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Vol. 64, No. 1, 2006
Issue release date: July 2006
Ann Nestlé [Fra] 2006;64:39–48
(DOI:10.1159/000093838)

Diarrhées persistantes dans les pays en développement

Bhutta Z.A.
Service de Pédiatrie et de Santé de l’Enfant, Université Aga Khan, Karachi, Pakistan
email Corresponding Author

Abstract

Les affections diarrhéiques sont globalement responsables d’un cinquième de la mortalité totale des enfants de moins de cinq ans, avec un nombre annuel de décès estimé à 2.2 millions. Une proportion significative de ces décès peut être liée à des épisodes de diarrhée persistante (définie comme une diarrhée persistant plus de 15 jours avec altération de la croissance). Il a été démontré que le cadre des diarrhées persistantes rassemblait des enfants chez lesquels la diarrhée était nettement plus sévère. Ces affections sont à l’origine de 36 à 54% de la mortalité totale due à des diarrhées. Bien que la pathogénie exacte de la diarrhée persistante demeure mal élucidée, la plupart des épisodes sont liés à des infections diarrhéiques aiguës antérieures avec prolongation de l’épisode le plus récent. Cette situation peut être liée à plusieurs facteurs propres à l’hôte tel que la préexistence d’une malnutrition, d’une carence en micronutriments et d’une immunodéficience et le traitement inadéquat de l’épisode le plus récent de diarrhée aiguë. La conséquence commune paraît être des lésions persistantes de la muqueuse intestinale qui ne parvient pas à se réparer. Contrairement aux diarrhées persistantes post-infectieuses, certains nourrissons peuvent présenter une diarrhée intraitable sévère due à divers troubles, dont beaucoup ont une base héréditaire. Ils forment aujourd’hui le type dominant de diarrhée prolongée dans les pays industrialisés. La prise en charge d’une diarrhée persistante repose sur une grande vigilance en matière de renutrition et sur l’identification précoce de complications. Bien que divers germes pathogènes aient été associés aux diarrhées persistantes, la place des médicaments antimicrobiens oraux est restreinte dans le traitement de routine de ces affections. L’attention portée à la réhydratation, le dépistage et le traitement appropriés des infections systémiques et la renutrition par la nutrition entérale au moyen d’aliments facilement absorbables sont essentiels pour la prise en charge de ces enfants, fréquemment dans un contexte ambulatoire. L’administration de zinc et de vitamine A peut raccourcir la durée d’une diarrhée persistante et aide également à réduire les récidives. Les stratégies les plus importantes de prévention de ces diarrhées demeurent cependant l’allaitement maternel exclusif au cours des six premiers mois de la vie, poursuivi durant deux ans avec des aliments complémentaires adéquats et une prise en charge optimale des épisodes diarrhéiques aigus.


 goto top of outline Mots-clés

  • Diarrhée persistante
  • Carence en micronutriments
  • Malnutrition
  • Immunodéficience
  • Traitement inapproprié, diarrhée aiguë

 goto top of outline Résumé

Les affections diarrhéiques sont globalement responsables d’un cinquième de la mortalité totale des enfants de moins de cinq ans, avec un nombre annuel de décès estimé à 2.2 millions. Une proportion significative de ces décès peut être liée à des épisodes de diarrhée persistante (définie comme une diarrhée persistant plus de 15 jours avec altération de la croissance). Il a été démontré que le cadre des diarrhées persistantes rassemblait des enfants chez lesquels la diarrhée était nettement plus sévère. Ces affections sont à l’origine de 36 à 54% de la mortalité totale due à des diarrhées. Bien que la pathogénie exacte de la diarrhée persistante demeure mal élucidée, la plupart des épisodes sont liés à des infections diarrhéiques aiguës antérieures avec prolongation de l’épisode le plus récent. Cette situation peut être liée à plusieurs facteurs propres à l’hôte tel que la préexistence d’une malnutrition, d’une carence en micronutriments et d’une immunodéficience et le traitement inadéquat de l’épisode le plus récent de diarrhée aiguë. La conséquence commune paraît être des lésions persistantes de la muqueuse intestinale qui ne parvient pas à se réparer. Contrairement aux diarrhées persistantes post-infectieuses, certains nourrissons peuvent présenter une diarrhée intraitable sévère due à divers troubles, dont beaucoup ont une base héréditaire. Ils forment aujourd’hui le type dominant de diarrhée prolongée dans les pays industrialisés.

