Role of cooked green banana in home management of acute diarrhea in under-5 children

Abstract

Background

Acute diarrhea is an important contributor to under-5 mortality. Green banana is traditionally used as a home-based remedy for diarrhea.

Objectives

To identify the effect of green banana on duration, recovery and prevention of severe dehydration in under-5 children with acute watery diarrhea with no/some dehydration.

Methods

This study was conducted in the rural field practice area of a tertiary care center between January 2020 and December 2021 in under-5 children presenting with acute diarrhea with no/some dehydration. One hundred fifty-three children were divided into group A (received cooked green banana supplementation along with standard management) and group B (received only standard management). Duration of diarrhea, proportion of children recovered, requirement of hospitalization, development of persistent diarrhea and number of diarrheal episodes in 1 year follow-up period were compared between two groups.

Results

Green banana supplementation was significantly associated with reduction in duration [median (interquartile range)—4 (1.5) day versus 5.5 (1) day, P < 0.001] of diarrhea, less hospitalization (9.2% versus 22.1%, P = 0.03) and early recovery, both at day 3 (17.1% versus 3.9%, P = 0.007) and day 7 (90.8% versus 77.9%, P = 0.03). Green banana also protected children from the development of persistent diarrhea (7.9% versus 19.5%, P = 0.04). It also reduced future episodes of diarrhea by 40.5%.

Conclusion

Green banana supplementation could be a promising adjunct therapy in acute diarrhea and thereby it might reduce under-5 mortality.

Lay Summary

Acute diarrhea is the second leading cause of under-5 mortality excluding neonatal causes in India where green banana has traditionally been used as a home-based remedy for diarrhea since ancient days. Some of the previous literatures have found promising results of green banana supplementation in prolonged diarrhea, dysentery and hospital management of acute diarrhea but none have considered it in the home management of diarrhea and have not reviewed its role on duration, recovery and prevention of severe dehydration in under-5 children with acute watery diarrhea with no/some dehydration. These issues along with the possible role of green banana in preventing future episodes of diarrhea have been addressed in our study. One hundred fifty-three under-5 children presenting with acute diarrhea with no/some dehydration were studied over 2 years dividing into group A (received cooked green banana supplementation along with standard management) and group B (received only standard management). Green banana supplementation was significantly associated with reduction in duration of diarrhea, less hospitalization and early recovery, lesser incidences of development of persistent diarrhea, and it also significantly reduced the future episodes of diarrhea. Hence, green banana could be a promising adjunct therapy in acute diarrhea and might reduce under-5 mortality.

acute diarrhea, under-5 mortality, green banana, no/some dehydration

INTRODUCTION

After failing to reach the targets of Millennium Development Goals, developing countries have now targeted to achieve the Sustainable Development Goals (SDGs). The third target of SDGs is to reduce the under-5 mortality to 25 per 1000 live births [1]. Childhood diarrhea is characterized by the onset of loose stools with or without associated systemic symptoms, e.g. vomiting, fever and abdominal cramps and is responsible for 8% of total global under-5 deaths [2]. Almost 90% of these casualties occur in Southeast Asia and Sub-Saharan Africa [3]. Though diarrheal death in India is reduced to half in the last decade, the proportional mortality due to diarrhea remains high contributing approximately 300 000 under-5 deaths every year [4].

Acute watery diarrhea is predominantly viral in origin resulting in enterotoxin-mediated loss of water and electrolytes [5]. Oral rehydration solution (ORS) and oral zinc, are the mainstay of the management of diarrhea [6, 7]. Green banana (Musa paradisiaca) had been used as a household remedy of multiple diseases including diarrhea since ancient days in Indian subcontinent [8]. Anti-diarrheal effect is mediated by Short Chain Fatty Acids (SCFAs) generated in the colon from amylase-resistant starch, the major constituent of green bananas [9]. SCFAs play a prime role in water and salt reabsorption in the colon and in maintaining epithelial integrity [10]. The single study from India describing the role of green banana in diarrhea included hospitalized children with no dehydration only and excluded the undernourished [11]. From the promising results of green banana supplementation in prolonged diarrhea, dysentery and hospital management of acute diarrhea, the question arises whether it would be effective in home management of diarrhea or not [11–13].

Hence, we conducted this study to identify the effect of cooked green banana supplementation on duration, recovery and prevention of severe dehydration in under-5 children with acute watery diarrhea with no/some dehydration. Another aim was to find the role of green banana in preventing future episodes of diarrhea, if any.

