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

∗ Co esponding au ho : Dwi Ap ilawa i Copy igh © 2025 Au ho (s) e ain he copy igh o his a icle. This a icle is published unde he e ms o he C ea i e Commons A ibu ion Liscense 4.0. Risk ac o s o mo ali y on dia hea child en unde i e yea s old hospi alized in D . Soe omo Gene al Academic Hospi al Su abaya 2023 Aulia Najma Adhyana Ku niawan 1, Dwi Ap ilawa i 2, *, Dwiyan i Puspi asa i 3 and Alpha Fa dah A hiyyah 3 1 Facul y o Medicine, Uni e si as Ai langga, Su abaya, Indonesia. 2 Dépa emen o Public Heal h Sciences, Facul y o Medicine, Uni e si as Ai langga, Su abaya, Indonesia. 3 Dépa emen o Pedia ics, Facul y o Medicine, Uni e si as Ai langga, Su abaya, Indonesia. Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 2752-2757 Publica ion his o y: Recei ed on 14 Ma ch 2025; e ised on 19 Ap il 2025; accep ed on 21 Ap il 2025 A icle DOI: h ps://doi.o g/10.30574/wja .2025.26.1.1391 Abs ac Th ough he yea s, dia hea has been one o he signi ican causes o mo ali y among child en unde he age o i e yea s old all o e he wo ld. Th oughou 2021, app oxima ely 444,000 child en unde i e yea s old died due o dia hea, making up abou 9% o all child en unde i e yea s old’s mo ali y. Dia hea is a gas oin es inal disease cha ac e ized by inc eased bowel mo emen s causing h ee o mo e s ool episodes along wi h a loose o wa e y consis ency wi hin 24 hou s. The e a e se e al isk ac o s ha con ibu e o he mo ali y o child en wi h dia hea unde he age o i e yea s old. This s udy aimed o de e mine which isk ac o s a e signi ican enough o cause he mo ali y o child en unde he age o i e yea s old su e ing om dia hea. This e ospec i e analy ic s udy was conduc ed by obse ing he medical eco ds o child en unde i e yea s old hospi alized in D . Soe omo Gene al Academic Hospi al Su abaya due o dia hea du ing 2023. Da a we e analyzed by using chi-squa e bi a ia e analysis wi h he SPSS e sion 30 applica ion. The esul s show ha sep ic shock and sep icaemia a e signi ican ac o s con ibu ing o he mo ali y o child en unde i e yea s old su e ing om dia hea. Fu he mo e, dehyd a ion, and s p o en o no signi ican ly a ec mo ali y in dia heal pa ien s unde he age o i e yea s old, ye his ac o is p o en o be signi ican o con ibu e o he pa ien ’s leng h o s ay in he hospi al wa d a RSUD D . Soe omo Su abaya. On he o he hand, a pa ien ’s gende and age a e p o en o be no signi ican o cause mo ali y in child en unde i e yea s old su e ing om dia hea. Keywo ds: Dia hea; Child en; Sep ic Shock; Sep icaemia; Dehyd a ion 1. In oduc ion Th ough he yea s, dia hea is s ill one o he leading cause o child en mo ali y wo ldwide, especially in child en unde he age o i e yea s old. Da a epo ed by he Indonesian Minis y o Heal h on 2018 epo ed ha he e we e a ound ou millions epo ed dia hea cases o child en unde he age o i e yea s old, o a ound 17% p e alence a e[1] Dia hea is a gas oin es inal disease cha ac e ized by inc eased bowel mo emen s esul ing o abno mal s ool episode, h ee o mo e s ool episode pe 24 hou s [2]. Dia hea migh be caused by se e al e iologies, based on i s oo causes i classi ies in o in ec ious dia hea and non-in