Risk factors of mortality on diarrhea children under five years old hospitalized in Dr. Soetomo General Academic Hospital Surabaya 2023

∗ Corresponding author: Dwi Aprilawati Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. Risk factors of mortality on diarrhea children under five years old hospitalized in Dr. Soetomo General Academic Hospital Surabaya 2023 Aulia Najma Adhyana Kurniawan 1, Dwi Aprilawati 2, *, Dwiyanti Puspitasari 3 and Alpha Fardah Athiyyah 3 1 Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia. 2 Département of Public Health Sciences, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia. 3 Département of Pediatrics, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia. World Journal of Advanced Research and Reviews, 2025, 26(01), 2752-2757 Publication history: Received on 14 March 2025; revised on 19 April 2025; accepted on 21 April 2025 Article DOI: https://doi.org/10.30574/wjarr.2025.26.1.1391 Abstract Through the years, diarrhea has been one of the significant causes of mortality among children under the age of five years old all over the world. Throughout 2021, approximately 444,000 children under five years old died due to diarrhea, making up about 9% of all children under five years old’s mortality. Diarrhea is a gastrointestinal disease characterized by increased bowel movements causing three or more stool episodes along with a loose or watery consistency within 24 hours. There are several risk factors that contribute to the mortality of children with diarrhea under the age of five years old. This study aimed to determine which risk factors are significant enough to cause the mortality of children under the age of five years old suffering from diarrhea. This retrospective analytic study was conducted by observing the medical records of children under five years old hospitalized in Dr. Soetomo General Academic Hospital Surabaya due to diarrhea during 2023. Data were analyzed by using chi-square bivariate analysis with the SPSS version 30 application. The results show that septic shock and septicaemia are significant factors contributing to the mortality of children under five years old suffering from diarrhea. Furthermore, dehydration, and s proven to not significantly affect mortality in diarrheal patients under the age of five years old, yet this factor is proven to be significant to contribute to the patient’s length of stay in the hospital ward at RSUD Dr. Soetomo Surabaya. On the other hand, a patient’s gender and age are proven to be not significant to cause mortality in children under five years old suffering from diarrhea. Keywords: Diarrhea; Children; Septic Shock; Septicaemia; Dehydration 1. Introduction Through the years, diarrhea is still one of the leading cause of children mortality worldwide, especially in children under the age of five years old. Data reported by the Indonesian Ministry of Health on 2018 reported that there were around four millions reported diarrhea cases of children under the age of five years old, or around 17% prevalence rate[1] Diarrhea is a gastrointestinal disease characterized by increased bowel movements resulting to abnormal stool episode, three or more stool episode per 24 hours [2]. Diarrhea might be caused by several etiologies, based on its root causes it classifies into infectious diarrhea and non-infectious diarrhea. Non-infectious diarrhea is usually caused by malabsorption, anatomical defect, malignancies, allergies, food poisoning, and others. While infectious diarrhea is caused by infectious pathogen[3] Notable risk factors contributing to diarrhea among children below 5 years old include nutritional condition such as wasting and malnutrition[4]. Study in children with low nutritional status shows an altered immune system, as a World Journal of Advanced Research and Reviews, 2025, 26(01), 2752-2757 2753 consequence, there is an elevated vulnerability to invasive infections, including those affecting the urinary and gastrointestinal systems, as well as an increased risk of septicemia[5]. A study done by Hartman et al., 2023 presents that infants below the age of 6 months has the highest risk of mortality, twice as high if compared to children between 2 and 5 years of age, this is happens because infants is more vulnerable to infections. Additionally, the study shows that female is attributed with a higher likelihood of mortality due to diarrhea as it is attributed to the lack of proper nutrition in female children. Diarrhea causes excessive water loss, making dehydration to be the most common complication for diarrhea patients. Approximately 20% of peadiatric deaths is associated with dehydration related to gastroenteritis[6]. Some publications also mentioned septic shock is featured in the death of patients with infectious diseases, including diarrhea [7]. The primary complication of diarrhea is dehydration leading to severe sepsis, and septic shock[7, 8] This study aimed to determine risk factors of mortality among diarrhea patients under the age of five years old hospitalized in RSUD Dr. Soetomo 2023. Proper understanding of the risk factors that may correlates with the mortality diarrhea is important, in order to give a comprehensive approach for patient with diarrhea. Thus, unwanted complication can be prevented and increases patient’s quality of life and decrease mortality rate of patients with diarrhea. 