METHODS

This study was conducted in the rural field practice area (residents were approximately 4000 in number) of a tertiary care center between January 2020 and December 2021, after taking necessary permission from the Institutional Ethics Committee (vide memo no BMC/PG/7259). All the children (aged between 6 and 60 months) presented with acute watery diarrhea with no/some dehydration [6, 7] were reviewed for inclusion in the study. Children with severe dehydration requiring hospitalization, with invasive diarrhea, major systemic illnesses, and whose parents denied consent or were planning to change residence were excluded from the study.

We conducted a pilot study [where 30 children (selected by complete enumeration) were randomized in two groups] in a nearby village (not included in the current study) and found that the average duration of diarrhea in two groups (with and without green banana supplementation) were respectively 4.8 days and 5.6 days. Assuming a 1.5-day reduction in duration of diarrhea as a clinically significant margin (approximately 25% reduction), and fixing α and β error, respectively at 5% and 10%, the sample required in either arm would approximately be 69 [14]. Considering 20% attrition, we planned to recruit 83 children in each arm. By reviewing the emergency and out-patient registers of the health center, we found that average monthly cases of diarrhea (with no and some dehydration) in under-5 children were approximately 14. Hence, we planned to recruit all the children aged between 6 and 60 months presenting with acute watery diarrhea between January 2020 and December 2020 to achieve desired sample size. A computer-generated randomization sequence (using block sizes of 2, 4 and 6) was concealed in sequentially numbered sealed, opaque envelopes. When the parent of an eligible child consented to enroll in the study, the on-duty nursing official opens the envelope and the group was allocated to the child accordingly. Children were recruited both from the Outpatient department (runs 9 AM–4 PM every day of the week except Holidays) and the emergency department (runs 24 h on all days of the week). They were recruited in the study at the time of presentation after evaluation by on-duty residents. Parents/care-givers were advised to attend either out-patient or emergency department, if any danger-signs appeared (decreased urination, inability to feed, lethargy etc).

All the children received standard management of diarrhea (ORS, home available fluids, elemental zinc 20 mg/day for 14 days for no and some dehydration) [6, 7]. If they developed signs of severe dehydration in course of treatment, they were hospitalized and managed with intravenous fluids and as per protocol [6, 7]. Children of group A in addition received cooked green bananas. Children aged <1, 1–3 and 3–5 years, respectively received 100, 200 and 300 g of cooked green banana (mixed with minimal amount salt, sugar and spices for better palatability) per day, for 5 days [11, 12]. This preparation was supplied to the parents by the Accrediated Social Health Activists (ASHA) after preparation in hospital kitchen along with plastic cups with specific capacities. Feeding of few purposively selected children was also supervised by ASHAs. ASHAs are female health-workers recruited by government in each village for creating health awareness, treating simple diseases, and, proper implementation of government-run health programs. Regaining of stool consistency with normal frequency was defined as recovery. If diarrhea with acute onset continued for 14 days or more, it was labeled as persistent diarrhea [15]. Socioeconomic status was defined according to modified BG Prasad scale [16]. ASHAs visited twice daily to the house of sick children till recovery, and children were examined by the on-duty doctors according to indication. All of them were followed up at quarterly intervals (at 3rd, 6th, 9th and 12th months) for one year by ASHAs. Two telephone numbers were also provided to the participants for any help. A pre-designed, pre-tested, semi-structured schedule was used for data collection. Primary outcome was the duration of diarrhea. The proportion of children who recovered from diarrhea on the third and seventh day, required hospitalization and developed persistent diarrhea, incidence rate of diarrhea in follow-up periods, and complications were treated as secondary outcomes.

Collected data were entered in IBM SPSS version 21.0 after double-checking. Shapiro–Wilk test was used to check normal distribution. The chi-square test and Student’s t-test were respectively being used for checking the significance of difference between proportions and means. Mann–Whitney U test was used for skewed data. Relative risks (RRs) were calculated with a 95% confidence interval (CI). An intention to treat analysis was also carried out. Kaplan–Meier analysis with log-rank (Mantel-Cox) chi-square test was performed taking recovery from diarrhea and hospitalization as outcome of interest. P < 0.05 was taken as the level of statistical significance.

RESULTS

One hundred sixty-four children had presented with acute diarrhea in the mentioned period and 11 were excluded (4—planning to change address, 3—refusal of consent, 3—severe acute malnutrition, and 1—previously diagnosed malabsorption syndrome) to finally recruit 153 children in the study. They were randomized into two groups A and B having 76 and 77 children respectively (Figure 1). The mean age of the study population was 2.8 ± 0.4 years and 56.9% of them were boys. Majority of them were Hindu (n = 94, 61.4%) and belonged to middle socioeconomic status (n = 93, 60.8%). Vomiting was the most common associated symptom (n = 38, 24.8%), followed by pain abdomen (n = 32, 20.9%). No significant difference (P > 0.05) was noted in the baseline socio-demographic (age, sex, religion, socioeconomic status, etc.) and clinical characteristics (associated symptoms, immunization, nutritional status, etc) between the children of group A and B (Table 1).

