Nutritional effects and management of diarrhoea in infancy

Dietary management of childhood diarrhea in low- and middle-income countries: a systematic review

Background

Current WHO guidelines on the management and treatment of diarrhea in children strongly recommend continued feeding alongside the administration of oral rehydration solution and zinc therapy, but there remains some debate regarding the optimal diet or dietary ingredients for feeding children with diarrhea.

Methods

We conducted a systematic search for all published randomized controlled trials evaluating food-based interventions among children under five years old with diarrhea in low- and middle-income countries. We classified 29 eligible studies into one or more comparisons: reduced versus regular lactose liquid feeds, lactose-free versus lactose-containing liquid feeds, lactose-free liquid feeds versus lactose-containing mixed diets, and commercial/specialized ingredients versus home-available ingredients. We used all available outcome data to conduct random-effects meta-analyses to estimate the average effect of each intervention on diarrhea duration, stool output, weight gain and treatment failure risk for studies on acute and persistent diarrhea separately.

Results

Evidence of low-to-moderate quality suggests that among children with acute diarrhea, diluting or fermenting lactose-containing liquid feeds does not affect any outcome when compared with an ordinary lactose-containing liquid feeds. In contrast, moderate quality evidence suggests that lactose-free liquid feeds reduce duration and the risk of treatment failure compared to lactose-containing liquid feeds in acute diarrhea. Only limited evidence of low quality was available to assess either of these two approaches in persistent diarrhea, or to assess lactose-free liquid feeds compared to lactose-containing mixed diets in either acute or persistent diarrhea. For commercially prepared or specialized ingredients compared to home-available ingredients, we found low-to-moderate quality evidence of no effect on any outcome in either acute or persistent diarrhea, though when we restricted these analyses to studies where both intervention and control diets were lactose-free, weight gain in children with acute diarrhea was shown to be greater among those fed with a home-available diet.

Conclusions

Among children in low- and middle-income countries, where the dual burden of diarrhea and malnutrition is greatest and where access to proprietary formulas and specialized ingredients is limited, the use of locally available age-appropriate foods should be promoted for the majority of acute diarrhea cases. Lactose intolerance is an important complication in some cases, but even among those children for whom lactose avoidance may be necessary, nutritionally complete diets comprised of locally available ingredients can be used at least as effectively as commercial preparations or specialized ingredients. These same conclusions may also apply to the dietary management of children with persistent diarrhea, but the evidence remains limited.

Effect of multiple fortification on the bioavailability of minerals in wheat meal bread

Bioavailability of calcium, iron and zinc as calcium carbonate (CaCO3), ferrous sulfate (FeSO4) and zinc sulphate (ZnSO4) @ 1,000, 40 and 20 mg kg(-1) respectively from fortified bread of 72% extraction straight grade flour was assessed. Fortified bread diets were fed to 64 female Sprague-Dawley Albino rats for a period of 28 days. The retention of Ca, Fe and Zn was measured in plasma, femur and liver tissues of rats. The results showed that the feed intake and live body weight of the experimental animals increased significantly with the time period. The Ca levels in plasma and liver did not change significantly while in femur, Ca retention changed significantly with changing type of the fortificants. Similarly, the results for percent apparent absorption (AA) of Ca also remained unchanged (P < 0.05). The Fe and Zn levels were significantly higher in the plasma, liver and femur of rats fed Fe and Zn fortified bread. Interaction of Ca, Fe and Zn resulted in their decreased bioavailability. However Ca, Fe and Zn absorption was higher in the rats fed triple fortified diet compared with those fed unfortified bread diet. This negative interaction did not appear to be great enough to discourage multiple fortification of flour to address minerals malnutrition in the vulnerable groups.

Dietary Intake and Clinical Response of Hospitalized Patients with Acute Diarrhea

Background

Diarrhea and malnutrition remain major health problems among children of developing countries. During diarrhea, the patient's dietary intake and absorption of nutrients are reduced while nutritional requirements are increased.

Objective

To determine the relationship between food intake and clinical response during the hospital stay of patients with acute diarrhea.

Methods

A hospital-based longitudinal study was conducted in 118 patients with acute diarrhea aged 6 to 59 months who required treatment for at least 3 days in the in-patient ward in Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B). Daily food intake was measured and anthropometric measurements were taken to assess nutritional status. Daily stool weight and clinical records were collected. The data were analyzed with SPSS/PC+, version 10, and EPI STAT, version 3.2.2.

