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OCR for page 11
2
THERAPY FOR DIARRHEA
ORAL REHYDRATION THERAPY
Death associated with acute diarrhea is most often
due to the dehydration that results from the loss of
body water and electrolytes in the stool. Lost water
and electrolytes can usually be replaced orally, and few
cases require intravenous therapy to prevent serious
complications or death. Because deficits of similar
size can occur whether diarrhea is associated with
bacteria or with viruses, treatment depends more on the
size of the deficit than on the specific type of
diarrhea or other characteristics of the patient. Thus,
it is possible to use similar hydration solutions in
persons with different types of diarrhea and of
different ages.
Dehydrated children who are not in shock and who are
able to drink should be rehydrated orally. The value of
oral Dehydration therapy (ORT) in industrialized and
developing countries has received considerable attention
and has been well documented.l0,ll,36~37~43
The oral Dehydration solution formula recommended by
the World Health Organization (WHO) contains, in
millimols per liter, the following: sodium, 90;
chloride, 80; potassium, 20; glucose, 111; and a base,
such as citrate tribasic or bicarbonate, 30. The volume
to be administered is that judged clinically to correct
the estimated deficit. Once Dehydration is completed,
hydration can be maintained during continuing diarrhea
by alternating between the oral solution and water.
Water can be provided by breast-feeding on demand or by
11
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giving plain water equal to about 50% of the volume of
the oral solution administered (i.e., 2 parts ORT
solution to 1 part water or breast milk).
If the complete formula is not available, ORT
solutions for treatment of diarrhea can be made with
salt and a source of glucose found in the home. The
source of glucose is usually crude or sometimes refined
household sugar; other sources, such as properly
prepared rice powder, appear to be better in
facilitating the absorption of electrolytes and water.
A number of recent studies have shown clear reductions
in stool output and duration of diarrhea when rice
powder (which contains glucose, amino acids, and
oligopeptides)32~39 or soy44 is used as a
substrate. It has been demonstrated that the addition
of an amino acid, such as glycine, to the standard
glucose-electrolyte oral Dehydration solution decreases
duration of diarrhea and fecal fluid losses.34~38
Rice powder and other cereals (or soy) are theoretically
advantageous, because they contain amino acids or
carbohydrate (in the form of glucose chains), each of
which promotes sodium transport. Additionally, because
the glucose is in the form of starch, more can be given
without increasing the osmolarity. The upper limit of
starch content has not yet been defined. Because
infants less than 6 months old have incomplete
development of pancreatic amylase, it is not certain
whether they can completely digest these starches. If an
improved ORT solution containing multiple water-soluble,
organic molecules becomes available, it could increase
the absorption of sodium and water and decrease the
diarrhea! volume and duration of diarrhea.
The small proportion of patients who have severe
dehydration and shock, or who are unable to drink,
require immediate intravenous therapy. The intravenous
fluid should be administered rapidly, to reverse shock
within 1 hour and to correct the estimated volume
deficit within 2-4 hours. It should contain enough
potassium and base to correct hypokalemia and acidosis.
Suitable intravenous Dehydration solutions, such as
Ringer's lactate, have been described elsewhere.52
Maintenance with ORT solution is then begun. Persistent
vomiting is often given as a reason for withholding ORT
solutions, but vomiting usually stops in the first 4
hours if ORT solutions are used.
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EFFECTS OF ORAL REHYDRATION THERAPY ON NUTRITIONAL STATUS
Initial clinical observations found that children
receiving oral Dehydration solutions often wanted to eat
within hours of the correction of fluid and electrolyte
depletion.33 That finding suggested that ORT could
have an additional benefit on nutritional status.
This potential benefit has now been examined in at
least seven studies of children with diarrhea (reviewed
in Hirschhornl7~. In these studies, nutritional
status was measured, and continued feeding was urged for
children treated either with or without ORT solutions.
Children receiving the oral rehydration solution showed
significantly greater gains in weight than children not
receiving the solution; the difference persisted over
time, even though not all gained weight at normal
rates. The mean monthly increment in weight in the oral
dehydration solution-groups was 70 g more than that in
the non-oral dehydration solution groups.