Figure 1

Study flow diagram showing the progression of study with time.

Table 1.

Base-line socio-demographic and clinical characteristics of children of group A (n = 76) and B (n = 77)

Variables	Group A (n = 76)	Group B (n = 77)	Significance
Age (years)a	2.7 ± 0.4	2.9 ± 0.3	Student’s t = 1.75, P = 0.08
Sexb
Male	42 (55.3)	45 (58.4)	χ2 = 0.16, P = 0.69
Female	34 (44.7)	32 (31.2)
Religionb
Hindu	46 (60.5)	48 (62.3)
Muslim	29 (38.2)	28 (36.4)	χ2 = 0.05, P = 0.97
Others	1 (1.3)	1 (1.3)
Socioeconomic statusb
Upper	12 (15.8)	14 (18.2)
Middle	45 (59.2)	48 (62.3)	χ2 = 0.71, P = 0.70
Lower	19 (25.0)	15 (19.5)
Weight for height/lengthb
Z score: −3 to 0	55 (72.4)	58 (75.3)	χ2 = 0.17, P = 0.67
Z-score >0	21 (27.6)	19 (24.7)
Mid-upper arm circumferenceb
11.5–12.5 cm	48 (63.2)	45 (58.4)	χ2 = 0.35, P = 0.55
>12.5 cm	28 (36.8)	32 (41.6)
Rotavirus vaccine	54 (71.0)	62 (80.5)	χ2 = 1.87, P = 0.17
Exclusive breast-feeding for 6 months	31 (40.8)	38 (49.4)	χ2 = 1.13, P = 0.29
Time passed since onset (h)a	28.1 ± 3.2	28.9 ± 4.0	Student’s t = 1.36, P = 0.17
Vomitingb	17 (22.3)	21 (27.2)	χ2 = 0.49, P = 0.48
Feverb	6 (7.9)	9 (11.7)	χ2 = 0.62, P = 0.43
Pain abdomenb	14 (18.4)	18 (23.4)	χ2 = 0.57, P = 0.45

a

Mean ± SD.

b

Number (percentage).

Both the duration of diarrhea [median (interquartile range)—4 (1.5) day versus 5.5 (1) day, P < 0.001] and proportion of children requiring hospitalization (9.2% versus 22.1%, P = 0.03), were significantly higher in group B. Significantly greater proportion of children recovered from diarrhea in group A at third (17.1% versus 3.9%, P = 0.007) and seventh day (90.8% versus 77.9%, P = 0.03). Proportion of persistent diarrhea was significantly higher in group B (7.9% versus 19.5%, P = 0.04). The incidence rate of diarrhea in the follow-up period in group A and B were respectively 3.7 episodes/100 person-month (95% CI: 2.9–4.6) and 5.2 episodes/100 person-month (95% CI: 4.3–6.2). The difference of incidence rate (−1.5 episodes/100 person-month, 95% CI = −0.2 to −2.7) between the groups was significant (P = 0.02) (Table 2). The proportion of children with diarrhea with respect to time was significantly higher [log-rank (Mantel-Cox) χ² = 24.25, P < 0.001] in group B (Figure 2). The cumulative hazard of hospitalization was also significantly greater [log-rank (Mantel-Cox) χ² = 5.20, P = 0.02] in the children of group B (Figure 3). However, 14.5% (n = 11) caregivers found the method cumbersome, and 3.9% children (n = 3) group A refused to take the specified amount of banana >3 times despite repeated efforts. Green banana was found to be protective for hospitalization due to diarrhea [RR = 0.42, 95% CI = 0.18–0.95, number needed to treat (NNT) = 7.8, 95% CI = 4.1–65.6] and development of persistent diarrhea (RR = 0.40, 95% CI = 0.17–0.99, NNT = 8.6, 95% CI = 4.5–119.7). Consumption of green banana was also associated with better recovery at third (RR = 0.86, 95% CI = 0.77–0.96, NNT = 7.6, 95% CI = 4.4–26.7) and seventh day (RR = 0.42, 95% CI = 0.18–0.95, NNT = 7.8, 95% CI = 4.1–65.6).

Figure 2

Kaplan–Meier’s analysis showing children with diarrhea (y-axis) with respect to time (x-axis) in both the groups (log-rank χ² = 24.25, P < 0.001). Solid and dashed lines respectively represent group A and B.

Figure 3

Kaplan–Meier’s analysis showing cumulative hazard of hospitalization (y-axis) with respect to time (x-axis) in both the groups (log-rank χ² = 5.20, P = 0.02). Solid and dashed lines respectively represent group A and B.