La prise en charge d’une diarrhée persistante repose sur une grande vigilance en matière de renutrition et sur l’identification précoce de complications. Bien que divers germes pathogènes aient été associés aux diarrhées persistantes, la place des médicaments antimicrobiens oraux est restreinte dans le traitement de routine de ces affections. L’attention portée à la réhydratation, le dépistage et le traitement appropriés des infections systémiques et la renutrition par la nutrition entérale au moyen d’aliments facilement absorbables sont essentiels pour la prise en charge de ces enfants, fréquemment dans un contexte ambulatoire. L’administration de zinc et de vitamine A peut raccourcir la durée d’une diarrhée persistante et aide également à réduire les récidives. Les stratégies les plus importantes de prévention de ces diarrhées demeurent cependant l’allaitement maternel exclusif au cours des six premiers mois de la vie, poursuivi durant deux ans avec des aliments complémentaires adéquats et une prise en charge optimale des épisodes diarrhéiques aigus.

Copyright © 2006 Nestec Ltd., Vevey/S. Karger AG, Basel


 goto top of outline References
  1. Black RE, Morris SS, Bryce J: Where and why are 10 million children dying every year? Lancet 2003;361:2226–2234.
  2. Snyder JD, Merson MH: The magnitude of the global problem of acute diarrheal disease: a review of active surveillance data. Bull World Heath Organ 1982;60:605–613.
  3. Bern C, Martines J, de Zoysa I, Glass RI: The magnitude of the global problem of diarrhoeal disease: a ten-year update. Bull World Health Organ 1992;70:705–714.
  4. Yusufzai M, Bhutta ZA: Global burden of childhood diarrhea; in Bhutta ZA (ed): Contemporary Issues in Childhood Diarrhea and Malnutrition. Karachi, Oxford University Press, 2000, pp 1–22.
  5. Kosek M, Bern C, Guerrant RL: The global burden of diarrheal disease as estimated from studies published between 1990 and 2000. Bull World Health Organ 2003;81:197–2004.
  6. Anonymous: Persistent diarrhoea in children in developing countries: memorandum from a WHO Meeting. Bull World Health Organ 1988;66:709–717.
  7. Anonymous: Evaluation of an algorithm for the treatment of persistent diarrhoea: a multicentre study. International Working Group on Persistent Diarrhoea. Bull World Health Organ 1996;74:479–489.
  8. Schorling JB, Wanke CA, Schorlling SK, McAullife JF, de Souza MA, Guerran RL: A prospective study of persistent diarrhea among children in an urban Brazilian slum: patterns of occurrence and etiologic agents. Am J Epidemiol 1990;132:144–156.
  9. Fauveau V, Henry FJ, Briend A, Yunus M, Chakraborty J: Persistent diarrhea as a cause of childhood mortality in rural Bangladesh. Acta Paediatr Suppl 1992;381:12–14.
  10. Victora CG, Huttly SRA, Fuch SC, et al: International differences in clinical patterns of diarrhoeal deaths: a comparison of children from Brazil, Senegal, Bangladesh and India. J Diarrhoeal Dis Res 1993;11:25–29.
  11. Bhan MK, Bhandari N, Sazawal S, Clemens J, Raj P: Descriptive epidemiology of persistent diarrhoea among young children in rural northern India. Bull World Health Organ 1989;67:281–288.
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  13. Lima AAM, Fang G, Schorling JB, Albuquerque L, Mc Aulliffe JA, Mota S, Leite R, Guerrant RL: Persistent diarrhea in northeast Brazil: etiologies and interaction with malnutrition. Acta Paediatr SuppI 1992;381:39–44.
  14. Moy RJ, Booth IW, Choto R-G, McNeish AS: Recurrent and persistent diarrhoea in a rural Zimbabwean community: a prospective study. J Trop Pediatr 1991;37:293–299.
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  37. Campbell DI, Elia M, Lunn PG: Growth faltering in rural Gambian infants is associated with impaired small intestinal barrier function, leading to endotoxemia and systemic inflammation. J Nutr 2003;133:1332–1338.
  38. Bhutta ZA, Nizami SQ, Thobani S: Factors determining recovery during nutritional therapy of persistent diarrhoea: the impact of diarrhoea severity and intercurrent infections. Acta Paediatr 1997;86:796–802.
  39. Alam NH, Faruque AS, Dewan N, Sarker SA, Fuchs GJ: Characteristics of children hospitalized with severe dehydration and persistent diarrhoea in Bangladesh. J Health Popul Nutr 2001;19:18–24.
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  51. Mahalanabis D, Bhan MK: Micronutrients as adjunct therapy of acute illness in children: impact on the episode outcome and policy implications of current findings. Br J Nutr 2001;85(suppl 2):S151–S158.