These results suggest that ORT programs can result
in nutritional benefit when oral rehydration solution is
combined with feeding. Such programs would be expected
to be most effective where the current practice is to
withhold food during illness. Other factors, such as
the adequacy of a child's usual diet and the parent's
ability to purchase food, will also influence the impact
of ORT.
NUTRITIONAL THERAPY
The subcommittee recommends continued feeding during
the active and early convalescent phases of diarrhea.
The benefits to be expected vary with the nutritional
quality of the foods offered, which can be increased by
temporary fortification. Even the usual diet, however,
is better than no food at all.
The primary objective of feeding should always be to
minimize the adverse effects of the illness on
nutritional status. A secondary objective is to promote
normal intestinal mucosal renewal and absorptive and
digestive functions. The objectives of therapy are the
same whether it is provided at home, in a community
health clinic, or in a hospital. Although more complex
- 13
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individualized dietary treatment might be available in a
hospital, the therapeutic principles are similar in all
settings.
Feeding will not diminish the necessity to maintain
fluid balance. Water and electrolytes must be included
in the assessment of nutrient needs. As noted, proper
Dehydration is the first therapeutic goal. Once normal
hydration status is restored--usually within a few
hours--dietary intake can resume.
Ideal therapy provides the nutrients to meet the
increased demands of illness and catch-up growth, in
addition to the usual requirement for maintenance,
growth, and physical activity. Choice of foods, mode of
preparation, and frequency of feeding depend on the
child's age, feeding history, and physiologic status.
Particular attention should be given to the nutrient
density of the food used, the quality of its
carbohydrate and fat, the biologic value of its protein,
and, if appropriate, its osmolarity. The need for
specific nutrient supplements also must be considered.
Cultural factors are particularly important
determinants of the management of diarrhea.
_ . . ~
c, _ .
Withholding
of food by a child s caretaker and failure to compensate
for a decrease in food intake during illness by
increasing feeding during convalescence are major
contributors to the adverse nutritional effects of
diarrhea. In addition to folk beliefs, medical advice
often supports the withholding of particular foods
during and after diarrhea. It will be difficult to
change folk beliefs without first obtaining the support
of the various medical practitioners in the community.
Careful attention will need to be paid to this group.
The development of specific protocols for the
dietary management of acute diarrhea in different
settings goes beyond the scope of this discussion. In
some cases, specific questions will need to be answered
and protocols tested before a diet is recommended.
However, sufficient information is available to provide
guidance that can be useful in the development of
clinical protocols for all levels of care--home,
community-based clinic, and hospital.
- 14
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CHOICE OF FOODS
Clear, pragmatic, and generally applicable sets of
feeding recommendations need to be formulated for
distinct sociocultural settings. In preparing such
recommendations, it is important to understand the
factors that affect food choices and target
populations. Criteria for choosing diets to meet normal
requirements and the additional needs for catch-up
growth should include the nutrient composition and
density of the foods, familiarity of the foods, and the
possibility of complementary nutrient mixtures that
maximize absorption, particularly that of
carbohydrates. The development of specific feeding
recommendations is constrained by cultural norms and
practices, economic limitations, the availability of
foods, and difficulty in preparing foods in the home.
Although the immediate availability of specific foods
and their costs usually are considered early in
treatment, their continued availability and costs during
the longer period of convalescence and catch-up growth
are equally important.
Food choices should be influenced by preillness
feeding histories. For example, breast-feeding should
be continued if possible. If a breast-fed child less
than 6 months old is growing normally, it can be assumed
that lactation is adequate and that nutritional deficits
can be corrected with breast milk alone. Ideally,
normal growth can be documented from measurements taken
during routine examinations. If those data are not
available, weight for length greater than the fifth
percentile can be used as a crude indicator that breast
milk is adequate. For infants older than 6 months with
or without wasting, breast-feeding should be continued,
but should be complemented with other foods. For the
child who has been weaned from human milk, appropriate
available weaning foods must be defined in each locale
.
