1) Diarrhea can cause secondary lactase deficiency and lactose intolerance by damaging the intestinal mucosa. This reduces absorption of lactose from cow's milk and regular formula.
2) Studies show low lactose formula improves early weight gain and recovery in infants with acute diarrhea compared to regular formula. Low lactose formula also improves recovery of lactose tolerance after diarrhea resolves.
3) For infants and children with diarrhea, guidelines recommend continued breastfeeding and early refeeding with low lactose foods and formula instead of complete milk avoidance to support adequate nutrition and faster recovery.
2. Agenda
What is diarrhea and what are different types?
Intestinal mucosal damage and impact on nutrition
Secondary Lactase Deficiency during diarrhea
Nutritional interventions in diarrhea
3. Acute
watery
diarrhoea
• Severe fluid loss and rapid dehydration in infected
patients which last for few hours or days(<14days)
• Common etiologic pathogens: V. cholera, or E. coli,
and rotavirus
Bloody
diarrhoea
• Intestinal damage and nutrient losses in infected
patients with blood in the stools
• It is also termed as dysentery
• Common etiologic pathogen : Shigella bacteria
Persistent
diarrhoea
• Continuous episode of diarrhea, with or without
blood loss, lasting for a minimum of 14 days
• Commonly affected: Malnourished children and
those with illnesses such as AIDS
UNICEF/WHO. Diarrhoea: Why children are still dying and what can be done? WHO 2009
Diarrhea
Passage of unusually loose or watery stools at least 3 times in 24
hours; stool consistency rather than frequency is most important
for infants
C
L
A
S
S
I
F
I
C
A
T
I
O
N
4. Childhood diarrhea is a major public
health burden in India1
Diarrhea is third most common
cause of death in children under
five years of age in India2
1.Shah D, Choudhury P, Gupta P, et al. Promoting appropriate management of diarrhea: a systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and
child health, India. Indian Pediatr. 2012;49(8):627-49.
2. Bajait C, Thawani V. Role of zinc in pediatric diarrhea. Indian J Pharmacol. 2011 May;43(3):232-5.
3. International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005–06: India: Volume I. Chapter 9. Child health page
no 223-266
Highest incidence of 18%
among children between 6-11
months2
Approximately 13.8 % in
children between 12-23
months2
5. Rotavirus is the leading cause of severe
diarrhea in Indian children under five years1
15-30% of diarrheal episodes in
hospitalized children, 7-15% in
community infections are caused
due to rotavirus
Shigella infection accounts for 10-
20% of diarrheal episodes
Infection with Vibrio cholerae can
lead to cholera outbreaks and
commonly affected children are 2-
5 year of age
1. Shah D, Choudhury P, Gupta P, et al. Promoting appropriate management of diarrhea: a systematic review of literature for advocacy and action:
UNICEF-PHFI series on newborn and child health, India. Indian Pediatr. 2012;49(8):627-49.
2. Kahn G,Fitzwater S, Tate J et al. Epidemiology and Prospects for Prevention of Rotavirus Disease in India. Indian Pediatr 2012;49: 467-474
Most Rotaviral infection
occurs in children under 2
years of age2
Prevalence of rotavirus
diarrhea is high in neonates
(22%-73%), in India2
6. Vicious circle of diarrhoea-malnutrition
Infection
(viral, bacterial etc.)
Diarrhoea
Intestinal Mucosa damage
/ Villous atrophy
Nutrient Loss
(Macro & micro)
Malnutrition
Loss of fluid &
electrolytes
Decreased Immunity
Reduced Lactase enzyme
Secondary Lactose
Intolerance
7. Impact of diarrhea on nutritional
status
Increased metabolic needs1
Increased protein and nutrient loss1
Reduction in micronutrient levels (E.g. zinc and
copper1,2)
1. Guerrant RL, Oria RB, Moore SR et al. Malnutrition as an enteric infectious disease with long-term effects on child development. Nutr Rev. 2008;66(9):487-509
2. Zinc and copper wastage during acute diarrhea. Nutr Rev. 1990;48(1):19-22
8. Decreased nutrient absorption during
diarrheal episodes
Diarrheal episodes result in villous atrophy and intestinal epithelial cell
damage resulting in
Decrease in absorption of micronutrients1
Decrease in absorption of macronutrients1
1.DeBoer MD, Lima AA, Oría RB et al. Early childhood growth failure and the developmental origins of adult disease: do enteric infections and malnutrition increase risk
for the metabolic syndrome? Nutr Rev.2012;70(11):642-53.
9. Intestinal mucosal damage and its effect
on lactase secretion
Lactase enzyme is located in the internal lining (Brush border
(microvilli) of the small intestine (Enterocyte).1
Reduction in the surface area of the microvilli caused by
infections is associated with reduced levels of enzymes
(including lactase) that are vital for digestion and absorption of
sugars.2,3
1. Swagerty DL. Lactose Intolerance. Am Fam Physician. 2002 May 1;65(9):1845-1851.
2. Vesa TH, Marteau P, Korpela R, et al. Lactose Intolerance. J Am Coll Nutrition. 2000;19:165S–175S.
3. Mohammadi SS, Singer SM. Regulation of intestinal epithelial cell cytoskeletal remodeling by cellular immunity following gut infection. Mucosal
Immunology 2013; 6:369–378
4. Guidance on the management of lactose intolerance and cow’s milk protein allergy and the prescription of specialized infant formula. NHS
5. Evidence-Based Research in Pediatric Nutrition. edited by H. Szajewska, R. Shami World Review of Nutrition and Dietetics 2013. Karger Publications
Secondary lactose intolerance lasts for 6 to 8 weeks4
Lactase activity returns to normal following healing of
damaged epithelium5
10. Congenital
Type of lactase
deficiency
Definition Characteristics
Complete absence of
lactase from birth
• Very rare
There are several types of
lactase deficiency
Heymann MB for the Committee on Nutrition, American Academy of Pediatrics Lactose intolerance in infants, children and adolescents. Pediatrics 2006; 118(3):1279-86.
