INTRODUCTION:

Diarrhea is defined as an increased incidence of bowel movements characterized by the loss of stool more than three times within 24 hours, resulting in fluid loss¹. Diarrhea is curable and preventable disease as the most important health problem in developing countries².

In 2016, there were three outbreaks of diarrhea in three provinces, with a total of 198 people and six deaths^3,4. According to the research conducted by Ravishankar and Syed Sagheer, every year around 5-8million children die from diseases caused by diarrhea with severe dehydration, especially in developing countries^5,6. The handling of diarrhea cases in Jakarta based on the results of the diarrhea sub-directorate survey shows that the rate of diarrhea pain is still high, so efforts are needed to improve the governance and quality of health services, one of which is through the implementation of clinical pathways³.

A clinical pathway is a pre-treatment concept compiled based on standard procedures from each profession in medical, nursing, pharmaceutical, and other health services. This concept refers to the service standards of each profession applied in hospitals. The implementation of hospitals in Indonesia is regulated in Law Number 47 of 2021 concerning Hospitals and the Health Law of the Republic of Indonesia Number 17 of 2023. These two laws emphasize the importance of protecting the safety of patients, the community, the hospital environment, and human resources in hospitals, with the aim of achieving safe, quality, and affordable health services³. Health beliefs are person’s ideas and attitude, about health and illness. They may be based on true information or wrong information. The health belief usually results from within a person⁷. The clinical pathway is also used as a tool to control the cost and quality of patient services in a case-mix payment system, such as Indonesian-Case Based Groups (INA-CBGs), which is a financing system for the National Health Insurance^8,9,10. The pathways are designed to be used in multidisciplinary workshops to explore alternative approaches to care¹¹. A clinical pathway is the integrated care map framed with the necessary and time bound care by the multi-disciplinary team to reduce the length of hospitalization say, cost-effectiveness, improves the level of satisfaction and patient outcome¹².

One of the Educational Hospitals in North Jakarta has developed and implemented a clinical pathway for acute diarrhea with mild-moderate dehydration in children since January 2021. This development aims to improve the quality of health services by controlling the rates set in the financing package based on the case-mix system, INA-CBGs. Evaluation of the effectiveness of the implementation of this clinical pathway is needed to assess whether its application can improve the quality of rational treatment in pediatric patients with acute diarrhea.

This research is expected to be one of the evaluation instruments for improving the quality of health services at the North Jakarta Education Hospital. In addition, this study also aims to see if there is a difference in clinical outcomes in pediatric patients with acute diarrhea before and after the implementation of the clinical pathway. Irrational medication use can lead to long hospitalizations, which is a serious problem in the treatment of acute diarrhea¹³. Multiple medications are also commonly associated with an irrational, excessive use of drugs and if taken together constitute a well-known risk factor in terms of patient’s health due to the increased risk of adverse drug reactions, interactions, medication errors, hospitalization and diminishing adherence to drug therapy¹⁴. Treatment of diarrhea mainly depends on replacing lost fluids through oral rehydration solutions, and this reduces the mortality and morbidity without affecting its intensity and duration¹⁵.

The development and implementation of clinical pathways are expected not only to improve the effectiveness of treatment but also the efficiency of treatment costs in hospitals¹³. This study aims to provide scientific evidence that supports the application of clinical pathways as a standard in the management of pediatric patients with acute diarrhea, as well as provide recommendations for better health policies in the future.

MATERIALS AND METHODS:

Method:

In this study, a quantitative approach was used with a retrospective cohort case study method in pediatric patients with acute diarrhea with mild-moderate dehydration. The period before and after the clinical pathway was applied, and the results were presented descriptively and analytically.

Ethical Approval:

Ethical approval was sourced from the the ethical medical committee of Universitas 17 Agustus 1945 Jakarta in Indonesia, and an approval letter, No.80/KEPK-UTA45JKT/EC/EXP/11/2023, was given before data collection. Data was collected in the North Jakarta Education Hospital, Indonesia.

Type of Research:

The research will use a retrospective method with a pre-and post-clinical pathway approach using secondary data, namely medical records of pediatric patients with acute diarrhea with mild-moderate dehydration who are hospitalized at the North Jakarta Education Hospital.

Location and Time of Research:

This research was conducted at the North Jakarta Education Hospital. Data were taken from January to December 2020 before the determination of the clinical pathway, and data collection continued after the determination of the clinical pathway from January to December 2021. This research was conducted from October 2023 to May 2024.

