Saudi Journal of Gastroenterology

: 1995  |  Volume : 1  |  Issue : 3  |  Page : 145--151

Diarrhea and malnutrition: A continuing pediatric challenge

Michael Gracey 
 From the Aboriginal Health Policy and Programs Branch, Health Department of Western Australia and Sichool of Public Health, Curtin University, Perth, Australia

Correspondence Address:
Michael Gracey
189 Royal Street. East Perth. W.A. 6004


Acute diarrhea is one of the most prevalent serious health problems in infants and children. This article provides an update on diarrhea and malnutrition, with particular emphasis on their interactions in pediatric patients.

How to cite this article:
Gracey M. Diarrhea and malnutrition: A continuing pediatric challenge.Saudi J Gastroenterol 1995;1:145-151

How to cite this URL:
Gracey M. Diarrhea and malnutrition: A continuing pediatric challenge. Saudi J Gastroenterol [serial online] 1995 [cited 2023 Feb 1 ];1:145-151
Available from:

Full Text

Infectious diarrhea is one of the most prevalent serious health problems of infants and young chil­dren. With improved management of acute infec­tious diarrhea in developing countries over recent years, more survivors are developing persistent diarrhea and its serious long-term consequences. The first estimate of global morbidity and mortal­ity from diarrheal disease based on active surveil­lance data, collected from 24 selected longitudinal studies of children, that had been conducted over three decades, was published in 1982[1]. The study showed that, using 1980 population esti­mates, there were annually 744-1000 million episodes of diarrhea and 4.6 million deaths from diarrheal disease in children under 5 years of age in Africa, Asia (excluding China) and Latin America. A ten-year update of that situation showed that the incidence of diarrhea was virtu­ally unchanged, but the estimated global mortality was lower[2]; the lower mortality is encouraging, but diarrheal disease is still a pressing pediatric problem, worldwide. Diarrheal disease is not con­fined to developing countries, although its impact is greatest there. In the United States, for exam­ple, there were about 500 reported diarrheal dis­ease deaths annually over a recent 10-year period in infants and children between 1 month and 4 years of age; 80% of those deaths were in infants under 12 months of age [3].

 Diarrhea and Nutrition

The potential impact of diarrhea on nutritional status through the negative impacts of stool losses, vomiting, anorexia, withholding of food, and the catabolic effect of infection are well accepted and the synergistic interactions of diarrhea and mal­nutrition are well recognized [4],[5],[6],[7],[8],[9]. A study from Colombia estimates that the average two to eight diarrheal episodes per year experienced by chil­dren in developing countries during the first 3 years of life, causes a total negative effect on body height of between 2.5 and 10 cm at 3 years of age [10]. The influence of malnutrition on diarrheal episodes seems to be variable. A community­based, prospective study of more than 700 chil­dren in a rural, lowland area of Bangladesh showed a diarrheal incidence of 4.6 episodes per year [9]. About three-quarters of the children were below 2 standard deviations ("Z" scores) underweight and height for age and about one­third were below - 2"Z" scores for weight-for­height. About 20% of the children were anergic, and these children had a 50% increased incidence of diarrhea. The association between undernutri­tion and diarrhea incidence was only modest, but a history of diarrhea in the previous three months was a strong predictor for diarrhea in individuals in the following three months. These factors have their greatest impact in the first three years of life [1],[2],[11],[12],[13].

It is important to attempt to define the terms "diarrhea" and "malnutrition." To define a 'nor­mal' stool in a healthy infant is difficult as it often depends on perceptions about what is `normal'. There can be wide variability in infant stooling patterns with some normal neonates passing up to six stools and some infants passing up to four stools daily. Breast-fed infants pass more stools than do other infants. Acute diarrhea usually means the onset was within 24 hours. It is also important to record whether the stools are watery or dysenteric: chronic diarrhea means that the diarrhea has lasted 14 days or more whether the stools are watery, loose, bulky or dysenteric [14].

Independent international comparisons of chil­dren's growth and nutritional status can be facili­tated by the use of the simple Z score method which allocates a standard deviation (Z) score to measurements from each child against reference values such as those produced by the United States' National Center for Health Statistics [15],[16],[17]. This method can be applied across age groups and for sexes combined to estimate nutri­tional status of children in communities or reg­ions. In order to distinguish acute malnutrition (wasting or emaciation) from chronic malnutri­tion (stunting) in groups of children, the following three indicators should be used: weight-for-age; height-for-age; and weight-for- height [18].