Primary
Decline in lactase
levels after birth to
clinical lactose
intolerance
Affects:
• 2% of adults in Northern Europe and North
America
• Nearly 100% of adults in Asia and American
Indian
• 60-80% of Africans and Ashkenazi Jew
• 50-80% of Latin Americans
Secondary
(transitory)
Temporary
deficiency resulting
from an injury of
the intestinal
mucosa
• Can follow gastrointestinal illness that
damages intestinal epithelial cells
• Young children with severe diarrhea are
at risk
• Up to 77% of children hospitalized with
acute diarrhea have lactose intolerance
11. Carbohydrate Intolerance in
Indian children with Acute Diarrhea
30.3
39.5
55.7
0
10
20
30
40
50
60
Incidence of
Carbohydrate intolerance
Well-
nourished
Under-
nourished
Marasmic
40.6% (110 infants) with
carbohydrate intolerance.
Incidence of carbohydrate
intolerance increased with
the degree of
malnourishment.
Percentageofinfants
1. Chandrasekaran R, Kumar V, Walia BN, Moorthy B. Carbohydrate intolerance in infants with acute diarrhoea and its complications. Acta Paediatr Scand. 1975
;64(3):483-8.
12. Secondary Lactose Intolerance in acute
diarrhea
0
0
0
1
1
1
14
6
90
Lactose-intolerant
Multiple Disaccharide
intolerance
Monosaccharide intolerance
Out of 110 infants with carbohydrate
intolerance, 90 infants had lactose intolerance.
Proportion of
carbohydrate
intolerant infants
Chandrasekaran R, Kumar V, Walia BN, Moorthy B. Carbohydrate intolerance in infants with acute diarrhoea and its complications. Acta Paediatr Scand. 1975 ;64(3):483-8.
14. Current Nutritional advices in Nutritional
Management of Diarrhea
• Breast feeding
• ORS
• Stop milk completely
• Low lactose diet (Curd
etc.)
• Banana
• Diluted cow’s
milk/formula
• Fruit Juice
• Glucose beverages
• Coconut water
• Khichdi (Rice Lentils)
• Lactose Free formula
15. • Early reintroduction of
feeds after acute
gastroenteritis risked
exacerbating the
illness, causing
protracted diarrhea
• Starvation for 24
hours or even longer
1. Murphy MS. Guidelines for managing acute gastroenteritis based on a systematic review of published research. Arch Dis Child. 1998;79(3):279-8
Early refeeding is
beneficial in
diarrhea
Early feeding helps in:
• Reducing the abnormal increase in intestinal permeability
• Enhancing enterocyte regeneration and promote recovery of
brush border membrane disaccharidases
Early Refeeding during diarrhea
16. ESPGHAN Recommendations on Early Refeeding
Children who require rehydration should continue to be
fed. Food should not be withdrawn for longer than 4 to 6
hours after the onset of rehydration.
Management of
feeding in
Gastroenteritis
1. Guarino A, Albano F, Ashkenazi S, et al; European Society for Paediatric Gastroenterology, Hepatology, and Nutrition; European Society for Paediatric Infectious
Diseases. European Society for Paediatric Gastroenterology, Hepatology, and Nutrition/European Society for Paediatric Infectious Diseases evidence-based guidelines for
the management of acute gastroenteritis in children in Europe. J Pediatr Gastroenterol Nutr. 2008 ;46 Suppl 2:S81-122
ESPHAGN: European Society of Paediatric Gastroenterology, Hepatology and Nutrition.
Early Refeeding during diarrhea
17. Role of milk in the diet of the child with
diarrhea
Milk is the main source of nutrients for the young child
According to UNICEF survey, ~29% of children were not eating anything
during diarrhea2
Limiting milk intake among young children can promote nutritional deficiency
if substitute sources of protein and energy are not consumed sufficiently1
1. Gaffey MF, Wazny K, Bassani DG, et al. Dietary management of childhood diarrhea in low- and middle-income countries: a systematic review. BMC Public Health.
2013;13 Suppl 3:S17.
2. Management Practices for Childhood Diarrhea in India. Survey of 10 districts. New Delhi: UNICEF; 2009
3. World Health Organization. Clinical management of acute diarrhea. Available at: http://www.childinfo.org/files/ENAcute_Diarrhoea_reprint.pdf accessed on 15 July
2014.
Decrease in diarrheal
frequency
Reduction in diarrheal
stool volume
Faster recovery from
diarrhea
Advantages of Breast-feeding during diarrhea3
World Health Organisation/UNICEF
Joint statement recommends
continued breastfeeding during
acute diarrhea in children3
18. Impact of High Lactose content (Cow’s
Milk/Regular Formula) in diarrhea
Infection1 Diarrhea
Damage to the
intestinal
mucosa
Secondary
transient lactase
deficiency
Regular Lactose
formula/Cow’s milk2,3
1. Heyman MB. Lactose intolerance in infants, children, and adolescents. Pediatrics 2006; 118: 1279 -1286
2. Penny ME, Paredes P, Brown KH. Clinical and nutritional consequences of lactose feeding during persistent postenteritis diarrhea. Pediatrics. 1989;84(5):835-44.
3. MacGillivray S, Fahey T, McGuire W. Lactose avoidance for young children with acute diarrhoea. Cochrane Database of Systematic Reviews. 2013, Issue 10. Art. No.: CD005433.
DOI: 10.1002/14651858.CD005433.pub2.
Undigested/unabsorbed
lactose
Osmotically Increased fluid
secretion in gut and gas in bowel
Altered bowel movements
(persitalsis)
19. Feeding Infants with Secondary Lactose-
Intolerance
A lactose restricted diet should be given during the period of secondary
lactose intolerance.
