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Nutritional Management of Acute Diarrhea in Infants and Children Subcommittee on Nutrition and Diarrheal Diseases Control Committee on I International Nutrition Programs Food and Nutrition Board Commission on Life Sciences National Research Council NATIONAL ACADEMY PRESS Washi ngton, D.C. 1985

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the coun- cils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The National Research Council was established by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and of advising the federal government. The Research Council operates in accordance with general policies determined by the Academy under the authority of its congressional charter of 1963, which establishes the Academy as a private, nonprofit, self-governing membership corporation. The Research Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in the conduct of their services to the government, the public, and the scientific and engineering communities. It is administered jointly by both Academies and the Institute of Medicine. The National Academy of Engineering and the Institute of Medicine were established in 1964 and 1970, respectively, under the charter of the National Academy of Sciences. The study summarized in this report was supported by Contract AID-ta-C-1428 and Grant DAN-0262-G-SS-4086-00 from the Agency for International Development. Copies available from: Food and Nutrition Board National Research Council 2101 Constitution Avenue, N.W. Washington, D.C. 20418 Printed in the United States of America

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SUBCOMMITTEE ON NUTRITION AND DIARRHEAL DISEASES CONTROL Richard A. Cash (Chairman), Harvard Institute for International Development, Cambridge, and Office of International Health, Harvard School of Public Health, Boston, Massachusetts Robert E. Black, Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland Kenneth H. Brown, Instituto de Investigacion Nutricional, Lima, Peru, and Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland Cutberto Garza, United States Department of Agriculture Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas Gerald Keusch, Division of Geographic Medicine, Tufts-New England Medical Center, Boston, Massachusetts Jon Rohde, Management Sciences for Health, Port-au-Prince, Haiti W. Allan Walker, Massachusetts General Hospital and Children's Hospital Medical Center, Boston, Massachusetts Linda D. Meyers, Senior Staff Officer Norman Grossblatt, Editor

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COMMITTEE ON INTERNATIONAL NUTRITION PROGRAMS Abraham Horwitz (Chairman), Pan American Health Organization, Washington, D.C. Maiden C. Nesheim (Vice-Chairman), Division of Nutritional Sciences, Cornell University, Ithaca, New York William P. Butz, Bureau of the Census, Washington, D.C. Cutberto Garza, United States Department of Agriculture Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas Reynaldo Martorell, Food Research Institute, Stanford University, Stanford, California Ellen Messer, International Food and Nutrition Program, Massachusetts Institute of Technology, Cambridge, Massachusetts Per Pinstrup-Andersen, International Food Policy Research Institute, Washington, D.C. Jon E. Rohde, Management Sciences for Health, Port-au-Prince, Haiti Fernando Viteri, Food and Nutrition Programs, Pan American Health Organization, Washington, D.C. Marian Zeitlin, School of Nutrition, Tufts University, Medford, Massachusetts Linda D. Meyers-, Senior Staff Officer TV

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FOOD AND NUTRITION BOARD Kurt J. Isselbacher (Chairman), Massachusetts General Hospital, Boston, Massachusetts Richard J. Havel (Co-Vice-Chairman), Cardiovascular Research Center, University of California School of Medicine, San Francisco, California Hamish N. Munro (Co-Vice-Chairman), Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts William E. Connor, Department of Medicine, Oregon Health Sciences University, Portland, Oregon Peter Greenwald, Division of Cancer Prevention and Control, National Cancer Institute, National Institutes of Health, Bethesda, Maryland M. R. C. Greenwood, Vassar College, Poughkeepsie, New York Joan D. Gussow, Department of Nutrition Education, Teachers College, Columbia University, New York James R. Kirk, Research and Development, Campbell Soup Company, Camden, New Jersey Reynaldo Martorell, Food Research Institute, Stanford University, Stanford, California Walter Mertz, Human Nutrition Research Center, Agricultural Research Service, Department of Agriculture, Beltsville, Maryland J. Michael McGinnis, Office of Disease Prevention and Health Promotion, Department of Health and Human Services, Washington, D.C. Maiden C. Nesheim, Division of Nutritional Sciences, Cornell University, Ithaca, New York (continued on next page)

