|Year : 2016 | Volume
| Issue : 4 | Page : 152-156
Medication prescribing pattern in pediatric diarrhea with focus on zinc supplements
Smita Dipak Sontakke1, Vipin Khadse1, CM Bokade2, VM Motghare1
1 Department of Pharmacology, Government Medical College, Nagpur, Maharashtra, India
2 Department of Pediatrics, Government Medical College, Nagpur, Maharashtra, India
|Date of Submission||10-May-2016|
|Date of Acceptance||31-May-2016|
|Date of Web Publication||7-Oct-2016|
Smita Dipak Sontakke
502, Silver Palms, Plot No. Q 9, Laxminagar, RPTS Road, Nagpur 440 022, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: To analyse medication prescribing pattern in paediatric diarrhoea with emphasis on zinc supplements. Methods: This was a prospective, observational, cross-sectional study carried out in a tertiary care teaching hospital after approval of the institutional ethics committee. Prescriptions of 200 patients attending the paediatric OPD and those admitted in paediatric wards were analyzed to get the following details: demographic characteristics: age, gender, weight, diagnosis; medication details: medicines prescribed, dose/strength, frequency, duration; prescription of zinc supplements: Salt, dose, frequency, duration; any precautions/instructions about medicine use. Results: It was observed that 184 (92%) out of 200 patients were prescribed ORS. Sixty-four percent of the prescriptions contained antimicrobials. Cotrimoxazole was the most frequently prescribed antimicrobial (57.81%). No fixed dose combination(FDC) of antimicrobials was prescribed. More than 90% of the prescriptions mentioned the dosage form, frequency of administration and duration of treatment and 97.95% of the drugs were prescribed by generic names. Zinc supplements (Zinc gluconate) were prescribed in only 27 patients (13.5%) out of 200. Conclusion: Inadequate prescribing of zinc supplements is a matter of concern, the causes of which need to be investigated. It appears that use of zinc in pediatric diarrhea can be increased through existing infrastructure by training and information, education and communication activities. After the prescribers are trained and convinced the next measure would be ensuring easy availability, affordability and accessibility of zinc
Keywords: Antimicrobials in pediatric diarrhea, drug utilization in diarrhea, zinc in diarrhea, zinc gluconate
|How to cite this article:|
Sontakke SD, Khadse V, Bokade C M, Motghare V M. Medication prescribing pattern in pediatric diarrhea with focus on zinc supplements. Int J Nutr Pharmacol Neurol Dis 2016;6:152-6
|How to cite this URL:|
Sontakke SD, Khadse V, Bokade C M, Motghare V M. Medication prescribing pattern in pediatric diarrhea with focus on zinc supplements. Int J Nutr Pharmacol Neurol Dis [serial online] 2016 [cited 2019 Oct 15];6:152-6. Available from: http://www.ijnpnd.com/text.asp?2016/6/4/152/191673
| Introduction|| |
Prevention and treatment of childhood diarrhea are a public health priority in India since this is one of the major causes of childhood morbidity and mortality. It has been reported that adherence to treatment guidelines for the management of childhood diarrhea is low worldwide and in India.  Drugs such as antibiotics, probiotics, and racecadotril are increasingly being prescribed for acute diarrhea in India.  Irrational use of antimicrobials in diarrhea further complicates the picture resulting in the emergence of drug-resistant strains and making subsequent treatments ineffective. Research for searching newer treatment modalities for reducing morbidity and mortality associated with pediatric diarrhea is on high agenda, but any new therapy needs time to establish in the mainstay till its safety and efficacy are proven and established.
One of the interventions in pediatric diarrhea which has been extensively studied and found to be efficacious is the use of zinc. The beneficial role of zinc in pediatric diarrhea has been proved in numerous clinical trials and various meta-analysis also support the same. , It has also been recommended by the WHO and United Nations Children's Emergency Fund (UNICEF).  Dose of zinc recommended by WHO is 10 mg for children below 6 months and 20 mg for children between 6 months to 5 years for 14 days. 
Oral zinc has also been recommended for the treatment of acute diarrhea in children by the Indian Academy of Pediatrics. [ 7 ] Zinc was included in the National Programme for the treatment of diarrhea in 2007.  In spite of this the use of zinc in pediatric diarrhea has not gained popularity with clinicians. Although not many studies have reported on the extent of zinc use in pediatric diarrhea, a survey conducted by UNICEF in India 30-36.3% of government and private practitioners of modern medicine mentioned that they prescribe zinc for pediatric diarrhea.  Another study from India reported that only 22% of all prescriptions for an episode of acute diarrhea in children included oral rehydration solution (ORS) with zinc. 