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  52. Rahman MM, Vermund SH, Wahed MA, Fuchs GJ, Baqui AH, Alvarez JO: Simultaneous zinc and vitamin A supplementation in Bangladeshi children: randomised double blind controlled trial. BMJ 2001;323:314–318.
  53. Khatun UH, Malek MA, Black RE, Sarkar NR, Wahed MA, Fuchs G, Roy SK: A randomized controlled clinical trial of zinc, vitamin A or both in undernourished children with persistent diarrhea in Bangladesh. Acta Paediatr 2001;90:376–380.
  54. Villamor E, Mbise R, Spiegelman D, Hertzmark E, Fataki M, Peterson KE, Ndossi G, Fawzi WW: Vitamin A supplements ameliorate the adverse effect of HIV-1, malaria, and diarrheal infections on child growth. Pediatrics 2002;109:E6.

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  55. Bhandari N, Bahl R, Saxena M, Taneja S, Bhan MK: Prognostic factors for persistent diarrhoea managed in a community setting. Indian J Pediatr 2000;67:739–745.
  56. Valentiner-Branth P, Steinsland H, Santos G, Perch M, Begtrup K, Bhan MK, Dias F, Aaby P, Sommerfelt H, Molbak K: Community-based controlled trial of dietary management of children with persistent diarrhea: sustained beneficial effect on ponderal and linear growth. Am J Clin Nutr 2001;73:968–974.
  57. Jones G, R Steketee RW, Black RE, Bhutta ZA, Morris SS and the Bellagio Child Survival Study Group: How many child deaths can we prevent this year? Lancet 2003;362:65–71.
  58. Travis P, Bennett S, Haines A, Pang T, Bhutta Z A, Hyder AA, Pielemeier NR, Mills A, Evans T: Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet 2004;364:900–906.
  59. Sheth M, Obrah M: Diarrhea prevention through food safety education. Indian J Pediatr 2004;71:879–882.
  60. Curtis V, Cairncross S: Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Lancet Infect Dis 2003;3:275–281.
  61. Luby SP, Agboatwalla M, Painter J, Altaf A, Billhimer WL, Hoekstra RM: Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan: a randomized controlled trial. JAMA 2004;291:2547–2554.

 goto top of outline Author Contacts

Zulfiqar Ahmed Bhutta
Department of Paediatrics and Child Health, Aga Khan University
PO Box 3500, Stadium Road
Karachi 74800 (Pakistan)
Tel. +92 21 4930051/ext 4724, Fax +92 21 4934294, E-Mail zulfiqar.bhutta@aku.edu


 goto top of outline Article Information

Number of Print Pages : 10
Number of Figures : 3, Number of Tables : 2, Number of References : 61


 goto top of outline Publication Details

Annales Nestlé (Ed. française)

Vol. 64, No. 1, Year 2006 (Cover Date: July 2006)

Journal Editor: Editorial Committee
ISSN: 0250–9644 (print), 1661–3732 (Online)

For additional information: http://www.karger.com/ANF


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

Les affections diarrhéiques sont globalement responsables d’un cinquième de la mortalité totale des enfants de moins de cinq ans, avec un nombre annuel de décès estimé à 2.2 millions. Une proportion significative de ces décès peut être liée à des épisodes de diarrhée persistante (définie comme une diarrhée persistant plus de 15 jours avec altération de la croissance). Il a été démontré que le cadre des diarrhées persistantes rassemblait des enfants chez lesquels la diarrhée était nettement plus sévère. Ces affections sont à l’origine de 36 à 54% de la mortalité totale due à des diarrhées. Bien que la pathogénie exacte de la diarrhée persistante demeure mal élucidée, la plupart des épisodes sont liés à des infections diarrhéiques aiguës antérieures avec prolongation de l’épisode le plus récent. Cette situation peut être liée à plusieurs facteurs propres à l’hôte tel que la préexistence d’une malnutrition, d’une carence en micronutriments et d’une immunodéficience et le traitement inadéquat de l’épisode le plus récent de diarrhée aiguë. La conséquence commune paraît être des lésions persistantes de la muqueuse intestinale qui ne parvient pas à se réparer. Contrairement aux diarrhées persistantes post-infectieuses, certains nourrissons peuvent présenter une diarrhée intraitable sévère due à divers troubles, dont beaucoup ont une base héréditaire. Ils forment aujourd’hui le type dominant de diarrhée prolongée dans les pays industrialisés. La prise en charge d’une diarrhée persistante repose sur une grande vigilance en matière de renutrition et sur l’identification précoce de complications. Bien que divers germes pathogènes aient été associés aux diarrhées persistantes, la place des médicaments antimicrobiens oraux est restreinte dans le traitement de routine de ces affections. L’attention portée à la réhydratation, le dépistage et le traitement appropriés des infections systémiques et la renutrition par la nutrition entérale au moyen d’aliments facilement absorbables sont essentiels pour la prise en charge de ces enfants, fréquemment dans un contexte ambulatoire. L’administration de zinc et de vitamine A peut raccourcir la durée d’une diarrhée persistante et aide également à réduire les récidives. Les stratégies les plus importantes de prévention de ces diarrhées demeurent cependant l’allaitement maternel exclusif au cours des six premiers mois de la vie, poursuivi durant deux ans avec des aliments complémentaires adéquats et une prise en charge optimale des épisodes diarrhéiques aigus.



