Diarrhea is the passage of loose or watery stools occurring three or more times in a 24-hour period which means an increased frequency or decreased consistency of bowel movements, and it affects people of all ages. It is usually a symptom of an infection in the intestinal tract, which can be caused by a variety of bacterial, viral, and parasitic organisms [1-5]. Diarrhea is the second leading cause of child morbidity and mortality, especially in the developing countries. Globally, it is estimated that there are 2.5 billion episodes and 1.5 million deaths annually in children under five years [6-8]. Various preventive techniques were reported in the literatures including hygiene, diet, medications, and supplements; although according to a general classification, health care, breastfeeding, immunization, supplemental zinc, and probiotics could be used. Simple remedies could be taken to reduce the number of mortality [9-13]. Fluid therapy with Oral Rehydration Solution (ORS) and other standard home solutions, non-stop feeding during diarrhea, and continued breastfeeding are the typical treatments [14-21].  Since 1970s, ORS has been the cornerstone of management in order to prevent life-threatening dehydration associated with diarrhea. Nevertheless, only less than 40% of children with diarrhea in developing countries received the recommended treatment and there has been a little progress toward the trend in the last decades [22-26]. Diarrhea turns mortal for majority with fluid loss and accompanying severe dehydration. Timely treatment from ORS has reduced morbidity and mortality from diarrhea[27-29]. Numerous studies about the maternal awareness of proper diet of children with diarrhea suggested that knowledge of the etiologic factors, symptoms, treatment, and caring methods in diarrheal children among mothers is inadequate, [30-34]. Most of the diarrhea episodes are treated in homes, and mothers are the key caregivers in children under five years old. They are the ones who decide about the nutrition and management of diarrhea in children therefore their knowledge about this common disorder is critically important [35-37]. Early and correct identification of diseases and prompt initiation of management plays a key role in reducing diarrhea related mortality [38-40].  An important aspect of diarrhea management is replenishing fluid and electrolyte loss. Patients should be encouraged to drink diluted fruit juice, Pedialyte or Gatorade. In more severe cases of diarrhea, IV fluid rehydration may become necessary [41-44]. Eating foods that are lower in fiber may aid in making stool firmer. A bland bananas, rice, applesauce, and toast 'BRAT' diet including bananas, toast, oatmeal, white rice, applesauce and soup/broth is well tolerated and may improve symptoms [45-49]. Anti-diarrheal therapy with anti-secretory or anti-motility agents may be started to reduce the frequency of stools. However, they should be avoided in adults with bloody diarrhea or high fever because they can worsen severe intestinal infections. Empiric antibiotic therapy with an oral fluoroquinolone can be considered in patients with more severe symptoms. Probiotic supplementation has been shown to reduce the severity and duration of symptoms and should be encouraged in patients with acute diarrhea[40,41]. The treatment of chronic diarrhea is specific to the etiology.  The first step is to categorize diarrhea into watery, fatty or inflammatory. Once categorized, an algorithm can be used to determine the next step in management. Most cases require additional fecal studies, lab work or imaging. More invasive procedures like colonoscopy or upper endoscopy may be required [33,42]. Variety of preventive interventions mentioned in the literature for diarrhea include drinking clean and refined water, employing modernized sanitary systems and washing the hands frequently with a soap or other disinfectants, which can decrease the risk of infection [43]. Simple remedies such as fluid therapy with Oral Rehydration Solution (ORS) and other standard homemade solutions, female education, incessant feeding at the time of diarrhea and continued breastfeeding are the common treatments, which can reduce the mortality rate [44]. However, in developing countries, the suggested remedies have been prescribed for children with diarrhea in roughly 40% of the cases and the movement towards the extensive use of these methods has been so slow over the last 10 years [35]. Although the standard of living is promoted, public hygiene has improved, water purification has become widespread and food safety is universally recognized, diarrheal disease still inflicts a considerable loss on the economy and the society [45]. Many studies on diarrhea in children have shown that proper and prompt care is essential to reduce the negative consequences. Immediate simple interventions by mothers/caregivers for childhood diarrhea is the key to save the children’s lives [46,47]. Effective interventions can prevent most diarrhea-related casualties in children<5 years old. The global coverage for most of these interventions is <50% [48]. Effective care is often insufficiently available, especially in the first 24 hours after the onset of illness and in areas where child mortality is high. Sometimes, the diarrhea can be resolved by dietary promotion and/or simultaneous adoption of typical methods used for the management of diarrhea. There has been a huge controversy about the best approach to dietary treatment of childhood diarrhea [49]. The mothers’ or caregivers’ knowledge and understanding of the types of food used in case of diarrhea may be effective in management of the disease. Promoting the habits regarding food and personal hygiene is certainly a practical method to reduce the difficulty of illness in children with diarrhea [50]. Nutrition should serve as a key for developmental intervention, as child mortality is a serious predictor of future outcomes. In fact, people who experience high levels of complications in childhood have been shown to have reduced cognition, height and maturity, and to be at risk for further complications and mortality [13]. Poor maternal perception about diarrhea and delayed care can lead to morbidity and [44]. A large number of studies conducted on mothers’ knowledge of appropriate diet for childhood diarrhea indicate that mothers have no sufficient information on the etiologic factors, symptoms, treatments and caring methods of this disease [51-53]. The aim of this study was to assess the different treatment measures taken by mothers at home to their children under-five years who suffered from diarrhea 