The quality of the mixture of dietary proteins
should be considered in selecting foods either to
complement breast milk or to provide all a child's
nutrient intake. Protein quality should be assessed on
the basis of digestibility and the balance of essential
amino acids, which are determinants of the efficiency
with which the protein is used for maintenance and
growth. Estimates of protein quality are found in
- 15
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several reference documents, such as Energy and Protein
Requirements.14~15 Animal protein generally is more
digestible and of higher biologic quality than plant
protein. However, processing techniques can be used to
improve digestibility of vegetable protein, and proteins
from different sources can be mixed to improve their
combined food value. For example, the value of
wheat-flour protein is inferior to that of casein, but
their combination in approximately equal proportions
(55% wheat, 45% casein) has a value equivalent to that
of 100X casein; the protein value of a corn and black
bean mixture (equal proportions) is substantially higher
than that of either component; and the value of a
mixture of corn and milk proteins (equal proportions) is
higher than that of either component. Clinical and
dietetic personnel must be encouraged to identify
locally available foods that can be combined to increase
food value economically.
Allergenic proteins, such as those found in cow's
milk, can easily cross a damaged intestinal mucosa and
sensitize a child. However, the subcommittee believes
that this risk is small, compared with the benefits of
continued nutrient intake. Known sensitivity to
specific foods contraindicates their use in dietary
management in an individual case.
On the basis of the fat-to-energy ratio of human
milk,2 which is considered to provide an optimal
combination of nutrients for an infant, the subcommittee
suggests that fat should supply about 40-50% of dietary
energy during the first 6 months of life and
approximately 35-40% for the remainder of early
childhood. As the fat content falls further and further
below the recommended proportions, the quantity of food
needed to supply appropriate amounts of energy becomes
excessively large; that progression increases the risk
that energy intake will be inadequate. Vegetable fats
that include relatively high proportions of unsaturated
fat or fats of medium chain length are recommended for
the first 6 months of life and are preferred during the
early phases of treatment for diarrhea, because they are
generally more digestible and absorbable than highly
saturated, long-chain fats.l3 Plant-seed oils (e.g.,
corn and soy) are relatively high in unsaturated fats,
including the essential fatty acids. In contrast,
coconut oil is more saturated and contains relatively
- 16
OCR for page 17
high proportions of medium-chain-length fats, but
contains practically none of the essential fatty
acids.1 Although sufficient information is not
available to make specific recommendations, a
combination of unsaturated fats and mixed long-chain
saturated fats should lead to better absorption than
saturated fats alone. Although malabsorption of fats
does not appear to exacerbate diarrhea, it does prolong
nutritional rehabilitation and adversely affects the
retention of nitrogen when protein intake
is marginal.
Carbohydrates usually account for 35-55% of dietary
energy during early infancy.3 The principal types of
dietary carbohydrate are starches and the disaccharides
sucrose and lactose. Although the feeding of lactose to
infants with gastroenteritis might be considered unwise,
because of the recognized loss of intestinal lactase
activity during intestinal infection, this type of
acquired lactase deficiency is seldom total. Lactose at
a concentration equivalent to that of half-strength
cow's milk is generally well tolerated in diarrhea,
especially in mixed foods, such as milk and cereal
combinations. Sucrose, the other major dietary
disaccharide, and processed vegetable starches usually
are easily digested and absorbed by children with
diarrhea. The potentially adverse effects of dietary
carbohydrate can be minimized by multiple feedings of
small amounts of mixtures of carbohydrates. This
strategy is the least likely to strain possibly
decreased capacity for carbohydrate digestion.
The potential for carbohydrate intolerance should be
carefully addressed in clinical protocols prepared for
primary health care workers. Misconceptions about
transient intolerance to carbohydrate all too often lead
to prolonged withholding of food. As a practical
matter, if single challenges with lactose-containing
foods do not aggravate clinical symptoms, continued
tolerance during convalescence may be assumed.