ec ious dia hea. Non-in ec ious dia hea is usually caused by malabso p ion, ana omical de ec , malignancies, alle gies, ood poisoning, and o he s. While in ec ious dia hea is caused by in ec ious pa hogen[3] No able isk ac o s con ibu ing o dia hea among child en below 5 yea s old include nu i ional condi ion such as was ing and malnu i ion[4]. S udy in child en wi h low nu i ional s a us shows an al e ed immune sys em, as a Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 2752-2757 2753 consequence, he e is an ele a ed ulne abili y o in asi e in ec ions, including hose a ec ing he u ina y and gas oin es inal sys ems, as well as an inc eased isk o sep icemia[5]. A s udy done by Ha man e al., 2023 p esen s ha in an s below he age o 6 mon hs has he highes isk o mo ali y, wice as high i compa ed o child en be ween 2 and 5 yea s o age, his is happens because in an s is mo e ulne able o in ec ions. Addi ionally, he s udy shows ha emale is a ibu ed wi h a highe likelihood o mo ali y due o dia hea as i is a ibu ed o he lack o p ope nu i ion in emale child en. Dia hea causes excessi e wa e loss, making dehyd a ion o be he mos common complica ion o dia hea pa ien s. App oxima ely 20% o peadia ic dea hs is associa ed wi h dehyd a ion ela ed o gas oen e i is[6]. Some publica ions also men ioned sep ic shock is ea u ed in he dea h o pa ien s wi h in ec ious diseases, including dia hea [7]. The p ima y complica ion o dia hea is dehyd a ion leading o se e e sepsis, and sep ic shock[7, 8] This s udy aimed o de e mine isk ac o s o mo ali y among dia hea pa ien s unde he age o i e yea s old hospi alized in RSUD D . Soe omo 2023. P ope unde s anding o he isk ac o s ha may co ela es wi h he mo ali y dia hea is impo an , in o de o gi e a comp ehensi e app oach o pa ien wi h dia hea. Thus, unwan ed complica ion can be p e en ed and inc eases pa ien ’s quali y o li e and dec ease mo ali y a e o pa ien s wi h dia hea. 2. Ma e ial and me hods This s udy is a e ospec i e analy ic s udy done by obse ing medical eco ds o pa ien s unde i e yea s old who we e hospi alized o dia hea in RSUD D . Soe omo, Su abaya in 2023. The pu pose o his s udy is o de e mine whe he ce ain a iables, such as age, gende , nu i ional s a us, dehyd a ion, sep icaemia, and sep ic shock a e a signi ican con ibu o s o he mo ali y o child en unde he age o i e yea s old hospi alized o dia hea in RSUD D . Soe omo, Su abaya. This s udy was conduc ed o 5 mon hs, om June o Oc obe 2024. Popula ions sample o his s udy a e 175 pa ien s selec ed wi h consecu i e sampling in acco dance wi h he inclusion and exclusion c i e ia equi ed o his esea ch. Inclusion c i e ia o his s udy a e pa ien s om age 0 mon hs – 60 mon hs, hospi alized in RSUD D . Soe omo Su abaya wi h diagnosis o dia hea as he medical indica ion o inpa ien . While he exclusion c i e ia o his esea ch a e pa ien s wi h congeni al abno mali ies, gene ic diso de s, immunocomp omised pa ien s, and pa ien s wi h me abolic diso de s, such as diabe es. Da a o pa ien s’ age and gende we e ga he ed om he demog aphic da a w i en on pa ien s’ medical eco d. Da a o dehyd a ion, sep icaemia, and sep ic shock on pa ien s’ a e ga he ed om he diagnosis eco ded medical eco d and labo a o y examina ions esul a ached in pa ien s’ medical eco d du ing hei hospi aliza ions o dia hea. The collec ed da a a e analyzed wi h S a is ical P oduc and Se ice Solu ion (SPSS) 30 e sion applica ion. Bi a ia e analysis was done o de e mine whe he he e is a signi ican ela ionships be ween he a iables (age, gende , dehyd a ion, sep icaemia, and sep ic shock) and mo ali y wi h chi-squa e hypo hesis es . 