Lactase deficiency resolves once the diarrhoea gradually diminishes with
the disappearance of underlying inflammation.
Secondary lactase intolerance is transient
1. Tomar BS. Lactose Intolerance and Other Disaccharidase Deficiency. Ind J Peadiatrics. 2014 Mar 6. [Epub ahead of print]
20. Reviewing the current options
Breast Milk
The Gold Standard
• Provides important
immune factors
Diluted Cow’s
Milk/Regular formula
Not suitable for infants
with diarrhea
• Compromises adequate
nutrition to the baby
• High osmolality
Lactose Free
formula
Limited indications
• Very severe diarrhea and
hospitalized children
• If trial with Low Lactose fails
• Congenital/Primary Lactose
Intolerance
Curd
• Good source of reduced lactose content.
• Not suitable for as a sole source of
nutrition as infant with diarrhea may
depend predominantly on milk for their
nutritional needs.
22. Recovery of lactose tolerance
after acute diarrhea
% of infants able to tolerate lactose
after acute diarrhea
1. Gabr M, Maraghi S, Morsi S. Management of lactose intolerance secondary to acute diarrhea with a soy based formula. Clin Ther 1979;
2: 271-6.
23. Low Lactose Formula Improves Early Weight
Gain in Infants with Acute Diarrhea
Group A – Lactose free corn syrup formula
Group B - Low-lactose milk formula,
Group C – Standard formula
Efficacy of refeeding after rehydration in 135 infants with
gastroenteritis indicated that
1. Wall CR, Webster J, Quirk P, et al. The nutritional management of acute diarrhea in young infants: effect of carbohydrate ingested. J
Pediatr Gastroenterol Nutr. 1994;19(2):170-4.
24. Comparison of Four Feeding Regimens in Well
Nourished Infants with Acute Gastroenteritis (1/2)
Assessed for
a. Weight change among
the four treatment
groups at two and five
days
b. Duration of diarrhoea
c. Failure of treatment
Infants (aged 6 weeks to 12 months)
with acute gastroenteritis (n=200)
previously fed with formula
Group A – ORS followed by gradual standard cows' milk formula
Group B - A low lactose formula (followed by standard formula)
Group C – Standard formula
Group D - Soya based milk
1. Conway SP, Iresont A. Acute gastroenteritis in well nourished infants: comparison of four feeding regimens. Archives of Disease in Childhood 1989, 64, 87-91
25. Comparison of Four Feeding Regimens in Well Nourished
Infants with Acute Gastroenteritis (2/2)
Early Weight Gain with Low Lactose Formula
1. Conway SP, Iresont A. Acute gastroenteritis in well nourished infants: comparison of four feeding regimens. Archives of Disease in Childhood 1989, 64, 87-91
Weight gain (p=0.01)
Group A (ORS followed by standard formula) babies lost weight initially
Group B babies (Low Lactose formula) gained weight significantly during initial
days
There was no
significant difference
in the duration of
diarrhea or failure of
treatment between the
regimens.
26. Low Lactose diet in Persistent Diarrhea
A double-blind prospective trial, which included 64 children, (3-36 months of age) with diarrhoea for
at least 14 days compared the effects of a milk-based diet containing lactose or the same diet with
95% prehydrolysed lactose
Treatment failure due to excessive purging with or without refusal to accept the diet in
12.1% of children fed lactose containing diet vs. 3.2% in hydrolysed group (p=0.20)
A greater purge of a mean 74.4 g/kg per day in the lactose group vs. 42.0 g/kg per day in
the hydrolysed lactose group (p<0.01)
Stoppage of diarrhoea within 30 hours of hospital admission in 35.5% of children in the
hydrolysed lactose group vs. 3.3% of those in the lactose group (p<0.001)
Lactose containing milk formula caused greater
purging and an increased risk of dehydration in
children with persistent diarrhea.
1. Penny ME, Paredes P, Brown KH. Clinical and nutritional consequences of lactose feeding during persistent postenteritis diarrhea.
Pediatrics. 1989;84(5):835-44.
The study results indicated
27. Low Lactose diet in Persistent Diarrhea
1. Penny ME, Paredes P, Brown KH. Clinical and nutritional consequences of lactose feeding during persistent postenteritis diarrhea.
Pediatrics. 1989;84(5):835-44.
Fecal wet weight by dietary group and day of study for successfully treated boys
only.
28. IAP recommendations
Persistent Diarrhea:
• Low Osmolarity and Low Lactose diet are recommended for
children with persistent diarrhea.
• Children with persistent diarrhea, who continue to have
diarrhea on the low lactose diets, should be given lactose
(milk) free diets.
Severe Malnutrition (Hospital Based Management):
Start feeding as soon as possible with a diet, which has:
• Osmolarity less than < 350 mosm/L.
• Lactose not more than 2-3 g/kg/day.
29. High osmolality foods can aggravate
diarrhea
• Hyperosmolar foods include
– Cow’s milk
– Boiled skim milk
– Hypertonic (10 to 20%) glucose solution
– Tinned milk formulas (Regular/High
lactose content)
– Commercial glucose-electrolyte
solutions containing dextrose polymers
in high concentration (10%)
1. Hirschhorn N. The treatment of acute diarrhea in children An historical and physiological perspective. Am. J. Clin. Nutr. 1980;33: 637-663
30. Low osmolarity oral rehydration therapy
is recommended
Advantages: Decreased need for
unscheduled IV therapy, Less
stool output and lesser risk of
hypernatraemia and less
vomiting.1
Modified low osmolarity ORS has a
total osmolarity of 245 mmol/l and
reduced levels of glucose and sodium
(WHO, 2004).
1. Acute diarrhea in adults and children: a global perspective. World Gastroenterology Organization Global Guidelines, February 2012.
