1) Diarrhea can cause secondary lactase deficiency and lactose intolerance by damaging the intestinal mucosa. This reduces absorption of lactose from cow's milk and regular formula. 2) Studies show low lactose formula improves early weight gain and recovery in infants with acute diarrhea compared to regular formula. Low lactose formula also improves recovery of lactose tolerance after diarrhea resolves. 3) For infants and children with diarrhea, guidelines recommend continued breastfeeding and early refeeding with low lactose foods and formula instead of complete milk avoidance to support adequate nutrition and faster recovery.

1. Nutritional Management of
Diarrhea

2. Agenda
What is diarrhea and what are different types?
Intestinal mucosal damage and impact on nutrition
Secondary Lactase Deficiency during diarrhea
Nutritional interventions in diarrhea

3. Acute
watery
diarrhoea
• Severe fluid loss and rapid dehydration in infected
patients which last for few hours or days(<14days)
• Common etiologic pathogens: V. cholera, or E. coli,
and rotavirus
Bloody
diarrhoea
• Intestinal damage and nutrient losses in infected
patients with blood in the stools
• It is also termed as dysentery
• Common etiologic pathogen : Shigella bacteria
Persistent
diarrhoea
• Continuous episode of diarrhea, with or without
blood loss, lasting for a minimum of 14 days
• Commonly affected: Malnourished children and
those with illnesses such as AIDS
UNICEF/WHO. Diarrhoea: Why children are still dying and what can be done? WHO 2009
Diarrhea
Passage of unusually loose or watery stools at least 3 times in 24
hours; stool consistency rather than frequency is most important
for infants
C
L
A
S
S
I
F
I
C
A
T
I
O
N

4. Childhood diarrhea is a major public
health burden in India1
Diarrhea is third most common
cause of death in children under
five years of age in India2
1.Shah D, Choudhury P, Gupta P, et al. Promoting appropriate management of diarrhea: a systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and
child health, India. Indian Pediatr. 2012;49(8):627-49.
2. Bajait C, Thawani V. Role of zinc in pediatric diarrhea. Indian J Pharmacol. 2011 May;43(3):232-5.
3. International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005–06: India: Volume I. Chapter 9. Child health page
no 223-266
Highest incidence of 18%
among children between 6-11
months2
Approximately 13.8 % in
children between 12-23
months2

5. Rotavirus is the leading cause of severe
diarrhea in Indian children under five years1
15-30% of diarrheal episodes in
hospitalized children, 7-15% in
community infections are caused
due to rotavirus
Shigella infection accounts for 10-
20% of diarrheal episodes
Infection with Vibrio cholerae can
lead to cholera outbreaks and
commonly affected children are 2-
5 year of age
1. Shah D, Choudhury P, Gupta P, et al. Promoting appropriate management of diarrhea: a systematic review of literature for advocacy and action:
UNICEF-PHFI series on newborn and child health, India. Indian Pediatr. 2012;49(8):627-49.
2. Kahn G,Fitzwater S, Tate J et al. Epidemiology and Prospects for Prevention of Rotavirus Disease in India. Indian Pediatr 2012;49: 467-474
Most Rotaviral infection
occurs in children under 2
years of age2
Prevalence of rotavirus
diarrhea is high in neonates
(22%-73%), in India2

6. Vicious circle of diarrhoea-malnutrition
Infection
(viral, bacterial etc.)
Diarrhoea
Intestinal Mucosa damage
/ Villous atrophy
Nutrient Loss
(Macro & micro)
Malnutrition
Loss of fluid &
electrolytes
Decreased Immunity
Reduced Lactase enzyme
Secondary Lactose
Intolerance

7. Impact of diarrhea on nutritional
status
Increased metabolic needs1
Increased protein and nutrient loss1
 Reduction in micronutrient levels (E.g. zinc and
copper1,2)
1. Guerrant RL, Oria RB, Moore SR et al. Malnutrition as an enteric infectious disease with long-term effects on child development. Nutr Rev. 2008;66(9):487-509
2. Zinc and copper wastage during acute diarrhea. Nutr Rev. 1990;48(1):19-22

