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Persistent Diarrhea
Nutritional care
Cape Town Sept-Oct 2015
GOES
Basic physiology
Fluids handling in the GIT
bull Small intestine ndash 8-9 liter pass through the Treitzligament
bull 2 liters from intake
bull 7 liters of GIT secretions
bull Large intestine ndash 1 lit fluids reach the ICV
bull Rectum ndash 200 gr are excreted in stool
Basic physiology
bull Stool volume is dependent on fluid content
ndash Water and electrolytes absorption
ndash Fluids secretion
ndash Gut motility
Enterocyte intracellular signalling leading to intestinal secretion
cAMP cGMPCa
cytoskeleton
Basic physiology
Regulation of fluid and electrolytes transport is under the control of regulatory mechanisms
bull Entero-endocrine system
bull ENS
bull Gut flora
bull Gut Immune system
Millennium Development
Goal 4 and 5 by 2015
127 million deaths in 1990 to 63 million in 2013
Definitions acute and chronic or persistent diarrhea
bull WHO ldquopassage of loose or watery stools at least three times in a 24 h periodrdquo
bull ESPGHANESPID a decrease in the consistency of stools (loose or liquid) andor an increase in the frequency of evacuations
ndash Acute diarrheas abrupt onset resolve within 14 days and are mostly caused by infections
ndash Persistent diarrhea episode of diarrhea lasting 14 days or longer (WHO)ndash Chronic diarrhea diarrhea lasting more than 14-30 daysndash Other chronic diarrheas mainly due to congenital defects of digestion
and absorption
Prevalence
bull PD in developed countries bull Prevalence 3-5 or even less
bull Major causes celiac disease food allergy diet induced IBDentericinfections different disorders
bull PD in developing countries bull Prevalence 5-25
bull Major causes serial enteric infections associated with malabsorption malnutrition micronutrients deficiency and immunodeficiency
Persistent diarrhea in developing countries
Infectious disease
Lactose intolerance
Malnutrition
Delayed intestinal mucosa recovery
Bacterial overgrowth
Chronic entropathy
ImmunedeficiencyHIV
Micronutrientdeficiencies
AnorexiaFood withdrawal
Dietarysensitisation
PD = Environmental Enteropathy
bull PD EE a condition characterized by morphologic changes in the gut of inhabitants of developing countries
bull EE is characterized by ndash Intestinal inflammation
ndash Partial villous atrophy
ndash Epithelial cell degenerative changes
bull Functional disturbances in EE includendash Reduced absorption
ndash Increased turnover of intestinal cells
ndash Increased mucosal permeability
ndash Generalized activation of the innate and adaptive immune system
Environmental Enteropathy
Young (less than 6 months)MalnutritionMale genderFeeding practice Micronutrient deficienciesDiarrheal severityChronic diseasesImmunodeficiency HIVAIDS
Selected etiologic agentsUse of antibiotics for AGESocioeconomic status Young mothers
PROLONGED PERSISTENTDIARRHEA
Risk factors for persistent prolonged diarrhea
Araya M et al Acta Paediatr Scand 1991Catassi C et al Pediatr Gastroenterol Nutr 1999
Persistent diarrhea socio-demographic and clinical profile of 264 children seen at
a referral hospital in Addis Ababa
bull 5762 children with all forms of diarrhea 264 (5) had PD
bull PD children characteristics
ndash 83 were below 18 months of age
ndash The peak occurrence was between the ages of 7 to 12 months
ndash 86 had associated malnutrition
ndash 83 lt 4 months were either fully or partially weaned
ndash Watery diarrhea with no dehydration was the main feature
ndash 7 of the patients had dysentery
ndash Average family income was low but literacy level seem to have had no effect
Ethiop Med J 1997 Jul35(3)161-8
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Basic physiology
Fluids handling in the GIT
bull Small intestine ndash 8-9 liter pass through the Treitzligament
bull 2 liters from intake
bull 7 liters of GIT secretions
bull Large intestine ndash 1 lit fluids reach the ICV
bull Rectum ndash 200 gr are excreted in stool
Basic physiology
bull Stool volume is dependent on fluid content
ndash Water and electrolytes absorption
ndash Fluids secretion
ndash Gut motility
Enterocyte intracellular signalling leading to intestinal secretion
cAMP cGMPCa
cytoskeleton
Basic physiology
Regulation of fluid and electrolytes transport is under the control of regulatory mechanisms
bull Entero-endocrine system
bull ENS
bull Gut flora
bull Gut Immune system
Millennium Development
Goal 4 and 5 by 2015
127 million deaths in 1990 to 63 million in 2013
Definitions acute and chronic or persistent diarrhea
bull WHO ldquopassage of loose or watery stools at least three times in a 24 h periodrdquo
bull ESPGHANESPID a decrease in the consistency of stools (loose or liquid) andor an increase in the frequency of evacuations
ndash Acute diarrheas abrupt onset resolve within 14 days and are mostly caused by infections
ndash Persistent diarrhea episode of diarrhea lasting 14 days or longer (WHO)ndash Chronic diarrhea diarrhea lasting more than 14-30 daysndash Other chronic diarrheas mainly due to congenital defects of digestion
and absorption
Prevalence
bull PD in developed countries bull Prevalence 3-5 or even less
bull Major causes celiac disease food allergy diet induced IBDentericinfections different disorders
bull PD in developing countries bull Prevalence 5-25
bull Major causes serial enteric infections associated with malabsorption malnutrition micronutrients deficiency and immunodeficiency
Persistent diarrhea in developing countries
Infectious disease
Lactose intolerance
Malnutrition
Delayed intestinal mucosa recovery
Bacterial overgrowth
Chronic entropathy
ImmunedeficiencyHIV
Micronutrientdeficiencies
AnorexiaFood withdrawal
Dietarysensitisation
PD = Environmental Enteropathy