3. Resul s and discussion Th oughou 2023, he e we e 253 child en unde 5 yea s old pa ien s hospi alized o dia hea in RSUD D . Soe omo ha me inclusion and exclusion c i e ia o his esea ch. Howe e , 78 pa ien s a e excluded as i me he exclusion c i e ia o his esea ch as explained i n he p ious chap e . Thus, lea ing 175 pa ien s wi h eligible da a ha me he inclusion c i e ia o his esea ch. E hical clea ance o da a collec ion p ocess o his esea ch has been g an ed by he E hical Commi ee o RSUD D . Soe omo, Su abaya. Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 2752-2757 2754 Table 1 The Dis ibu ion and Cha ac e is ic o Resea ch’s Subjec s Cha ac e is ic To al % Gende Male 99 56 Female 76 44 Age 0-12 mon hs old (in an s) 86 49 13- 60 mon hs old (child en) 89 51 Nu i ional S a us Unde nu i ion 78 44.5 No mal 97 55.5 Dehyd a ion Wi hou dehyd a ion 48 28 Mild/mode a e/se e e dehyd a ion 127 72 Sep icaemia Wi hou sep icaemia 169 96.5 Sep icaemia 6 3.5 Sep ic Shock Wi hou sep ic shock 2 1.14 Sep ic shock 173 98.86 Pa ien s’ Discha ged S a us Reco e ed 172 98.2 Dea h 3 1.71 Each a iable o he da a p esen ed in Table 1 we e hen analyzed by using bi a ia e chi-squa e es acknowledge whe he he e is a signi ican co ela ion be ween he es ed a iable and he mo ali y o dia hea pa ien s unde i e yea s old. Table 2 Bi a ia e Chi-Squa e Tes Analysis o Pa ien s’ Gende and Mo ali y Gende Discha ged S a us OR (CI 95%) P alue Reco e ed Dea h To al 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%) To al 172 (98.2%) 3 (1.71%) 175 (100%) Table 2 p esen s he esul o bi a ia e chi-squa e analysis o pa ien s’ gende and mo ali y. Da a shown in abo e indica e ha he e is no signi ican co ela ions be ween pa ien s’ gende and mo ali y on dia hea pa ien s unde i e yea s old. This can be p o en by he p alue sco e o 0.127 and wide con idence in e al ange ha includes 1o odd a io, anging om ha indica es no signi ican co ela ion. Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 2752-2757 2755 Table 3 Bi a ia e Chi-Squa e Tes Analysis o Pa ien s’Age and Mo ali y Age Discha ged S a us OR (CI 95%) P alue Reco e ed Dea h To al In an s (0-12 mon hs) 84 (48%) 2 (1.14%) 86(49.15%) 2.095 (0.186 – 23.539) 0.375 Child en (13-60 mon hs) 88 (50.2%) 1 (0.57%) 89 (50.85%) To al 172(98.29%) 3 (1.71%) 175 (100%) Table 3 p o ides he bi a ia e analysis esul be ween pa ien s’ age and mo ali y o dia hea pa ien s unde he age o i e yea s old. Howe e , he esul shows no signi ican co ela ion be ween pa ien s’ age and mo ali y on child en unde i e yea s old wi h dia hea. Table 4 Bi a ia e Chi-Squa e Tes Analysis o Deg ee o Dehyd a ion and Mo ali y; Deg ee o Dehyd a ion and Hospi al Leng h o S ay Deg ee o Dehyd a ion