The selection of foods also requires the evaluation
of bulk and nutrient concentrations relative to energy
content. One must consider gastric capacity, number of
feedings per day, and nutrient needs of the child. If
the amount of food that meets estimated energy needs
exceeds the expected gastric capacity, the diet is too
bulky. Some examples of energy-bulk relationships are
- 17
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shown in Table 1. Bulk can be reduced by increasing the
fat content of the diet. Infections accompanied by
vomiting or the consumption of foods with high osmolar-
ity or fat content will slow gastric emptying and often
decrease tolerance to bulk. To minimize these problems,
frequent feedings (e.g., every 2-4 hours, depending on
the age of the child) of smaller quantities are highly
desirable. Estimates of the energy density necessary to
meet energy requirements are shown in Table 2.
Ideally, foods should provide twice the
protein-to-calorie ratio that is normally required. No
food is likely to satisfy this ratio for all essential
nutrients at all ages, so supplementation or
fortification with key nutrients might be needed for
nutrient replenishment. Mixing of plant and animal
foods often increases the nutrient-to-calorie ratio
substantially. Diet manuals, such as Cameron and
Hofvander's Manual for Feeding Infants and Young
Children,9 and nutrition texts such as Latham's Human
Nutrition in Tropical Africa,2 suggest specific,
practical approaches for reducing food bulk and
increasing nutrient density. Cameron and Hofvander9
include sample recipes that could be developed and
tested for local use.
When a child's clinical status does not permit the
introduction of complex foods at the beginning of
treatment, the addition of starches, cereal powders,
proteins, amino acids, or small polypeptides to standard
oral Dehydration solutions can be beneficial. Such
additions might speed Dehydration by reducing stool
volume and at the same time mitigate energy and protein
deficits. If this feeding regimen is adopted, the child
should be offered more complex foods within 12 hours.
FOOD PREPARATION
In addition to the nutritional concerns described
above, preparation of food should consider consistency,
digestibility, and acceptability. Dilute watery paps or
soups and excessively bulky foods should be avoided as
primary nutrient sources if possible. When formulated
appropriately, watery paps or soups can be used as
18
OCR for page 19
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- 19
OCR for page 20
TABLE 2
Minimal Dietary Energy Density Needed to Satisfy Energy
Requirements According to Age and Number of Feedings Per Daya
Number of
Feedings
Per Day
3 6-
9-11 12-23 24-36
Expec ted body
weight, kgb 6.7 8.3 9.6 11.4 13.6
Usual energy
requirement, kcal/dayC
770 915 1,010 1,175 1,360
Estimated gastric
capacity, mid 200 250 290 340 410
Energy dens ity
necessary to meet 8 48 46 44 43 41
energy requirement, 6 64 61 58 58 55
kcal/100 mle 4 96 92 87 86 83
aCalculated by subcommittee.
b50th percentile of National Center for Health Statistics reference
weights .16
CProduct of expected body weight and FAo/WH014 energy requirements
of 115, 110, 105, 103, and 100 kcal/kg-day for ascending ale categories
dEstimated as 3% of body weight, rounded to nearest 10 ml.2
e [ 100 ( energy requirement ) / ( feedings /day) ] / ( gas tric capac ity) .
- 20
OCR for page 21
adjuncts to fluid and electrolyte therapy, but never as
a complete diet, because the concentrations of energy
and nutrients in these preparations are usually too low.
Digestibility can be influenced in various ways.
Local food-processing techniques should be used whenever
possible, because of their familiarity to the
population. For example, the digestibility of legumes
can be improved through familiar cooking, fermenting, or
germinating techniques that are not ordinarily used for
infant feeding; particle size can be reduced by using
simple food mills. If it is desirable to reduce lactose
content, partially fermented products, such as yogurt,
can be used. Mixing dried-milk preparations with
vegetables or cereals also reduces the lactose content
of the final diet potentially without reducing the
biologic value of the milk protein substantially.
Because adequate food storage facilities are
generally not available in the home, use of freshly
prepared foods to minimize microbial contamination and
growth should be encouraged. Reoffering of previously
prepared food might be unavoidable, but reheating to a
boil before feeding will reduce the hazards of consuming
heavily contaminated food.