Constituents of low osmolarity ORS
solution1
ORS: oral rehydration salts, WHO: World Health Organization
31. Maltodextrin
A polysaccharide used in place of glucose in standard ORS
Compared to standard ORS,
maltodextrin when hydrolysed
may yield more glucose without
increasing intraluminal
osmolarity
The increased
glucose may
promote higher
absorption of
sodium and
water
May reduce
the stool
output
Glucose
• 20g/L; total osmolarity
311 mmol/L
Maltodextrin
• (30-80g/L; total
osmolarity about
230mmol/L)
Suggested
mechanis
m of
action
1. EB-Mougi M, Hendawi A, Koura H, et al. Efficacy of standard glucose-based and reduced osmolarity maltodextrin-based oral rehydration
solutions: Effect of sugar malabsorption. Bulletin of the World Health Organization. 1996;74(5): 471–477.
32. Medium Chain Triglycerides
• The WHO recommends feeding of fats or oils during
diarrhea:
– To enhance the nutrient density of foods
– To provide maximum energy when there is limited absorptive
capacity
• Medium-chain triglycerides can be used as a supportive
nutritional therapy as they:
– Increase the calorie value
– Improve the palatability, digestibility, absorption and transport of a
diet indicated for diseases with maldigestion/malabsorption
1. Tanchoco CC, Cruz AJ, Rogaccion JM, et al. Diet supplemented with MCT oil in the management of childhood diarrhea. Asia Pac J Clin Nutr. 2007;16
(2):286-292.
33. • Easily hydrolysed and rapidly absorbed
• Can be absorbed even before hydrolysis
• Do not enter the lymph system and they pass through the
portal venous system as albumin-bound free fatty acids
• Do not require lipoprotein lipase for oxidation as they are
incorporated into chylomicrons
Medium Chain Triglycerides (MCTs)
1. Tanchoco CC, Cruz AJ, Rogaccion JM, et al. Diet supplemented with MCT oil in the management of childhood diarrhea. Asia Pac J Clin Nutr. 2007;16
(2):286-292.
34. Clinical Evidence
MCT: Medium chain triglycerides
1. Tanchoco CC, Cruz AJ, Rogaccion JM, et al. Diet supplemented with MCT oil in the management of childhood diarrhea. Asia Pac J Clin Nutr. 2007;16
(2):286-292.
*3 tsp MCT oil equally divided and incorporated in
formula/daily meals given during the diahrreal episode.
• Higher rate of weight gain in MCT supplemented children (0.22 ± 0.22
kg/day) compared to the non-supplemented children (-0.048 ± .26
kg/day; p=0.042)
• Decreased trend towards reduction in the duration of intervention
• Safe; no vomiting, dehydration, or fat intolerance
• No increase in the serum cholesterol and triglyceride levels
Therapeutic effects and safety of MCT oil
supplementation* in children (aged 6 months
to 47 months, n=17) with diarrhea:
35. Zinc Supplementation
1. Khan WU, Sellen DW, University of Toronto, Toronto, Canada. April 2011. Zinc supplementation in the management of diarrhoea.Available at:
http://www.who.int/elena/titles/bbc/zinc_diarrhoea/en/ Accessed on: 03 Apr 2014.
2. Galvao TF, Thees MFRS, Pontes RF, et al. Zinc supplementation for treating diarrhea in children: a systematic review and meta-analysis. Rev Panam Salud Publica.
2013;33(5):372–377.
Zinc aids in protein synthesis, cell growth and
differentiation, immune function, and intestinal transport
of water and electrolytes.1
Zinc supplementation along with ORS has
shown:1
Reduction in the duration and severity of diarrheal
episodes
Reduction in the possibility of subsequent infections
over 2–3 months
A 2013 systematic review and metaanalysis of 18 randomized
clinical trials has also confirmed that oral zinc supplementation in
children <5 years significantly reduces duration of the diarrhea.
This effect is more prominent in malnourished children.2
36. Mechanism of Action of Zinc
Inhibits cAMP-induced, chloride-dependent fluid secretion
by obstructing basolateral potassium channels
Enhances the absorption of water and electrolytes
Improves restoration of the intestinal epithelium and boosts
the levels of brush border enzymes
Enhances the immune response and thereby promotes
better clearance of the pathogens
1. Baiait C, Thawani V. Role of zinc in pediatric diarrhea. Indian J Pharmacol. 2011;43(3):232–235.
37. Based on the WHO/UNICEF/IAP
recommendations, Government of India
recommends:1
• Supplementation to be started as soon
as diarrhea starts
• Children >6 months: 20 mg/day of
elemental zinc for 14 days
• Children aged 2-6 months: 10 mg/day
of elemental zinc for 14 days
1. Shah D, Choudhury P, Gupta P, et al. Promoting appropriate management of diarrhea: a systematic review of literature for advocacy and action: UNICEF-PHFI series on
newborn and child health, India. Indian Pediatr. 2012;49(8):627-49 7
Recommendation by Government of India
38. Nucleotides
• Non-protein nitrogenous compounds1
• Supports Immunity: Increased Serum IgA
concentrations
• Favourable effects on the fecal microbial
composition (increase in bifidobacteria)1
• Exert trophic effect on GI epithelium3
1. Singhal A, Macfarlane G, Macfarlane S, et al. Dietary nucleotides and fecal microbiota in formula-fed infants: a randomized controlled trial. Am J Clin
Nutr. 2008 ;87(6):1785-92.
2. Yau KI, Huang CB, Chen W, et al. Effect of nucleotides on diarrhea and immune responses in healthy term infants in Taiwan. J Pediatr Gastroenterol Nutr.
2003;36(1):37-43.
3. http://www.ncbi.nlm.nih.gov/books/NBK54100/
Nucleotide supplementation has beneficial effects on
the growth of the intestinal epithelium.3
39. Summary and Conclusion
In India, childhood diarrhea accounts for third most common
cause of death in under five age group
Diarrhea results in villous atrophy and decreased absorption of
micro-and macro-nutrients. The lactase-containing epithelial
cells may be lost , leading to secondary lactase deficiency.