Discha ged S a us OR (CI 95%) P alue Leng h o S ay P alue Reco e ed Dea h ≥5 days <5 days Mild/ Mode a e/ Se e e Dehyd a ion 124 (70.8%) 3 (1.14%) 1.024 (0.997 – 1.052) 1.154 80 (45.7%) 47 (26.8%) 0.022 Wi hou Dehyd a ion 48 (27.5%) 0 (0.57%) 21 (12%) 27 (15.4%) To al 172 (98.3%) 3(1.71%) 101 (57.7%) 74 (42.2%) Table 4 p esen s he esul o bi a ia e analysis be ween deg ee o dehyd a ion and mo ali y o dia hea pa ien s unde he age o i e yea s old and he bi a ia e analysis esul be ween deg ee o dehyd a ion and pa ien s’ du a ion o hospi aliza ion. The chi-squa e bi a ia e analysis o he ela ionship be ween deg ee o dehyd a ion and mo ali y shows he e is no signi ican co ela ion be ween he wo, his is suppo ed by he p alue sco e o 1.154. Howe e , he e is a signi ican co ela ion be ween deg ee o dehyd a ion and pa ien s’ hospi aliza ion leng h o s ay. Pa ien wi h dehyd a ion ends o ha e longe hospi aliza ion du a ion compa ed pa ien s wi hou dehyd a ion. This is suppo ed by he p alue sco e o 0.022. Table 5 Bi a ia e Chi-Squa e Tes Analysis o Sep icaemia and Mo ali y Sep icaemia Discha ged S a us OR (CI 95%) P alue Reco e ed Dea h To al Sep icaemia 4 (2.3%) 2 (1.2%) 6 (3.5%) 84.00 (6.257 – 1127.785) <0.001 Wi hou Sep icaemia 168 (96%) 1 (0.57%) 169 (96.5%) To al 172 (98.3%) 3 (1.71%) 175 (100%) Table 5 p o ides he esul o bi a ia e analysis be ween sep icemia and mo ali y o dia hea pa ien s unde i e yea s old. This able p o e ha sep icaemia is a s a is ically signi ican ac o ha co ela es wi h mo ali y o dia hea pa ien s unde he age o i e yea s old. Pa ien s wi h sep icaemia ha e highe isk o mo ali y compa ed o pa ien s wi hou sap icaemia his is suppo ed wi h high odds a io sco e, 84.00 and p alue sco e o <0.001. Table 6 p esen s he esul o bi a ia e analysis chi-squa e es be ween sep ic shock and mo ali y o dia hea pa ien s unde he age o i e yea s old. Based on he esul s, i can be concluded ha pa ien s wi h sep ic shock has a signi ican ly highe odds o mo ali y a e compa ed o pa ien s wi hou sep ic shock, his is suppo ed wi h he low odds a io o 0.06 ha sugges s he nega i e impac o sep ic shock on eco e y and he p alue sco e o <0.001. Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 2752-2757 2756 Table 6 Bi a ia e Chi-Squa e Tes Analysis o Sep ic Shock and Mo ali y Sep ic shock Discha ged S a us OR (CI 95%) P alue Reco e ed Dea h To al Sep ic shock 0 2 (1.2%) 2 (1.2%) 0.06 (0.001-0.041) <0.001 Wi hou Sep ic shock 173 (98.8%) 0 173 (98.8%) To al 173 (98.8%) 2 (1.2%) 175 (100%) Following an in-dep h analysis examina ion o possible isk ac o s in luencing mo ali y o dia hea on pa ien s’ unde he age o i e yea s old hospi alized in RSUD D . Soe omo Su abaya, se e al ema kable obse a ions can be highligh ed. The e we e se e al ac o s ha a e s a is ically signi ican o a ibu es on mo ali y on pa ien s wi h dia hea unde he age o i e yea s old hospi alized in RSUD D . Soe omo. These ac o s a e sep icaemia and sep ic shock. I is well known ha dia hea is one o he mos common cause o sep icaemia among child en unde he age o i e yea s old. Sep icaemia in child en is li e- h ea ening o gan dys unc ion (Phoenix Sepsis Sco e ≥2) due o in ec