Diarrhea Prevention Steps in Children
ACUTE CHILDHOOD DIARRHEA: A REVIEW OF RECENT
ADVANCES IN THE STANDARD MANAGEMENT
ADVANCES IN THE STANDARD MANAGEMENT
Feeding During Diarrhea :
Seema Alam, Rajeev Khanna, Uzma Firdaus
Pediatric Gastroenterology Section, Department of Pediatrics, JNMC, AMU, Aligarh
Corresponding Author: Dr Seema Alam, Reader, Department of Pediatrics, JN Medical College, AMU, Aligarh, UP. Email: firstname.lastname@example.org
The relationship between infection and malnutrition is bidirectional. Infection adversely affects nutritional status through reductions in ietary intake and intestinal absorption as well as increased catabolism. On the other hand, malnutrition predisposes to infection because of its negative impact on the barrier protection of the mucous membranes and host immune function.
The Lancet approach indicates that 57% of the annual deaths among under-fives can be prevented through achievement of high coverage of basic public health and nutrition interventions. 9 in the developing world the risk for death during diarrhea in children with mild, moderate and severe malnutrition is 2.32, 5.39 and 12.50 respectively (28) . In India the prevalence of exclusive breastfeeding is about 22 to 81 % across the various states (9) . Data from Delhi reveals that exclusive breastfeeding is 21.1 % at 6 weeks; this falls to about 3-4 % at the 22-weeks 29 . Non-breastfed infants had a higher risk of dying when compared with those who had been predominantly breastfed (HR = 10.5; 95% CI = 5.0-22.0; p < 0.001) as did partially breastfed infants (HR = 2.46; 95% CI = 1.44-4.18; p = 0.001) 29 . In a study to see the effect of community based promotion of exclusive breastfeeding, diarrheal illnesses were significantly less in the intervention group 30 . Fully weaned Guatemalan children reduced their energy intake by 30% during acute infections, whereas Bangladeshi children who were still breastfeeding reduced their intakes by only about 7%, suggesting that breastfeeding may protect against diarrhea-induced reductions in intake. It has been observed diarrhea-induced growth deficit (which could be as much as one third of the total growth deficit) was absent in fully breastfed infants in an urban field site in West Africa, and concluded that exclusive breastfeeding prevents the adverse nutritional consequences of diarrhea (33) . Colombian children in these studies who lived in control villages displayed the expected negative relationship between diarrheal prevalence and height at 3 y of age, while there was no effect of diarrhea on the height of those children who lived in villages where food supplements were being distributed (34) . Investigators also described associations between anthropometric indicators of nutritional status and the duration of illness (35) , the severity of fecal purging (36) and, most important, the case-fatality rates (37) . In each case, preexisting malnutrition was associated with an increased severity of diarrheal disease.
A meta-analysis 38 that was conducted to re-examine the issue of lactose free diet in diarrhea indicated that the rates of treatment failure were nearly twofold greater (22 vs. 12%) in the groups that received lactose-containing milk feeding. However, the excess rate of treatment failure was confined to those studies that enrolled children with initial severe dehydration. Among the studies that enrolled children with mild or no dehydration, there was no difference in the treatment failure rates. Hence it is safe to manage majority of children by using lactose-containing milk, especially if they have no dehydration. Dehydrated children may benefit from reduced lactose intake (5 gm of lactose per 150 kcal) and close supervision during the early phase of therapy. In a study done at our centre among children less than 4 months with persistent diarrhea, 71% of the infants were receiving lactose free formulae at admission (39) . Almost all the children improved on replacement of the lactose free formulae with low lactose milk cereal diet. Low lactose milk cereal diet provides stimulus for earlier regeneration of mucosal lactase, which is not possible with a lactose free diet. Moreover, the commercially prepared lactose free preparations have high antigenic value which in turn may result in hypersensitivity reaction in the intestinal mucosa and cause prolongation of diarrhea. A proportional hazards regression model controlling for age, diarrheal etiology, and severity of dehydration on admission revealed that the frequently fed group (on cow's milk) had a significantly shorter duration of diarrhea, greater weight gain and lower fecal frequency as well as fecal weight 40 . This could be due to the presence of decreased lactose load in the frequent smaller feeds, which can be achieved in mixed diets based on staple foods. As reviewed previously (41) , a number of studies examined the use of mixed diets based on staple foods, and others assessed the effects of individual food components, such as dietary fiber and micronutrients, on the outcome of diarrhea. In general, children fared at least as well with mixed diets as they did with more highly processed formulas, and dietary fiber was found to reduce the duration of the period of liquid stool excretion (42).
Exclusive breastfeeding in those less than 6 months should be continued. In those top fed, relactation should be encouraged especially if the child is less than 4 months of age 39 . Bottle-feeding should be discouraged. Milk cereal diets fed with katori help in rectifying the faulty feeding habits. Low lactose milk cereal diet frequently fed to the child has better palatability and helps in early recovery from diarrhea. Low lactose milk cereal diets and lactose free diets are easy to prepare, economical and better acceptable (Table 5). Only if indicated then the child should be shifted from to lactose free diet (Table 6). Encourage the child to take 100 kcal / kg and tube feeds can be considered if severe anorexia is present. Once the child recovers from diarrhea on lactose free diet the milk should be introduced gradually over 2-3 weeks on follow up visits. Intensive nutrition education significantly improves the status of malnourished children with or without supplementary feeding. So if effective feeding has been instituted and instructed to mother during diarrhea, it not only has positive effect on the severity of diarrhea but also improves long- term nutrition of the child.
Table 5: Low Lactose and Lactose Free Diets: Ingredients, Caloric content and Feeding Schedule
* for children < 6 months puffed rice powder (murmura) can be halved and oil can be increased to 1.5 tsf.
** precooked semolina (suji) or precooked porridge (dalia) or banana can also replace the puffed rice powder. In case of vegetarians, double the amount of semolina or porridge can replace puffed rice powder and egg white.
Table 6: Indications for shift from Low Lactose to Lactose Free Diet
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