2. Material and methods This study is a retrospective analytic study done by observing medical records of patients under five years old who were hospitalized for diarrhea in RSUD Dr. Soetomo, Surabaya in 2023. The purpose of this study is to determine whether certain variables, such as age, gender, nutritional status, dehydration, septicaemia, and septic shock are a significant contributors to the mortality of children under the age of five years old hospitalized of diarrhea in RSUD Dr. Soetomo, Surabaya. This study was conducted for 5 months, from June to October 2024. Populations sample for this study are 175 patients selected with consecutive sampling in accordance with the inclusion and exclusion criteria required for this research. Inclusion criteria for this study are patients from age 0 months – 60 months, hospitalized in RSUD Dr. Soetomo Surabaya with diagnosis of diarrhea as the medical indication for inpatient. While the exclusion criteria for this research are patients with congenital abnormalities, genetic disorders, immunocompromised patients, and patients with metabolic disorders, such as diabetes. Data for patients’ age and gender were gathered from the demographic data written on patients’ medical record. Data for dehydration, septicaemia, and septic shock on patients’ are gathered from the diagnosis recorded medical record and laboratory examinations result attached in patients’ medical record during their hospitalizations of diarrhea. The collected data are analyzed with Statistical Product and Service Solution (SPSS) 30 version application. Bivariate analysis was done to determine whether there is a significant relationships between the variables (age, gender, dehydration, septicaemia, and septic shock) and mortality with chi-square hypothesis test. 3. Results and discussion Throughout 2023, there were 253 children under 5 years old patients hospitalized of diarrhea in RSUD Dr. Soetomo that met inclusion and exclusion criteria for this research. However, 78 patients are excluded as it met the exclusion criteria for this research as explained itn the prvious chapter. Thus, leaving 175 patients with eligible data that met the inclusion criteria for this research. Ethical clearance for data collection process of this research has been granted by the Ethical Committee of RSUD Dr. Soetomo, Surabaya. World Journal of Advanced Research and Reviews, 2025, 26(01), 2752-2757 2754 Table 1 The Distribution and Characteristic of Research’s Subjects Characteristic Total % Gender Male 99 56 Female 76 44 Age 0-12 months old (infants) 86 49 1360 months old (children) 89 51 Nutritional Status Undernutrition 78 44.5 Normal 97 55.5 Dehydration Without dehydration 48 28 Mild/moderate/severe dehydration 127 72 Septicaemia Without septicaemia 169 96.5 Septicaemia 6 3.5 Septic Shock Without septic shock 2 1.14 Septic shock 173 98.86 Patients’ Discharged Status Recovered 172 98.2 Death 3 1.71 Each variable of the data presented in Table 1 were then analyzed by using bivariate chi-square test acknowledge whether there is a significant correlation between the tested variable and the mortality of diarrhea patients under five years old. Table 2 Bivariate Chi-Square Test Analysis of Patients’ Gender and Mortality Gender Discharged Status OR (CI 95%) P value Recovered Death Total Male 97 (55.4%) 2 (1.14%) 99(56.5%) 2.18 (0.18-23.53) 0.127 Female 75 (42.8%) 1 (0.57%) 76 (43.4%) Total 172 (98.2%) 3 (1.71%) 175 (100%) Table 2 presents the result of bivariate chi-square analysis of patients’ gender and mortality. Data shown in above indicate that there is no significant correlations between patients’ gender and mortality on diarrhea patients under five years old. This can be proven by the p value score of 0.127 and wide confidence interval range that includes 1of odd ratio, ranging from that indicates no significant correlation. World Journal of Advanced Research and Reviews, 2025, 26(01), 2752-2757 2755 Table 3 Bivariate Chi-Square Test Analysis of Patients’Age and Mortality Age Discharged Status OR (CI 95%) P value Recovered Death Total Infants (0-12 months) 84 (48%) 2 (1.14%) 86(49.15%) 2.095 (0.186 – 23.539) 0.375 Children (13-60 months) 88 (50.2%) 1 (0.57%) 89 (50.85%) Total 172(98.29%) 3 (1.71%) 175 (100%) Table 3 provides the bivariate analysis result between patients’ age and mortality of diarrhea patients under the age of five years old. However, the result shows no significant correlation between patients’ age and mortality on children under five years old with diarrhea. Table 4 Bivariate Chi-Square Test Analysis of Degree of Dehydration and Mortality; Degree of Dehydration and Hospital Length of Stay Degree of Dehydration Discharged Status OR (CI 95%) P value Length of Stay P value Recovered Death ≥5 days <5 days Mild/ Moderate/ Severe Dehydration 124 (70.8%) 3 (1.14%) 1.024 (0.997 – 1.052) 1.154 80 (45.7%) 47 (26.8%) 0.022 Without Dehydration 48 (27.5%) 0 (0.57%) 21 (12%) 27 (15.4%) Total 172 (98.3%) 3(1.71%) 101 (57.7%) 74 (42.2%) Table 4 presents the result of bivariate analysis between degree of dehydration and mortality of diarrhea patients under the age of five years old and the bivariate analysis result between degree of dehydration and patients’ duration of hospitalization. The chi-square bivariate analysis of the relationship between degree of dehydration and mortality shows there is no significant correlation between the two, this is supported by the p value score of 1.154. However, there is a significant correlation between degree of dehydration and patients’ hospitalization length of stay. Patient with dehydration tends to have longer hospitalization duration compared patients without dehydration. This is supported by the p value score of 0.022. Table 5 Bivariate Chi-Square Test Analysis of Septicaemia and Mortality Septicaemia Discharged Status OR (CI 95%) P value Recovered Death Total Septicaemia 4 (2.3%) 2 (1.2%) 6 (3.5%) 84.00 (6.257 – 1127.785) <0.001 Without Septicaemia 168 (96%) 