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FOOD AND NUTRITION BOARD (Continued) Ronald C. Shank, University of California, Irvine, California Robert H. Wasserman, Department/Section of Physiology, New York State College of Veterinary Medicine, Cornell University, Ithaca, New York Myron Winick, Institute of Human Nutrition, Columbia University, New York Sushma Palmer , Executive Director vim

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PREFACE In October 1983, the Office of Nutrition of the Agency for International Development (AID) asked the National Research Council to review nutritional aspects of acute diarrhea in children and to prepare guidelines for incorporating nutritional considerations into its treatment. In response, the Subcommittee on Nutrition and Diarrheal Diseases Control was established in September 1984 under the auspices of the Committee on International Nutrition Programs of the Food and Nutrition Board in the Research Council's Commission on Life Sciences. This report presents the results of the subcommittee's efforts. The report is written primarily for health profes- sionals who will be advising on programs and policy related to nutrition and diarrhea therapy. It is tech- nical in orientation and, although not a manual itself, can be used as a guide in preparing manuals, training courses, public education materials, and communication strategies directed toward all those responsible for child care. The message is aimed at management of diar- rhea in less-developed countries, but the information and technical insights are relevant to an understanding of diarrhea and its management throughout the world. Similarly, although many children in industrialized countries are better protected from the nutritional consequences of acute diarrhea, the recommendations in this report hold equally well for children of all countries. The first chapter examines the nutritional conse- quences of acute diarrhea and the premise that continued feeding during diarrhea is not generally harmful and e e V11 -

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indeed can be highly beneficial. Chapter 2 presents general guidance for nutritional management, including comments on choice of foods, food preparation, frequency of feeding, and monitoring of therapy. The chapter also provides an overview of oral Dehydration therapy, which is aimed at correcting electrolyte losses and maintain- ing fluid balance. Chapter 3 outlines research needs emerging from the subcommittee's literature review, and Chapter 4 summarizes the subcommittee's major findings. Two aspects of the diarrhea-nutrition complex are not covered in this report: the nutritional management of severe protein-energy malnutrition, including the diarrhea accompanying it, and the relationship of nutri- tional state of the child to susceptibility to diarrhea! and other infections. Both have been extensively reviewed elsewhere (see, for example Torun and Viteri 48 and Mata et al.28~. The subcommittee wishes to thank members of the Committee on International Nutrition Programs and the Food and Nutrition Board for their helpful comments on drafts of the report. The subcommittee also acknowl- edges the continued interest and support of Martin J. Foreman and Nicolaas Luykx of the Office of Nutrition, AID. In addition, the subcommittee is grateful for the contributions of Sushma Palmer, Executive Director, Food and Nutrition Board, who reviewed and commented on drafts; Shirley E. Cole of the Food and Nutrition Board staff, who provided administrative and secretarial assistance early in the project; Avis I. Harris, also of the Food and Nutrition Board staff, who was responsible for manuscript preparation and for design and layout of the final report; and Norman Grossblatt, of the Commission on Life Sciences staff, who edited the report. Most importantly, the subcommittee wishes to express its appreciation to Linda D. Meyers, Senior Staff Officer, Food and Nutrition Board, and convener of the subcommittee, who worked closely with us throughout the project. Her contributions were invaluable, and working with her was a pleasure foretell of us. Ric rd A. sh Chairman, Subcommittee on Nutrition and Diarrheal Diseases Control . . . veal

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CONTENTS 1 Nutritional Consequences of Acute Diarrhea . Introduction Decrease in Dietary Intake Decrease in Intestinal Absorption Increase in Nutrient Requirements Potential Complications of Continued Feeding 2 Therapy for Diarrhea . . . . . . . . Oral Rehydration Therapy Effects of Oral Rehydration Therapy on Nutritional Status Nutritional Therapy Choice of Foods Food Preparation Frequency and Progression of Feeding Monitoring Nutritional Therapy for Diarrhea Antibiotic and Antidiarrheal Agents ~ 3. Research Recommendations . Basic Research Programmatic Research 4. Summary . Appendix: Energy Needs for Recovery from the Effects of Diarrhea References . . 2 4 7 8 11 11 13 13 15 18 21 23 25 27 27 28 29 1X 31 35

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