Lactose feeding during persistent diarrhoea

Stool Reducing Sugars and Stool pH Are Poor Screening Tests for Intestinal Disaccharidase Deficiencies in Children

BACKGROUND

Tests for stool reducing sugars and stool pH are ordered for children with osmotic diarrhea to screen for carbohydrate malabsorption.

METHODS

We compared the results of the two screening tests, stool reducing sugars and stool pH, with a more definitive result from an intestinal tissue disaccharidase activity assay ordered for pediatric patients (<18 years old). Overall, 159 patients had results for tissue disaccharidase and stool reducing sugars, but only 115 had additional results of stool pH. Forty-six of the 159 patients had mild, moderate, or severe disaccharidase deficiencies. The sensitivity and specificity of the screening tests were calculated for individual disaccharidase deficiencies. In addition, trends of abnormal tissue disaccharidase, stool reducing sugars, and stool pH results were examined in different age groups.

RESULTS

The sensitivities for stool reducing sugars and stool pH were 9% to 28% and specificities were 74% to 81% for individual disaccharidase deficiencies. Infants (0 years of age) had the highest percentage of abnormal results across all three tests; however, the positive predicative values were 54% and 50% for stool reducing sugars and stool pH, respectively.

CONCLUSIONS

The screening tests, stool reducing sugars and stool pH, had low sensitivity compared with results of measured tissue disaccharidase activity in pediatric patients. Infants had the highest percentage of abnormal results for all three tests, but the screening tests still performed poorly in that age group. This study suggests that stool reducing sugars and stool pH should not be used as screening tests for carbohydrate malabsorption due to disaccharidase deficiencies in pediatric patients.

Enteroviruses in gastrointestinal diseases

Gastrointestinal diseases including diarrhoea constitute a major cause of morbidity and mortality in infants and young children especially in developing countries. Worldwide deaths among all ages due to diarrhoea during 2015 were estimated to be about 1.31 million, diarrhoeal deaths in children below 5 years of age being 499 000. Rotavirus accounted for about 200 000 deaths. Although diarrhoeal deaths decreased significantly during the last two decades, they still represent the third largest cause of infantile deaths. Several bacterial, viral, parasitic, fungal and non-infectious diarrhoea causing agents have been identified, but 30% to 40% of diarrhoeal cases remain undiagnosed. Enteroviruses transmit by the faecal-oral route and replicate first in intestinal cells before spreading to the target organ. They have been associated with diarrhoea in a few studies, but their causative role in diarrhoea in humans has not been systematically demonstrated. In view of the recent demonstration that enteroviruses cause diarrhoea in newborn mice pups, thus validating Koch's postulates, the purpose of this review is to emphasise the importance of recognising enteroviruses as major gastrointestinal pathogens associated with acute and persistent diarrhoea and non-diarrhoeal increased frequency of bowel movements in infants, young children and adults. Our studies and several other subsequent studies reported from different countries should stimulate strategies to reduce the burden of infantile gastrointestinal disease, which has hitherto remained unaddressed.

Nutritional Management of Diarrhoea

Diarrhoeal disease may cause, precipitate, or exacerbate protein-energy and micronutrient malnutrition through five possible mechanisms: 1) reduced food intake-reduction of food intake during diarrhoea may be due to the child's anorexia, maternal food-withholding behaviour, or both; 2) decreased absorption of nutrients-structural damage to the intestine, as well as the physical action of increased intestinal movement and reduced fluid transit time, interact to produce decreased absorption of nutrients; 3) increased catabolic losses-under the influence of the inflammatory process, diarrhoea of infectious origin induces an average daily negative nitrogen balance of 0.9 g/kg/day, as muscle protein is converted to glucose through gluconeogenesis by the liver; this glucose is used as a fuel by tissues to sustain the hypermetabolism associated with fever; 4) nutrient loss from the intestine-in diarrhoea nutrients are lost directly from the intestinal tract; 5) metabolic inefficiency due to micronutrient deficiency-the increased rate of tissue synthesis displayed by children recovering from protein-energy malnutrition may be hampered by a limited supply of nutrients from the body pool, which in turn may not be replenished fast enough by dietary intake. The two main driving forces that determine nutritional care of the sick child in the home are advice from healthcare providers (mainly physicians) and the mothers’ own beliefs; a third determinant of care is the social support network available to mothers or social pressure to act in a determined way. Therefore, health providers should be knowledgeable about appropriate feeding management of illness, and should provide sound advice to mothers.