In India diarrhea kills nearly 650 children a day which indicate that diarrhea management is not implemented properly.  Thus, it appears that there is huge gap between diarrhea management policies and effective program implementation. One such inadequacy is an inadequate use of zinc supplements in pediatric diarrhea as reported in published literature. Hence, it is essential to promote and improve the prescription of zinc salts in pediatric diarrhea for effective control of this condition. The first step toward improving the use of zinc supplements in the treatment of pediatric diarrhea is to get an idea about the existing pattern of use of this drug. Hence, this study was planned with the objectives of analyzing medication prescribing pattern in pediatric diarrhea with emphasis on zinc supplements.
| Materials and Methods|| |
This was a prospective, observational, cross-sectional study which was initiated after approval of the Institutional Ethics Committee. The study was conducted in pediatric outpatient department (OPD) and pediatric wards of a tertiary care teaching hospital. Patients of either gender, up to 12 years of age, suffering from diarrhea (three or more unformed stools in the prior 24 h) and able to accept oral fluids or feeds were included in the study. The patients suffering from any chronic or severe illness and receiving medication for any other condition apart from the current episode of diarrhea were excluded. Parents or person accompanying the patients, who met the selection criteria were briefed about the study, and an informed consent was obtained from those willing to participate. After pediatricians' consultation, the prescriptions were analyzed and the following information was recorded in the case record form: Contact details, demographic characteristics: Age, gender, weight, diagnosis, medication details: Medicines prescribed, dose/strength, frequency, duration, prescription of zinc supplements: Salt, dose, frequency, duration, any precautions/instructions about medicine use. A total of 200 prescriptions were analyzed.
| Results|| |
This study was conducted in a total of 200 patients from pediatric OPD and pediatric wards of a tertiary care teaching government hospital.
[Table 1] shows that 92 patients were male and 108 female. A number of patients below 5 years of age were 136, while 64 patients were between 5 and 12 years. A number of patients having diarrhea for more than 24 h were 141 while the duration of diarrhea was <24 h in 59 patients. All the patients had acute gastroenteritis out of which 131 had dehydration.
[Table 2] shows the number of drugs per prescriptions. Three drugs were prescribed in maximum prescriptions, 108 (54%). Maximum five drugs were prescribed in two prescriptions. The total number of drugs prescribed was 539.
[Table 3] shows that ORS accounted for 34.13% of total drugs prescribed, antimicrobials (23.74%) and nonsteroidal anti-inflammatory drugs (NSAIDs) were 23.37% of total drugs. Zinc supplements were prescribed for 27 patients only which accounts for only 5% of total drugs.
|Table 3: Distribution of drugs according to pharmacological category (n=539)|
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[Table 4] shows that cotrimoxazole was the most commonly prescribed antimicrobial (57.81%) while albendazole and metronidazole were prescribed to 14.06% and 7.81% of patients, respectively.
[Table 5] shows that 97.95% drugs were prescribed by generic name. Dosage form was mentioned for 96.3% of drugs. The frequency of drug administration was mentioned for 96.3% drugs, and the duration of drug treatment was mentioned for 93.32% drugs.
Fifty percent of the prescriptions mentioned instructions for preparing ORS solution.
Zinc gluconate in a dose of 2.5 ml orally for 14 days was prescribed to 27 OPD patients along with ORS. No indoor patient was given zinc supplements.
| Discussion|| |
Children represent a large part of the population in developing countries. This population is prone to suffer from recurrent infections including infections of the gastrointestinal system. Acute watery diarrhea is one of the common childhood illnesses accounting for the major proportion of pediatric hospital visits. 