bull PD EE a condition characterized by morphologic changes in the gut of inhabitants of developing countries
bull EE is characterized by ndash Intestinal inflammation
ndash Partial villous atrophy
ndash Epithelial cell degenerative changes
bull Functional disturbances in EE includendash Reduced absorption
ndash Increased turnover of intestinal cells
ndash Increased mucosal permeability
ndash Generalized activation of the innate and adaptive immune system
Environmental Enteropathy
Young (less than 6 months)MalnutritionMale genderFeeding practice Micronutrient deficienciesDiarrheal severityChronic diseasesImmunodeficiency HIVAIDS
Selected etiologic agentsUse of antibiotics for AGESocioeconomic status Young mothers
PROLONGED PERSISTENTDIARRHEA
Risk factors for persistent prolonged diarrhea
Araya M et al Acta Paediatr Scand 1991Catassi C et al Pediatr Gastroenterol Nutr 1999
Persistent diarrhea socio-demographic and clinical profile of 264 children seen at
a referral hospital in Addis Ababa
bull 5762 children with all forms of diarrhea 264 (5) had PD
bull PD children characteristics
ndash 83 were below 18 months of age
ndash The peak occurrence was between the ages of 7 to 12 months
ndash 86 had associated malnutrition
ndash 83 lt 4 months were either fully or partially weaned
ndash Watery diarrhea with no dehydration was the main feature
ndash 7 of the patients had dysentery
ndash Average family income was low but literacy level seem to have had no effect
Ethiop Med J 1997 Jul35(3)161-8
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Basic physiology
bull Stool volume is dependent on fluid content
ndash Water and electrolytes absorption
ndash Fluids secretion
ndash Gut motility
Enterocyte intracellular signalling leading to intestinal secretion
cAMP cGMPCa
cytoskeleton
Basic physiology
Regulation of fluid and electrolytes transport is under the control of regulatory mechanisms
bull Entero-endocrine system
bull ENS
bull Gut flora
bull Gut Immune system
Millennium Development
Goal 4 and 5 by 2015
127 million deaths in 1990 to 63 million in 2013
Definitions acute and chronic or persistent diarrhea
bull WHO ldquopassage of loose or watery stools at least three times in a 24 h periodrdquo
bull ESPGHANESPID a decrease in the consistency of stools (loose or liquid) andor an increase in the frequency of evacuations
ndash Acute diarrheas abrupt onset resolve within 14 days and are mostly caused by infections
ndash Persistent diarrhea episode of diarrhea lasting 14 days or longer (WHO)ndash Chronic diarrhea diarrhea lasting more than 14-30 daysndash Other chronic diarrheas mainly due to congenital defects of digestion
and absorption
Prevalence
bull PD in developed countries bull Prevalence 3-5 or even less
bull Major causes celiac disease food allergy diet induced IBDentericinfections different disorders
bull PD in developing countries bull Prevalence 5-25
bull Major causes serial enteric infections associated with malabsorption malnutrition micronutrients deficiency and immunodeficiency
Persistent diarrhea in developing countries
Infectious disease
Lactose intolerance
Malnutrition
Delayed intestinal mucosa recovery
Bacterial overgrowth
Chronic entropathy
ImmunedeficiencyHIV
Micronutrientdeficiencies
AnorexiaFood withdrawal
Dietarysensitisation
PD = Environmental Enteropathy
bull PD EE a condition characterized by morphologic changes in the gut of inhabitants of developing countries
bull EE is characterized by ndash Intestinal inflammation
ndash Partial villous atrophy
ndash Epithelial cell degenerative changes
bull Functional disturbances in EE includendash Reduced absorption
ndash Increased turnover of intestinal cells
ndash Increased mucosal permeability
ndash Generalized activation of the innate and adaptive immune system
Environmental Enteropathy
Young (less than 6 months)MalnutritionMale genderFeeding practice Micronutrient deficienciesDiarrheal severityChronic diseasesImmunodeficiency HIVAIDS
Selected etiologic agentsUse of antibiotics for AGESocioeconomic status Young mothers
PROLONGED PERSISTENTDIARRHEA
Risk factors for persistent prolonged diarrhea
Araya M et al Acta Paediatr Scand 1991Catassi C et al Pediatr Gastroenterol Nutr 1999
Persistent diarrhea socio-demographic and clinical profile of 264 children seen at
a referral hospital in Addis Ababa
bull 5762 children with all forms of diarrhea 264 (5) had PD
bull PD children characteristics
ndash 83 were below 18 months of age
ndash The peak occurrence was between the ages of 7 to 12 months
ndash 86 had associated malnutrition
ndash 83 lt 4 months were either fully or partially weaned
ndash Watery diarrhea with no dehydration was the main feature
ndash 7 of the patients had dysentery
ndash Average family income was low but literacy level seem to have had no effect
Ethiop Med J 1997 Jul35(3)161-8
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Enterocyte intracellular signalling leading to intestinal secretion
cAMP cGMPCa
cytoskeleton
Basic physiology
Regulation of fluid and electrolytes transport is under the control of regulatory mechanisms
bull Entero-endocrine system
bull ENS
bull Gut flora
bull Gut Immune system
Millennium Development
Goal 4 and 5 by 2015
127 million deaths in 1990 to 63 million in 2013
Definitions acute and chronic or persistent diarrhea
bull WHO ldquopassage of loose or watery stools at least three times in a 24 h periodrdquo
bull ESPGHANESPID a decrease in the consistency of stools (loose or liquid) andor an increase in the frequency of evacuations
ndash Acute diarrheas abrupt onset resolve within 14 days and are mostly caused by infections
ndash Persistent diarrhea episode of diarrhea lasting 14 days or longer (WHO)ndash Chronic diarrhea diarrhea lasting more than 14-30 daysndash Other chronic diarrheas mainly due to congenital defects of digestion