A cross-sectional hospital based study were done on 200 mother whose babies have acute diarrhea and admitted to pediatric ward at Salah Al-Deen general hospital in Tikrit city, during the period from 10th of June 2020 to 10th June 2021  aged  below 5 years.

Study acceptance from mothers were taken and acceptance from Salah Al –deen hospital. Each case (mother whose babies have acute diarrhea) were assessed by a prepared questionnaire that include (name,  age,  sex,  residence,……etc). Diarrhea considered as acute if it was lasting less that 14 days, whether with blood or without, with fever and vomiting or without. The questionnaire was completed by an interview. It had three parts. In the first section, the demographic characteristics, including age, sex and residence. The second part, including education of mothers and the number of children were recorded. In the third part, the knowledge about diarrhea and its management were evaluated using multiple choice questions and the occupation and the number of children were recorded.  In the knowledge about diarrhea and its management were evaluated using multiple-choice questions. Mothers’ knowledge regarding home treatment of acute diarrhea were taken. Some questions were, e.g: “How do you perform the breast feeding during diarrhea?” “What is ORS?” The results were putted in tables and figures for further statistical analysis 

Statistical analysis

The relations between the knowledge and the variables such as age, sex, maternal education, number of children, residence and the number of children were analyzed using computerized statistically, Minitab version 17 statistic program. Comparison was carried out using Chi-square (X2) and P. value ≤ 0.5   Significant

The study showed no significant distribution of studied children to according to age and sex, although most cases were below 24 months and 58% of total cases were females, Table 4.1

Table 1: Distribution of studied children according to age and gender

X2 : 0.89                 P. value: 0.92  (Non-significant)

The study showed 58% of studied children were from rural families and 42% were from urban families, Figure 1

Figure 1:  Residence distribution of studied children

The study also showed that, more than one third of mothers were illiterate and 25% complete primary school, and most of illiterate and primary school mothers were from rural areas.

Table 2: Relation of educational level of mother with their residence

X2: 47.8                P. value: 0.0001  (Highly significant)

The study revealed that 24.5% of women feed their children by breast feeding 20.5% bottle feeding,  15% mixed feeding while 40% with solid feeding, Figure 2

Figure 2: Distribution of  studied mothers according to type feeding

The study revealed a significant relation between type of feeding and educational level of studied mothers (P<0.01), Table 3

Table 3: Type of feeding in regard to educational level of studied mothers

P. value: 0.0011 

The study the prevalence of bloody diarrhea among total children enrolled in the study was 11%, Figure 3

Figure 3: Distribution of  studied children according to type diarrhea

In this study, majority of diarrheal children drinking from tap water (82%), 79% were with poor sterilization conditions in their families, and some of cases were different risk factors, Table 4

Table 4: Risk factors of diarrhea

P. value: 0.001

 In this study, nearly half of women who children suffered from diarrhea used antibiotics  (51%), while 5% uses sagwa to manage diarrhea, 15% uses ORS and only 8% use zinc or probiotic to manage diarrhea in their children, Table 5

Table 5: Action taken by mother to manage diarrhea

The study showed significant relation between relation of source of knowledge of mothers and action to manage diarrhea, in this regard,  nearly half of  women took their information from relative or media to use antibiotics in treatment of diarrhea,  and 80% used sagwa as treatment as they know from relatives and most of them new that ORS used in management of diarrhea from physician and TV, Table 4.6.

