Year : 1995 | Volume
: 1 | Issue : 3 | Page : 145--151
Diarrhea and malnutrition: A continuing pediatric challenge
From the Aboriginal Health Policy and Programs Branch, Health Department of Western Australia and Sichool of Public Health, Curtin University, Perth, Australia
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.
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Gracey M. Diarrhea and malnutrition: A continuing pediatric challenge.Saudi J Gastroenterol 1995;1:145-151
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Gracey M. Diarrhea and malnutrition: A continuing pediatric challenge. Saudi J Gastroenterol [serial online] 1995 [cited 2023 Feb 1 ];1:145-151
Available from: https://www.saudijgastro.com/text.asp?1995/1/3/145/34051
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. 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; 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 .
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 ,,,,,. 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 . 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 . 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 ,,,,.
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 .
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 ,,. 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 .
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. 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" ,. Seasonal patterns to childhood diarrhea have been documented in many other tropical locations, e.g. in Pakistan and in Thailand, where there are two definite seasonal peaks; the summer one associated with bacterial infections and the winter one related to 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 . Although rotavirus infections are widely considered a winter disease in temperate zones, Cook et al  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. Other viruses may cause diarrheal disease in humans; these include Norwalk virus, Norwalk-like viruses (small, round structured viruses), enteric adenoviruses caliciviruses and astroviruses.
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 . Many microorganisms can be involved; these include Escherichia coli , the invasive bacteria (Salmonella, Shigella, Campylobacter, Yersinia, enteroinvasive E. coli), vibrios and anaerobes such as Clostridium spp.. Better laboratory methods to detect enteric pathogens and to investigate underlying pathogenic mechanisms ,,, 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 , Campylobacter  and cyanobacteria, or blue-green algae ,,.
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. 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 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 . 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.
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 ,. 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 .
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 . ORT is gradually becoming accepted in the West  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 ,, 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 ,
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 .
- 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 ,.
- Food-based ORT (e.g. based on rice powder or other cereals or local staples) can be used to help reduce fecal losses .
- 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  or zinc .
Drugs have a very little role in the management of infants and children with acute diarrhea ; 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 . 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  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 . Antidiarrheal drugs (such as opiates) and antiemetics should not be used in infants or children; they are not efficacious and can be dangerous.
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 .
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 . Some of these include:
1) host factors:
- young age, particularly below 12 months
- impaired immune function
2) environmental factors:
- 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)
- 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 ,,. 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 . 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 . PD might also be caused by secondary sugar intolerance  or intolerance to foreign proteins, such as cow's milk , perhaps because of facilitation of sensitization to these substances through altered intestinal permeability associated with mucosal injury .
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