and absorption
Prevalence
bull PD in developed countries bull Prevalence 3-5 or even less
bull Major causes celiac disease food allergy diet induced IBDentericinfections different disorders
bull PD in developing countries bull Prevalence 5-25
bull Major causes serial enteric infections associated with malabsorption malnutrition micronutrients deficiency and immunodeficiency
Persistent diarrhea in developing countries
Infectious disease
Lactose intolerance
Malnutrition
Delayed intestinal mucosa recovery
Bacterial overgrowth
Chronic entropathy
ImmunedeficiencyHIV
Micronutrientdeficiencies
AnorexiaFood withdrawal
Dietarysensitisation
PD = Environmental Enteropathy
bull PD EE a condition characterized by morphologic changes in the gut of inhabitants of developing countries
bull EE is characterized by ndash Intestinal inflammation
ndash Partial villous atrophy
ndash Epithelial cell degenerative changes
bull Functional disturbances in EE includendash Reduced absorption
ndash Increased turnover of intestinal cells
ndash Increased mucosal permeability
ndash Generalized activation of the innate and adaptive immune system
Environmental Enteropathy
Young (less than 6 months)MalnutritionMale genderFeeding practice Micronutrient deficienciesDiarrheal severityChronic diseasesImmunodeficiency HIVAIDS
Selected etiologic agentsUse of antibiotics for AGESocioeconomic status Young mothers
PROLONGED PERSISTENTDIARRHEA
Risk factors for persistent prolonged diarrhea
Araya M et al Acta Paediatr Scand 1991Catassi C et al Pediatr Gastroenterol Nutr 1999
Persistent diarrhea socio-demographic and clinical profile of 264 children seen at
a referral hospital in Addis Ababa
bull 5762 children with all forms of diarrhea 264 (5) had PD
bull PD children characteristics
ndash 83 were below 18 months of age
ndash The peak occurrence was between the ages of 7 to 12 months
ndash 86 had associated malnutrition
ndash 83 lt 4 months were either fully or partially weaned
ndash Watery diarrhea with no dehydration was the main feature
ndash 7 of the patients had dysentery
ndash Average family income was low but literacy level seem to have had no effect
Ethiop Med J 1997 Jul35(3)161-8
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Basic physiology
Regulation of fluid and electrolytes transport is under the control of regulatory mechanisms
bull Entero-endocrine system
bull ENS
bull Gut flora
bull Gut Immune system
Millennium Development
Goal 4 and 5 by 2015
127 million deaths in 1990 to 63 million in 2013
Definitions acute and chronic or persistent diarrhea
bull WHO ldquopassage of loose or watery stools at least three times in a 24 h periodrdquo
bull ESPGHANESPID a decrease in the consistency of stools (loose or liquid) andor an increase in the frequency of evacuations
ndash Acute diarrheas abrupt onset resolve within 14 days and are mostly caused by infections
ndash Persistent diarrhea episode of diarrhea lasting 14 days or longer (WHO)ndash Chronic diarrhea diarrhea lasting more than 14-30 daysndash Other chronic diarrheas mainly due to congenital defects of digestion
and absorption
Prevalence
bull PD in developed countries bull Prevalence 3-5 or even less
bull Major causes celiac disease food allergy diet induced IBDentericinfections different disorders
bull PD in developing countries bull Prevalence 5-25
bull Major causes serial enteric infections associated with malabsorption malnutrition micronutrients deficiency and immunodeficiency
Persistent diarrhea in developing countries
Infectious disease
Lactose intolerance
Malnutrition
Delayed intestinal mucosa recovery
Bacterial overgrowth
Chronic entropathy
ImmunedeficiencyHIV
Micronutrientdeficiencies
AnorexiaFood withdrawal
Dietarysensitisation
PD = Environmental Enteropathy
bull PD EE a condition characterized by morphologic changes in the gut of inhabitants of developing countries
bull EE is characterized by ndash Intestinal inflammation
ndash Partial villous atrophy
ndash Epithelial cell degenerative changes
bull Functional disturbances in EE includendash Reduced absorption
ndash Increased turnover of intestinal cells
ndash Increased mucosal permeability
ndash Generalized activation of the innate and adaptive immune system
Environmental Enteropathy
Young (less than 6 months)MalnutritionMale genderFeeding practice Micronutrient deficienciesDiarrheal severityChronic diseasesImmunodeficiency HIVAIDS
Selected etiologic agentsUse of antibiotics for AGESocioeconomic status Young mothers
PROLONGED PERSISTENTDIARRHEA
Risk factors for persistent prolonged diarrhea
Araya M et al Acta Paediatr Scand 1991Catassi C et al Pediatr Gastroenterol Nutr 1999
Persistent diarrhea socio-demographic and clinical profile of 264 children seen at
a referral hospital in Addis Ababa
bull 5762 children with all forms of diarrhea 264 (5) had PD
bull PD children characteristics
ndash 83 were below 18 months of age
ndash The peak occurrence was between the ages of 7 to 12 months
ndash 86 had associated malnutrition
ndash 83 lt 4 months were either fully or partially weaned
ndash Watery diarrhea with no dehydration was the main feature
ndash 7 of the patients had dysentery
ndash Average family income was low but literacy level seem to have had no effect
Ethiop Med J 1997 Jul35(3)161-8
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Millennium Development
Goal 4 and 5 by 2015
127 million deaths in 1990 to 63 million in 2013
Definitions acute and chronic or persistent diarrhea
bull WHO ldquopassage of loose or watery stools at least three times in a 24 h periodrdquo
bull ESPGHANESPID a decrease in the consistency of stools (loose or liquid) andor an increase in the frequency of evacuations
ndash Acute diarrheas abrupt onset resolve within 14 days and are mostly caused by infections