8. Decreased nutrient absorption during
diarrheal episodes
Diarrheal episodes result in villous atrophy and intestinal epithelial cell
damage resulting in
Decrease in absorption of micronutrients1
Decrease in absorption of macronutrients1
1.DeBoer MD, Lima AA, Oría RB et al. Early childhood growth failure and the developmental origins of adult disease: do enteric infections and malnutrition increase risk
for the metabolic syndrome? Nutr Rev.2012;70(11):642-53.

9. Intestinal mucosal damage and its effect
on lactase secretion
 Lactase enzyme is located in the internal lining (Brush border
(microvilli) of the small intestine (Enterocyte).1
 Reduction in the surface area of the microvilli caused by
infections is associated with reduced levels of enzymes
(including lactase) that are vital for digestion and absorption of
sugars.2,3
1. Swagerty DL. Lactose Intolerance. Am Fam Physician. 2002 May 1;65(9):1845-1851.
2. Vesa TH, Marteau P, Korpela R, et al. Lactose Intolerance. J Am Coll Nutrition. 2000;19:165S–175S.
3. Mohammadi SS, Singer SM. Regulation of intestinal epithelial cell cytoskeletal remodeling by cellular immunity following gut infection. Mucosal
Immunology 2013; 6:369–378
4. Guidance on the management of lactose intolerance and cow’s milk protein allergy and the prescription of specialized infant formula. NHS
5. Evidence-Based Research in Pediatric Nutrition. edited by H. Szajewska, R. Shami World Review of Nutrition and Dietetics 2013. Karger Publications
Secondary lactose intolerance lasts for 6 to 8 weeks4
Lactase activity returns to normal following healing of
damaged epithelium5

10. Congenital
Type of lactase
deficiency
Definition Characteristics
Complete absence of
lactase from birth
• Very rare
There are several types of
lactase deficiency
Heymann MB for the Committee on Nutrition, American Academy of Pediatrics Lactose intolerance in infants, children and adolescents. Pediatrics 2006; 118(3):1279-86.
Primary
Decline in lactase
levels after birth to
clinical lactose
intolerance
Affects:
• 2% of adults in Northern Europe and North
America
• Nearly 100% of adults in Asia and American
Indian
• 60-80% of Africans and Ashkenazi Jew
• 50-80% of Latin Americans
Secondary
(transitory)
Temporary
deficiency resulting
from an injury of
the intestinal
mucosa
• Can follow gastrointestinal illness that
damages intestinal epithelial cells
• Young children with severe diarrhea are
at risk
• Up to 77% of children hospitalized with
acute diarrhea have lactose intolerance

11. Carbohydrate Intolerance in
Indian children with Acute Diarrhea
30.3
39.5
55.7
0
10
20
30
40
50
60
Incidence of
Carbohydrate intolerance
Well-
nourished
Under-
nourished
Marasmic
40.6% (110 infants) with
carbohydrate intolerance.
Incidence of carbohydrate
intolerance increased with
the degree of
malnourishment.
Percentageofinfants
1. Chandrasekaran R, Kumar V, Walia BN, Moorthy B. Carbohydrate intolerance in infants with acute diarrhoea and its complications. Acta Paediatr Scand. 1975
;64(3):483-8.

12. Secondary Lactose Intolerance in acute
diarrhea
0
0
0
1
1
1
14
6
90
Lactose-intolerant
Multiple Disaccharide
intolerance
Monosaccharide intolerance
Out of 110 infants with carbohydrate
intolerance, 90 infants had lactose intolerance.
Proportion of
carbohydrate
intolerant infants
Chandrasekaran R, Kumar V, Walia BN, Moorthy B. Carbohydrate intolerance in infants with acute diarrhoea and its complications. Acta Paediatr Scand. 1975 ;64(3):483-8.