 goto top of outline Author Contacts

Zulfiqar Ahmed Bhutta
Department of Paediatrics and Child Health, Aga Khan University
PO Box 3500, Stadium Road
Karachi 74800 (Pakistan)
Tel. +92 21 4930051/ext 4724, Fax +92 21 4934294, E-Mail zulfiqar.bhutta@aku.edu


 goto top of outline Article Information

Number of Print Pages : 10
Number of Figures : 3, Number of Tables : 2, Number of References : 61


 goto top of outline Publication Details

Annales Nestlé (Ed. française)

Vol. 64, No. 1, Year 2006 (Cover Date: July 2006)

Journal Editor: Editorial Committee
ISSN: 0250–9644 (print), 1661–3732 (Online)

For additional information: http://www.karger.com/ANF


Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Black RE, Morris SS, Bryce J: Where and why are 10 million children dying every year? Lancet 2003;361:2226–2234.
  2. Snyder JD, Merson MH: The magnitude of the global problem of acute diarrheal disease: a review of active surveillance data. Bull World Heath Organ 1982;60:605–613.
  3. Bern C, Martines J, de Zoysa I, Glass RI: The magnitude of the global problem of diarrhoeal disease: a ten-year update. Bull World Health Organ 1992;70:705–714.
  4. Yusufzai M, Bhutta ZA: Global burden of childhood diarrhea; in Bhutta ZA (ed): Contemporary Issues in Childhood Diarrhea and Malnutrition. Karachi, Oxford University Press, 2000, pp 1–22.
  5. Kosek M, Bern C, Guerrant RL: The global burden of diarrheal disease as estimated from studies published between 1990 and 2000. Bull World Health Organ 2003;81:197–2004.
  6. Anonymous: Persistent diarrhoea in children in developing countries: memorandum from a WHO Meeting. Bull World Health Organ 1988;66:709–717.
  7. Anonymous: Evaluation of an algorithm for the treatment of persistent diarrhoea: a multicentre study. International Working Group on Persistent Diarrhoea. Bull World Health Organ 1996;74:479–489.
  8. Schorling JB, Wanke CA, Schorlling SK, McAullife JF, de Souza MA, Guerran RL: A prospective study of persistent diarrhea among children in an urban Brazilian slum: patterns of occurrence and etiologic agents. Am J Epidemiol 1990;132:144–156.
  9. Fauveau V, Henry FJ, Briend A, Yunus M, Chakraborty J: Persistent diarrhea as a cause of childhood mortality in rural Bangladesh. Acta Paediatr Suppl 1992;381:12–14.
  10. Victora CG, Huttly SRA, Fuch SC, et al: International differences in clinical patterns of diarrhoeal deaths: a comparison of children from Brazil, Senegal, Bangladesh and India. J Diarrhoeal Dis Res 1993;11:25–29.
  11. Bhan MK, Bhandari N, Sazawal S, Clemens J, Raj P: Descriptive epidemiology of persistent diarrhoea among young children in rural northern India. Bull World Health Organ 1989;67:281–288.
  12. Black RE: Persistent diarrhea in children of developing countries. Pediatr Infect Dis J 1993;12:751–761.
  13. Lima AAM, Fang G, Schorling JB, Albuquerque L, Mc Aulliffe JA, Mota S, Leite R, Guerrant RL: Persistent diarrhea in northeast Brazil: etiologies and interaction with malnutrition. Acta Paediatr SuppI 1992;381:39–44.
  14. Moy RJ, Booth IW, Choto R-G, McNeish AS: Recurrent and persistent diarrhoea in a rural Zimbabwean community: a prospective study. J Trop Pediatr 1991;37:293–299.
  15. Bhutta ZA, Ghishan F, Lindley K, Memon IA, Mittal S, Rhoads JM: Persistent and chronic diarrhea and malabsorption: Working Group report of the second World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2004;(suppl 2):S711–S716.
  16. Adejuyigbe EA, Oyelami O, Onayemi O, Durosinmi MA: Paediatric HIV/AIDS in Ile-Ife, Nigeria. Cent Afr J Med 2003;49:74–78.
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