ndash Persistent diarrhea episode of diarrhea lasting 14 days or longer (WHO)ndash Chronic diarrhea diarrhea lasting more than 14-30 daysndash Other chronic diarrheas mainly due to congenital defects of digestion
and absorption
Prevalence
bull PD in developed countries bull Prevalence 3-5 or even less
bull Major causes celiac disease food allergy diet induced IBDentericinfections different disorders
bull PD in developing countries bull Prevalence 5-25
bull Major causes serial enteric infections associated with malabsorption malnutrition micronutrients deficiency and immunodeficiency
Persistent diarrhea in developing countries
Infectious disease
Lactose intolerance
Malnutrition
Delayed intestinal mucosa recovery
Bacterial overgrowth
Chronic entropathy
ImmunedeficiencyHIV
Micronutrientdeficiencies
AnorexiaFood withdrawal
Dietarysensitisation
PD = Environmental Enteropathy
bull PD EE a condition characterized by morphologic changes in the gut of inhabitants of developing countries
bull EE is characterized by ndash Intestinal inflammation
ndash Partial villous atrophy
ndash Epithelial cell degenerative changes
bull Functional disturbances in EE includendash Reduced absorption
ndash Increased turnover of intestinal cells
ndash Increased mucosal permeability
ndash Generalized activation of the innate and adaptive immune system
Environmental Enteropathy
Young (less than 6 months)MalnutritionMale genderFeeding practice Micronutrient deficienciesDiarrheal severityChronic diseasesImmunodeficiency HIVAIDS
Selected etiologic agentsUse of antibiotics for AGESocioeconomic status Young mothers
PROLONGED PERSISTENTDIARRHEA
Risk factors for persistent prolonged diarrhea
Araya M et al Acta Paediatr Scand 1991Catassi C et al Pediatr Gastroenterol Nutr 1999
Persistent diarrhea socio-demographic and clinical profile of 264 children seen at
a referral hospital in Addis Ababa
bull 5762 children with all forms of diarrhea 264 (5) had PD
bull PD children characteristics
ndash 83 were below 18 months of age
ndash The peak occurrence was between the ages of 7 to 12 months
ndash 86 had associated malnutrition
ndash 83 lt 4 months were either fully or partially weaned
ndash Watery diarrhea with no dehydration was the main feature
ndash 7 of the patients had dysentery
ndash Average family income was low but literacy level seem to have had no effect
Ethiop Med J 1997 Jul35(3)161-8
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Definitions acute and chronic or persistent diarrhea
bull WHO ldquopassage of loose or watery stools at least three times in a 24 h periodrdquo
bull ESPGHANESPID a decrease in the consistency of stools (loose or liquid) andor an increase in the frequency of evacuations
ndash Acute diarrheas abrupt onset resolve within 14 days and are mostly caused by infections
ndash Persistent diarrhea episode of diarrhea lasting 14 days or longer (WHO)ndash Chronic diarrhea diarrhea lasting more than 14-30 daysndash Other chronic diarrheas mainly due to congenital defects of digestion
and absorption
Prevalence
bull PD in developed countries bull Prevalence 3-5 or even less
bull Major causes celiac disease food allergy diet induced IBDentericinfections different disorders
bull PD in developing countries bull Prevalence 5-25
bull Major causes serial enteric infections associated with malabsorption malnutrition micronutrients deficiency and immunodeficiency
Persistent diarrhea in developing countries
Infectious disease
Lactose intolerance
Malnutrition
Delayed intestinal mucosa recovery
Bacterial overgrowth
Chronic entropathy
ImmunedeficiencyHIV
Micronutrientdeficiencies
AnorexiaFood withdrawal
Dietarysensitisation
PD = Environmental Enteropathy
bull PD EE a condition characterized by morphologic changes in the gut of inhabitants of developing countries
bull EE is characterized by ndash Intestinal inflammation
ndash Partial villous atrophy
ndash Epithelial cell degenerative changes
bull Functional disturbances in EE includendash Reduced absorption
ndash Increased turnover of intestinal cells
ndash Increased mucosal permeability
ndash Generalized activation of the innate and adaptive immune system
Environmental Enteropathy
Young (less than 6 months)MalnutritionMale genderFeeding practice Micronutrient deficienciesDiarrheal severityChronic diseasesImmunodeficiency HIVAIDS
Selected etiologic agentsUse of antibiotics for AGESocioeconomic status Young mothers
PROLONGED PERSISTENTDIARRHEA
Risk factors for persistent prolonged diarrhea
Araya M et al Acta Paediatr Scand 1991Catassi C et al Pediatr Gastroenterol Nutr 1999
Persistent diarrhea socio-demographic and clinical profile of 264 children seen at
a referral hospital in Addis Ababa
bull 5762 children with all forms of diarrhea 264 (5) had PD
bull PD children characteristics
ndash 83 were below 18 months of age
ndash The peak occurrence was between the ages of 7 to 12 months
ndash 86 had associated malnutrition
ndash 83 lt 4 months were either fully or partially weaned
ndash Watery diarrhea with no dehydration was the main feature
ndash 7 of the patients had dysentery
ndash Average family income was low but literacy level seem to have had no effect
Ethiop Med J 1997 Jul35(3)161-8
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Prevalence
bull PD in developed countries bull Prevalence 3-5 or even less
bull Major causes celiac disease food allergy diet induced IBDentericinfections different disorders
bull PD in developing countries bull Prevalence 5-25
bull Major causes serial enteric infections associated with malabsorption malnutrition micronutrients deficiency and immunodeficiency
Persistent diarrhea in developing countries
Infectious disease
Lactose intolerance
Malnutrition
Delayed intestinal mucosa recovery