 Patterns of Infectious Diarrhea

The patterns of infectious diarrhea that occur in infants and young children differ throughout the world. In cooler and temperate regions, for exam­ple, childhood gastroenteritis tends to be a winter illness. In the tropics, diarrheal episodes tend to occur throughout the year, although seasonal increases can occur in the dry season, the wet season, the hot season, the cool season, or combina­tions depending on the local climate and associated risk factors such as: living conditions, crowding, community hygiene and the presence of vectors that can spread diarrhea-causing microor­ganisms[12]. In tropical North West Australia where I have worked in aboriginal communities for many years, diarrhea is much more frequent during the wet, summer season which is the hot­test and most humid part of the year, and when heavy monsoonal rains arrive from South East Asia-this is known locally as the "diarrhea season" [20],[21]. Seasonal patterns to childhood diarrhea have been documented in many other tropical locations, e.g. in Pakistan[22] and in Thailand, where there are two definite seasonal peaks; the summer one associated with bacterial infections and the winter one related to viruses[23].

 Etiologic Agents

1. Viruses

There is an impressively long list of etiology agents that can cause infectious diarrhea: (i) vir­uses, (ii) bacteria and (iii) parasites. Data from 34 studies on the etiology of childhood gastroen­teritis showed that rotavirus was detected in 11­71% of children (median = 33%) and that rates of detection were independent of the geographic region or the level of economic development, as well as of the method of detection used [24]. Although rotavirus infections are widely consi­dered a winter disease in temperate zones, Cook et al [24] found that their incidence peaked in winter primarily in the Americas, and that peaks in autumn or spring are common in other parts of the world. In tropical localities close to the Equator, no seasonal trend emerged and in most of the world, rotavirus occurs year round, suggest­ing that low-level transmission could maintain the infection. That review about rotavirus diarrhea suggests an epidemiologic pattern - seasonal in cooler months, universal spread in temperate and tropical regions in developed and less-developed settings - that is similar to childhood viruses (like measles) spread by the respiratory route rather than the more usual fecal-oral route of transmis­sion of enteric pathogens. Others have also suggested that respiratory droplet spread may be significant in the transmission of rotavirus infections[25]. Other viruses may cause diarrheal dis­ease in humans; these include Norwalk virus, Nor­walk-like viruses (small, round structured vir­uses), enteric adenoviruses caliciviruses and astroviruses[26].

2. Bacteria

Diarrhea caused by enteric bacterial infections is very important, worldwide, especially in tropi­cal developing countries. It is a serious problem among older children and adults, as well as in infants and young children [19]. Many microor­ganisms can be involved; these include Escherichia coli [27], the invasive bacteria (Sal­monella, Shigella, Campylobacter, Yersinia, enteroinvasive E. coli), vibrios and anaerobes such as Clostridium spp.[28]. Better laboratory methods to detect enteric pathogens and to inves­tigate underlying pathogenic mechanisms [29],[30],[31], combined with more detailed and controlled epidemiologic investigations have helped to define roles for "newer" bacterial causes of diarrhea. These include, for example, Aeromona spp [32], Campylobacter [33] and cyanobacteria, or blue-green algae [34],[35],[36].

Food-borne diarrheal disease, caused by vari­ous agents, is of huge public health importance and may cause tens of millions of episodes annu­ally in North America, alone[37]. Foods pre­pared in homes under unhygienic living condi­tions, as occurs in poorer parts in developing countries, are often contaminated with pathogens and are, therefore, a major risk factor for diarrheal disease. Most of the 1,400 million episodes of diarrheal diseases that occur in chil­dren under five years of age are due to pathogens that can be transmitted through food; pathogenic strains of E. coli are a major proportion of the organisms involved[38] including enterohemor­ragic strains such as 0157:H7. Bacterial food­borne diarrhea can be caused by other agents such as Salmonella or Campylobacter or can be due to the action of preformed toxins, e.g. with staphylococcal food poisoning.

