenicity.
Eukaryot Cell. 2003;2:295–305
51. Dey I, Keller K, Belley A, Chadee K. Identification and characterization of a cyclooxygenase-like enzyme from Entamoeba histolytica. Proc Natl Acad Sci USA.
2003;100:13561–13566.
52. Akinbami FO. Diarrhoea disease in childhood. In Azubike JE, Nkanginieme KEO (ed).
Paediatrics and child health in a tropical region.2nd ed. 2007. African educational series, Owerri, Nigeria. Pp283-287
53. Duggal AK, Yadav P, Agarwal AK, Rewari BB. Clinical approach to altered serum sodium levels. Journal Indian Academy of Clinical Medicine. 2006;7(2):91-103 54. Tobin EA, Paul-West OV, Isah EC. Assessment of knowledge of ORS, child feeding
and drug practices in South-South Nigeria. Nigerian Journal of Medicine.
2011;24(46):22-5
55. United Nations Children’s Education Fund. Diarrhoea: why children are still dying and what can be done. Retrieved from http://7pointplan.org/global-burden-childhood-diarrhoea.html
Accessed 24/05 /2012
56. Black RE, Morris SS, Bryce J. Where and why are 10 million children every year?
Lancet.2003;(316):2226-2234
57. Rao KV, Vinod KM, Retherford LA. Knowledge and use of ORT for childhood diarrhoea in India: effects of exposure to mass media. National Family Health Summit Report. Available from http://rehydrate.org/ors/ort-knowledge.htm Accessed 12th June 2012
103
58. Dryden MS, Gabb RJ, Wright SK. Empirical treatment of severe acute community acquired gastroenteritis with ciprofloxacin. Clin Infect Dis. 2006;22(6):1019-25 59. De Bruyn G. Diarrhoea in adults (acute). West J Med. 2002;172(6)409-412
60. Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tan PI. The role of the haemolytic-uraemic sundrome after antibiotic treatment of Escherichia coli 0157-H7 infections. N Engl J med. 2000;342(26):1930-6
61. Steidler L. Microbiological immunological strategies for treatment of inflammatory bowel disease. Microbes and Infections. 2002;3(1):1127-1166
62. Report of a joint FAO/WHO expert consultation on evaluation of Health and Nutritional properties of probiotics in Food including powder milk with live Lactic Acid Bacteria. Food and Agriculture Organization of the United Nations, World Health Organization. Retrieved 04/11/2009
63. Kliger B, Cohrissen A. Probiotics. Am Fam Physician. 2008;783(9):1073-1078
64. Steidler L. Microbiological immunological strategies for treatment of inflammatory bowel disease. Microbes and Infections. 2001;3(1):1127-1166
65. Siezen, R. J. and Wilson, G. Probiotics genomics. Microbial Biotechnology, 2010: 3: 1–
9. doi: 10.1111/j.1751-7915.2009.00159.
66. Oyetayo VO, Oyetayo FL. Potential of probiotics as biotherapeutic agents targeting the innate immune system. African Journal of Biotechnology.2005;4(2)123-127
67. Vasiljevic T, Shah NP. Probiotics from Metchinkoff to bioactives. International Dairy Journal. 2008;18(7):714-728
68. Park J, Floch MH. Prebiotics, probiotics and dietary fibre in gastrointestinal disease.
Gastroenterol Clin North Am. 2007;36(1):47-63
69. Marayan SS, Jalgasner S, Shahan S, Kulkarni VN. Probiotics: current trends in the treatment of diarrhoea. Hong Kong Med J. 2010;16(3):213-218
104
70. Yan F, Polk DB. Probiotics as functional food in the treatment of diarrhoea. Current Opinion in clinical Nutrition and Metabolic care. 2006;9(6):717-21