Bacterial overgrowth
Chronic entropathy
ImmunedeficiencyHIV
Micronutrientdeficiencies
AnorexiaFood withdrawal
Dietarysensitisation
PD = Environmental Enteropathy
bull PD EE a condition characterized by morphologic changes in the gut of inhabitants of developing countries
bull EE is characterized by ndash Intestinal inflammation
ndash Partial villous atrophy
ndash Epithelial cell degenerative changes
bull Functional disturbances in EE includendash Reduced absorption
ndash Increased turnover of intestinal cells
ndash Increased mucosal permeability
ndash Generalized activation of the innate and adaptive immune system
Environmental Enteropathy
Young (less than 6 months)MalnutritionMale genderFeeding practice Micronutrient deficienciesDiarrheal severityChronic diseasesImmunodeficiency HIVAIDS
Selected etiologic agentsUse of antibiotics for AGESocioeconomic status Young mothers
PROLONGED PERSISTENTDIARRHEA
Risk factors for persistent prolonged diarrhea
Araya M et al Acta Paediatr Scand 1991Catassi C et al Pediatr Gastroenterol Nutr 1999
Persistent diarrhea socio-demographic and clinical profile of 264 children seen at
a referral hospital in Addis Ababa
bull 5762 children with all forms of diarrhea 264 (5) had PD
bull PD children characteristics
ndash 83 were below 18 months of age
ndash The peak occurrence was between the ages of 7 to 12 months
ndash 86 had associated malnutrition
ndash 83 lt 4 months were either fully or partially weaned
ndash Watery diarrhea with no dehydration was the main feature
ndash 7 of the patients had dysentery
ndash Average family income was low but literacy level seem to have had no effect
Ethiop Med J 1997 Jul35(3)161-8
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Persistent diarrhea in developing countries
Infectious disease
Lactose intolerance
Malnutrition
Delayed intestinal mucosa recovery
Bacterial overgrowth
Chronic entropathy
ImmunedeficiencyHIV
Micronutrientdeficiencies
AnorexiaFood withdrawal
Dietarysensitisation
PD = Environmental Enteropathy
bull PD EE a condition characterized by morphologic changes in the gut of inhabitants of developing countries
bull EE is characterized by ndash Intestinal inflammation
ndash Partial villous atrophy
ndash Epithelial cell degenerative changes
bull Functional disturbances in EE includendash Reduced absorption
ndash Increased turnover of intestinal cells
ndash Increased mucosal permeability
ndash Generalized activation of the innate and adaptive immune system
Environmental Enteropathy
Young (less than 6 months)MalnutritionMale genderFeeding practice Micronutrient deficienciesDiarrheal severityChronic diseasesImmunodeficiency HIVAIDS
Selected etiologic agentsUse of antibiotics for AGESocioeconomic status Young mothers
PROLONGED PERSISTENTDIARRHEA
Risk factors for persistent prolonged diarrhea
Araya M et al Acta Paediatr Scand 1991Catassi C et al Pediatr Gastroenterol Nutr 1999
Persistent diarrhea socio-demographic and clinical profile of 264 children seen at
a referral hospital in Addis Ababa
bull 5762 children with all forms of diarrhea 264 (5) had PD
bull PD children characteristics
ndash 83 were below 18 months of age
ndash The peak occurrence was between the ages of 7 to 12 months
ndash 86 had associated malnutrition
ndash 83 lt 4 months were either fully or partially weaned
ndash Watery diarrhea with no dehydration was the main feature
ndash 7 of the patients had dysentery
ndash Average family income was low but literacy level seem to have had no effect
Ethiop Med J 1997 Jul35(3)161-8
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
PD = Environmental Enteropathy
bull PD EE a condition characterized by morphologic changes in the gut of inhabitants of developing countries
bull EE is characterized by ndash Intestinal inflammation
ndash Partial villous atrophy
ndash Epithelial cell degenerative changes
bull Functional disturbances in EE includendash Reduced absorption
ndash Increased turnover of intestinal cells
ndash Increased mucosal permeability
ndash Generalized activation of the innate and adaptive immune system
Environmental Enteropathy
Young (less than 6 months)MalnutritionMale genderFeeding practice Micronutrient deficienciesDiarrheal severityChronic diseasesImmunodeficiency HIVAIDS
Selected etiologic agentsUse of antibiotics for AGESocioeconomic status Young mothers
PROLONGED PERSISTENTDIARRHEA
Risk factors for persistent prolonged diarrhea
Araya M et al Acta Paediatr Scand 1991Catassi C et al Pediatr Gastroenterol Nutr 1999
Persistent diarrhea socio-demographic and clinical profile of 264 children seen at
a referral hospital in Addis Ababa
bull 5762 children with all forms of diarrhea 264 (5) had PD
bull PD children characteristics
ndash 83 were below 18 months of age
ndash The peak occurrence was between the ages of 7 to 12 months
ndash 86 had associated malnutrition
ndash 83 lt 4 months were either fully or partially weaned
ndash Watery diarrhea with no dehydration was the main feature
ndash 7 of the patients had dysentery
ndash Average family income was low but literacy level seem to have had no effect
Ethiop Med J 1997 Jul35(3)161-8
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Environmental Enteropathy
Young (less than 6 months)MalnutritionMale genderFeeding practice Micronutrient deficienciesDiarrheal severityChronic diseasesImmunodeficiency HIVAIDS
Selected etiologic agentsUse of antibiotics for AGESocioeconomic status Young mothers
PROLONGED PERSISTENTDIARRHEA
Risk factors for persistent prolonged diarrhea
Araya M et al Acta Paediatr Scand 1991Catassi C et al Pediatr Gastroenterol Nutr 1999
Persistent diarrhea socio-demographic and clinical profile of 264 children seen at
a referral hospital in Addis Ababa
bull 5762 children with all forms of diarrhea 264 (5) had PD