13. Nutritional Interventions for diarrhea

14. Current Nutritional advices in Nutritional
Management of Diarrhea
• Breast feeding
• ORS
• Stop milk completely
• Low lactose diet (Curd
etc.)
• Banana
• Diluted cow’s
milk/formula
• Fruit Juice
• Glucose beverages
• Coconut water
• Khichdi (Rice Lentils)
• Lactose Free formula

15. • Early reintroduction of
feeds after acute
gastroenteritis risked
exacerbating the
illness, causing
protracted diarrhea
• Starvation for 24
hours or even longer
1. Murphy MS. Guidelines for managing acute gastroenteritis based on a systematic review of published research. Arch Dis Child. 1998;79(3):279-8
Early refeeding is
beneficial in
diarrhea
Early feeding helps in:
• Reducing the abnormal increase in intestinal permeability
• Enhancing enterocyte regeneration and promote recovery of
brush border membrane disaccharidases
Early Refeeding during diarrhea

16. ESPGHAN Recommendations on Early Refeeding
Children who require rehydration should continue to be
fed. Food should not be withdrawn for longer than 4 to 6
hours after the onset of rehydration.
Management of
feeding in
Gastroenteritis
1. Guarino A, Albano F, Ashkenazi S, et al; European Society for Paediatric Gastroenterology, Hepatology, and Nutrition; European Society for Paediatric Infectious
Diseases. European Society for Paediatric Gastroenterology, Hepatology, and Nutrition/European Society for Paediatric Infectious Diseases evidence-based guidelines for
the management of acute gastroenteritis in children in Europe. J Pediatr Gastroenterol Nutr. 2008 ;46 Suppl 2:S81-122
ESPHAGN: European Society of Paediatric Gastroenterology, Hepatology and Nutrition.
Early Refeeding during diarrhea

17. Role of milk in the diet of the child with
diarrhea
 Milk is the main source of nutrients for the young child
According to UNICEF survey, ~29% of children were not eating anything
during diarrhea2
Limiting milk intake among young children can promote nutritional deficiency
if substitute sources of protein and energy are not consumed sufficiently1
1. Gaffey MF, Wazny K, Bassani DG, et al. Dietary management of childhood diarrhea in low- and middle-income countries: a systematic review. BMC Public Health.
2013;13 Suppl 3:S17.
2. Management Practices for Childhood Diarrhea in India. Survey of 10 districts. New Delhi: UNICEF; 2009
3. World Health Organization. Clinical management of acute diarrhea. Available at: http://www.childinfo.org/files/ENAcute_Diarrhoea_reprint.pdf accessed on 15 July
2014.
Decrease in diarrheal
frequency
Reduction in diarrheal
stool volume
 Faster recovery from
diarrhea
Advantages of Breast-feeding during diarrhea3
World Health Organisation/UNICEF
Joint statement recommends
continued breastfeeding during
acute diarrhea in children3

18. Impact of High Lactose content (Cow’s
Milk/Regular Formula) in diarrhea
Infection1 Diarrhea
Damage to the
intestinal
mucosa
Secondary
transient lactase
deficiency
Regular Lactose
formula/Cow’s milk2,3
1. Heyman MB. Lactose intolerance in infants, children, and adolescents. Pediatrics 2006; 118: 1279 -1286
2. Penny ME, Paredes P, Brown KH. Clinical and nutritional consequences of lactose feeding during persistent postenteritis diarrhea. Pediatrics. 1989;84(5):835-44.
3. MacGillivray S, Fahey T, McGuire W. Lactose avoidance for young children with acute diarrhoea. Cochrane Database of Systematic Reviews. 2013, Issue 10. Art. No.: CD005433.
DOI: 10.1002/14651858.CD005433.pub2.
Undigested/unabsorbed
lactose
Osmotically Increased fluid
secretion in gut and gas in bowel
Altered bowel movements
(persitalsis)