Results

The duration of diarrhea was 50% greater in patients with lower energy intake (less than 50% of the recommended dietary allowance [RDA]) than in those with higher energy intake (6 vs. 4 days, p = <.001). Patients with lower energy intake had 22% greater stool output than those with higher energy intake (122.65 vs. 100.37 mL/kg body weight/day, p = .04). Among patients with lower energy intake, the weight-for-age and weight-for-height z-scores (WAZ and WHZ) at discharge from the hospital were higher than those at admission (−3.53±1.25 vs. −3.67±1.31 and 1.95±1.23 vs. −2.14±1.22, respectively; p = .001 for both comparisons), but these scores did not differ at admission and discharge among patients with higher energy intake. The Kaplan–Meier survival function showed that 80% of well-nourished children (WAZ ≥ −2), as compared with 58% of malnourished children (WAZ < −2), recovered by the 4th day of treatment ( p < .01). The length of the recovery period was related negatively with total energy intake ( p = <.001) and mid-upper-arm circumference ( p = .004) and positively with stool weight.

Conclusions

Food intake was reduced in the hospitalized children because of severe illness. Patients with lower energy intake as a percentaqe of RDA had delayed clinical recovery and higher stool output.

Consumption of foods by young children with diagnosed campylobacter infection – a pilot case–control study

Objective:

To determine whether parentally reported habitual intake of specific foods differed between children with diagnosedCampylobacter jejuniinfection and children of a comparison group without diagnosed infection.

Design, setting and subjects:

Information was collected from the parents or primary caregivers of South Australian children aged 1–5 years with diagnosedC. jejuni(cases,n=172) and an age- and gender-matched group of uninfected children (controls,n=173). Frequency of consumption of 106 food and drink items was determined for the preceding two months by food-frequency questionnaire. Four children in the control group had recorded diarrhoeal episodes during the assessment period and were excluded, so 169 responses were evaluated for this group. Information was gathered on possible confounders including socio-economic status. Response frequencies were classified into three levels of consumption (rarely, weekly or daily) and statistical comparison was made by frequency of consumption of foods versus the ‘rarely’ classification for cases and controls, respectively.

Results:

Frequency of consumption of most foods, including starchy foods and fruits and vegetables, did not differ between cases and controls. However, reported consumption of eight food items (block and processed cheese (slices and spread), salami/fritz (a form of processed sausage), chicken nuggets, pasteurised milk, fish (canned or fresh) and hot French fries) was significantly higher by controls.

Conclusions:

The hypothesis that reported consumption of starchy foods was lower by cases than by controls was not supported by the data. However, consumption of some processed and unprocessed foods was higher by controls. Some of these foods have established bactericidal actionsin vitrothat may indicate a possible mechanism for this apparent protection.

Homeopathic Combination Remedy in the Treatment of Acute Childhood Diarrhea in Honduras

BACKGROUND

Despite the widespread availability of oral rehydration therapy, diarrheal illness remains a major cause of morbidity and mortality around the world. Previous studies have shown individualized homeopathic therapy to be effective in treating childhood diarrhea, but this approach requires specialized training.

OBJECTIVE

A homeopathic combination medicine, if effective, could be used by health personnel on a widespread basis.

METHODS

A double-blind randomized controlled trial was conducted in Honduras to evaluate the effectiveness of a homeopathic combination therapy to treat acute diarrhea in children. A total of 292 children with acute diarrhea was recruited; 145 were randomized to the experimental group and 147 to the placebo group. Tablets containing a combined preparation of the five most common single homeopathic remedies used to treat diarrhea or placebo were administered by a parent after each unformed stool. Children were followed up daily for 7 days or until symptoms resolved, whichever occurred first. Time until resolution of symptoms, daily rate of unformed stools, and total number of unformed stools were compared between the two groups.

RESULTS

There was no significant difference in the likelihood of resolution of diarrheal symptoms between the treatment and placebo groups (hazard ratio = 1.02, 95% confidence interval: 0.79-1.32), with a median time until resolution of 3 days for both groups. Children in the treatment group had an average of 2.6 unformed stools per day compared to 2.8 among those in the placebo group; this difference was not significant (p = 0.43). The median number of unformed stools was 7 among children in the treatment group and 8 among those in the placebo group (p = 0.41).

DISCUSSION

The homeopathic combination therapy tested in this study did not significantly reduce the duration or severity of acute diarrhea in Honduran children. Further study is needed to develop affordable and effective methods of using homeopathy to reduce the global burden of childhood diarrhea.