There is increased nutritional requirement during diarrheal
episode and energy dense foods are recommended.
Presence of lactose intolerance can lead to prolongation of
diarrhea and milk containing products may worsen diarrhea.
40. Summary and Conclusion
Use of a low lactose diet enables milk consumption even during
diarrhea which constitutes a major portion of an Infant’s diet.
Lactose free formulations should be reserved for severe lactose
intolerance where the trial with low lactose diet has failed
Use of Zinc, Medium-chain triglycerides (MCTs), Maltodextrins
and Nucleotides along with early refeeding is a novel approach
in the nutritional management of diarrhea.
Diarrhoea is defined as the passage of unusually loose or watery stools at least 3 times in 24 hours; stool consistency rather than frequency is most important for infants
There are three main types of childhood diarrhea, which are potentially life-threatening and require different treatment modalities.
Acute watery diarrhoea: It is associated with severe fluid loss and rapid dehydration in the infected patients. It lasts for several hours or days. The most common pathogens involved in the etiology of acute watery diarrhoea include V.cholera, E.coli and rotavirus.
Bloody diarrhoea: It is characterized by visible blood loss in stools and is termed as dysentery. It leads to intestinal damage and nutrient losses in infected patients. The most common etiologic pathogen involved in causation of blood diarrhoea includes Shigella bacteria
Persistent diarrhoea- It is a continuous episode of diarrhoea, with or without blood loss and which lasts for at least 14 days. Malnourished children and those with illnesses such as AIDS are commonly affected with this type of diarrhoea. Their condition is further worsened by diarrhoea.
Reference
UNICEF/WHO. Diarrhoea: Why children are still dying and what can be done? WHO 2009
It has been observed that one out of every five children who die out of diarrhoea worldwide is an Indian1
In India, nearly 41 children lose their lives every single hour due to diarrhoea.1
Diarrhoea is one of the top five causes of death in infants and children belonging to under five age group. According to Sample Registration System (SRS) Report (2009) on causes of death (2001-2003), diarrhea is the third most common cause of death in under-five children and accounts for 14% deaths i,e 0.24 million deaths in this age group. It is the the leading causes of childhood deaths beyond infancy. Diarrhoeal diseases are responsible for 24% of deaths in children aged 1-4 years and 17% of deaths in children belonging to 5-14 years age group. Across all the surveys, infants aged 6-12 months were at increased risk of developing diarrhea.
Reference
Bajait C, Thawani V. Role of zinc in pediatric diarrhea. Indian J Pharmacol. 2011 May;43(3):232-5.
Shah D, Choudhury P, Gupta P, et al. Promoting appropriate management of diarrhea: a systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and child health, India. Indian Pediatr. 2012;49(8):627-49.
Diarrhea, the third leading killer of children in India today, is responsible for 13% of all deaths in children <5 years of age and kills an estimated 300,000 children in India each year [1]. Rotavirus is the leading cause of severe diarrhea in Indian children under 5, and has been projected to cause 457,000 to 884,000 hospitalizations, 2,000,000 outpatient visits, and 122,000-153,000 deaths annually. Most Rotaviral infection occurs in children under 2 years of age2. Prevalence of rotavirus diarrhoea is high in neonates (22%-73%), in India2
• 15-30% of diarrhoeal episodes in hospitalized children; 7-15% in community infections are caused due to rotavirus infection. Almost all episodes of rotaviral diarrhoea leading to hospitalization are reported in children < 2 years.
It is also the most commonly isolated agent in neonatal infections.
• Diarrheogenic E. coli is the most common bacterial pathogen.
• Shigella spp. is responsible for about 10-20% of episodes. Visible blood is present in stools in half
to two-thirds of these episodes.
• Vibrio cholerae predominantly occurs in outbreaks. Most affected children are 2-5 yr old.
References
1.Shah D, Choudhury P, Gupta P, et al. Promoting appropriate management of diarrhea: a systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and child health, India. Indian Pediatr. 2012;49(8):627-49.
2.Kahn G,Fitzwater S, Tate J et al. Epidemiology and Prospects for Prevention of Rotavirus Disease in India. Indian Pediatr 2012;49: 467-474
Malnutrition and repeated enteric infections reduce nutrient availability due to intestinal malabsorption, increased metabolic needs, increased losses , and disturbed nutrient uptake and transport. These effects are additionally influenced by intestinal host pathogen interactions
Reference
Guerrant RL, Oria RB, Moore SR et al. Malnutrition as an enteric infectious disease with long-term effects on child development. Nutr Rev. 2008 ;66(9):487-505.
Zinc and copper wastage during acute diarrhea. Nutr Rev. 1990;48(1):19-22
Diarrhoeal episodes are associated with atrophy of the villi. The villi are blunted, crypts deepened and there is increased inflammation of the lamina propria during these episodes. These changes in the gut epithelium leads to decreased absorption of macronutrients and micronutrients.1 Lactase enzyme deficiency can also occur resulting in secondary lactose intolerance. Acute infection causing small intestinal injury with loss of the lactase-containing epithelial cells from the tips of the villi leads to secondary lactase deficiency.2
References
1.DeBoer MD, Lima AA, Oría RB et al. Early childhood growth failure and the developmental origins of adult disease: do enteric infections and malnutrition increase risk for the metabolic syndrome? Nutr Rev.2012;70(11):642-53.
2. Heyman MB. Lactose intolerance in infants, children, and adolescents. Pediatrics. 2006;118(3):1279-86
Lactase activity is detectable in humans as early as eight weeks' gestation in fetal gut.2
The secretion of this enzyme is affected by intestinal diseases that cause cell damage. A reduction in the surface area of the microvilli which are a result of infections are directly linked to reduced levels of enzymes including lactase that is vital for digestion and absorption of sugars.3,4
References
Swagerty DL. Lactose Intolerance. Am Fam Physician. 2002 May 1;65(9):1845-1851.