International travel can cause episodes of diarrhea which is commonly known as "traveller's diarrhea"; this can affect infants and young chil­dren as well as older travellers [39]. Up to 50% of episodes are due to enterotoxigenic E. coli but other varieties of E. coli can be involved, as well as other enteric pathogens including Salmonella, Shigella, Aeromonas, viruses and parasites (39­43). Personal hygiene, e.g. feeding practices, when travelling in high-risk, diarrhea-endemic areas is a very important factor to reduce the risk of these episodes of diarrhea.

3. Parasites

Intestinal parasitoses are prevalent in develop­ing countries and are serious hazards to health. Some parasites, such as hookworms, can have serious nutritional consequences related to repeated gastrointestinal blood loss; others, such as Enterobius and Trichuris trichiura usually do not cause serious clinical consequences, while others (e.g. Giardia intestinalis) appear much more likely to cause diarrhea and other gastroin­testinal symptoms especially where standards of personal and community hygiene are poor. Apart from fecal-oral transmission from infected humans, infected domestic animals, (e.g. dogs) may be involved [44],[45]. Cryptosporidium has become recognized lately as an important human intestinal parasite because it can cause severe, life-threatening diarrhea in immunocompromised hosts and because it can cause diarrheal outbreaks in children (e.g. in day-care centers) and chronic diarrhea in children without evidence of immune deficiency; the parasite is distributed worldwide and pediatricians should be alert for it, in children with diarrhea [46].


There have been major advances in the man­agement of childhood diarrheal dehydration over recent years; foremost among these is the wide­spread use of oral rehydration therapy (ORT). This therapy is feasible, efficacious, and safe in hospital treatment and at the primary care level in developing countries, in the prevention of metabolic complications of diarrhea and dehydra­tion and in reduced hospitalization [47]. ORT is gradually becoming accepted in the West [48] although it has been referred to as "the under­used simple solution" because of the resistance of pediatricians and other medical practitioners in countries like the United Sates [49],[50], where there may be widely-held perceptions that intra­venous fluids are usually needed in children with acute diarrheal episodes. Dietary management is a very important but often, poorly-managed aspect of treatment of childhood diarrhea. Earlier approaches that permitted the bowel to "rest" for some days are outmoded and tended to worsen the potentially-negative nutritional impacts of stool losses, vomiting, infection and widespread inappropriate feeding practices in nutritionally­ vulnerable infants and young children [47],[51]

There are several important basic principles:

- Breast-feeding should be continued during diarrhea and additional fluids should be given to replace fluids and electrolytes that are lost with abnormal fecal losses.

- Most young children with acute diarrhea can be successfully managed with continued feed­ing of undiluted nonhuman milk. Routine dilution of milk and routine use of lactose-free formula, without a clinical indication, are therefore not needed, especially when ORT and early feeding, in addition to milk, com­prise the basic approach to management [52].

- In children who are on milk other than breastmilk, this can be reintroduced after rehydration has been achieved. Lactose-free formulas may be needed for patients with severe mucosal damage and secondary lactose intolerance, while a small proportion of chil­dren, particularly those who are young and malnourished, may be intolerant to all dietary carbohydrates including monosaccharides [53],[54].

- Food-based ORT (e.g. based on rice powder or other cereals or local staples) can be used to help reduce fecal losses [55].

- In children aged 4 to 6 months or more, soft or semi-solid foods should be offered as soon as the child is rehydrated - there is no need to with­hold or restrict feeding until the diarrhea has stopped. These foods should be mashed or pureed and offered in small amounts at least six times daily.

- Extra food should be given for at least two weeks after the diarrhea has stopped in order for any weight-for-height deficit to be cor­rected.

- Attention may be required to correct specific micronutrient deficiencies, e.g. vitamin A [56] or zinc [57].

Drugs have a very little role in the management of infants and children with acute diarrhea [51]; yet they are often used indiscriminately, particu­larly antimicrobials and so-called antidiarrheal remedies, that may come from pharmaceutical sources but often, from uncontrolled suppliers. There are several reasons why antibiotics should not generally be used in childhood gastroenteritis including the fact that some episodes (e.g. those caused by viruses) would not respond; many enteric bacteria are already antibiotic-resistant; indiscriminate usage of antibiotics encourages the development of plasmid-transmitted drug resis­tance; and antibiotic treatment can prolong car­riage for some microorganisms, such as Sal­monella. Furthermore, antibiotics are also expen­sive and have significant side-effects. Antibiotics are appropriate for the treatment of bacterial infections that can produce bacteremia, such as typhoid fever, for which chloramphenicol or ampicillin can be used [28]. Antibiotics may be indicated for other reasons, such as treatment of a coexistent respiratory infection or other serious infections particularly in young, small and com­proriised infants and young children.

