Year : 1996 | Volume
: 2 | Issue : 1 | Page : 11--14
The nutritional management of acute diarrhea
William C MacLean
Pediatric Nutrition Research and Development, Ross Products Division, Abbott Laboratories, Columbus. Ohio, USA
William C MacLean
Pediatric Nutrition Research & Development, Ross Products Division, Abbott Laboratories, Columbus, Ohio
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.
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MacLean WC. The nutritional management of acute diarrhea.Saudi J Gastroenterol 1996;2:11-14
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MacLean WC. The nutritional management of acute diarrhea. Saudi J Gastroenterol [serial online] 1996 [cited 2021 Dec 6 ];2:11-14
Available from: https://www.saudijgastro.com/text.asp?1996/2/1/11/34035
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  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.
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