1 (0.57%) 169 (96.5%) Total 172 (98.3%) 3 (1.71%) 175 (100%) Table 5 provides the result of bivariate analysis between septicemia and mortality of diarrhea patients under five years old. This table prove that septicaemia is a statistically significant factor that correlates with mortality of diarrhea patients under the age of five years old. Patients with septicaemia have higher risk of mortality compared to patients without sapticaemia this is supported with high odds ratio score, 84.00 and p value score of <0.001. Table 6 presents the result of bivariate analysis chi-square test between septic shock and mortality of diarrhea patients under the age of five years old. Based on the results, it can be concluded that patients with septic shock has a significantly higher odds of mortality rate compared to patients without septic shock, this is supported with the low odds ratio of 0.06 that suggests the negative impact of septic shock on recovery and the p value score of <0.001. World Journal of Advanced Research and Reviews, 2025, 26(01), 2752-2757 2756 Table 6 Bivariate Chi-Square Test Analysis of Septic Shock and Mortality Septic shock Discharged Status OR (CI 95%) P value Recovered Death Total Septic shock 0 2 (1.2%) 2 (1.2%) 0.06 (0.001-0.041) <0.001 Without Septic shock 173 (98.8%) 0 173 (98.8%) Total 173 (98.8%) 2 (1.2%) 175 (100%) Following an in-depth analysis examination of possible risk factors influencing mortality of diarrhea on patients’ under the age of five years old hospitalized in RSUD Dr. Soetomo Surabaya, several remarkable observations can be highlighted. There were several factors that are statistically significant to attributes on mortality on patients with diarrhea under the age of five years old hospitalized in RSUD Dr. Soetomo. These factors are septicaemia and septic shock. It is well known that diarrhea is one of the most common cause of septicaemia among children under the age of five years old. Septicaemia in children is life-threatening organ dysfunction (Phoenix Sepsis Score ≥2) due to infection, with septic shock involving cardiovascular dysfunction (score ≥1), thus patient with septicaemia has higher odds of developing septic shock that may results to death [9]This is in line with the research conducted by Sarmin et al., 2019 done in Bangladesh with subjects of 1000 diarrhea patients within the age of 0-59 months where out of 1000 patients treated for diarrhea, 191 suffered from septicaemia, and 70 dies out of septic shock [7] Nevertheless, some factors such as degree of dehydration is proven to be statistically significant factors that contributes notably to the duration of hospital stay for patients with diarrhea, yet those factors is not significantly affect mortality of diarrhea on the dependent variable of this research. Dehydration is the most common complication of diarrhea, this cascade happens as a result of fluid loss during the frequent stool episode[8]. A study done in Wangaya General Hospital Denpasar supported this research as it proves that there were correlations between degree of dehydration and patient’s length of stay. Patients who experienced dehydration has longer hospital stay compared to patients who are not dehydrated[10]findings is in line with this research, where the p value score of the correlation between dehydration and patient’s length of stay. In this research, age and gender are not statistically correlated with the mortality of diarrhea patients under five years old in this study. Study done in Dhaka by Jarman, et al., 2018 regarding the correlation between gender and the severity of diarrhea manifestation between boys and girls are quite similar [11] Hartman et al., 2023, found that female children have a higher likelihood of mortality due to diarrhea, which is attributed to the lack of proper nutrition. Moreover, Hartman et al., 2013, reported that infants under six months of age are at the highest risk of mortality compared to older children [4]. Infants are more susceptible to infections due to the immaturity of their immune systems[12]However, in this research, no significant correlation between age, gender, and mortality was observed. This finding may be attributed to research limitations, such as a small sample size or a low event rate (mortality). 4. Conclusion Septic shock and septicemia were found to be significantly associated with mortality among children under five years old hospitalized with diarrhea at RSUD Dr. Soetomo in 2023. In contrast, no statistically significant association was observed between gender, age, or degree of dehydration and mortality in this study population. It is important to note, however, that previous studies have reported a significant relationship between the degree of dehydration and mortality. The lack of such an association in this study may be influenced by improvements in public health interventions, such as enhanced sanitation, increased breastfeeding rates, early recognition of diarrhea, and greater household use of oral rehydration solutions and zinc supplementation. Furthermore, while the degree of dehydration was not associated with mortality, it was found to significantly correlate with the length of hospital stay. Compliance with ethical standards Acknowledgements Authors would like to thank the Head and Staffs of Medical Record and ITKI (Instalasi Teknologi Komunikasi dan Informasi) Division of RSUD Dr. Soetomo for providing the data needed for this research activity. World Journal of Advanced Research and Reviews, 2025, 26(01), 2752-2757 2757 Disclosure of Conflict of interest There is no conflict of interest to be disclosed. 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