bull PD children characteristics
ndash 83 were below 18 months of age
ndash The peak occurrence was between the ages of 7 to 12 months
ndash 86 had associated malnutrition
ndash 83 lt 4 months were either fully or partially weaned
ndash Watery diarrhea with no dehydration was the main feature
ndash 7 of the patients had dysentery
ndash Average family income was low but literacy level seem to have had no effect
Ethiop Med J 1997 Jul35(3)161-8
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Young (less than 6 months)MalnutritionMale genderFeeding practice Micronutrient deficienciesDiarrheal severityChronic diseasesImmunodeficiency HIVAIDS
Selected etiologic agentsUse of antibiotics for AGESocioeconomic status Young mothers
PROLONGED PERSISTENTDIARRHEA
Risk factors for persistent prolonged diarrhea
Araya M et al Acta Paediatr Scand 1991Catassi C et al Pediatr Gastroenterol Nutr 1999
Persistent diarrhea socio-demographic and clinical profile of 264 children seen at
a referral hospital in Addis Ababa
bull 5762 children with all forms of diarrhea 264 (5) had PD
bull PD children characteristics
ndash 83 were below 18 months of age
ndash The peak occurrence was between the ages of 7 to 12 months
ndash 86 had associated malnutrition
ndash 83 lt 4 months were either fully or partially weaned
ndash Watery diarrhea with no dehydration was the main feature
ndash 7 of the patients had dysentery
ndash Average family income was low but literacy level seem to have had no effect
Ethiop Med J 1997 Jul35(3)161-8
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Persistent diarrhea socio-demographic and clinical profile of 264 children seen at
a referral hospital in Addis Ababa
bull 5762 children with all forms of diarrhea 264 (5) had PD
bull PD children characteristics
ndash 83 were below 18 months of age
ndash The peak occurrence was between the ages of 7 to 12 months
ndash 86 had associated malnutrition
ndash 83 lt 4 months were either fully or partially weaned
ndash Watery diarrhea with no dehydration was the main feature
ndash 7 of the patients had dysentery
ndash Average family income was low but literacy level seem to have had no effect
Ethiop Med J 1997 Jul35(3)161-8
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Etiologic studies of 130 prolonged episodes of acute diarrhea
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Diarrhea attack rates of acute (lt7 days)
prolonged (ge7 and lt14 days) and persistent (ge14
days) episodes per child-year by age
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
Infants with ProD were twice as likely to develop PD
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14
days) and persistent (ge14 days)
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
PD affect nutritional status
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on
anthropometry
Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164
first acute (n=308) prolonged (n=145) and persistent (n=62)
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Effects of repeated diarrheal episodes on childhood growth curves
Gastroenterology 2010 October 139(4) 1156ndash1164
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
1007 children with 597638 child-days of diarrhea surveillance
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Optimal nutritional therapy is generallyconsidered the cornerstone
of its management
PD is a nutritional disorder
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Approach to infant with chronic diarrhea in developing countries
bull Persistent diarrhea following an acute infection is the predominant type of diarrhea
bull Diagnostic resources are often limited
bull Algorithmic approach to diagnosis and management is practical and usually effective
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Evaluation steps
bull Algorithmic approach to diagnosis and management is practical and usually effective
bull Initial assessment of hydration and nutritional status
bull Specific testing for pathogens and empiric therapy if necessary
bull Evaluation for extraintestinal infections
bull Evaluation of nutritional status and nutritional rehabilitation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Watery vs Bloody Diarrhea
Classify the diarrhea based on its appearance
bull Watery diarrhea cholera or rotavirus in young children
bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at
particularly high risk for morbidity and mortality
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Laboratory testing
bull Fluids electrolytes and dietary management are not dependent on etiology
bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption
bull Testing the stool for pH and glucose using a urine
bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption
Specific laboratory testing is not essentialfor the management
of persistent diarrhea in developing countries
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Laboratory testing
bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter
bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica
bull Fecal antigen for giardia infection rotavirus
bull Dark-field or phase contrast microscopy to identify V cholera
raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Treatment approach to infant with chronic diarrhea in developing countries
bull Inpatient treatment is advisable
bull Children with moderate severe malnutrition
bull Presence of dehydration
bull Systemic infections
bull Infants younger than 4 months
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Treatment approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
bull Micronutrientsrsquo supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Micronutrients and Vitamins Deficiencies
bull Children with chronic diarrhea and malnutrition are often deficient in