A large number of studies on medication prescribing pattern in various acute and chronic illnesses including pediatric diarrhea are reported. This study has mainly focused on studying medication prescribing pattern in pediatric diarrhea with focus on zinc supplements. On analyzing the drug use pattern, it was observed that 92% of patients were prescribed ORS, this is an encouraging finding as it is always recommended to use ORS in a patient of diarrhea as the majority of patients respond to ORS alone. ORS was prescribed to 58% patients in another study in pediatric diarrhea.  Sixty-four percent of the prescriptions contained antimicrobials. Cotrimoxazole was the most frequently prescribed antimicrobial (57.81%). This probably may be due to availability of this drug in the hospital pharmacy. This being a government hospital majority of the patients are from low socioeconomic strata and do not afford to purchase medicines from outside. This is in contrast to another study were broad spectrum antibiotics were most commonly prescribed and often in illogical combinations, ofloxacin with ornidazole being the most frequent oral antibiotic prescribed (22% of the prescriptions containing antibiotics).  In another study from Dhaka in acute watery diarrhea in children below 5 years, prescriptions containing antibiotics were 52% and 75% in OPDs of government and private hospitals, respectively.  In our study, no fixed dose combination (FDC) of antimicrobials was prescribed. This is a highly significant and positive finding since irrational use of FDCs of antimicrobials is known to be widespread in diarrhea. But still, the high rate of prescription of antimicrobials seems to be alarming. Accompanying symptoms like the presence of fever, pain, blood in the stool, and vomiting also increase prescribing of antimicrobials. As is well-known antimicrobials have limited role in the management of diarrhea as the majority of the cases are of viral etiology and require symptomatic treatment rather than antimicrobials. Extensive and irrational use of antimicrobials particularly when not indicated results in the development of antimicrobial resistance which is a serious problem not only for the individual patient but also for the entire population.
Sixty-three percent of prescriptions contained NSAIDs such as paracetamol. NSAIDs may have been prescribed since many patients of diarrhea usually have fever. Another positive finding of our study is that more than 90% of the prescriptions mentioned the dosage form, frequency of administration and duration of treatment. Although this is an encouraging finding, it is expected that 100% of the prescriptions should be mentioning all these details. About 97.95% of the drugs were prescribed by generic names. Prescribing drugs by generic names are always advocated. Although this is not often practiced in the private set-up, even many government hospitals do not follow prescribing by generic names. Considering this fact the high percentage of prescriptions by generic names in our study is definitely a noteworthy finding.
Zinc supplements (zinc gluconate) were prescribed in only 27 patients (13.5%), out of 200. They were prescribed only to OPD patients and not in indoor patients for which there seems to be no obvious reason. Zinc supplements were prescribed for the period of 14 days which is as per WHO recommendation.
In a study from Ujjain, in acute diarrhea in children, ORS with zinc was prescribed in 22% of prescriptions.  In yet another study from Pakistan, zinc supplements were prescribed to only 2% of all the children with diarrhea.  Surprisingly, in a study carried out in government and private hospitals in Dhaka in acute watery diarrhea in children below 5 years zinc supplements were prescribed in more than 90% of the cases.  the use of zinc in childhood diarrhea has been recommended by WHO, UNICEF, and Indian Academy of Pediatrics and zinc is also included in the National Programme for the treatment of diarrhea since 2007. In spite of this, inadequate prescribing of zinc supplements is a matter of concern, the causes of which need to be investigated. Although investigating the causes is beyond the scope of this study, a review of the published literature gives some idea about the same.
One of the reasons is that the known benefits of zinc supplementation are still not widely appreciated by clinicians and health-care workers in developing economies.  That seems to be the reason that zinc tablets are not included in the formularies of even tertiary care hospitals and most public health facilities still do not procure zinc. Otherwise, if zinc supplements can be prescribed to more than 90% of pediatric diarrhea patients in Bangladesh, the same also is possible in India. Lack of advocacy seems to be the major cause responsible. Hence, the first and foremost step to overcome this problem is increasing awareness about the importance of zinc in diarrhea among all health professionals involved in the management of pediatric diarrhea. The beneficial effect of such educational intervention has been reported in a study where government and private health-care providers and village health workers were trained to prescribe zinc and ORS for use in diarrheal episodes in 1-month-old-to 5-year-old children. In the intervention group, use of zinc and ORS increased from 36.5% to 59.8% and 34.8% to 59.2%, after 3 months and 6 months of starting the intervention, respectively.  Hence, it appears that use of zinc in pediatric diarrhea can be increased through existing infrastructure by training and information, education and communication activities. After the prescribers are trained and convinced, the next measure would be ensuring easy availability, affordability and accessibility of zinc. This is possible only if zinc is made available in adequate quantities in all public health-care facilities. There may be various policy and programmatic barriers in implementing such measures. But even these can be overcome if the policy makers and administrators are convinced about its importance particularly the improved cost-effectiveness of zinc.
To conclude, inadequate prescribing of zinc supplements is a matter of concern, the causes of which need to be investigated. Lack of advocacy seems to be the major cause responsible. Hence, the first and foremost step to overcome this problem is increasing awareness about the importance of zinc in diarrhea among all health professionals involved in the management of pediatric diarrhea.
We thank the Indian Council of Medical Research for providing financial grant to this study under the short term studentship scheme.
Financial support and sponsorship
Indian Council of Medical Research.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]