Antiparasitic drugs should be used for amebiasis only after antibiotic treatment of bloody diarrhea for shigellosis has failed; or if there is microscopic evidence of trophozoites of Entameba histolytica with erythrocytes seen in the feces. It may be reasonable to treat patients with cysts or trophozoites of Giardia intestinalis (G. lamblia) identified by microscopy in stool speci­mens or upper intestinal aspirates because in areas where giardiasis is common, asymptomatic car­riage is not unusual. WHO [58] recommends treatment in such patients when diarrhea has lasted at least 14 days or more. Children with strongyloidiasis should be treated with thiaben­dazole in an attempt to eradicate the infection to prevent autoinfection, but this is not always effec­tive and repeated courses may be required [59]. Antidiarrheal drugs (such as opiates) and anti­emetics should not be used in infants or children; they are not efficacious and can be dangerous.

 Persistent Diarrhea

As many as three to 20% of episodes of acute diarrhea in children in developing countries become persistent, i.e. last 14 days or more [60].

With the increasingly successful management of patients with acute diarrhea, those episodes that become persistent are assuming greater impor­tance, particularly because they have adverse nut­ritional consequences and cause about one-third to one-half of all childhood diarrheal deaths.

A group of risk factors that predispose infants and children to persistent diarrhea (PD) has been identified by WHO [61]. Some of these include:

1) host factors:

- young age, particularly below 12 months

- malnutrition

- impaired immune function

2) environmental factors:

- overcrowding

- inadequate hygiene

- living close to animals

- fecal-oral transmission of enteric pathogens

3) previous infections:

- recent acute diarrhea

- previous persistent diarrhea

- respiratory tract infection

4) pre-illness feeding practices:

- recent introduction of milk

5) microbial isolates during acute phase:

- enteroadherent E. coli (EAEC)

- Shigella

- multiple pathogens

6) drug usage during acute diarrhea:

- antimicrobial therapy

- antiparasitic drugs

Bacterial contamination of the small intestinal contents in infants with enteropathogenic E. coli (EPEC) and other fecal-type microorganisms has been suggested as a causative factor in the pathogenesis of persistent diarrhea [62],[63],[64]. Given the complexities of the intestinal microflora and the technical difficulties involved in its investiga­tion and documentation of detailed populations of aerobic and strict or facultative anaerobic bac­teria, it is not surprising that there have been some inconsistencies between reported studies. The South African workers, for years, have used and reported beneficial results from oral administra­tion of a mixture of gentamicin, metronidazole and the bile-salt binding resin, cholestyramine, in infants with severe persistent diarrhea [65]. Although the results of this study are difficult to interpret because of its complex design. Their experience suggests that continuing microbial contamination, corrected by antibiotic adminis­tration coupled with cholestyramine, is important in PD; however, short-term intermittent antibio­tic treatment failed to show consistently better growth in Burmese village children [66]. PD might also be caused by secondary sugar intoler­ance [53] or intolerance to foreign proteins, such as cow's milk [67], perhaps because of facilitation of sensitization to these substances through altered intestinal permeability associated with mucosal injury [68].


