| Abstract|| |
Acute diarrhea may have a profound effect on nutritional status worldwide. After rehvdration, proper nutritional management can mitigate these effects. This paper discusses the advantages and disadvantages of continued feeding, emphasizing that breastfeeding should not be stopped during episodes of acute diarrhea.
|How to cite this article:|
MacLean WC. The nutritional management of acute diarrhea. Saudi J Gastroenterol 1996;2:11-4
The World Health Organization has estimated that children under the age of five in developing countries have an average of two episodes of diarrhea per year. If there is anything surprising about that figure, it is how low it is. Pediatricians caring for children in more-developed areas would not be surprised to see a child have several episodes of diarrhea in the first few years of life.
The effect of diarrhea on the prevalence of protein-energy malnutrition and infant mortality in less-developed countries is well recognized. The effect of acute infectious diarrhea on infants in more-developed countries has not been apparent. In 1982, Cushing and Anderson published an interesting study examining the effect of diarrhea on weight gain of infants in their practice  . They found that weight crossed to a lower major percentile (50th to 25th, 25th to 10th, etc.) in 1 1 of 62 episodes, one to four weeks after recovery. This was not the acute weight loss associated with dehydration, but a significant faltering in weight gain. Clearly, what distinguishes infants in moredeveloped societies from those in developing countries, is the frequency with which they experience acute diarrhea. Infants in cleaner environments have periods of time between episodes, during which catch-up growth is possible. In 1986, the World Health Organization estimated that, depending on the area of the world involved, between 24% and 45% of childhood mortality was related to diarrheal disease. The key issues in nutritional management of diarrhea are: appropriate use of oral rehydration and appropriate feeding, thereafter.
| Oral Fluid Therapy|| |
Oral rehydration solutions are based on the well-described physiologic principle that couples glucose and sodium absorption at the brush border of the small intestinal enterocyte. Either glucose or sodium can be absorbed alone, but when present together in appropriate ratios, each facilitates the absorption of the others. The movement of the positively-charged sodium ion attracts the negatively-charged chloride ion. The movement of solute osmotically pulls solvent (water) across the membrane.
There are literally, hundreds of studies in the literature documenting the efficacy of oral rehydration. From the pediatric perspective, one of the most compelling is that of Pizarro et al from 1983  . Pizarro and colleagues studied 242 neonates treated with oral rehydration (WHO solution used 2:1 with water). Average age of subjects was 19 days. The duration of diarrhea was approximately 3 1/2 days. Mild to moderate dehydration was present in 90%. Approximately 69% of infants were vomiting prior to therapy. This figure is of particular importance, because vomiting is a hallmark of rotavirus diarrhea, one of the most frequent types of infectious diarrhea in the first two years of life. If one allows vomiting at the time of presentation to preclude the use of ORS, most children who would benefit from this form of therapy will be excluded. Pizarro successfully rehydrated 234 of the 242 infants (97%). Average time to rehydration was about 7 1/2 hours, and children ingested approximately 26 ml/kg/hr. Weight gain after rehydration averaged 5.6 %, documenting that these children were indeed dehydrated. Pizarro's study is important in that, it documents the usefulness of ORS even in neonates.
Some physicians are tempted to use common household beverages for oral fluid therapy. This is inappropriate. These beverages are often low in electrolytes (many soft drinks) and high in carbohydrate. Fruit juices are particularly undesirable in the latter respect. The World Health Organization has suggested that carbohydrate content of ORS be approximately 2%. The American Academy of Pediatrics recommends a maximum of 21/2%  . Fruit juices often contain seven percent carbohydrate or more. In addition, fruit juices may contain high levels of fructose and sorbitol, both of which are poorly absorbed under certain conditions. Plain water is also used frequently in treating diarrhea; at least in the U.S. Dr Lawrence Finberg reported that 37 (25%) of 150 consecutive infants admitted to his hospital in New York City for diarrheal dehydration had serum sodiums less than 133 mEq/L . This is the result of inappropriate fluid therapy prior to presentation.
