In the first year of life enteritis is the main cause of death. Only in the first week, and probably also in the first month of life infectious diseases and prematurity are of more importance. The infantile diarrhoea (infantile coli – enteritis) can occur in sporadic cases or in epidemics. In the maternity ward of the University Gadjah Mada occurred an epidemic of infantile diarrhoea during the period July till December 1955. this epidemic is described by Ismangoen in the Journal of Tropical Pediatrics, June 1957. In this period of 6 month 154 babies were born in this maternity-ward. Of these newborn 53 suffered form diarrhoea.
Special circumstances made it possible to make an attempt at identification of the causative organism in one of these patients. In Statens Serum Institut, Copenhagen, the isolated micro-organisms were identified as Escheria coli 0-group 126 and as Salmonella worthington 1, 13, 23 : 1, w. In his analysis of these cases of infantile coli-enteritis Ismangoen demonstrated that the danger to be infected is greater among the newborn infants who receive a formula or mixed food than among the infants who receive breast-milk only. Among the infants receiving a formula or mixed food 70 out 117 suffered from diarrhoea, while among the infants receiving breast-milk only 3 out of 37 suffered from diarrhoea within the first days of life. In this group of 73 patients, 20 patients died, mortality was 27%.
Also in the maternity-ward of the Bethesda hospital an epidemic of infantile diarrhoea occurred. During the period May – September 1957 56 out of 241 newborn infants born in this ward, suffered from infantile diarrhoea during this period. This means that 23% of all the newborns who were exposed to infection really fell ill, notwithstanding all the measures taken to prevent this. Mortality among these 56 patients was 34%.
The measures taken were:
Isolation of the patients suffering from enteritis.
All the newborn infants, who were already exposed to infection, were put in quarantine, Instead of keeping all the infants together in one room after the beginning of the epidemic the nursing method was changed into “Rooming in maternity Plan”.
The check on nursing and milk preparing was intensified. Because there is a lack of qualified nurses most of the nursing work is done by pupil nurses. It was tried to refuse new admissions, but because this appeared to be impossible under the working conditions in Jogjakarta the maternity-ward could not be closed till the epidemic had diminished.
A final enquiry into the causative organism of this diarrhoea epidemic was impossible at Jogjakarta at the time. Also among these patients it appeared that a formula enhanced the chance of being infected, just as this was demonstrated by Ismangoen. Mortality among the premature babies was higher than among the newborn infants with a birthweight above 2,500 gram.
Beside these 56 cases of infantile diarrhoea which occurred as an epidemic in the neonatal ward during the period May-September 1957, sporadic cases among the newborn infants in the period July 1, 1957 – July 1, 1958 were also observed. Especially the newborn infants in the maternity-ward who got a formula became the victims of this disease. Out of the 52 sporadic cases of infantile diarrhoea 39 got a formula.
Table VIII – 10.
Enteritis among newborn infants born in the Bethesda-maternity ward
during the period July 1, 1954 till July 1, 1958.
Mortality among premature babies also in this group of sporadic cases of infantile diarrhoea was higher than among the other newborn infants suffering from this disease. A review of the group of 52 cases which occurred sporadically or as a small epidemic of 2-3- or 4 cases are given in table VIII-10.
Table VIII – 11.
Review of 545 infants suffering from enteritis, who were admitted and treated in the two children’s ward at Jogjakarta during the period July 1, 1954 till July 1, 1958.
Put on a formula is the last emergency measure in child feeding on Java. The absence of breast-milk is nearly the same as a death-sentence for the newborn infant, because the possibilities for preparing a formula in the rural areas are rather small. Therefore a formula was decided on in emergency cases only. Among the infants who got a formula in hospital we observed many cases of infantile diarrhoea.
A third group of infants suffering from diarrhoea were admitted in both children’s wards after examination in the out-patients clinic. Hundreds of infants suffering from diarrhoea were examined in the out-patients clinic during the period July 1, 1954 – July 1, 1958. Admitted in the children’s ward of the Bethesda hospital were 286 infants suffering from diarrhoea of whom 177 in the first six months of life. In the University children’s ward 259 infants suffering from diarrhoea were admitted during the period May 1, 1955 till July 1, 1958 of whom 171 in the first six months of life. The greater part of the pediatric work in Jogjakarta consists of the treatment of children suffering from malnutrition of from diarrhoea. In many cases the patients suffer from both diseases at the same time. Many children and especially toddlers who are suffering from both diseases at the same time have because of their unsatisfactory nutritional condition a more severe prognosis than the children suffering from enteritis who are in a good nutritional condition. Many patients suffering from diarrhoea were in the first three months of life. The prognosis of the patients suffering from enteritis becomes in the second half year of life somewhat better than in the first half year of life. This is demonstrated with the mortality figures of the enteritis patients in the different age-groups.