71. Reid G. Probiotic lactobacilli for urogenital health in women. J Clin Gastroenterol.
2008;42(suppl 3 pt2):s234-6
72. Vanderhoof JA. Probiotics in Allergy Management. Journal of paediatric gastroenterology and nutrition. 2008;42 suppl 2:s38-40
73. Hichson M, D’souza AL,Muthi N et al. Use of probiotics lactobacillus preparation to prevent diarrhoea associated with antibiotics: randomized double blind placebo controlled trial. BMJ. 2007;335(7610):80
74. Allen SJ, Okoko B, Martinez E, Gregorio G, Dans LF. Probiotics for treating infectious diarrhoea. Cochrane Database of Systematic review. 2004;(2) CD003048
75. Lamberti LM, Christa L, Walker F, Bladi RE. Systemic review of diarrhoea duration and severity in children and adults in low and middle income countries. BMC Public Health. 2012;12:832
76. Vernacchio L, Vezina RM, Mitchell AA, Lesko M. Diarrhoea in American infants and young children in the community setting: incidence, clinical presentation and microbiology. Pediatr Infect Dis J. 2006;25(1):2-7
77. Szajewska H, Skoka A, Dylag M. Meta-analysis: sacchromyces boulardii for treating acute diarrhoea in children. Aliment Pharmacol Ther.2007;25(3):257-264
78. Grillo P, Terrin G. Probiotics for treatment of acute diarrhoea in children. Randomized clinical trial of five different preparations. Br Med J. 2007;335(76150):340
79. De vrese M, Marteau PR. Probiotics and Prebiotics; effects on diarrhoea. J Nutr.2007;137(3):803s-811s
80. Sur D, Manna B, Niyogi SK, Ramamorthy T. Role of probiotic in preventing acute diarrhoea in children: a community –based randomized double-blind
placebo-105
controlled field trial in an urban slum. Epidemiology and Infection. 2011;139(6):919-26
81. Grandy G, Medina M, Soria R, Tera CG, Araya M. Probiotics in the treatment of acute rotavirus diarrhoea. A randomized double-blind controlled trial using two different probiotic preparations in Bolivian children. BMC Infectious Diseases. 2010;10:253 82. Canani RB, Grillo P, Terrin G. Probiotics for treatment of acute diarrhoea in children.
Randomized clinical trial of five different preparations. Br Med J.
2007;335(76150):340
83. Leyer GJ, Li S, Mubasher ME, Reifer L, Ovwehand AC. ProbioticsEffects on cold and influenza-like symptom incidence and duration in children. Paediatrics.
2009;124(2):172-179
84. Nagata S, Ashara T, Ohta T, Yamada T, Kondo S, Bian L et al. Effects of the continous intake of probiotic-fermented milk containing lactobacillus casei strain shirota on fever in a mass outbreak of norovirus gastroenteritis and the faecal microflora in a health service facility for the aged. British Journal of Nutrition. 2011;106(4):549-556
85. Francavilla R, Miniello V, Magista AM, De Canio R. A randomized controlled trial of Lactobacillus GG in children with functional abdominal pain. Paediatrics. 2010;
126(6);1445-52
86. Al-Hosni M, Duevas M, Hank M, Stuart LA et al. Probiotics supplemented feeding in extremely low-birth weight in infants. J Perinatol. 2012;32(4):253-9
87. Chouraqui JP, Brathool D, Labaure JM, Hascot JM. Assessment of the safety, tolerance and protective effect against diarrhoea of infant formulas containing mixtures of probiotics or probiotics and prebiotics in a randomized controlled trial. Am J Clin Nutr.
2008;87(5):1365-1373
106
88. Wollowski I, Rechkemmer G, Pool-Zobel BL. Preventive role of probiotics and prebiotics in colon cancer. The American Journal of clinical Nutrition.
2001;73(suppl2): 451s-455s
89. Huey-Shi Lye, Chiu-Yin Kuan, Joo-Ann Ewe, Wai-Yee Fung, Min-Tze Liong. The Improvement of Hypertension by Probiotics: Effects on Cholesterol, Diabetes, Renin
and Phytoestrogens. The international Journal of Molecular Sciences. 2009;10(9):3755-3775
90. Hamilton-Miller JM. The role of probiotics in the treatment and prevention of Helicobacter pylori infection. Journal of Antimicrobial agents. 2003;12(4):360-6 91. Lesbros-Pantoflickova D, Corthesa-Theulaz I, Blum AL. J Nutr. 2007;137 93Suupl 2):
812s-8s
92. Niedzielink K, Kordecki H, Birkenfeld B. A controlled double blind randomized study on the efficacy of Lactobacillus Plantarium 299V in patients with irritable bowel syndrome. Eur J Gastroenterol Hepatol. 2001;13(10):1143-7
93. Besselink MG, VanSantvoor HC, Buskens G. Probiotic Prophylaxis in predicted severe acute pancreatitis: a randomized double blind placebo controlled trial. Lancet.