Weaver LT, Laker MF. Neonatal intestinal lactase activity. Archives of Disease in Childhood 1986: 61: 896-899
Vesa TH, Marteau P, Korpela R, et al. Lactose Intolerance. J Am Coll Nutrition. 2000;19:165S–175S.
Mohammadi SS, Singer SM. Regulation of intestinal epithelial cell cytoskeletal remodeling by cellular immunity following gut infection. Mucosal Immunology 2013; 6:369–378
Let us discuss the return of lactase activity following healing of epithelium.
It is widely known that secondary lactose intolerance lasts for about 6 to 8 weeks.1
The lactase activity returns to normal following healing of damaged epithelium2
References
Guidance on the management of lactose intolerance and cow’s milk protein allergy and the prescription of specialized infant formula. NHS
Evidence-Based Research in Pediatric Nutrition. edited by H. Szajewska, R. Shami World Review of Nutrition and Dietetics 2013. Karger Publications
The study results showed that a large proportion of children with acute diarrhoea have carbohydrate intolerance.
About 40.6% (110 infants) had carbohydrate intolerance. The incidence of carbohydrate intolerance increased with the degree of malnourishment. Incidence of carbohydrate intolerance was higher in the severely dehydrated infants (83.3% vs. 22.7% in the mildly dehydrated group)
Reference:
Chandrasekaran R, Kumar V, Walia BN, Moorthy B. Carbohydrate intolerance in infants with acute diarrhoea and its complications. Acta Paediatr Scand. 1975 ;64(3):483-8.
The study findings indicated that a large proportion of children with acute diarrhoea and carbohydrate intolerance have secondary mild lactose intolerance. Of the 110 infants with carbohydrate intolerance, 90 infants had lactose intolerance. 74/90 infants had mild lactose intolerance.
Reference
Chandrasekaran R, Kumar V, Walia BN, Moorthy B. Carbohydrate intolerance in infants with acute diarrhoea and its complications. Acta Paediatr Scand. 1975 ;64(3):483-8.
Let us look at the importance of early refeeding. In the early years it was considered that early reintroduction of feeds after acute gastroenteritis risked exacerbating the illness, causing protracted diarrhea. Children were routinely starved for 24 hours or even longer. It has been established now that early refeeding is beneficial in diarrhea.
Early refeeding helps in:
Reducing the abnormal increase in intestinal permeability
Enhancing enterocyte regeneration and promote recovery of brush border membrane disaccharidases
References
1. Murphy MS. Guidelines for managing acute gastroenteritis based on a systematic review of published research. Arch Dis Child. 1998;79(3):279-284.
The European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPHAGN) recommends that children who require rehydration should continue to be fed. Food should not be withdrawn for longer than 4 to 6 hours after the onset of rehydration. The ESPHAGAN recommends that breastfed children should continue rehydration and maintenance phases and non-breast fed children should be rehydrated for 4 hours and then normal diet should be recommenced.
Reference
1. Guarino A, Albano F, Ashkenazi S, et al; European Society for Paediatric Gastroenterology, Hepatology, and Nutrition; European Society for Paediatric Infectious Diseases. European Society for Paediatric Gastroenterology, Hepatology, and Nutrition/European Society for Paediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe. J Pediatr Gastroenterol Nutr. 2008 ;46 Suppl 2:S81-122
Milk is the main source of nutrients for the young child. Limiting milk intake among young children can promote nutritional deficiency if substitute sources of protein and energy are not consumed sufficiently1
Individual components of milk from humans and other mammalian species may influence the severity, duration, and nutritional outcome of childhood diarrhea in different ways. The beneficial effects that of breast-milk outweigh any negative effects that may result due to the presence of lactose.
Breast-milk although contains lactose has been shown to help decrease the frequency of diarrhea and reduces diarrhoeal stool volume. Breast-feeding during diarrhoea also helps in faster recovery from the infection.2
Even after infection has set in breast milk contain various component that help fight off the infection. It contains Oligosaccharides that promote the growth of beneficial microflora in the gut3. It also contains bacterial components derived from the mother that influence the infant's developing immune system4 Breast milk contains factors that stimulate infants immune system3 It also contains anti-infective agents such as secretory immunoglobulin A (sIgA), immunoglobulin G, immunoglobulin M, lactoferrin, fibronectin, leukocytes, lysozyme, lactoperoxidase and other enzymes that prevent aspects of infective action such as microbial adhesion, colonization, multiplication etc3
References:
. Gaffey MF, Wazny K, Bassani DG, et al. Dietary management of childhood diarrhea in low- and middle-income countries: a systematic review. BMC Public Health. 2013;13 Suppl 3:S17.
Khin MU, Nyunt-Nyunt-Wai, Myo-Khin, et al. Effect on clinical outcome of breast feeding during acute diarrhoea. Br Med J (Clin Res Ed). 1985 ;290(6468):587-9
Joneja JM. Breast Milk: A vital defense against infection. Can Fam Physician. 1992 ;38:1849-55.
Thomas DW, Greer FR; American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition. Probiotics and prebiotics in pediatrics. Pediatrics. 2010 ;126(6):1217-31
Now let us see what will happen to the vicious cycle of diarrhoea in the presence of lactose feeding in infants.
Acute infection causes small intestinal injury which has already been shown to cause loss of the lactase-containing epithelial cells from the tips of the villi.
This loss of villi cells leads to secondary lactose deficiency and consequently to lactose malabsorption.
Feeding lactose containing formula at this stage further aggravates diarrhoea as the lactose cannot be digested and causes a substantial rise in fluid and gas in the bowel.1-3
References
Heyman MB. Lactose intolerance in infants, children, and adolescents. Pediatrics 2006; 118: 1279 -1286
Penny ME, Paredes P, Brown KH. Clinical and nutritional consequences of lactose feeding during persistent postenteritis diarrhea. Pediatrics. 1989;84(5):835-44.