ion, wi h sep ic shock in ol ing ca dio ascula dys unc ion (sco e ≥1), hus pa ien wi h sep icaemia has highe odds o de eloping sep ic shock ha may esul s o dea h [9]This is in line wi h he esea ch conduc ed by Sa min e al., 2019 done in Bangladesh wi h subjec s o 1000 dia hea pa ien s wi hin he age o 0-59 mon hs whe e ou o 1000 pa ien s ea ed o dia hea, 191 su e ed om sep icaemia, and 70 dies ou o sep ic shock [7] Ne e heless, some ac o s such as deg ee o dehyd a ion is p o en o be s a is ically signi ican ac o s ha con ibu es no ably o he du a ion o hospi al s ay o pa ien s wi h dia hea, ye hose ac o s is no signi ican ly a ec mo ali y o dia hea on he dependen a iable o his esea ch. Dehyd a ion is he mos common complica ion o dia hea, his cascade happens as a esul o luid loss du ing he equen s ool episode[8]. A s udy done in Wangaya Gene al Hospi al Denpasa suppo ed his esea ch as i p o es ha he e we e co ela ions be ween deg ee o dehyd a ion and pa ien ’s leng h o s ay. Pa ien s who expe ienced dehyd a ion has longe hospi al s ay compa ed o pa ien s who a e no dehyd a ed[10] indings is in line wi h his esea ch, whe e he p alue sco e o he co ela ion be ween dehyd a ion and pa ien ’s leng h o s ay. In his esea ch, age and gende a e no s a is ically co ela ed wi h he mo ali y o dia hea pa ien s unde i e yea s old in his s udy. S udy done in Dhaka by Ja man, e al., 2018 ega ding he co ela ion be ween gende and he se e i y o dia hea mani es a ion be ween boys and gi ls a e qui e simila [11] Ha man e al., 2023, ound ha emale child en ha e a highe likelihood o mo ali y due o dia hea, which is a ibu ed o he lack o p ope nu i ion. Mo eo e , Ha man e al., 2013, epo ed ha in an s unde six mon hs o age a e a he highes isk o mo ali y compa ed o olde child en [4]. In an s a e mo e suscep ible o in ec ions due o he imma u i y o hei immune sys ems[12]Howe e , in his esea ch, no signi ican co ela ion be ween age, gende , and mo ali y was obse ed. This inding may be a ibu ed o esea ch limi a ions, such as a small sample size o a low e en a e (mo ali y). 4. Conclusion Sep ic shock and sep icemia we e ound o be signi ican ly associa ed wi h mo ali y among child en unde i e yea s old hospi alized wi h dia hea a RSUD D . Soe omo in 2023. In con as , no s a is ically signi ican associa ion was obse ed be ween gende , age, o deg ee o dehyd a ion and mo ali y in his s udy popula ion. I is impo an o no e, howe e , ha p e ious s udies ha e epo ed a signi ican ela ionship be ween he deg ee o dehyd a ion and mo ali y. The lack o such an associa ion in his s udy may be in luenced by imp o emen s in public heal h in e en ions, such as enhanced sani a ion, inc eased b eas eeding a es, ea ly ecogni ion o dia hea, and g ea e household use o o al ehyd a ion solu ions and zinc supplemen a ion. Fu he mo e, while he deg ee o dehyd a ion was no associa ed wi h mo ali y, i was ound o signi ican ly co ela e wi h he leng h o hospi al s ay. Compliance wi h e hical s anda ds Acknowledgemen s Au ho s would like o hank he Head and S a s o Medical Reco d and ITKI (Ins alasi Teknologi Komunikasi dan In o masi) Di ision o RSUD D . Soe omo o p o iding he da a needed o his esea ch ac i i y. Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 2752-2757 2757 Disclosu e o Con lic o in e es The e is no con lic o in e es o be disclosed. S a emen o e hical app o al This esea ch ecei ed e hical app o al om he Heal h Resea ch E hics Commi ee o he Facul y o Medicine, Uni e si as Ai langga, Su abaya, Indonesia. Re e ences [1] A Thoba i J, Su a man, Mulyadi AWE, e al. Di ec and indi ec cos s o acu e dia hea in child en unde i e yea s o age in Indonesia: Heal h acili ies and communi y su ey. Lance Reg Heal h Wes Pac; 19. Epub ahead o p in 2022. DOI: 10.1016/j.lanwpc.2021.100333. [2] Schille LR, Pa di DS, Sellin JH. Ch onic Dia hea: Diagnosis and Managemen . Clinical Gas oen e ology and Hepa ology; 15. Epub ahead o p in 2017. DOI: 10.1016/j.cgh.2016.07.028. [3] Imanadhia A, Ranuh IRG, Nuswan o o D. E iology Based on Clinical Mani es a ion o Acu e Dia hea Incidence o Child en Hospi alized in D . Soe omo Gene al Hospi al Su abaya Pe iod 2011-2013. Biomolecula and Heal h Science Jou nal; 2. Epub ahead o p in 2019. DOI: 10.20473/bhsj. 2i1.12744. [4] Ha man RM, Cohen AL, An oni S, e al. Risk Fac o s o Mo ali y Among Child en Younge Than Age 5 Yea s Wi h Se e e Dia hea in Low- and Middle-income Coun ies: Findings F om he Wo ld Heal h O ganiza ion- coo dina ed Global Ro a i us and Pedia ic Dia hea Su eillance Ne wo ks. Clinical In ec ious Diseases; 76. Epub ahead o p in 2023. DOI: 10.1093/cid/ciac561. [5] Dipasquale V, Cucino a U, Romano C. Acu e malnu i ion in child en: Pa hophysiology, clinical e ec s and ea men . Nu ien s; 12. Epub ahead o p in 2020. DOI: 10.3390/nu12082413. [6] P isco A, Capalbo D, Gua ino S, e al. How o in e p e symp oms, signs and in es iga ions o dehyd a ion in child en wi h gas oen e i is. A ch Dis Child Educ P ac Ed; 106. Epub ahead o p in 2021. DOI: 10.1136/a chdischild-2019-317831. [7] Sa min M, A oze F, Sha i uzzaman, e al. P edic o o Dea h in Dia heal Child en Unde 5 Yea s o Age Ha ing Se e e Sepsis in an U ban C i ical Ca e Wa d in Bangladesh. Glob Pedia Heal h; 6. Epub ahead o p in 2019. DOI: 10.1177/2333794X19862716. [8] Pu i DNA, Ongo MRD, And iany S. Acu e dia hoea wi h se e e dehyd a ion and complica ions in a 1-yea -old child: a case epo in a hospi al wi h low esou ce se ing. In J Res Med Sci; 11. Epub ahead o p in 2023. DOI: 10.18203/2320-6012.ij ms20233725. [9] Wa son RS, Ca ol ED, Ca e MJ, e al. The bu den and con empo a y epidemiology o sepsis in child en. The Lance Child and Adolescen Heal h 2024; 8: 670–681. [10] Budiha djo SN, Su yawan IWB, Sucip a AAM. The ela ionship be ween nu i ional s a us wi h leng h o s ay in 1-5 yea s old child en wi h dia hea a Wangaya Gene al Hospi al Denpasa . Indonesia Jou nal o Biomedical Science 2020; 14: 113–117. [11] Ja man AF, Long SE, Robe son SE, e al. Sex and gende di e ences in acu e pedia ic dia hea: A seconda y analysis o he Dhaka s udy. J Epidemiol Glob Heal h; 8. Epub ahead o p in 2018. DOI: 10.2991/j.jegh.2018.08.102. [12] Aulia M, T i a na S, I iani Y, e al. Pedia ic so a sco e o de ec ing sepsis in child en. Paedia ica Indonesiana(Paedia ica Indonesiana); 61. Epub ahead o p in 2021. DOI: 10.14238/pi61.1.2021.1-7.