Population and sample:

Study Population: All pediatric patients with a diagnosis of acute diarrhea with mild-moderate dehydration were admitted to the North Jakarta Education Hospital.

Study Sample: Pediatric patients diagnosed with acute diarrhea with mild-moderate dehydration were hospitalized at the North Jakarta Education Hospital for the period of January-December 2020 and January-December 2021 before and after the implementation of the clinical pathway.

a. Inclusion criteria:

1. Pediatric patients aged 1 to <18 years with a diagnosis of acute diarrhea with mild–moderate dehydration with or without comorbidities who were hospitalized at the North Jakarta Educational Hospital for the period January-December 2020 and the January–December 2021 period.

2. Pediatric patients aged 1 to <18 years with comorbidity COVID-19 after the clinical pathway
period.

3. Pediatric patients aged 6 to 18 years who have been vaccinated COVID-19 or who have not
been vaccinated against COVID-19 after the period clinical pathways.

b. Exclusion criteria:

1. The patient's medical record data is incomplete.

2. Patients treated <24 hours.

3. Forced to go home.

Data Analysis Design:

Demographic data, comorbidities, history of previous illnesses, dehydration score, clinical outcomes and administration of therapy in accordance with the clinical pathway descriptively. Using chi-square and fisher exact tests by the SPSS application 27.0 is used when the variable to be used is on a categorical scale. The chi-square statistic is used to determine the association between two variables which include comparison of length of stay, clinical outcomes and its rationality.

RESULT:

Demographic Profile of Pediatric Patients with Acute Diarrhea with Dehydration:

Figure 1. Gender of pediatric patients with acute diarrhea.

From the data in Figure 1, the gender distribution of patients before the clinical pathway amounted to 137 patients; based on the gender of the patients, there were 78 patients (56.9%) male and 59 patients (43.1%) female. The gender of patients after the clinical pathway was 137, with the number of male patients being 77 patients (56.2%) and the number of female patients being 60 patients (43.8%).

Figure 2. Age of pediatric patients with acute diarrhea.

In Figure 2, the age categories of patients before the clinical pathway are 125 patients (91.2%), the age range of 5-8 years 6 patients (4.4%), the age range of 9-13 years 4 patients (2.9%) and the age range of 14-18 years 2 patients (1.5%) with a total of 137 patients. The age category of patients after the clinical pathway was 110 patients (80.3%), the age range of 5-8 years was 16 patients (11.7%), the age range of 9-13 years was 8 patients (5.8%), and the age range of 14-18 years was 3 patients (2.2%) with a total of 137 patients. It can be concluded that the age range of 1-4 years before and after the clinical pathway diagnosed with acute diarrhea with dehydration is more than other age ranges of patients.

Table 1. Comorbidities in pediatric patients with acute diarrhea with dehydration

Comorbidities	Before Clinical Pathway	After Clinical Pathway
Without comorbidities	99 (72.3%)	63 (46%)
Gastrointestinal Disorders
Nausea-vomiting	17 (12.4%)	26 (19%)
Paralytic ileus		1 (0.7%)
Infection Disorders
Typhoid fever		10 (7.3%)
Bronchopneumoniae	4 (2.9%)	10 (7.3%)
Dengue Hemorrhagic Fever	3 (2.2%)
COVID-19	2 (1.5%)
Lymphatic tuberculosis		1 (0.7%)
Upper respiratory tract infection	1 (0.7%)	7 (5.1%)
Sepsis	1 (0.7%)	1 (0.7%)
Ascariasis	1 (0.7%)
Upper respiratory tract infection+ Thyphoid fever	1 (0.7%)	2 (1.5%)
Tuberculosis+Sepsis+ Pneumoniae+COVID-19	1 (0.7%)
Meningitis tuberculosis+Bronchopneumoniae+COVID-19	1 (0.7%)
Bronchopneumoniae+COVID-19	1 (0.7%)
Lung tuberculosis	1 (0.7%)	2 (1.5%)
Bronchopneumoniae+ Typhoid fever		1 (0.7%)
Lung tuberculosis+Urinary tract infection+Fimosis+Rhinitis		1 (0.7%)
Urinary tract infection+Hematury		1 (0.7%)
Typhoid fever+Dengue Hemorrhagic Fever		1 (0.7%)
Helminthiasis+Encephalopathy		1 (0.7%)
Respiratory Disorders
Cough	1 (0.7%)	1 (0.7%)
Rhinitis		1 (0.7%)
Infections and Indigestion
Bronchopneumoniae+Nausea-vomiting	1 (0.7%)
Appendicitis+Nausea-vomiting	1 (0.7%)
Ascariasis+Nausea-vomiting		1 (0.7%)
Dengue Hemorrhagic Fever+Constipation		1 (0.7%)
Nausea-vomiting+Candidiasis		1 (0.7%)
Typhoid fever+Nausea-vomiting		2 (1.5%)