bull Vitamin A zinc folic acid copper and selenium
bull Micronutrients deficiencies bull Impair immune system function
bull Delay mucosal recovery
Micronutrient and vitamin supplementation are part of nutritional rehabilitation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Micronutrients deficiency
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Micronutrients and Vitamins
bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper
and magnesium for two weeks
bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Zinc supplementation
bull The WHO recommends zinc supplementation for children with diarrhea in developing countries
bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days
bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials
bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63
Bhutta ZA Am J Clin Nutr 2000
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Mean difference in duration of
acute and persistent diarrhea
Lukacik M et al Pediatrics 2008121326-336
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Correction of dehydration acidosis electrolyte abnormalities hypoglycemia
and treatment of concomitant infections should be the first priorities
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Approach to infant with chronic diarrhea in developing countries
bull Correction of hydration status
bull Nutritional management plan
bull Treatment of infections
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Dietary management
Dietary management should be addressed ASAP
bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)
bull There is no need to limit fat intake
bull Breastfeeding should be continued whenever possible
bull Secondary lactase deficiency should be thought for and addressed
Nutritional compromise is present in most cases of persistent diarrhea in developing countries
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Nutrients Absorption During Acute and Chronic Diarrhea
Thobani S et al Pediatric enteral nutrition 1994
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Predicted Catch-Up Growth at Different Energy Intakes
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Optimal protein intake
All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
General Rehabilitation Principles
bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml
Brown KH Acta Pediatr Scand Suppl 1991
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Elemental diets Milk-based diets
Chicken-based feedsTraditional local diets
What to feed
EN PN
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Available ProductsDeveloped Countries
bull Home-made recipes
Developing countries
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)
Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Available Formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk
However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes
What is the role of lactose Free diets
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Solomons NWet al Am J Clin Nutr 1984
The routine reduction of lactose content from a milk-based diet for severe protein-energy
malnutrition offers no advantages
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Severely malnourished diarrhea (n=196 3-60 months)
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)
BMC Pediatrics 2010
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)
ndash Perianal skin erosion (p = 0044)
ndash High mean stool frequency (p =lt 0001)
ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)
ndash Young age of 3-12 months
ndash Lack of up to-date immunization
ndash Persistent diarrhoea vomiting dehydration and abdominal distension
ndash Exclusive breastfeeding for less than 4 months
ndash Worsening of diarrhoea on initiation of therapeutic milk
BMC Pediatrics 2010
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Dietary managementLactose free diet
bull Secondary disaccharidase lactase deficiencies suspected
bull A low-lactose diet may be necessary
bull Milk based feeds
ndash Mixing milk with cereals small frequent feedings
ndash Lactose-free formulas are an alternative
ndash Use yogurt
bull Non-milk based feeds
ndash Use other source of protein egg or pureed chicken
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Available lactose-free formulae
Cowrsquos milk based Formulae
Soy based formulae
Hydrolysed protein based formulae
Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy
of PD and intestinal disease especially when dietary protein sensitivity is suspected
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM
Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)
155 completed the study 39 died 6 lost to follow up
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)
Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ
Amadi B et al J Trop Pediatr 2005
AAP
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
bull 3 month feeding study
bull Growth significantly improved in subjects with CD fed EleCare WAz
bull Symptoms also improved
bull EleCare in improving symptoms in pediatric subjects with CD
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
bull Total elimination of milk is not required in the initial treatment of patients with
bull In addition milk-cereal mixtures are easy to prepare in the household
bull Further dietary modification may be restricted to those children whose treatment fails with such diets
Pediatrics 1996981122-1126
116 children 3 to 24 months of age with diarrhea
Probability of continuing diarrhea by dietary group
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Dietary manipulations during PD
Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days
Bhutta ZA et al Acta Paediatr Suppl 1992