Table 4.6: Relation of source of knowledge of mothers and action to manage diarrhea

P. value: 0.0001 

The study showed  significant relation between risk factors of diarrhea and educational levels of mothers and most mothers with illiterate and primary school levels have high risk of diarrhea and, Table 7

Table 7: Relation of educational level of mother with risk factor of diarrhea

P. value: 0.0028 

The study a significant relation between educational level of mother and source of knowledge about management of diarrhea, Table 8

Table 8: Relation between educational level of mother and source of knowledge about management of diarrhea

P. value: 0.0001 

The study a significant relation between educational level of mother and action taken by mother to manage diarrhea , Table 9

Table 49: Relation between educational level of mother and Action taken by mother to manage diarrhea

   P. value: 0.0001  

The study showed no significant distribution of studied children in according to age and sex, although most cases were below 24 months and 58% of total cases were females, In agreement with our finding, [55] indicated that most diarrheal children was occurred within the age group 25-36 month followed by (25%) in the age group 13-24 month. It has been suggested that in developing countries the infection is usually acquired before five years of age [50]. The results of the present study indicated that the highest incidence of diarrhea was observed in children aged 6-24 months, which is consistent with the results of other studies [43,44]. A multiple indicators survey performed by National Centre for health information and UNICEF (2000) reported that the prevalence rate of diarrhea in children was 39.2% in children <two years old [45]. One of the reasons why the prevalence of diarrhea increases between the ages of 6 and 24 months can be the introduction of complementary food and the unsanitary preparation of weaning food [46]. As age increase, exposure to various infection sources increases hence the ultimate rate of infection [54]. The study showed 58% of studied children were from families lived in rural areas and 42% belonged to urban areas, this agree with  recent studies  done [56]. Furthermore, it was indicated that children living in rural areas were more vulnerable to diarrhea than their urban counterparts and children from rural households were 1.9 times more likely to have diarrhea as compared to their counterparts [34,44]. Due to poor sanitation, contact with contaminated water supply, low level of education and malnutrition.   Our results support the findings of prior studies that have also described that of diarrheal children belonged to families who lived in rural areas [57,58].  People living in urban areas are provided with better access to health services, education and other social support systems which are either not available or not easily accessible to residents in rural areas [59].  The study also showed that, more than third mothers were illiterate and 25% complete primary school, and most of illiterate and primary school mothers were from rural areas. This is goes with many studies done  around the world.   The reason why most of the cases have illiterate mothers is that due to the usual correlation between maternal educational level and malnutrition due to much reason like the way of preparation of milk or food or the way of sterilization [60-62]. Another finding of the present study was that compared to those mothers with lower levels of education, the ones who had higher levels of education pursued a higher level of care for their children. These mothers are usually able to employ health-related information and services in a better way and are efficiently prepared to make proper decisions in this regard. This finding is coherent with the findings of the study of [63]. The study revealed that 24.5% of women feed their children by breast feeding 20.5% bottle feeding,  15% mixed feeding while 40% with solid feeding, Figure 4.2. In this study, 20.5% bottle feeding,  15% mixed feeding, and the risk of developing acute diarrhea among such infants was higher and statistically significant compared to their counter parts ( 24.5% breast feeding). This finding is consistent with the one reported from   [64] who found that 40% of the cases were not exclusively breastfeed and the risk of developing acute diarrhea among such infants.  [65] also found similar results. Exclusive breastfeeding limits exposure to ingestion of enteric bacteria from contaminated water, food and bottle-feeding, and offers extra protection against illness, hence reduces the episodes of diarrhea.  