In Table 1, in the treatment of pediatric patients with acute diarrhea with dehydration hospitalized at the North Jakarta Education Hospital, the highest comorbidities before and after the clinical pathway were nausea and vomiting (12.4% before the clinical pathway and 19% after the clinical pathway), then in the second place in the form of typhoid fever as much as 7.3% after the clinical pathway and bronchopneumoniae (2.9% before the clinical pathway and 7.3% after the clinical pathway).

Table 2. Types of dehydration in children with acute diarrhea

Types of Dehydration	Before Clinical Pathway	After Clinical Pathway
Mild	59 (43.1%)	16 (11.7%)
Moderate	78 (56.9%)	121 (88.3%)
Total	137 (100%)	137 (100%)

In Table 2 types of dehydration in this study, in patients with acute diarrhea with dehydration before the clinical pathway, there were 59 patients (43.1%) with mild dehydration, 78 patients with moderate dehydration (56.9%), and after the clinical pathway with mild dehydration amounting to 16 patients (11.7%) and moderate dehydration amounting to 121 patients (88.3%).

Table 3. Length of treatment for pediatric patients with acute diarrhea with dehydration

Length of Stay	Before clinical pathway	After clinical pathway	*P-Value
1-3 days	62 (45.3%)	59 (43.1%)	0.715
4-6 days	75 (54.7%)	78 (56.9%)
Total	137 (100%)	137 (100%)
Mean	3.934	3.839
Deviation Standard	1.207	1.037
*Chi-square test

In Table 3, the results of the research on the length of treatment and treatment before and after the implementation of the clinical pathway, seen from the medical record data from the first day the patient enters until the patient is allowed to go home or the patient moves to a non-infectious room and the condition of the patient moving to the ICU or the patient dies, can be seen in the description of the last resume written by the doctor.

A comparison of the length of hospitalization before the clinical pathway and after the clinical pathway in 2020 and 2021 statistically using the chi-square test method with the result of an asymptotic significance value of 0.715 greater than 0.05 so that the length of hospitalization before the implementation of the clinical pathway and after the implementation of the clinical pathway shows that after the implementation of the clinical pathway, there is no difference in the length of hospitalization of patients with acute diarrhea and dehydration at the North Jakarta Education Hospital.

Table 4. Appetite of pediatric patients with acute diarrhea with dehydration

Appetite	Before Clinical Pathway	After Clinical Pathway
Not Wanting to Eat	18 (13.1%)	23 (16.8%)
Eat Less	86 (62.8%)	92 (67.1%)
Eat regularly	33 (24.1%)	22 (16.1%)
Total	137 (100%)	137 (100%)

In Table 4, the appetite data before the clinical pathway who did not want to eat amounted to 18 patients (13.1%), 86 patients (62.8%) ate little, and 33 patients (24.1%) ate regularly. The appetite after the clinical pathway did not want to eat amounted to 23 patients (16.8%), 92 patients ate little (67.1%), and ate regularly 22 patients (16.1%).

In Table 5 of the administration of symptomatic therapy for patients with acute diarrhea with dehydration before the application of the clinical pathway and after the application of the clinical pathway, the data showed that the administration of antipyretic/analgesic drugs used to reduce fever in pediatric patients with acute diarrhea with dehydration after the clinical pathway decreased compared to before the clinical pathway of 105 patients (76.6%).

Antiemetic drugs were administered as a symptom of nausea. Zinc was given as a symptomatic therapy supplement in the treatment of children with acute diarrhea with dehydration after the clinical pathway of 116 patients (84.7%) and 130 patients (94.9%), an increase compared to before the clinical pathway of 93 patients (67.9%) and 127 patients (92.7%).