Effective ways of communicating desirable food
preparation practices need to be developed. For
example, food preparation in a clinic or hospital can
serve as an excellent educational tool for mothers*, and
the opportunity should be taken whenever possible. Home
visits by health care workers to reinforce food
selection and food preparation lessons may well be
essential for program success.
FREQUENCY AND PROGRESSION OF FEEDING
Breast-fed infants should continue to be nursed,
even during Dehydration, by alternating between oral
Dehydration solutions and breast milk. Recent studies
*For convenience, "mother" is used to refer to the person
with primary responsibility for the care of a child.
- 21
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have shown that breast-feeding is an effective adjunct
to ORT and offsets the need to provide plain
water.20~22
Meals should be small and frequent in the early
phase, because smaller meals are better tolerated. For
older infants, at least six feedings a day should be
attempted early in treatment; more frequent feedings are
often necessary in younger infants.
When children are hospitalized and refuse to eat, it
is reasonable to consider continuous nasogastric
feeding. This approach takes full advantage of residual
digestive and absorptive capacities through the slow,
steady introduction of small quantities of food.
Nasogastric feeding might increase stool frequency
without markedly increasing stool volume. The first
meal by this route should consist of a 50% dilution of a
0.7-kcal/ml formulation; it should be followed in 3-4
hours by a meal that is diluted by 25% and then by a
full-strength meal at the next feeding. Various
strategies should be considered. For example, high
volumes of dilute feedings might be tolerated better
than equivalent amounts of nutrients in more
concentrated feedings in early phases of treatment.
When continuous nasogastric feeding is chosen, special
care must be taken to ensure that the protocols for
preparation and delivery include steps to minimize
contamination. As in the preparation of other foods, it
is best to prepare these immediately before use and not
to leave more food than needed for 4 hours of feeding at
room temperature at the bedside.
During convalescence, defined as extending from
cessation of liquid stools to return to preillness
nutritional status, the quantity and frequency of
feeding are determined by ad libitum intakes. Keeping
track of a child's weight will ensure that ad libitum
intakes meet the estimated nutrient needs and that the
. ·
. . .
race or recovery is appropriates Flexibility in the
reeking regimen promotes rapid convalescence. The early
resumption of the customary feeding pattern, which
probably includes three or four meals per day for older
infants and very young children, is unlikely to provide
sufficient nutrients for full recovery in a reasonable
period.
.
22
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MONITORING NUTRITIONAL THERAPY FOR DIARRHEA
In the monitoring of nutritional therapy for
diarrhea, close clinical observation of the
child--including food intake, willingness to eat,
activity, and apparent discomfort- might be more useful
than merely keeping track of the frequency, quantity,
and quality of stools.
The mother plays a key role in the management of the
dietary intake of a child with acute diarrhea, and her
ability to assess the child's progress is therefore
critical. To help gain the mother's confidence, health
workers need to be sympathetic to her perception of the
cause, course, and desired treatment for diarrhea. Many
cultures distinguish a considerable array of diarrhea!
illnesses, which have different causes and treatments.
These can be the basis for deriving credible, simple,
and physiologically sound guidelines to help a family
manage diarrhea in the home, as well as to decide when a
child should no longer be treated at home, but should be
taken to a clinic or hospital. Easily recognized
indicators of the severity of illness should be used in
the formulation of these guidelines--e."., frequency of
stools, duration of illness, clinical signs of
dehydration, state of alertness, willingness to eat and
drink, fever, and blood in the stools. Primary health
care workers also need criteria for identifying infants
who require more individualized attention. The criteria
should reflect educational and physical resources
available at each level of health care--home,
and hospital. Sophisticated indicators of clinical
(e.g., measurement of fluid input
and stool output), but daily monitoring of weight gain
is more feasible and highly useful. In an optimal
regimen, a daily gain of at least 20 or 30 g in a
previously healthy child can be expected. with much more
status would be useful
~ . .
clonic,
, .
weight gain seen in a recovering child who had been
undernourished.