19. Feeding Infants with Secondary Lactose-
Intolerance
A lactose restricted diet should be given during the period of secondary
lactose intolerance.
Lactase deficiency resolves once the diarrhoea gradually diminishes with
the disappearance of underlying inflammation.
Secondary lactase intolerance is transient
1. Tomar BS. Lactose Intolerance and Other Disaccharidase Deficiency. Ind J Peadiatrics. 2014 Mar 6. [Epub ahead of print]

20. Reviewing the current options
Breast Milk
The Gold Standard
• Provides important
immune factors
Diluted Cow’s
Milk/Regular formula
Not suitable for infants
with diarrhea
• Compromises adequate
nutrition to the baby
• High osmolality
Lactose Free
formula
Limited indications
• Very severe diarrhea and
hospitalized children
• If trial with Low Lactose fails
• Congenital/Primary Lactose
Intolerance
Curd
• Good source of reduced lactose content.
• Not suitable for as a sole source of
nutrition as infant with diarrhea may
depend predominantly on milk for their
nutritional needs.

21. Clinical Evidence with Low Lactose
Formulae

22. Recovery of lactose tolerance
after acute diarrhea
% of infants able to tolerate lactose
after acute diarrhea
1. Gabr M, Maraghi S, Morsi S. Management of lactose intolerance secondary to acute diarrhea with a soy based formula. Clin Ther 1979;
2: 271-6.

23. Low Lactose Formula Improves Early Weight
Gain in Infants with Acute Diarrhea
Group A – Lactose free corn syrup formula
Group B - Low-lactose milk formula,
Group C – Standard formula
Efficacy of refeeding after rehydration in 135 infants with
gastroenteritis indicated that
1. Wall CR, Webster J, Quirk P, et al. The nutritional management of acute diarrhea in young infants: effect of carbohydrate ingested. J
Pediatr Gastroenterol Nutr. 1994;19(2):170-4.

24. Comparison of Four Feeding Regimens in Well
Nourished Infants with Acute Gastroenteritis (1/2)
Assessed for
a. Weight change among
the four treatment
groups at two and five
days
b. Duration of diarrhoea
c. Failure of treatment
Infants (aged 6 weeks to 12 months)
with acute gastroenteritis (n=200)
previously fed with formula
Group A – ORS followed by gradual standard cows' milk formula
Group B - A low lactose formula (followed by standard formula)
Group C – Standard formula
Group D - Soya based milk
1. Conway SP, Iresont A. Acute gastroenteritis in well nourished infants: comparison of four feeding regimens. Archives of Disease in Childhood 1989, 64, 87-91

25. Comparison of Four Feeding Regimens in Well Nourished
Infants with Acute Gastroenteritis (2/2)
Early Weight Gain with Low Lactose Formula
1. Conway SP, Iresont A. Acute gastroenteritis in well nourished infants: comparison of four feeding regimens. Archives of Disease in Childhood 1989, 64, 87-91
Weight gain (p=0.01)
Group A (ORS followed by standard formula) babies lost weight initially
Group B babies (Low Lactose formula) gained weight significantly during initial
days
There was no
significant difference
in the duration of
diarrhea or failure of
treatment between the
regimens.

26. Low Lactose diet in Persistent Diarrhea
A double-blind prospective trial, which included 64 children, (3-36 months of age) with diarrhoea for
at least 14 days compared the effects of a milk-based diet containing lactose or the same diet with
95% prehydrolysed lactose
Treatment failure due to excessive purging with or without refusal to accept the diet in
12.1% of children fed lactose containing diet vs. 3.2% in hydrolysed group (p=0.20)
A greater purge of a mean 74.4 g/kg per day in the lactose group vs. 42.0 g/kg per day in
the hydrolysed lactose group (p<0.01)
Stoppage of diarrhoea within 30 hours of hospital admission in 35.5% of children in the
hydrolysed lactose group vs. 3.3% of those in the lactose group (p<0.001)
Lactose containing milk formula caused greater
purging and an increased risk of dehydration in
children with persistent diarrhea.
1. Penny ME, Paredes P, Brown KH. Clinical and nutritional consequences of lactose feeding during persistent postenteritis diarrhea.
Pediatrics. 1989;84(5):835-44.
The study results indicated