MacGillivray S, Fahey T, McGuire W. Lactose avoidance for young children with acute diarrhoea. Cochrane Database of Systematic Reviews. 2013, Issue 10. Art. No.: CD005433. DOI: 10.1002/14651858.CD005433.pub2.
Secondary lactase intolerance is transient and the lactase deficiency resolves once the diarrhoea gradually diminishes with the disappearance of underlying inflammation.
A lactose restricted diet should be given during the period of secondary lactose intolerance.
Reference
Tomar BS. Lactose Intolerance and Other Disaccharidase Deficiency. Ind J Peadiatrics. 2014 Mar 6. [Epub ahead of print]
A study by Conway et al. assessed the effects of rapid refeeding with either a standard cows' milk formula feed (SMA Gold Cap), a low lactose formula (HN25), or a soya based milk (Formula S) with a period of fasting followed by a gradual reintroduction of full strength feeds, in the treatment of acute gastroenteritis in well nourished infants. The study included two hundred well hydrated babies of 6 weeks to 12 months of age who had been fed on formula feeds and who were admitted with acute gastroenteritis. They were randomly allocated to receive either a standard return to full milk feeds, or immediate full strength feeds with one of three milk formulas: HN25, SMA Gold Cap or Formula S.
The infants were assessed for weight change among the four treatment groups at two and five days, duration of diarrhoea and failure of treatment.
Reference
Conway SP, Iresont A. Acute gastroenteritis in well nourished infants: comparison of four feeding regimens. Archives of Disease in Childhood 1989, 64, 87-91
Let us now look at clinical evidence of feeding lactose during diarrhoea in young children.
In a double-blind prospective trial, which included 64 children, of 3-36 months of age with diarrhoea for at least 14 days who were randomly assigned to receive either a milk-based diet containing lactose or the same diet with 95% prehydrolysed lactose, it was found that
Treatment failure due to excessive purging with or without refusal to accept the diet occurred in 12.1% of children who were fed lactose containing feed compared to 3.2% in hydrolysed group
A greater purge of a mean 74.4 g/kg per day in the lactose group vs. 42.0 g/kg per day in the hydrolysed lactose group (p<0.01)
Stoppage of diarrhoea within 30 hours of hospital admission in 35.5% of children in the hydrolysed lactose group vs. 3.3% of those in the lactose group (p<0.001).
The study findings thus indicate that lactose containing human milk formula caused greater purging and increased the risk of dehydration in children who suffered from persistent diarrhoea.
Reference
Penny ME, Paredes P, Brown KH. Clinical and nutritional consequences of lactose feeding during persistent postenteritis diarrhea. Pediatrics. 1989;84(5):835-44.
Let us now look at clinical evidence of feeding lactose during diarrhoea in young children.
In a double-blind prospective trial, which included 64 children, of 3-36 months of age with diarrhoea for at least 14 days who were randomly assigned to receive either a milk-based diet containing lactose or the same diet with 95% prehydrolysed lactose, it was found that
Treatment failure due to excessive purging with or without refusal to accept the diet occurred in 12.1% of children who were fed lactose containing feed compared to 3.2% in hydrolysed group
A greater purge of a mean 74.4 g/kg per day in the lactose group vs. 42.0 g/kg per day in the hydrolysed lactose group (p<0.01)
Stoppage of diarrhoea within 30 hours of hospital admission in 35.5% of children in the hydrolysed lactose group vs. 3.3% of those in the lactose group (p<0.001).
The study findings thus indicate that lactose containing human milk formula caused greater purging and increased the risk of dehydration in children who suffered from persistent diarrhoea.
Reference
Penny ME, Paredes P, Brown KH. Clinical and nutritional consequences of lactose feeding during persistent postenteritis diarrhea. Pediatrics. 1989;84(5):835-44.
Based on these, this is what iap recommends
Hyperosmolar foods causes hypernatraemia that can aggravate diarrhoea.
High osmolality foods that can aggravate diarrhoea include
Cow’s milk
Boiled skim milk
Hypertonic (10 to 20%) glucose solution
Tinned milk formulas
Commercial glucose-electrolyte solutions containing dextrose polymers in high concentration (10%)
Reference
Hirschhorn N. The treatment of acute diarrhea in children An historical and physiological perspective. Am. J. Clin. Nutr. 1980;33: 637-663
Let us look at the benefits of low osmolarity oral rehydration therapy.
Modified low osmolarity ORS has a total osmolarity of 245 mmol/l and reduced levels of glucose and sodium which was introduced by WHO in 2004.
Constituents of low osmolarity solution include1
Sodium 75 mmol/L
Chloride 65 mmol/L
Anhydrous glucose 75 mmol/L
Potassium 20 mmol/L
Trisodium citrate 10 mmol/L
Total osmolarity 245 mmol/L.
Advantages include decreased need for unscheduled IV therapy, less stool output and lesser risk of hypernatraemia and less vomiting compared to standard ORS.1
References
Acute diarrhea in adults and children: a global perspective. World Gastroenterology Organisation Global Guidelines, February 2012.
Maltodextrin has also been used to lower the osmolarity of the ORS. Maltodextrin is a polysaccharide which can be used in place of glucose in standard ORS. Glucose at 20g/L has a total osmolarity of 311mmol/L whereas maltodextrin at 30-80g/L has a total osmolarity about 230mmol/L. It is suggested that when hydrolysed maltodextrin may yield more glucose than what is provided by standard ORS without increasing intra luminal osmolarity. The increased glucose may promote higher absorption of sodium and water and may reduce the stool output.
Reference
1. EB-Mougi M, Hendawi A, Koura H, et al. Efficacy of standard glucose-based and reduced osmolarity maltodextrin-based oral rehydration solutions: Effect of sugar malabsorption. Bulletin of the World Health Organization. 1996;74(5): 471–477.