Despite the value of ORS, there are some contraindications to its use. Infants who are in shock, who have persistent vomiting, those with CNS disturbances that preclude their being able to drink, or those with injuries to the mouth and pharyngeal area may be better off treated with intravenous therapy. Use in infants < 2.5 kg also needs to be carried out with caution.
| Feedings During Acute Diarrhea|| |
Once oral rehydration is complete (in the first six to eight hours of therapy) the issue of continued feeding arises. The World Health Organization has recommended for more than a decade, that infants and children continue to be fed during episodes of acute diarrhea. It is instructive to look at why the long-standing practice of recommending clear fluids and short-term starvation followed by regrading of the diet, was originally adopted by the pediatric community worldwide. There are a number of theoretical disadvantages to discontinuing feeding during diarrhea. Malabsorption may be aggravated, and this, in turn, may cause damage to the intestinal mucosa, fluid loss, acidosis, and bile acid depletion. Some have argued that continued feeding may foster bacterial overgrowth. Finally, there is concern that the damaged mucosa may allow the absorption of whole proteins, and that this could trigger food allergies subsequently.
There is no question that continued feeding will be associated with some degree of malabsorption. Pathophysiologically, diarrhea most commonly results either from malabsorption or fluid secretion. In pediatric practice, most organisms cause mucosal damage and, hence, are associated with malabsorption.
Torres-Pinedo et al  documented the effects of continued milk feeding on infants with diarrhea nearly 30 years ago. In an in-hospital study, they studied patients who were given, in successive 24hour periods diluted evaporated milk, intravenous fluids without bicarbonate and subsequently intravenous fluids with bicarbonate. During the period of milk feeding serum pH, which had been normal, decreased and serum lactate increased. This was shown to be due to the absorption of lactate, which resulted from the fermentation of lactose entering the colon. During the periods of intravenous fluids and subsequently with added bicarbonate, pH returned to normal and stool lactate levels decreased. Others have shown that malabsorption of fat occurs during the period following acute diarrhea , . This may result in as much as 25% of fat being lost in the stool.
Given the information above, why have public health authorities recommended continued feeding during episodes of diarrhea ? First, it is the effort to maintain breastfeeding. For reasons that are not completely understood, breast-fed infants seem to tolerate breast milk during episodes of diarrhea despite the large amounts of lactose in this feeding. Maintaining breastfeeding is obviously of paramount importance. Second, is the desire to maintain adequate protein and calorie intakes. In a study in rural Bangladesh, Black et al  found that the average prevalence of diarrhea in children two to 12 months of age was 170 per 1,000 days. In other words, these children were having diarrhea 17% of the time. Withholding food only during the acute episode would result in a marked decrease in nutrient intake.
There is certainly, evidence that food in the gastrointestinal tract is a major stimulant to hyperplasia of the mucosa. Up to 40% of the energy used by epithelial cells lining the small intestine and up to 70% of that in the large intestine is derived from luminal nutrients. Direct evidence that continued feeding induces more rapid repair of the mucosa, however, is lacking.
Despite these theoretical considerations there are experimental considerations suggesting that continued feeding during diarrhea is beneficial. As long ago as 1948. A.W. Chung  recognized that treatment has been dominated by the appearance of the stools, rather than the appearance and well-being of the patient. Chung and Viscorova  carried out a study of 115 infants with acute diarrhea, randomizing children to gradual refeeding or to rapid feeding and a return to full intake within 24 hours. Mortality in both groups was approximately 10% high by our standards, but acceptable at that time. There was no difference between the two groups in mortality and infants who were fed during the episode gained weight more rapidly.
More recently, Santosham et al  , carried out a randomized study of continued feeding during acute diarrhea. Using lactose-free formula, they randomized infants either to full-strength formula or to gradual re-introduction of halfstrength formula following the period of oral rehydration. Children who were fed fully, experienced a reduction in stool output and duration of diarrhea. Stool output was approximately 40% and duration of diarrhea approximately 60% of the gradual re-introduction group. Brown et al  recently studied a similar formula with and without added fiber. In an in-patient metabolic study they showed a significant reduction in the duration of liquid stool excretion in infants, fed the fiber-containing formula. Other studies by this same group have suggested that the addition of solid foods that contain fiber. may also have a beneficial effect on the duration of liquid stool excretion.