The likelihood that mothers will follow the recommendations given by the health-care system (whether formal or informal) will be greater if these conform to mothers’ cultural norms and their explanatory model of disease. Feeding practices followed in health facilities should be consistent with those advised for the mothers at home. In order to make a successful change in a given practice, culture-sensitive interventions should be used.

Non-polio enterovirus association with persistent diarrhea in children as revealed by a follow-up study of an Indian cohort during the first two years of life

BACKGROUND

We recently reported significant association of non-polio enteroviruses (NPEVs) with acute diarrhea in children. Persistent diarrhea (PD) remains a major cause of morbidity and mortality in infants below two years of age in developing countries. Understanding age-dependent frequency and duration of NPEV infections is important to determine their association with persistent diarrhea and disease burden.

OBJECTIVES

A cohort of 140 infants was followed for 6 months to 2 years of age to determine the frequency, duration, and association with PD of NPEV infections in comparison with rotavirus and other agents.

STUDY DESIGN

Stool samples were collected every 14 days, and diarrheal episodes and their duration were recorded. Enteroviruses were characterized by RT-PCR and VP1 gene sequence analysis, rotavirus by electropherotyping, and other agents by PCR.

RESULTS

Of 4545 samples, negative for oral polio vaccine strains, 3907 (85.96%) and 638 (14.04%) were NPEV-negative and NPEV-positive, respectively, representing 403 (8.87%) infection episodes. About 68% of NPEV infections occurred during the first year with every child having at least one episode lasting between four days and four months. Approximately 38% and 22% of total diarrheal episodes were positive for NPEV and RV, respectively. While about 18% of NPEV infection episodes were associated with diarrhea, 6% being persistent, 13% of total diarrheal episodes were persistent involving infections by monotype NPEV strains or sequential infections by multiple strains and other agents.

CONCLUSIONS

This is the first report revealing NPEVs as the single most frequently and persistently detected viral pathogen in every PD episode.

Lactose digestion and maldigestion: implications for dietary habits in developing countries

Milk is an important source of high quality protein, energy, calcium, potassium, phosphorus and riboflavin. It also has good functional properties and a highly acceptable taste, making milk a good alternative for the nutrition of children and for food programmes in developing countries. However, in some instances it has been advocated that milk or milk based products might not be appropriate for nutritional support, given the high prevalence of lactose intolerance among populations in those countries. After reviewing studies in different regions of the world it is concluded that:

1. Prevalence of lactose maldigestion in children and adults is significantly reduced, to less than half in most studies, when assessed with a dose of milk similar to that normally taken in the diet, as distinct from a large dose of lactose used in the lactose tolerance test.

2. Lactose intolerance as a result of consuming a glass of milk occurs only in a small proportion (about 30% in most studies) of lactose maldigesters. Even this small group can ingest smaller amounts of milk without adverse symptoms and there is good evidence that colonic metabolism in these people adapts to the presence of lactose to reduce or eliminate adverse symptoms.

3. Lactose maldigestion and intolerance in children in developing countries is more likely to exist in association with gastrointestinal damage associated with diarrhoea, malnutrition and/or infection.

4. There is no evidence to support a reduction or elimination of milk intake for people in developing countries because of lactose maldigestion or intolerance.