2008;371(9613):651-9
94. Bee Peta. Probiotics, not so friendly afterall. The London Times. November 11 2008 95. So-called friendly bacteria may be dangerous according to new research-so which
should you be taking. Daily Mail. January 2008
96. Timmerman HM, Kuning CJ, Mulder L, Rumbouts FM, Beynen AC. Monostrain, Multistrain and Multispecies Probiotics- A comparison of functionality and efficacy.
Int J. Food Microbiol 2004;96(3):219-33
107
97. Fasoli S. International Journal of Food Microbiology. Bacterial composition of commercial probiotic products as evaluated by PCR-DGGE analysis. 2003;82(1):59-70
98. Plateau State Government website. http://www.Plateaustategov.org/history/people-cul.html
Accessed 5th June 2012
99. Cetina-Sauri G, Basto GS. Therapeutic evaluation of Saccharomyces boulardii in children with acute diarrhoea. Annales de Pediatre. 2004;41(6):317-400
100. James FJ. Sample size, randomization and probability theory. In Jonan GE, David LK(editors) Epidemiology, biostatistics and preventive medicine. 2nd ed.
Philadelphia, Pennsylvania. W.B. Sanders . 2002 page 456
101. Choyon KS. Dynamics of risk determinants regarding diarrhoea affected slum children in urban Dhaka: a dysfunctional health care system. Current research Journal of social sciences. 2012;4(4):304-313
102. Folquet MA, Sazonou R, Guedehoussou T, Vandeplas Y. Sacchromyces Boulardii in acute gastroenteritis in children. Webmed Central Paediatrics.
2011;2(11):VMC001627
103. Ansari M, Izham M, Mishankar R. A survey of mothers knowledge about childhood diarrhoea and its management among a marginalized community of Murang, Nepal.
Australasian Medical Journal. 2011;4(9):474-479
104. Bizuneh T, Zewdeneh SM, Abebe A, Lema E. Rotavirus infection in under five children in Jimma Hospital, South-West Ethopia. J Health Dev.2004;18(1):19-24 105. Oyemade A, Omokhodium FO, Olawuyi JF, Mynepalli KC. Environmental and
personal hygiene practice: ridk factors for diarrhoea among children of Nigerian market women. J Diarrhoeal Dis Rev. 1998;16(4):241-247
108
106. Brian A, Curtis V, Gatam UP. Background paper on measuring wash and food hygiene practices: Definition of goals to be tackled. Posted 2012 by the WHO/UNICEF joint monitoring program
107. Plate DK, Strausmann BI, Wilson ML. Water sources are associated with childhood diarrhoea prevalence in rural east-central Mali. Tropical Medicine and International Health.2004;9(3):416-425.
108. Idowu AO, Oluremi BB, Odubanwo KM. Bacteriological analysis of well water samples in Sagamu. African journal of Clinical and Experimental Microbiolgy.
2011;12(2):86-91
109. Al-Mazrou YY, Khan MU, Aziz KM, Farid SM. Factors associated with diarrhoea prevalence in Saudi Arabia. J Fam Community Med. 1995;2:27-34
110. Fening K, Edoh DA. The impact of socio-economic status and sanitation levels on the prevalence of diarrhoea diseases in the Akim Oda area of Ghana. The Internet Journal of Epidemiology. 2009;6(2):DO1:10.5580/15c
111. Gray C, Kung-SJ. Food allergy in South Africa: Joining the food allergy epidemic?
Current Allergy And Clinical Immunology.2007;25(1)24-29
112. Das Gracas M, Perreira C, Atull ER, Barbosa SP. Prevalence and associated risk factors for Giardia lamblia infection among children hospitalized for diarrhoea in Goiana, Goias state, Brazil. Rev Inst. Med. Trop. S Paulo. 2007;49(3):52-59 113. Mbonye AK. Risk factors for Diarrhoea and upper respiratory tract infection among
children in a rural area in Uganda. J Health Popul Nutr. 2004;22(1):37:52-58 114. Surawicz, Christain M. Antibiotic-associated diarrhoea in children: How many
dirty Diapers? J Ped Gastroenterol Nutr. 2003;37:22-26