27. Low Lactose diet in Persistent Diarrhea
1. Penny ME, Paredes P, Brown KH. Clinical and nutritional consequences of lactose feeding during persistent postenteritis diarrhea.
Pediatrics. 1989;84(5):835-44.
Fecal wet weight by dietary group and day of study for successfully treated boys
only.

28. IAP recommendations
Persistent Diarrhea:
• Low Osmolarity and Low Lactose diet are recommended for
children with persistent diarrhea.
• Children with persistent diarrhea, who continue to have
diarrhea on the low lactose diets, should be given lactose
(milk) free diets.
Severe Malnutrition (Hospital Based Management):
Start feeding as soon as possible with a diet, which has:
• Osmolarity less than < 350 mosm/L.
• Lactose not more than 2-3 g/kg/day.

29. High osmolality foods can aggravate
diarrhea
• Hyperosmolar foods include
– Cow’s milk
– Boiled skim milk
– Hypertonic (10 to 20%) glucose solution
– Tinned milk formulas (Regular/High
lactose content)
– Commercial glucose-electrolyte
solutions containing dextrose polymers
in high concentration (10%)
1. Hirschhorn N. The treatment of acute diarrhea in children An historical and physiological perspective. Am. J. Clin. Nutr. 1980;33: 637-663

30. Low osmolarity oral rehydration therapy
is recommended
Advantages: Decreased need for
unscheduled IV therapy, Less
stool output and lesser risk of
hypernatraemia and less
vomiting.1
Modified low osmolarity ORS has a
total osmolarity of 245 mmol/l and
reduced levels of glucose and sodium
(WHO, 2004).
1. Acute diarrhea in adults and children: a global perspective. World Gastroenterology Organization Global Guidelines, February 2012.
Constituents of low osmolarity ORS
solution1
ORS: oral rehydration salts, WHO: World Health Organization

31. Maltodextrin
A polysaccharide used in place of glucose in standard ORS
Compared to standard ORS,
maltodextrin when hydrolysed
may yield more glucose without
increasing intraluminal
osmolarity
The increased
glucose may
promote higher
absorption of
sodium and
water
May reduce
the stool
output
Glucose
• 20g/L; total osmolarity
311 mmol/L
Maltodextrin
• (30-80g/L; total
osmolarity about
230mmol/L)
Suggested
mechanis
m of
action
1. EB-Mougi M, Hendawi A, Koura H, et al. Efficacy of standard glucose-based and reduced osmolarity maltodextrin-based oral rehydration
solutions: Effect of sugar malabsorption. Bulletin of the World Health Organization. 1996;74(5): 471–477.

32. Medium Chain Triglycerides
• The WHO recommends feeding of fats or oils during
diarrhea:
– To enhance the nutrient density of foods
– To provide maximum energy when there is limited absorptive
capacity
• Medium-chain triglycerides can be used as a supportive
nutritional therapy as they:
– Increase the calorie value
– Improve the palatability, digestibility, absorption and transport of a
diet indicated for diseases with maldigestion/malabsorption
1. Tanchoco CC, Cruz AJ, Rogaccion JM, et al. Diet supplemented with MCT oil in the management of childhood diarrhea. Asia Pac J Clin Nutr. 2007;16
(2):286-292.

33. • Easily hydrolysed and rapidly absorbed
• Can be absorbed even before hydrolysis
• Do not enter the lymph system and they pass through the
portal venous system as albumin-bound free fatty acids
• Do not require lipoprotein lipase for oxidation as they are
incorporated into chylomicrons
Medium Chain Triglycerides (MCTs)
1. Tanchoco CC, Cruz AJ, Rogaccion JM, et al. Diet supplemented with MCT oil in the management of childhood diarrhea. Asia Pac J Clin Nutr. 2007;16
(2):286-292.