Effect of a low-cost food on the recovery and death rate of malnourished children

OBJECTIVES

Nutritional rehabilitation in Africa relies mainly on imported skim milk enriched with a sugar and salt mixture. We evaluated whether milk plus porridge made from local ingredients improves the outcome of childhood nutritional rehabilitation versus milk alone.

PATIENTS AND METHODS

This study was conducted in a nutritional unit in Lacor (Northern Uganda). The porridge, made from cheap locally available ingredients (maize flour, dried fish or meat, peanut butter and oil) supplemented with proteins and fats, provides 1.1 energy units, 4.4 kJ/g. We randomly sampled the files of 100 cases discharged in October, November and December 2001 (preintervention), in 2002 (soon after intervention onset) and in 2003 (more than 1 year after intervention onset). We recorded the average hospital days and average oedema-free weight gain at discharge in the 3 groups.

RESULTS

Average oedema-free weight gain increased from 21 g/d (95% confidence interval [CI], 12-29) in 2001 to 35 g/d (95% CI, 25-45) in 2002 and reached 59 g/d (95% CI, 51-65) in 2003. Mortality decreased from 22% to 7.8%, and nutritional failures (insufficient weight gain) decreased by greater than 50%.

CONCLUSIONS

The low-cost porridge supplement (2640 euros/yr per 100 children) was effective in treating malnutrition. Widespread use of the porridge, which resulted in better outcomes than milk alone, could produce a savings in the medium- to long-term, thereby releasing resources for other uses. A high-energy porridge that is made from locally available ingredients and does not require imported foods seems to be appropriate for supplementary feeding after mother's milk in this setting.

Randomised trial of different rates of feeding in acute diarrhoea

OBJECTIVE

To compare the effect of different feeding frequencies on the speed of recovery from diarrhoea.

METHODS

A randomised, non-blinded trial provided 0.452 MJ/kg/day as either 6 or 12 feeds of cows' milk each day to 262 hospitalised male infants aged 3-12 months with acute diarrhoea. Stool frequency, stool weight, body weight, and diarrhoea complications were monitored until recovery or for 14 days.

RESULTS

A proportional hazards regression model controlling for age, diarrhoea aetiology, and severity of dehydration on admission revealed that the frequently fed group had a significantly shorter duration of diarrhoea (hazards ratio, 1.29; 95% confidence interval, 1.002 to 1.653). Frequently fed infants had a significantly greater weight gain and significantly lower faecal frequency and faecal weight.

CONCLUSIONS

Breast feeding remains the preferred method of feeding infants with acute diarrhoea, but feeding cows' milk to adequately nourished infants with acute diarrhoea is safe and is more rapidly effective if provided in frequent feeds with low energy loads.

Nutritional management in diarrhoeal disease

Adequate nutritional intervention in diarrhoeal disease in children is crucial in obtaining optimal control of a disorder that may become life-threatening. During recent years, important advances have been made in our understanding of the pathophysiology of diarrhoeal states, in the formulation of oral rehydration solutions and in the role of micro- and macronutrients in diarrhoeal disorders. This chapter outlines some of the relevant concepts in the pathophysiology of diarrhoeal disease and provides a rationale for nutritional intervention. Guidelines for nutritional management in the settings of acute-onset diarrhoea, post-enteritis protracted diarrhoea and chronic non-specific diarrhoea are provided, mostly based on controlled clinical trials and meta-analyses of evidence-based medicine.

Management of lactose intolerance

The management of lactose intolerance comprises two parts: (1) the basic principles of treatment in persons intolerant to a dietary dose of lactose, and (2) main manoeuvres to reduce the lactose content in food, and/or consumption of special products of milk or exogenous lactase enzyme. The tactics of management depend on the type of hypolactasia, the severity of intolerance, and on the age of the patient. Special attention is paid to the development of lactose intolerance in some patients via iatrogenic mechanisms such as certain drugs, gastric surgery and ionizing radiation.