In summary, children with acute diarrhea who are being breastfed should be given ORS as needed. Breastfeeding should be interrupted for as short a time as possible. Return to solid foods in the older infant or child should begin, once the child has appetite. The appropriate re-feeding of children who are formula-fed is somewhat controversial. ORS and early re-feeding are standard. Whether or not lactose-free feedings are needed is debated. Some studies show a high incidence of lactose intolerance following acute infectious enteritis  . A recent meta-analysis suggested, that this was confined predominantly to children with moderate to severe dehydration  . The choice between lactose-containing and lactosefree formula must be made based on the patient's age, severity of illness, and availability of the feeding. All agree that force-feeding a child who is anorectic, or continued feeding in the face of excessive stool output is unwarranted.
| References|| |
|1.||Cushing AH. Anderson L. Diarrhea in breast-fed and non-breast- fed infants. Pediatrics 1982:70:921. |
|2.||Pizarro D. Posada G. Mata L. Treatment of 242 neonates with dehydrating diarrhea with an oral glucose-electrolyte solution. J Pediatr 1983:102:153-6. |
|3.||American Academy of Pediatrics Committee on Nutrition: Use of oral fluid therapy and posttreatment feeding following enteritis in children in a developed country. Pediatrics 1985:75:358-61. |
|4.||Finherg L. Too little water has become too much: the changing epidemiology of water balance and convulsions in infant diarrhea. Am J Dis Child 1986:140:524. |
|5.||Torres-Pinedo R. Lavastida M. Rivera CL. Studies on infant diarrhea: I. A comparison of the effects of milk feeding and intravenous therapy upon the composition and volume of the stool and urine. J Clin Invest 1966:45:469-80. |
|6.||MacLean WC Jr, Klein GL, Lopez de Romana G, et al. Transient steatorrhea following episodes of mild diarrhea in early infancy. J Pediatr 1978:92:562-5 |
|7.||Jonas A, Avigal S, Diver-Haber A. Disturbed fat absorption following infectious gastroenteritis in children. J Pediatr 1979:95:366-72. |
|8.||Black RE, Brown KIT, Becker S, et al. Longitudinal studies of infectious diseases and physical growth of children in rural Bangladesh: I. Patterns of morbidity. Am J Epidemiol 1982;115:305-14. Beisel WR: Syposium on the impact of infection on nutritional status of the host. Am J Clin Nutr 1977:30:1203-566. |
|9.||Chung AW. The effect of oral feeding at different levels on the absorption of foodstuffs in infantile diarrhea. J Pediatr 1948;33:1-13. |
|10.||Chung AW, Viscorova B. The effect of early oral feeding versus early oral starvation on the course of infantile diarrhea. J Pediatr 1948;33:14-22. |
|11.||Santosham M, Foster S, Reid R, Bertrando R, Yolken R, Burns B, Sack RB. Role of soy-based , lactose-free formula during treatment of acute diarrhea. Pediatrics 1985:76:292-8. |
|12.||Brown KH, Perez F, Peerson JM, Fadel J, Brunsgaard G, Ostrom KM, MacLean WC Jr. Effect of dietary fiber (soy polysaccharide) on the severity, duration and nutritional outcome of acute, watery diarrhea in children. Pediatrics 1993;92:241-7. [PUBMED] |
|13.||Davidson GP, Goodwin D, Robb TA. Incidence and duration of lactose malabsorption in children hospitalized with acute enteritis: study in a well-nourished urban population. J Pediatr 1984;105:587-90. [PUBMED] |
|14.||Brown KH, Peerson JM, Fontaine O. Use of nonhuman milk in the dietary management of young children with acute diarrhea: a mega-analysis of clinical trials. Pediatrics 1994:93:17-27. |
William C MacLean
Pediatric Nutrition Research & Development, Ross Products Division, Abbott Laboratories, Columbus, Ohio
Source of Support: None, Conflict of Interest: None