The causative organisms of enteritis in these cases could not be ascertained. In the first three months of life it is very probable that pathogenic E.coli strains are of great importance while after the third month of life Shigella strains are of importance.
In 1958 Lie kian Joe and Sahab published the results of their examination of pathogenic E.coli in Djakarta children. The coli strains which were isolated during epidemics of infantile diarrhoea belonged to the 0-group 111 and 0-group 86. Especially premature babies appeared also in Djakarta to become the Victims of this disease. The possibility that E.coli could be of importance for the enteritis among infants in Indonesia was first mentioned by Straub in his thesis (1927). pg.97. He considered it very probable, because of the results of his detailed examination, that pathogenic strains of normal enterobacteriaceae were of importance in the pathogenesis of infantile enteritis. Only after the work of Bray and Beavan in 1944/45 could this supposition be confirmed.
The probability that Shigellas are the causative organisms in many cases of enteritis will be discussed in the next chapter.
The treatment of the enteritis patients was: an adapted feeding-scheme, chloromycetin or aureomycin and if necessary intravenous fluid therapy and small blood transfusions. In Javanese infants the equilibrium of fluid and electrolytes is easily disturbed by infections and especially by enteritis. The condition of dehydration can arise in a few hours. Many children suffering from enteritis were brought to the out-patients clinic in a condition of dehydration. The circumstance that the equilibrium of fluid and electrolytes is so easily disturbed by enteritis is an important threat to the lives of these patients.
The clinical picture of dehydration with the symptoms of rapid pulse, a lost elasticity of the skin, sunken eyes, a staring look in the eyes, a deep respiration, sunken fontanel, cold hands and feet which was so frequently seen was in many cases the indication to treat the infant with an intravenous fluid drip by drip therapy. Out of 286 infants suffering from severe enteritis 130 got intravenous fluid therapy in the Bethesda children’s ward, while 136 out of the 259 infants admitted with enteritis in the University children’s ward were treated with intravenous fluid therapy.
Nearly always one drip by drip infuse is running in the children’s ward and sometimes 8 at the same time.
Also during other infections we observed that the equilibrium of fluid and electrolytes was disturbed. In some case of malaria, cystitis and pneumonia we observed that the patient became dehydrated without a serious loss of fluid.
To illustrate the rapid development of the condition of dehydration we like to mention the following short case histories.
UNTUNG: A Javanese boy of 8 months. On March 10, 1958 in the evening he got a fever. In the night of march 10 to 11 he also developed diarrhoea and votimed three times. The next morning a convulsion occurred. Just after the convulsion the mother took the child to hospital in the early morning. Since the beginning of the disease the child 9 times lost watery stools and at the moment he arrived in the hospital he was already in a serious condition of dehydration. The skin when picked up remained in sharp folds and there was a deep respiration. The eyes were sunkun and the child was dozy. No neck stiffness. The bodyweight was 5,300 grams. In the stools many leucocytes were found by microscopical examination. The child was immediately admitted and was treated with intravenous fluid therapy. The condition rapidly worsened and three hours after the fluid therapy started the child died. The whole course of the disease from the first fever till death was 16 hours. The culture of the stools was negative. Shigellas nor Salmonella could be isolated from the stools.
Beside the rapid development of the condition of dehydration which is often the final state before death in enteritis, also a course of enteritis is observed in which cerebral symptoms are the most striking. This course of enteritis is less frequent than the course leading to dehydration. In the period July 1, 1954 till July 1, 1958 in both children’s wards a total number of 12 cases of enteritis was observed suffering from enteritis with cerebral symptoms. In the Bethesda children’s ward there were 8 and in the University’s children’s ward 4 cases. Out of these 12 patients who were all older than 5 month of life 11 died. One short case history of this rather rare type of development in enteritis is mentioned below.
NUGROHO: A Javanese boy born at June 8, 1956 with a birthweight of 3,240 grams. Because the mother suffered from tuberculosis of the spinal column and was admitted in Bethesda hospital the child was nursed in the neonatal room of the maternity-ward for several months.
The infants was put on a formula. On February 17, 1957 the child was discharged from the hospital when it was seven months of age with a bodyweight of 6,400 grams.
The formula could be contained at home. Three days after dismissal the boy was admitted again, but now in the children’s ward. On February 19 he started with diarrhoea and became seriously ill. He had loose stools 5 times a day. The fever at the moment of admission (February 20) was 40ºC. After admission the fever rose to 42ºC. Just after admission the child got a convulsion. The lumbar puncture showed that there was clear and normal spinal fluid. There was no dehydration. The bodyweight at admission was 5,910 grams. In the stools a lot of mucus was visible which contained may leucocytes, when microscopically examined. The culture of the stools was negative. The high fever could be brought down with wet sheets to 40ºC. The child remained unconscious and had slight twitches in arms and legs. Eleven hours after admission he died. The whole duration of the disease from the first symptom till death was 26 hours.