1Synder JD, Merson MH. The magnitude of the global problem of acute diarrheal disease: a review of active surveillance data. Bull WHO 1982;60:605-13.
2Bern C, Martines J, de Zoysa I, Glass RI. The mag­nitude of the global problem of diarrheal disease: a ten­year update. Bull WHO 1992;70:705-14.
3Ho M.S, Glass RI, Pinsky PF et al. Rotavirus as a cause of diarrheal morbidity and mortality in the United States. J Infect Dis 1988;158:1112-6.
4Scrimshaw NS, Taylor CE, Gordon JE. Interactions of nutrition and infection. World Health Organization Monograph Series, No.57 World Health Organization, Geneva, 1968.
5Gracey M (Ed) Diarrheal Disease and Malnutrition. Churchill Livingstone, Edinburgh, 1985.
6Guerrant RL, Schorling JB, McAuliffe JF, de Souza MA. Diarrhea as a cause and an effect of malnutrition: diarrhea prevents catch-up growth and malnutrition increases diarrhea frequency and duration. Am J Trop Med Hyg 1992;47(Suppl 1):28-35.
7Lima AAM, Fang G, Schorling JB, et al. Persistent diarrhea in Northeast Brazil: etiologies and interactions with malnutrition. Acta Pediatrica 1992; Suppl. 381:39­-44.
8Yip R, Sharp TW. Acute malnutrition and high child­hood mortality related to diarrhea. J A Med A 1993:270:387-590.
9Baqui AH, Black RE, Sack RB, Chowdhury HR, Yunus M, Siddique AK. Malnutrition, cell-mediated immune deficiency, and diarrhea: a community-based longitudi­nal study in rural Bangladeshi children. AM J Epidemiol 1993;137:355-65.
10Lutter CK, Mora JO, Habicht J.P. et al. Nutritional sup­plementation: effects on child stunting because of diarrhea. Am J Clin Nutr 1989;50:1-8.
11Guerrant RL, Hughes JM, Lima NL, Crane J. Diarrhea in developed and developing countries: magnitude, spec­ial setting and etiologies. Rev Infect Dis 1990;12(Suppl 1): 541S-55S.
12Gracey M. Environmental hygiene, undernutrition, and diarrhea. In: Pediatric Gastroenterology and Hepatol­ogy 3rd edn., M Gracey and V Burke (Editors). Blackwell Scientific Publications, Boston 1993a, pp 332-­50.
13Haggerty PA, Muladi K, Kirkwood BR, Ashworth A, Manunebo M. Community-based hygiene education to reduce diarrheal disease in rural Zaire: impact of the intervention on diarrheal morbidity. Intern Epidemiol 1994;23:1050-9.
14Gracey M. Persitent childhood diarrhea: patterns pathogenesis and prevention. J Gastroenterol Hepatol 1993b;8:259-66.
15Hamill PVV, Drizd JA, Reed RB, Roche AF, Moore WM. Physical growth: National Center for health Statis­tics Percentiles. Am J Clin Nutr 1979;32:607-29.
16Dibley MJ, Staehling N, Niebury PH, Trowbridge FL. Interpretation of Z-score anthropometric indicators derived from the international growth reference. Am J Clin Nutr 1987;46:749-62.
17Keller W. Stature and weight as indicators of undernutri­tion. In: Anthropometric Assessment of Nutritional Status JH Himes(Ed). pp 113-22. Wiley-Loss, New York, 1991.
18WHO. Measuring change in nutritional status. Guidelines for assessing the nutritional impact of supple­mentary feeding programmes for vulnerable groups. World Health Organization, Geneva, 1983.
19Gracey M, Bouchier IAD (Eds). Infectious Diarrhea. Bailliere's Clinical Gasroenterology 1993;7(2):195-552.
20Berry RJ, Bettelheim KA, Gracey M. Studies on enterotoxigenic Escherichia coli isolated from persons without diarrhea in Western Australia. J Hyg (Cam­bridge)1983;90:99-106.
21Gunzburg S, Gracey M, Burke V, Chang B. Epidemiol­ogy and microbiology of diarrhea in young aboriginal children in the Kimberley region of Western Australia. Epidemiol and Infect 1992;108:67-70.
22Mahmud A, Jalil F, Karlberg J, Lindbald BS. Early child health in Lahore, Pakistan: VII. Diarrhea. Acta Pediat­rica 1993;Suppl390:79-85.