Table 5. Length of treatment for pediatric patients with acute diarrhea with dehydration

Length of Stay	Before clinical pathway	After clinical pathway	*P-Value
1-3 days	62 (45.3%)	59 (43.1%)	0.715
4-6 days	75 (54.7%)	78 (56.9%)
Total	137 (100%)	137 (100%)
Mean	3.934	3.839
Deviation Standard	1.207	1.037
*Chi-square test

In Table 5, the results of the research on the length of treatment and treatment before and after the implementation of the clinical pathway, seen from the medical record data from the first day the patient enters until the patient is allowed to go home or the patient moves to a non-infectious room and the condition of the patient moving to the ICU or the patient dies, can be seen in the description of the last resume written by the doctor.

Table 6. Clinical Outcomes of Pediatric Patients with Acute Diarrhea with Dehydration

Clinical Outcomes	Before Clinical Pathway	After Clinical Pathway	*P-Value
Improved: Patients Are Allowed to Go Home or Move to Non-Infectious Rooms	135 (98.5%)	135 (98.5%)	1
Worsening: Critical Patients or Dying	2 (1.5%)	2 (1.5%)
Total	137 (100%)	137 (100%)
*Chi-square, fisher exact test

In Table 6, the clinical outcome of pediatric acute diarrhea patients before and after clinical pathway, the clinical outcome of being allowed to go home was 270 (98.5%) and the clinical outcome with worsening was 4 patients (1.5%). Statistically, the clinical outcome in patients with acute diarrhea with dehydration has a p-value of 1 which is greater than 0.05, so it can be interpreted that the clinical outcome in patients with acute diarrhea with dehydration before and after the clinical pathway is not much different.

DISCUSSION:

Demographic Profile of Pediatric Patients with Acute Diarrhea with Dehydration:

Based on the gender of the patients, 56.9% were male and 43.1% female, of which the percentage of male sex after the clinical pathway was 56.2% and the percentage of female gender was 43.8%. In this study, the percentage of male sex is greater than that of females. This is supported by research conducted by Herleeyana Meriyani (2018) who said that the gender of pediatric patients with acute diarrhea was most suffered by males in the toddler group¹⁶. This is because boys are more active and play more in the outdoor environment, so they are easily exposed to agents that cause diarrhea, much physical activity in men can make the physical condition of the body quickly decrease, including a decrease in the immune system, so that they are more at risk of developing diseases including acute diarrhea¹⁶.

In the age category of patients, the age range of 1-4 years before and after the clinical pathway diagnosed with acute diarrhea with dehydration is more than other age ranges of patients. Based on the research conducted, hospitalized pediatric patients who are diagnosed with acute diarrhea with the highest dehydration aged 1-4 years this will affect treatment therapy, especially in oral administration, in contrast to the results of other studies that state that the age of children in the age range of 6-8 years who suffer the most from diarrhea is 60% higher than other age groups¹⁷. This study is different from the previous research, where the most patients were in the age range of 6-10 years old, with details of 5-year-old patients as many as 10 patients (22%), while at the age of 11-12 years there were 6 patients (13%), and patients who are affected by diarrhea were at the age of 6-10 years, which is as many as 30 patients (65%)¹⁸.

Comorbidities of Pediatric Patients with Acute Diarrhea with Dehydration:

In the treatment of pediatric patients with acute diarrhea with dehydration hospitalized at the North Jakarta Education Hospital, the highest comorbidities before and after the clinical pathway were nausea and vomiting; then the second was typhoid fever and bronchopneumoniae. Nausea and vomiting are some of the signs/symptoms experienced by patients with diarrhea caused by bacteria or viruses that begin to infect the stomach wall and intestinal lining. This infection triggers the digestive organs to produce more fluid, making the stomach feel uncomfortable, and eventually the patient experiences nausea and vomiting¹⁹.

Typhoid fever or typhoid fever is an acute infection of the small intestine caused by Salmonella typhi or Salmonella paratyphi by being transmitted to humans through food or drinks contaminated by human feces after passing through the stomach so that germs reach the small intestine^20,21.

Types of Dehydration in Pediatric with Acute Diarrhea:

Before and after the clinical pathway, most of these patients experienced moderate degrees of dehydration compared to mild dehydration. Patients with acute diarrhea with dehydration experience the loss of a certain amount of fluid and electrolytes in the body in the form of sodium, chloride, potassium, and bicarbonate so that symptoms of diarrhea can occur without dehydration, mild dehydration, moderate dehydration and dehydrationi^22,23. In this study, before and after the clinical pathway, pediatric patients diagnosed with acute diarrhea with moderate dehydration were the highest. This result is the same as the other research where 30 subjects with acute diarrhea without dehydration (21.4%) and 93 subjects with mild moderate dehydration (66.4%) were obtained²⁴.