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull RCT chicken-based diet elemental (Vivonex) and soy
bull 56 children severe malnutrition PD aged 3 to 36 months
bull Isocaloric diets NGT 150 mlkg per day
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Forty-one children (732) were successfully treated
ndash 13 Vivonex 13 Nursoy 15 chicken
ndash No differences in diarrheal outcomes
ndash All groups had significant weight gain
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
J Pediatr 1997 Sep131(3)405-12
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT
bull Treatment failure was independent of the diet and was associated with the presence of infection on admission
bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups
bull CONCLUSIONS
ndash The chicken-based diet was as effective as Vivonex or soy
ndash Was well tolerated inexpensive and widely available
ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD
J Pediatr 1997 Sep131(3)405-12
Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
bull 460 children with persistent diarrhea age 4-36 months
bull Bangladesh IndiaMexico Pakistan Peru Viet Nam
bull Malnourished (WAz -303 plusmn 086)
bull Severe associated conditions (45 required rehydration infections)
bull The overall success rate of the treatment algorithm was 80
bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B
bull The children at the greatest risk for treatment failure
ndash Acute associated illnesses (cholera septicaemia and UTI)
ndash Required intravenous antibiotics
ndash Highest initial purging rates
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines
bull This study should help establish rational and effective treatment for persistent diarrhoea
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
ldquoHome Maderdquo Solutions
bull Milk based
bull Chicken meat based
bull Combinations with cereals
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Rice based diet compositionl
Akbar MS et al J Trop Pediatr 1993
Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in
Bangaladesh
Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Time to improvement of diarrhea in patients using rice-based diet
Cumulative recovery from persistent diarrhea with a rice-based diet
Akbar MS et al J Trop Pediatr 1993
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
LGG in the Treatment of PD in Indian Children
Basu S et al J Clin Gastroenterol 2007
All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions
bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls
Evans S et al Arch Dis Child 201398184-188
Nutrition Content of Modular Feeds How Accurate is Feed Production
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Preparation errors included
Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes
Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers
Fewer errors occurred with powdered than liquid ingredients
Evans S et al Arch Dis Child 201398184-188
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Dietary manipulations during PDOutcomeDietIntervention
No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27
Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992
For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk
1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk
Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989
No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure
1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet
Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994
The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets
Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk
Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months
can be safely rehabilitated with home made products of high nutritional value
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Practical Decisions
Decide on the route of administration GUT
Decide on the type of formula
Decide on concentration volume and rate of delivery
Decide on oral vs EN vs PN
Monitoring
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Delivery of Enteral Nutrition
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Delivery of Enteral Nutrition
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation
Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday
Initiate Parenteral Nutrition in the presence of significant enteral
intolerance
Delivery of Enteral Nutrition
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Vomiting diarrhea
Dehydration refeeding
Technical complications
Infectious complications
Complications of Enteral Nutrition
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Conclusions and Recommendations
bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Conclusions and Recommendations
bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections
bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment
bull Laboratory testing of stool is not essential
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Conclusions and Recommendations
bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Conclusions and Recommendations
bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Conclusions and Recommendations
bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Conclusions and Recommendations
bull Empirical antibiotic treatment is not generally recommended (Grade 1B)
bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)
bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation
Nutritional managementSummary
RecoomendationsFeeding type
Continue without changeBreast feeding
Use full-strength undiluted CM based formula
May do better in PDLactose-free or yogurt
No convincing studiesAmino-acid based formulas
Promising not much studiedWeaning mixtures prepared from local staple
YES in developing countriesMicronutrients supplementation