Controlled, double-blind, randomized clinical trial to evaluate the impact of fruit juice consumption on the evolution of infants with acute diarrhea

In order to assess the effects of juice feedings during acute diarrhea a double-blind, randomized study was performed in 90 children, mean age of 10 +/- 4.28 months. Thirty patients with acute diarrhea were fed twice-daily 15 ml/kg of Apple Juice (AJ), 30 received White Grape Juice (WGJ), and 30 were given colored and flavored water (WA) as part of their age appropriate dietary intake. The duration and severity of diarrhea were the main endpoint variables of the study performed in a metabolic unit. The patients were similar among the 3 groups, had diarrhea for 50-64 hours prior to admission, and were dehydrated when admitted to the unit for study. Half of the patients in each group were well nourished and the others had mild to moderate degrees of malnutrition. Rotavirus infection was the agent causing the illness in 63% of the patients. The infants fed juice ingested 14-17% more calories than those given WA, (those receiving AJ and WGJ ingested 95 and 98 Calories/Kg/d respectively) whereas those receiving WA consumed 81 cal/kg/d). The increased energy intake was not at the expense of other foods or milk formula. The mean body weight gain was greater among patients receiving WGJ (+ 50.7 gm) as compared with the patients in the AJ group (+ 18.3 gm) or the patients fed WA (- 0.7 gm) (p = 0.08). The duration of the illness was longer in the infants fed juice as compared with those given WA (p = 0.006), the mean +/- SD duration in hours was 49.4 +/- 32.6, 47.5 +/- 38.9 and 26.5 +/- 27.4 in patients fed AJ, WGJ and WA respectively. All patients improved while ingesting juice and none of them developed persistent diarrhea; most recovered within 50 hours of the beginning of treatment and less than one fourth had diarrhea longer than 96 hours in the unit. The fecal losses were also increased among the juice fed patients (p = 0.001); the mean +/- SD fecal excretion in g/kg/h was 3.94 +/- 2.35, 3.59 +/- 2.35, and 2.19 +/- 1.63 in AJ, WGJ and WA respectively. The stool output was highest during the first day of treatment among all the patients, though those fed AJ had the highest volume of fecal losses and those who received WA had the lowest stool excretion. After the first day of treatment the differences in fecal excretion were not significant. The ability to tolerate carbohydrates during the illness and immediately after recovery was similar among the 3 groups of patients. Intake of juices with different fructose/glucose ratios and osmolarities resulted in more fecal losses and more prolonged diarrhea as compared with water feedings, but the patients given juice ingested more calories and gained more weight, particularly among those being fed the juice with equimolar concentrations of fructose and glucose.

Malnutrition and health in developing countries

Malnutrition, with its 2 constituents of protein-energy malnutrition and micronutrient deficiencies, continues to be a major health burden in developing countries. It is globally the most important risk factor for illness and death, with hundreds of millions of pregnant women and young children particularly affected. Apart from marasmus and kwashiorkor (the 2 forms of protein- energy malnutrition), deficiencies in iron, iodine, vitamin A and zinc are the main manifestations of malnutrition in developing countries. In these communities, a high prevalence of poor diet and infectious disease regularly unites into a vicious circle. Although treatment protocols for severe malnutrition have in recent years become more efficient, most patients (especially in rural areas) have little or no access to formal health services and are never seen in such settings. Interventions to prevent protein- energy malnutrition range from promoting breast-feeding to food supplementation schemes, whereas micronutrient deficiencies would best be addressed through food-based strategies such as dietary diversification through home gardens and small livestock. The fortification of salt with iodine has been a global success story, but other micronutrient supplementation schemes have yet to reach vulnerable populations sufficiently. To be effective, all such interventions require accompanying nutrition-education campaigns and health interventions. To achieve the hunger- and malnutrition-related Millennium Development Goals, we need to address poverty, which is clearly associated with the insecure supply of food and nutrition.

Effects of separate delivery of zinc or zinc and vitamin A on hemoglobin response, growth, and diarrhea in young Peruvian children receiving iron therapy for anemia

INTRODUCTION

Anemia is the most prevalent nutritional deficiency in the world. Attempts to improve iron indexes are affected by deficiency of and interaction between other micronutrients.

OBJECTIVE

Our goal was to assess whether zinc added to iron treatment alone or with vitamin A improves iron indexes and affects diarrheal episodes.