Susceptibility to bloody diarrhea may be explained by many factors such as declining level of maternal immunity, introduction of bottle feeding and solid food which may be contaminated by enteropathogens, together with introduction of foreign material to the mouth of these children as they have learned to crawl up and pick subjects in their hands by this age, which increases the risk of exposure to fecal pathogens [19].The study revealed a significant relation between type of feeding and educational level of studied mothers (P<0.01), Table 4.2. [66] in a cross sectional study on the incidence and risk factors of diarrheal illness among children under-five years  showed that relation between type of feeding and educational level of studied mothers and most of employed women practice artificial feeding. Mother’s literacy influences hygiene practices, child feeding, and sanitation practices, which in turn very important factor for childhood diarrhea [62].The study the prevalence of bloody diarrhea among total children enrolled in the study was 11%, Figure 4.3. In agreement with our finding, [55] indicated that the 13% of children suffered from diarrhea were with bloody diarrhea [67] in study done recently showed that the prevalence of bloody diarrhea among  children under-five years was 10.5%. Lastly, lack of maternal hand washing was significantly associated with childhood diarrhea. The rationale for hand washing after going to latrine to reduce the load of microorganisms has been well documented as fecal-oral microorganism transmissions due to post-defecation contamination of hands and fingers is well known [68]. Several studied showed that, children whose families used home based water treatment were less likely to experience diarrhea compared to their counterparts [67-69]. This is related to water contamination during fetching, transportation and storage, which might increase the risk of diarrhea [19].   Our finding was consistent with the results of the study conducted [70] who acute infective bloody diarrhea in children below five years admitted to children welfare hospital in Medical City-Baghdad who showed a significant association with diarrhea morbidity. This difference might be attributed to less information exposure about the risk the factors of acute diarrhea and their prevention methods among the participants of this study [20].   Consistent with our findings, several recent global and local studies recognized that access to an improved water source for drinking purpose reduces the morbidity related to diarrheal diseases [71-73].  In another study, diarrhea wass strongly associated with the source of drinking water, as it is more prevalent among citizens who are relying on non-improved water sources than those using improved water sources for drinking [74].  In contrast to our findings, a case–control study among hospitalized children in the Gaza Strip indicated that no relationship exists between the source of drinking water and the incidence of diarrhea [75]. This incompatible result may be either due to the heterogeneity of the study sample, Nonetheless, there is a growing body of evidence suggesting that improved sources of water are not utterly safe [76].In this study, nearly half of  women who children suffered from diarrhea used antibiotics (51%),  while 5% uses sagwa to manage diarrhea, 15% uses ORS and only 8% use zinc or probiotic to manage diarrhea in their children, The main problem with acute diarrhea is its ability to cause rapid fluid loss through stools in addition to electrolytes loss.  Different epidemiological studied indicated that most of the episodes of diarrhea are treated in homes, and mothers are key care-givers in diarrhea and the poor knowledge of the mothers requires to be addressed by the health system[77-79]. In similar study, [80] indicated that half of mother did not know any type of fluids used for management of diarrhea at home and 18.1% knew that ORS is one of the fluids used in diarrhea. In study done [81]  showed that the management options used by mothers to manage their children during diarrhea were giving antimicrobials drugs (38.3%), treatment at health facilities (24.9%), herbal medication (19.3%), homemade fluids (15%) and ORS (12.5%) respectively. Similar study in Nigeria [82] revealed that mothers used treatment at health facility (32.9%), ORS (54.8%) and homemade fluids (6.0%) respectively as an important measure to control diarrhea. In addition, treatment at health facilities (45.3%), herbal medication (7.7%) and homemade fluids (13.4%) were the management options used by mothers as reported by the study conducted in Kenya [83].   Integrated Community case Management of Childhood Illness (ICCM) strategy recommends that uncomplicated diarrhea could be managed successfully at home by continuing to feed the child, offering more fluids and administering Oral Rehydration Solution (ORS) correctly. Many factors affecting the morbidity and mortality of the diarrhea like antibiotics abuse, but the herbal (sagwa) use appears to be one of significant factor in our community [84]. The use of herbal products and supplements has increased over the last three decades with at least 80% of people worldwide depend on them. Many of these herbs are still unlicensed as well as their use is not monitored [85,86]. Sagwa use is a common problem in our community especially in rural areas where most of admitted patients were from the rural area since mothers from these areas are more likely to use the sagwa due to the low level of their education, low socioeconomic status of the families and easy accessibility to sagwa. moreover, thinking of the sagwa is safer than the medications