Table 2.

Comparison of outcome measures in group A (n = 76) and B (n = 77)

Outcome measure	Group A (n = 76)	Group B (n = 77)	Significance
Duration of diarrhea (days)a	4 (1.5)	5.5 (1)	Z-score = 5.76, P < 0.001
Required hospitalizationb	7 (9.2)	17 (22.1)	χ2 = 4.79, P = 0.03
Recovery within 3 daysb	13 (17.1)	3 (3.9)	χ2 = 7.13, P = 0.007
Recovery within 7 daysb	69 (90.8)	60 (77.9)	χ2 = 4.79, P = 0.03
Developed Persistent diarrheab	6 (7.9)	15 (19.5)	χ2 = 4.34, P = 0.04
Anal excoriationb	8 (10.5)	12 (15.6)	χ2 = 2.40, P = 0.12
Incidence rate of diarrhea in follow-up period (/100 person-month)c	3.7 (2.9–4.6)	5.2 (4.3–6.2)	P < 0.001

a

Median (interquartile range).

b

Number (percentage).

c

Figure in parenthesis represents 95% CI.

DISCUSSION

Our study demonstrated significant beneficial effects of green banana supplementation in reducing the length of illness, early recovery and less hospitalization due to the development of dehydration. Multiple previous studies also documented early recovery from diarrhea and less degree of dehydration in children who received supplemental green banana [11, 12]. However, minute differences were noted in the values of RRs calculated by Gunasekaran, et al. [11] possibly due to the inclusion of hospitalized children in their study. Rabbani, et al. [17] also documented the benefits of green banana in shigellosis. Green banana contains 84% amylase-resistant starch, which reaches the colon unaltered and generates SCFAs (predominantly acetate, propionate and butyrate) when fermented by intestinal flora [9]. Protonated absorbed SCFAs dissociate to release H⁺, which were secreted in exchange of Na⁺, K⁺ and Mg⁺⁺ through ion exchangers located at the apical membrane of intestinal epithelium [18]. They alter acid-base balance of the colon to promote absorption of weak electrolytes and also inhibit cyclic adenosine monophosphate mediated Cl⁻ secretion in animal models [19, 20]. SCFAs also exhibit microbicidal effects- by promoting the growth of commensals and competitively inhibiting the growth of pathologic microorganisms, expression of peptides with antimicrobial properties (bacteriocins), and modification of microenvironment of colonic crypts (reduction of luminal pH and oxygen level) [21, 22]. These might also be responsible for the preventive roles of green banana in persistent diarrhea documented in multiple previous reports [13, 23]. However, neither of the earlier works reported the role of green banana in preventing future episodes of diarrhea. The current study documented an effective reduction in the episodes of diarrhea with green banana supplementation in 1-year follow-up period. Butyrate helps in the expression of claudin 3 and 4, which in turn maintains the integrity of epithelial membrane and reduces the permeability of tight junctions [24]. SCFAs also exert a positive jejunotrophic effect, mediated by the autonomic nervous system [25]. Moreover, butyrate acts as the prime oxidative fuel of colonocytes and decreases the synthesis of different inflammatory mediators especially thromboxane B₂ [26]. All these collectively lead to better epithelial regeneration and integrity leading to the prevention of further episodes of diarrhea. Similar to Gunasekaran, et al. [11] we also did not observe significant difference in adverse events between the two groups. However, grievous complications might be missed due to exclusion of children with severe dehydration in both the studies. Acceptability of supplemented banana is also better in this study than the previous report, probably because of home-management of children [11].

Regular examination of the children by trained workers, achievement of an adequate sample size to ensure appropriate power of the study, and follow-up for 1 year with minimal attrition (<10%)—are the strengths of the study. However, there are certain limitations—blinding could not be done (due to the nature of the study) and specific inclusion criteria (children requiring hospitalization and with dysentery were excluded) limit the generalizability of the findings. Supervised feeding was also not possible for all the children due to limited manpower.

CONCLUSION

Cooked green banana plays a useful role in reducing the duration of diarrhea leading to early recovery and preventing further episodes in short-term follow-up period. Hence, it could be a promising adjunct therapy to the prevailing practices, especially in resource-limited countries. However, the final recommendation could only be made after confirmation of findings in further large multi-centric trials.

ACKNOWLEDGEMENTS

We are thankful to Dr. Taraknath Ghosh, Professor of Pediatrics, Burdwan Medical College, Burdwan, West Bengal, India for helping in conceptualizing the study.

FUNDING

We wish to confirm that there are no known conflicts of interest associated with this article entitled ‘Role of Cooked Green Banana in Home Management of Acute Diarrhea in Under-five Children’ and there has been no significant financial support for this work that could have influenced its outcome.