DESIGN

This was a randomized, placebo-controlled, double-blind trial conducted in Peru. Anemic children aged 6-35 mo were assigned to 3 treatment groups: ferrous sulfate (FS; n = 104), ferrous sulfate and zinc sulfate (FSZn; n = 109), and ferrous sulfate, zinc sulfate, and vitamin A (FSZnA; n = 110). Vitamin A or its placebo was supplied only once; iron and zinc were provided under supervision >/=1 h apart 6 d/wk for 18 wk.

RESULTS

The prevalence of anemia was 42.97%. The increase in hemoglobin in the FS group (19.5 g/L) was significantly less than that in the other 2 groups (24.0 and 23.8 g/L in the FSZn and FSZnA groups, respectively). The increase in serum ferritin in the FS group (24.5 mug/L) was significantly less than that in the other 2 groups (33.0 and 30.8 mug/L in the FSZn and FSZnA groups, respectively). The median duration of diarrhea and the mean number of stools per day was significantly higher in the FS group than in other 2 groups (P < 0.005).

CONCLUSION

Adding zinc to iron treatment increases hemoglobin response, improves iron indexes, and has positive effects on diarrhea. No additional effect of vitamin A was found.

Fatores de risco para doença diarréica no lactente: um estudo caso-controle

O objetivo deste estudo foi identificar os fatores de risco associados à presença de episódios diarréicos em lactentes menores de seis meses, residentes na Zona da Mata Meridional do Estado de Pernambuco, Brasil. O desenho do estudo foi do tipo caso-controle, aninhado numa coorte. Foi estudado um total de 397 crianças, sendo 239 casos e 158 controles (1,5:1). Foi calculado o odds ratio(OR), intervalo de confiança (IC) de 95%, e realizada análise de regressão logística para identificar fatores preditores da variável a ser explicada. Na análise multivariada, a ausência de água canalizada (OR = 3,60; IC95% 1,49-8,74) e aleitamento materno por menos de 6 meses (OR = 2,06; IC95% 1,26-3,38) foram os fatores significantemente associados com a ocorrência de diarréia, após o ajuste pelas demais variáveis.

Fatores de risco para diárreia persistente em lactentes

RACIONAL: A diarréia persistente é uma doença multicausal. A análise do risco para o prolongamento do quadro diarréico envolve variáveis ambientais, biológicas e do manejo clínico. OBJETIVO: Identificar fatores de risco para a diarréia persistente em crianças hospitalizadas na fase aguda do quadro diarréico. PACIENTES E MÉTODOS: O estudo foi do tipo caso-controle. A amostra consistiu de 216 crianças menores de 24 meses hospitalizadas por diarréia de início abrupto, no Instituto Materno-Infantil de Pernambuco, Recife, PE. O grupo de casos incluiu as crianças com diarréia persistente e o de controles aquelas com diarréia aguda. Foram analisadas variáveis socioeconômicas, biológicas, de morbidade anterior, clínicas e do manejo terapêutico prévio à admissão. Utilizou-se o odds ratio não ajustado e ajustado, com seus respectivos intervalos de confiança de 95%, observando-se o nível de significância de 5%. A análise multivariada foi feita através de regressão logística. RESULTADOS: O risco de persistência da diarréia foi maior nas crianças com: disenteria, febre no início do quadro, dieta suspensa e uso de antibiótico à admissão hospitalar. O risco de diarréia persistente foi cerca de três vezes maior para crianças sem geladeira no domicílio e que apresentavam hiperemia perianal ao exame físico na admissão hospitalar, sendo estas as variáveis que apresentaram significância estatística após o ajuste para fatores de confusão. CONCLUSÕES: A melhoria das condições ambientais e o manejo adequado e individualizado da criança hospitalizada por diarréia pode contribuir para a redução da morbidade da doença.

Post-infective diarrhoea

When diarrhoea caused by gastroenteritis persists for more than two weeks it is referred to as persistent diarrhoea in developing countries. Whilst the Control of Diarrhoeal Diseases programme has decreased mortality from acute diarrhoea, mortality from persistent diarrhoea has not been so responsive. A number of factors have been identified which are determinants for the progression of an acute episode to one which persists in developing communities. In one study from west Africa, current infection with Cryptosporidium parvum was the most significant factor. In studies from Brazil and India, continuing infection with enteropathogenic Escherichia coli was identified in 50% of infants with persistent diarrhoea. Persistent small intestinal mucosal damage is of key importance in such children. Management of established cases is complex and difficult. However, there is clear evidence that zinc is involved in the recovery of small intestinal mucosa after injury. Zinc supplementation may indeed significantly reduce the duration of persistent diarrhoea. However, the whole question of public health supplementation with zinc, vitamin A, or other supplements, is contentious at present.