Whenever care outside the home is warranted, health
workers should involve the mother to the greatest extent
possible. If she is taught basic facts about
dehydration and feeding and participates in her child's
care and recovery, she is more likely to recognize the
importance of feeding during diarrhea and to continue
feeding during future episodes. Ideally in all cases,
- 23
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the mother should feed the child, for she usually has
the experience necessary to succeed in this feeding. In
many societies, however, women are overwhelmed with
demands on their time, and finding the time necessary
for the almost continuous feeding required for rapid
recovery is difficult. If the time required for the
optimal care of an acutely ill child is beyond the
mother's resources, older siblings, grandparents, and
fathers can often be enlisted to share the
responsibility.
Although following these guidelines will usually
result in a successful outcome, dietary management
sometimes fails. Failure cannot be predicted, but it is
most likely in children who were already moderately to
severely malnourished. In such children, salt and water
deficits can be corrected, but hypokalemia, common in
undernourished children, might persist for several
days. Potassium-containing foods (e.g., citrus juices
and bananas) are useful adjuncts to oral Dehydration.
Whether at home or in the clinic, failure to respond can
be anticipated if the patient's hydration status does
not improve within 24 hours of the beginning of oral
Dehydration and dietary management.
Once feeding begins, refusal to eat, extensive
vomiting after eating, and increased stool output are
signs of food intolerance.
complaints associated with the production of gas or
explosive diarrhea are also important signs of food
intolerance and are usually related to the carbohydrates
being fed. High stool acidity and the presence of large
amounts of reducing substances in the stool are due to
malabsorption of carbohydrates. If clinical status is
clearly worsening, the carbohydrates being fed should be
changed or lessened. The presence of undigested food
particles in the stool is evidence of the need for
longer cooking time, greater use of refined raw
materials, or the use of more finely pureed foods.
Abdominal distention and
In adjusting dietary management because of these
adverse clinical responses, it is important to stress
that it is the child, and not the stool, that is being
treated. Feeding should continue even in children whose
diarrhea! losses have continued, if their intake and
weight gain are appropriate. Discontinuation of feeding
should not be considered an option. If substantial
- 24
-
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diarrhea continues, fluid replacement is necessary--with
either oral rehydration solution or, when absolutely
indicated, intravenous fluids--and the diet should not
be changed too often. It usually takes 2-3 days to
assess clinical response. This allows time for the
natural diarrhea process to abate and any complications
of feeding to become apparent. Continued feeding often
improves absorptive capacity, as substrates needed for
tissue repair are provided; however, treatment of more
difficult cases might require the introduction of
simpler, more easily digested foods.
ANTIBIOTIC AND ANTIDIARRHEAL AGENTS
Adequate fluid replacement alone can usually prevent
death from secretory (watery) diarrhea. However, in
some severe cases of secretory diarrhea (e.g., in
cholera), adjunctive therapy with antibiotics markedly
reduces the duration and volume of diarrhea.
Antimicrobial therapy is more important for dysenteric
diarrhea! illness than for secretory diarrhea.
Antibiotics might decrease the duration of diarrhea, the
period of discomfort, the potentially lethal
complications of gram-negative bacterial infection, and
the nutritional deterioration caused by excessive loss
of protein in stools in such infection.
Antidiarrheal drugs--such as diphenoxylate,
loperamide, tincture of opium, and paregoric--can reduce
symptoms of abdominal cramps, but do not substantially
alter diarrhea! stool losses and might even prolong the
illness. Adsorbents--such as kaolin, pectin, and
activated charcoal--have no value in the treatment of
infectious diarrhea. Bismuth subsalicylate in very
large doses decreases the number of stools, but is not a
practical or cost-effective therapeutic agent. In
addition, substantial absorption of the salicylate might
lead to toxicity, especially in children. Antisecretory
drugs might reduce stool volume moderately, but are not
effective enough to justify the expense and the risk of
side effects.
25
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Representative terms from entire chapter:
oral rehydration