Appetite Data of Pediatric Patients with Acute Diarrhea with Dehydration:

In this study, as many as 86 patients (62.8%) before the clinical pathway and 91 patients (67.1%) after the clinical pathway were known to have little patient appetite data. This is due to patients feeling stressed while hospitalized with maladaptive characteristics, namely the child becomes uncooperative, does not sleep well and does not want to eat. The cause of difficulty eating in pediatric patients with acute diarrhea with dehydration, the appetite of only eating a little can result from underlying diseases or organic disorders, biological interactions and environmental factors, especially familial²⁵.

Symptomatic Therapy for Pediatric Patients with Acute Diarrhea with Dehydration:

The administration of symptomatic therapy of drugs in patients with acute diarrhea with dehydration before the application of the clinical pathway and after the application of the clinical pathway, where the data showed that the administration of antipyretic/analgesic drugs after the clinical pathway decreased compared to before the clinical pathway. This is supported by a study on the drug therapy profile in inpatients with acute diarrhea in children at the State General Hospital where the use of antipyretics reduces fever symptoms in 25 patients (54.3%), acute diarrhea with the type of antipyretic or analgetic used is paracetamol²⁶. Antiemetic drugs relieve nausea symptoms, and zinc is given as a symptomatic therapy supplement in the treatment of children with acute diarrhea with dehydration. Data showed that the use of antiemetics and zinc increased after the clinical pathway compared to before because using of antiemetics potentially extending stay for better symptom control in the hospital.

In this study, there was the provision of symptomatic therapy outside the recommendations of the clinical pathway in accordance with comorbidities in pediatric patients with acute diarrhea with dehydration. Symptomatic therapy outside of the clinical pathway recommendations in pediatric patients with acute diarrhea with dehydration such as syrup antacids and domperidone syrup is a symptomatic therapy that supports accelerated healing in pediatric patients with acute diarrhea with dehydration at the North Jakarta Education Hospital. This study was supported by a study on the drug therapy profile in inpatients with acute diarrhea in children at the State General Hospital where ondansetron was able to reduce symptoms of nausea and vomiting and as many as 30 patients (65.2%)²⁶. According to WHO and UNICEF, the use of zinc is part of the management of acute diarrhea treatment because zinc can reduce the duration of diarrhea by 25-30% and reduce the duration of severity of persistent diarrhea, if given regularly. In addition, zinc administration is also effective in preventing acute and persistent diarrhea and can reduce the prevalence of diarrhea caused by dysentery and shigellosis²⁶.

Length of Treatment for Pediatric Patients with Acute Diarrhea with Dehydration:

The length of treatment for pediatric patients with acute diarrhea with dehydration recommended by the North Jakarta Education Hospital clinical pathway is a maximum of 3 days of treatment. The length of treatment of pediatric patients with acute diarrhea after the clinical pathway decreased compared to before the clinical pathway. This is different from the treatment time of 4-6 days which is not in accordance with the recommendations for the length of treatment of the clinical pathway of the North Jakarta Education Hospital in pediatric patients with acute diarrhea with dehydration where after the implementation of the clinical pathway, it increases the length of treatment compared to before the clinical pathway. The increase in the length of treatment of 4-6 days is influenced by the number of comorbidities in pediatric patients with acute diarrhea with dehydration where according to the number of comorbidities after the clinical pathway is more, amounting to 22 comorbidities compared to before the clinical pathway which amounted to 16 comorbidities only.

According to the clinical pathway of the North Jakarta Education Hospital, the length of treatment for children with acute diarrhea with dehydration is three days (maximum) in accordance with the clinical pathway of the North Jakarta Education Hospital. If the patient has comorbidities, it can be treated for more than 3 days but can increase the risk of patients experiencing nosocomial infections, according to the other research, there was found that the length of treatment days and these comorbidities are related to the incidence of nosocomial infections²⁷.

The length of treatment of patients with acute diarrhea with dehydration at the North Jakarta Edcuation Hospital is determined by many factors, one of which is in the form of feeding can affect the length of treatment of patients with acute diarrhea in children, the administration of probiotics, the administration of zinc supplements and the degree of dehydration can affect the length of treatment such as a study on acute diarrhea patients at BRSU Tabanan, Bali Indonesia with severe dehydration turned out to be longer²⁸. The length of treatment can be affected by the degree of dehydration²⁹.