Let me take you through some of the novel nutrients used in the management of diarrhoea.
According to WHO recommendation with regard to feeding infants during diarrhea, it is advised that fats or oils be given to these infants to enhance the nutrient density of foods.
Fats offer concentrated form of energy that theoretically may prove to be advantageous in diarrhoea as it may provide maximum energy when there is limited absorptive capacity
Medium-chain triglycerides (MCT) are one such fat-based special-purpose food that can be used as a supportive nutritional therapy as it:
increases the calorie value
Improves the palatability, digestibility, absorption and transport of a diet indicated for diseases with maldigestion/malabsorption
Reference
1. Tanchoco CC, Cruz AJ, Rogaccion JM, et al. Diet supplemented with MCT oil in the management of childhood diarrhea. Asia Pac J
Clin Nutr. 2007;16 (2):286–292.
Let us go through the advantages of using medium chain triglycerides(MCTs) rather than long chain triglycerides (LCTs). The rationale for the use of MCT is mainly based on the differences between the digestion, absorption, transport and catabolism of MCT and LCTs.
MCTs are easily hydrolysed by pancreatic lipase and thus more rapidly absorbed than conventional fats. In fact, MCTs can be absorbed even before hydrolysis.
Absorption of MCTs does not require formation of bile salts or micelles and they are more rapidly transported across mucosal cells compared to LCTs.
MCTs do not enter the lymph system and they pass through the portal venous system as albumin-bound free fatty acids.
MCTs do not require lipoprotein lipase for oxidation as they are incorporated into chylomicrons.
When we translate these benefits to clinical use, there is no additional penalty imposed on the intestinal anatomy or physiology which is already disturbed due to diarrhoea since absorption is rapid with MCTs.
Reference
1. Tanchoco CC, Cruz AJ, Rogaccion JM, et al. Diet supplemented with MCT oil in the management of childhood diarrhea. Asia Pac J
Clin Nutr. 2007;16 (2):286-292.
A clinical trial compared the therapeutic effects and safety of MCT-supplemented and non-MCT supplemented diets in children with diarrhoea. Seventeen hospitalised infants aged 6 months to 47 months with diahrrhoea participated in the study. Three teaspoon of MCT oil equally divided and incorporated in formula/daily meals was given during the diahrroeal episode. The trial concluded that MCT supplementation resulted in weight gain among children, higher rate of weight gain was observed in MCT supplemented children (0.22 ± 0.22 kg/day) compared to the non-supplemented children (-0.048 ± .26 kg/day; p=0.042). The study also reported decreased trend towards reduction in the duration of intervention, was safe and did not cause vomiting, dehydration, or fat intolerance. The supplementation did not elevate the serum cholesterol and triglyceride levels.
Reference
1. Tanchoco CC, Cruz AJ, Rogaccion JM, et al. Diet supplemented with MCT oil in the management of childhood diarrhea. Asia Pac J
Clin Nutr. 2007;16 (2):286-292.
Zinc aids in protein synthesis, cell growth and differentiation, immune function, and intestinal transport of water and electrolytes.1
Supplementation along with ORS has shown to reduce the duration and severity of diarrheal episodes and possibility of subsequent infections over 2–3 months.1
References
Khan WU, Sellen DW, University of Toronto, Toronto, Canada. April 2011. Zinc supplementation in the management of diarrhoea.Available at: http://www.who.int/elena/titles/bbc/zinc_diarrhoea/en/ Accessed on: 03 Apr 2014.
Galvao TF, Thees MFRS, Pontes RF, et al. Zinc supplementation for treating diarrhea in children: a systematic review and meta-analysis. Rev Panam Salud Publica. 2013;33(5):372–377.
The exact physiological role of zinc on intestinal ion transport has not been confirmed yet. However, animal studies have demonstrated that zinc inhibits cAMP-induced, chloride-dependent fluid secretion by inhibiting basolateral potassium channels. Zinc also enhances the absorption of water and electrolytes, improves restoration of the intestinal epithelium, boosts the levels of brush border enzymes, and enhances the immune response, and thereby promotes better clearance of the pathogens.
References
1. Baiait C, Thawani V. Role of zinc in pediatric diarrhea. Indian J Pharmacol. 2011;43(3):232–235.
Based on the WHO/UNICEF/IAP recommendations, Government of India recommends:1
Supplementation needs to be started as soon as diarrhea starts
Children older than 6 months: 20 mg of elemental zinc for 14 days.
Children aged 2-6 months: 10 mg per day of elemental zinc for 14 days.
Reference
Shah D, Choudhury P, Gupta P, et al. Promoting appropriate management of diarrhea: a systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and child health, India. Indian Pediatr. 2012;49(8):627-497.
Dietary nucleotides are nonprotein nitrogenous compounds that are thought to be important for growth, repair, and differentiation of the gastrointestinal tract.1
Potential mechanisms of reducing diarrheal incidence:
Influence on immunologic maturation and increased resistance to enteric pathogens.2
Favorable effects on the fecal microbial composition such as increase in bifidbacteri.1
Regulate GI mucosal growth and development3
Nucleotide supplementation has beneficial effects on the growth of the intestinal epithelium.3
References
Singhal A, Macfarlane G, Macfarlane S, et al. Dietary nucleotides and fecal microbiota in formula-fed infants: a randomized controlled trial. Am J Clin Nutr. 2008 ;87(6):1785-92.
Yau KI, Huang CB, Chen W, et al. Effect of nucleotides on diarrhea and immune responses in healthy term infants in Taiwan. J Pediatr Gastroenterol Nutr. 2003;36(1):37-43.
Rao JN, Wang JY. San Rafael (CA): Morgan & Claypool Life Sciences; 2010. Available at: http://www.ncbi.nlm.nih.gov/books/NBK54100/
Accessed on 15th July, 2014.