23Wasi C, Louisirirotchanakul S, Thakerngpol K, Sarasook S, Surakhaka M, Varavithya W, et al. The epidemiological study on viral diarrhea in Thailand. Journal of the Medical Association of Thailand 1984;67:370-7.
24Cook SM, Glass RI, Le baron CW, Ho M.S. Global sea­sonality of rotavirus infections. Bull WHO 1990;68:171­7.
25Ansari SA, Springthorpe VS, Sattar SA. Survival and vehicular spread of human rotaviruses: possible relation to seasonality of outbreaks. Rev Infect Dis 1991;13:448­-61.
26Schwab KS, Shaw RD. Viruses. Bailliere's Clinical Gas­troenterology M Gracey and IAD Bouchier (Editors). Bailliere Tindall, London 1993;7:307-31.
27Echeverria P, Savarino SJ, Yamamoto T. Escherichia coli diarrhea. In: Infectious Diarrhea, Gracey and IAD Bouchier (Editors). Bailliere's Clinical Gastroenterol­ogy 1993;7(2):243-62.
28Griffiths JK, Gorbach SL. Other bacterial diarrheas. In: Infectious Diarrhea, M Gracey and IAD Bouchier (Editors). Bailliere's Clinical Gastroenterology 1993;7(2):263-305.
29Thorne GM. Diagnostic tests in gastrointestinal infec­tions. Cur Opi Gastroenterol 1993;9:126-33.
30Thorn GM. Diagnostic tests in gastrointestinal infec­tions. Cur Opi Gastroenterol 1994;10:112-8.
31Booth IW, McNeish AS. Mechanisms of diarrhea. In: Infectious Diarrhea, Gracey and IAD Bouchier (Eds) Bailliere's Clinical Gastroenterology 1993;7(2):213-42.
32Burke V, Gracey M, Robinson J et al. The microbiology of childhood gastroenteritis: Aeromonas species and other infective agents. J Infect Dis 1983;148:68-74.
33Blaser MJ, Reller B. Campylobacter enteritis. N Engl J Med 1981;305:1444-52.
34Long EG, Ebrahimzadeh A, White EH, Shwisher B, Callaway CS. Alga associated with diarrhea in patients with acquired- immunodeficiency syndrome and in travellers. J Clin Microbiol 1990;28:1101-4.
35Hoge CW, Shlim DR, Rajah R, Triplett J, Shear M, Rabold JE, Echeverria P. Epidemiology of diarrheal ill­ness associated with coccidian-like organism among travellers and foreign residents in Nepal. Lancet 1993;341:1175-9.
36Bendall RP, Lucas S, Moody A, Tovey G, Chiodini PL. Diarrhea associated with cyanobacterium-like bodies: a new coccidian enteritis of man. Lancet 1993;341:590-2.
37Todd E. Epidemiology of food-borne illness: North America. Lancet 1990;336:789-90.
38Motarjemi Y, Kaferstein F, Moy G, Quevedo F. Con­taminated weaning food: a major risk factor for diarrhea and associated malnutrition. Bull WHO 1993;71:79-92.
39Hutchins P, Hinchoda P, Phillips A, Walker-Smith J. Traveller's diarrhea with a vengeance in children of UK immigrants visiting their parental homeland. Arch Dis Child 1982;57:208-11.
40Gracey M, Burke V, Robinson J, Masters PL, Stewart J, Pearman J. Aeromonas spp. in travellers' diarrhea. Br Med J 1984;289:658.
41Gorbach SL, Edelman R. Travellers'diarrhea: National Institutes of Health Consensus Development Confer­ence. Rev Infect Dis 1986;8(suppl. 2) 109S-233S.
42Farthing MJG, DuPont HL, Guandalini S, Keusch GT, Steffen R. Treatment and prevention of traveller's diarrhea. Gastroenterol Intern 2,5:162-75.
43Farthing MJG. Traveller's diarrhea. Br Med J (Editorial) 1993a;306:1425-6.
44Meloni BP, Thompson RCA, Hopkins RM, Reynoldson JA, Gracey M. The prevalence of Giardia and other intestinal parasites in children, dogs and cats from aboriginal communities in the Kimberley. Med J Aust 1993;158:157-9.
45Thompson RCA, Reynoldson JA, Lymbery AJ. Giar­dia: from molecules to disease and beyond. Parasitology Today 1993;9:313-5.
46Farthing MJG. Intestinal parasites. Bailliere's Clinical Gastroenterology Gracey and IAD Bouchier (Editors) Bailliere Tindall, London 1993b;7:333-64.
47Gracey M. Treatment of acute diarrhea in different set­tings. In: Pediatr Gastroenterology and hepatology 3rd edn., M Gracey and V Burke (Editor) Blackwell Scien­tific Publications,Boston, 1993c, pp 301-17.