In this study, there are still patients with acute diarrhea with dehydration who experience a treatment period of 4-6 days, which is not in accordance with the clinical pathway. This can be caused by children of growing age having a higher proportion of fluid compared to adults³⁰. A statistical comparison of the length of hospitalization before and after the clinical pathway in 2020 and 2021 shows that after the implementation of the clinical pathway, it is not possible to reduce the length of hospitalization for patients with acute diarrhea with dehydration at the North Jakarta Education Hospital.

This study is supported by different diagnoses carried out by Siswanto and Chaldyanto, who researched the difference in average length of stay in Dengue Hemorrhagic Fever patients before and after the clinical pathway, it is known that the average length of stay after the clinical pathway is greater than the average length of stay before the clinical pathway so that in this study it does not prove that there is a decrease in the average length of treatment of Dengue Hemorrhagic Fever patients after the implementation of the clinical pathway. This is due to the different conditions of the patients³¹.

Clinical Outcome of Pediatric Patients with Acute Diarrhea with Dehydration:

The clinical outcomes of pediatric acute diarrhea patients with dehydration before and after the clinical pathway can be statistically interpreted that the clinical outcomes in patients with acute diarrhea with dehydration before and after the clinical pathway are not much different.

The clinical outcome indicators applied before and after the clinical pathway are that the patient is allowed to go home or recover with clinical signs of diarrhoea-free pediatric patients with no signs of dehydration symptoms, no signs of secondary infection, this is in accordance with the recommendations of the clinical outcome clinical pathway of the North Jakarta Education Hospital. On the contrary, there was a difference in the average length of treatment between before and after the implementation of the clinical pathway. This is due to symptomatic therapy in the form of administering antiemetics after the clinical pathway which increases compared to before the clinical pathway. Supported by research on the clinical pathway resulting in a continuous improvement in the treatment of acute diarrhea with the use of fluids can reduce length of stay in patients with the addition of antiemetics in the form of ondansentron, there is an increase in the decrease in length of stay after the recommended oral ondansentron is added to the clinical pathway³².

Clinical outcome indicators before and after the clinical pathway are patients experiencing worsening symptoms accompanied by clinical signs of pediatric patients still having diarrhea with signs of dehydration symptoms, and there are signs of secondary infection. This is due to the existence of severe comorbidities that require patients to be transferred to special treatment rooms such as the ICU.

CONCLUSION:

Based on the study's results, there was increased adherence to recommended medications such as zinc and antipyretic was decreased. It can be concluded that the application of the clinical pathway in inpatient patients with acute diarrhea with dehydration has increased the effectiveness of drug use as recommended, although not significantly change in clinical outcomes due to recovery rates. The other results showed a no significant decreased in the length of hospital stay after the application of the clinical pathway, although a slight trend suggests for further investigation because it also acknowledges the limitations about sample size and reiterates the significance of further research to provide a more definitive descriptive.

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Received on 08.06.2024 Revised on 01.10.2024

Accepted on 07.12.2024 Published on 10.04.2025

Available online from April 12, 2025

Research J. Pharmacy and Technology. 2025;18(4):1731-1738.

DOI: 10.52711/0974-360X.2025.00248

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

	Symptomatic Therapy	Before Clinical Pathway	After Clinical Pathway
Electrolyte liquid	Administered electrolyte fluid	137 (100%)	137 (100%)
Antipyretic/analgetic	Given antipyretic/analgetic	105 (76.6%)	104 (75.9%)
	No antipyretic/analgesic given	32 (23.4%)	33 (24.1%)
Antihistamine	Given antihistamines	9 (6.6%)	30 (15.7%)
	Not given antihistamines	128 (93.4%)	107 (84.3%)
Antiemetic	Given antiemetics	93 (67.9%)	116 (84.7%)
	Not given antiemetics	44 (32.1%)	21 (15.3%)
Zink	Zinc given	127 (92.7%)	130 (94.9%)
	Not given zinc	10 (7.3%)	7 (5.1%)
Probiotic	Given probiotics	117 (85.4%)	129 (94.2%)
	Not given probiotics	20 (14.6%)	8 (5.8%)
Total		137 (100%)	137 (100%)