as well as difficulty access the health centers [87,88]. The health education plays major role in preventing the use of sagwa in these children. Sagwa intake was more common in children of low education level or illiterate mothers and primary school mother, similar results was concluded  in a study done in Iraq [86]. Since illiterate mother has no proper ideas about treating diarrheal disease and easily misled by others to use sagwa, and she cannot appreciate the biohazards of sagwa to their children [88]. Multiple studies reported mothers beliefs that modern medicines are powerful , and more effective in treating diarrhea than ORS [45,50]. Multiple studies reported drugs were widely available and affordable in the public and private sector, typically without prescription [69,71]. In many contexts, mothers stocked drugs at home, purchasing them in advance or saving leftover medication from previous illnesses [19,66,67].The study showed significant relation between relation of source of knowledge of mothers and action to manage diarrhea, in this regard,  nearly half of  women took their information from relative or media to use antibiotics in treatment of diarrhea,  and 80% used sagwa as treatment as they know from relatives and most of them new that ORS used in management of diarrhea from physician and TV. In similar studies, mothers with good knowledge about control of diarrhea  had have better results due to the source of information for good management [87,88]. Similar finding was observed from studies conducted in different countries in which better educated mothers had good knowledge [91,92].  In another study, the knowledge of ORS packets was lowest among mothers who were not regularly exposed to any mass media [93]. Another study revealed that caregivers’ previous experience and seeking advice from health facilities were found to be the positive determinants of ORT intake [94].  In another study the mothers who received their information from media and personal reading had better knowledge compared to those whom their source of the information was their physician or their relatives. Studies showed that the former experiences of the mothers are related to their knowledge about the management of diarrhea [95].  The study showed that and most children belonged mothers with illiterate and primary school levels have most risk factors of diarrhea and there was significant relation between risk factors of diarrhea and educational levels of mothers, Table 4.7.  [77] study identified that mothers who have primary education and secondary and above education were 5 and 11 times more likely to have good knowledge about risk factors of diarrhea as compared to illiterates. Similarly, educational status of mother was significantly associated in studies conducted in India, Iran, and Nigeria [96-98]. The study a revealed significant relation between educational level of mother and source of knowledge about management of diarrhea, Table 4.8. The fact is that as the educational level of caregivers increased, the level of awareness and knowledge increases. This is the general truth that mothers who get information from television, radio newspaper, friends, and so forth about diarrhea know more about home management of diarrhea. Similarly, the source of information was also significantly associated with knowledge in the study conducted in Iran [99].  Other studies has also identified that mothers who had no information about diarrhea were by less likely to have the good practice compared with their counterparts. This may be due to the fact that mothers who had information about diarrhea have a good opportunity to manage diarrhea at home [100,101].  The study showed a significant relation between educational level of mother and action taken by mother to manage diarrhea , The study that 50.33% of women use ORS to treat diarrhea was with primary educational level, 16.67% for each of illiterate and secondary level. [77] study identified that mothers who were illiterate and educated till primary school were by 94.8% and 85.7% less likely to practice more as compared to those mothers who had secondary and above educational level. This also supported by the studies conducted at different part in the worlds [96-98]. The justification is that as the educational level of mothers increased, they become more skillful towards diarrhea management. Mothers' basic knowledge about diarrhoea depends on various factors such as educational status, prior experience of managing the disease and even ethnicity [102-104]. Studies in the literature show that though most of the mothers were familiar with the term oral rehydration solution (ORS), there were knowledge gaps as regards its correct preparation and administration [105,106]. The signs of dehydration due to diarrhoea remain unnoticed by the majority of the mothers. [107,108]. There are certain fluids which are beneficial to give during diarrhoea but most mothers in a rural community in Kenya were unaware of most of these

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the College of Medicine, Tikrit, University.

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