48Walker-Smith JA. Management of infantile gastroen­teritis. Arch Dis Child 1990;65:917-8.
49Avery ME, Snyder JD. Oral therapy for acute diarrhea: the underused simple solution. N Engl J Med 1990;323:891-4.
50Synder JD. Use and misuse of oral therapy for diarrhea: comparison of US practices with American Academy of Pediatrics recommendations. Pediatrics 1991;87:28-33.
51Rivin B, Sanosham M. Rehydration and malnutrition management. In: Infectious Diarrhea, M Gracey and IAD Bouchier. ( Editors)Bailliere's Clinical Gastroen­terology 1993;7(2):451-76.
52Brown KH, Peerson JM, Fontaine O. Use of nonhuman milk in the dietary management of young children with acute diarrhea: a meta-analysis of clinical trials. Pediat­rics 1994;93:17-27.
53Gracey M, Anderson CM. Disorders of carbohydrate digestion and absorption. In: Pediatric Gastroenterology and Hepatology 3rd edn. M Gracey and V Burke. (Editors) Blackwell Scientific Publications, Boston, 1993,; pp 380-402.
54Salazar-Lindo E, Sack RB, Chea-Woo E et al, Bicarbo­nate versus citrate in oral rehydration therapy in infants with watery diarrhea: a controlled clinical trial. J Pediatr 1986;108:55-60.
55Cereal-based oral rehydration solutions-bridging the gap between fluids and food. Lancet (Editorial) 1992;339:219-20.
56Editorial. Vitamin A and malnutrition/infection complex in developing countries. Lancet 1990;336:1349-51.
57Sachdev HPS, Mittal NK, Mittal SK, Yadav HS. A con­trolled trial on utility of oral zinc supplementation in acute dehydrating diarrhea in infants. J Pediatr Gas­troenterol Nutr 1988;7:877-81.
58WHO. Management of the patient with diarrhea. Prog­ramme for Control of Diarrheal Disease, World Health Organization, Geneva, 1992.
59Grove DI. Parasitic intestinal infections. In: Pediatric Gastroenterology and Hepatology, 3rd edn, M Gracey and V Burke. (Editors) Blackwell Scientific Publica­tions, Boston, 1993, pp 318-31.
60Bhan MK, Raj P, Khoshoo V, Bhandari N et al. Quanti­ation and properties of fecal and upper small intestinal aerobic miroflora in infants and young children with per­sistent diarrhea. J Pediatr Gastroenterol 1989;9:40-5.
61WHO. Persitent diarrhea in children in developing coun­tries: Memorandum from a WHO meeting. Bull WHO 1988;66:709-17.
62Gracey M, Stone DE. Small intestinal microflora in Australian Aboriginal children with chronic diarrhea. Austr N Zeal J Med 1972;3:215-9.
63Penny MA, Handereda de Silva DG, McNeish AS. Bacterial contamination of the small intestine of infants with enteropathogenic Escherichia coli and other enteric infections: a factor in the etiology of persistent diarrhea ? Br Med J 1986;292:1223-6.
64Omioke IU, Abiodun PO. Upper small intestinal micro­flora in diarrhea and malnutrition in Nigerian children. J Pediatr Gastroenterol Nut 1989;9:314-21.
65Hill ID, Mann MD, Househam KC, Bowie MD. Use of oral gentamycin, metronidazole and cholestyramine in the treatment of severe persistent diarrhea in infants. Pediatrics 1986;77:477-81.
66Khin-Maung-U, Bolin TD, Duncombe VM, Pereira SP, Myo-Khin, Nyunt-Nyunt-Wai, Linklater JM. Effect of short-term intermittent antibiotic treatment on growth of Burmese (Myanmar) village children. Lancet 1990;336:1090-3.
67Iyngkaran N, Yadav M, Boey CE, Meng LL, Puthucheary SD, Lam KL. Effect of diet on the clinical course and repair of the small bowel mucosa in infantile gastroenteritis. J Gastroenterol Hepatol 1988;3:337-44.
68Lunn PG, Northrop-Clews CA, Downes RM. Recent developments in the nutritional management of diarrhea. 2. Chronic diarrhea and malnutrition in Gam­bia: studies on intestinal permeability. Trans R Soc Trop Med Hyg 1991;85:8-11.