34. Clinical Evidence
MCT: Medium chain triglycerides
1. Tanchoco CC, Cruz AJ, Rogaccion JM, et al. Diet supplemented with MCT oil in the management of childhood diarrhea. Asia Pac J Clin Nutr. 2007;16
(2):286-292.
*3 tsp MCT oil equally divided and incorporated in
formula/daily meals given during the diahrreal episode.
• Higher rate of weight gain in MCT supplemented children (0.22 ± 0.22
kg/day) compared to the non-supplemented children (-0.048 ± .26
kg/day; p=0.042)
• Decreased trend towards reduction in the duration of intervention
• Safe; no vomiting, dehydration, or fat intolerance
• No increase in the serum cholesterol and triglyceride levels
Therapeutic effects and safety of MCT oil
supplementation* in children (aged 6 months
to 47 months, n=17) with diarrhea:

35. Zinc Supplementation
1. Khan WU, Sellen DW, University of Toronto, Toronto, Canada. April 2011. Zinc supplementation in the management of diarrhoea.Available at:
http://www.who.int/elena/titles/bbc/zinc_diarrhoea/en/ Accessed on: 03 Apr 2014.
2. Galvao TF, Thees MFRS, Pontes RF, et al. Zinc supplementation for treating diarrhea in children: a systematic review and meta-analysis. Rev Panam Salud Publica.
2013;33(5):372–377.
Zinc aids in protein synthesis, cell growth and
differentiation, immune function, and intestinal transport
of water and electrolytes.1
Zinc supplementation along with ORS has
shown:1
Reduction in the duration and severity of diarrheal
episodes
Reduction in the possibility of subsequent infections
over 2–3 months
A 2013 systematic review and metaanalysis of 18 randomized
clinical trials has also confirmed that oral zinc supplementation in
children <5 years significantly reduces duration of the diarrhea.
This effect is more prominent in malnourished children.2

36. Mechanism of Action of Zinc
Inhibits cAMP-induced, chloride-dependent fluid secretion
by obstructing basolateral potassium channels
Enhances the absorption of water and electrolytes
Improves restoration of the intestinal epithelium and boosts
the levels of brush border enzymes
Enhances the immune response and thereby promotes
better clearance of the pathogens
1. Baiait C, Thawani V. Role of zinc in pediatric diarrhea. Indian J Pharmacol. 2011;43(3):232–235.

37. Based on the WHO/UNICEF/IAP
recommendations, Government of India
recommends:1
• Supplementation to be started as soon
as diarrhea starts
• Children >6 months: 20 mg/day of
elemental zinc for 14 days
• Children aged 2-6 months: 10 mg/day
of elemental zinc for 14 days
1. Shah D, Choudhury P, Gupta P, et al. Promoting appropriate management of diarrhea: a systematic review of literature for advocacy and action: UNICEF-PHFI series on
newborn and child health, India. Indian Pediatr. 2012;49(8):627-49 7
Recommendation by Government of India

38. Nucleotides
• Non-protein nitrogenous compounds1
• Supports Immunity: Increased Serum IgA
concentrations
• Favourable effects on the fecal microbial
composition (increase in bifidobacteria)1
• Exert trophic effect on GI epithelium3
1. Singhal A, Macfarlane G, Macfarlane S, et al. Dietary nucleotides and fecal microbiota in formula-fed infants: a randomized controlled trial. Am J Clin
Nutr. 2008 ;87(6):1785-92.
2. Yau KI, Huang CB, Chen W, et al. Effect of nucleotides on diarrhea and immune responses in healthy term infants in Taiwan. J Pediatr Gastroenterol Nutr.
2003;36(1):37-43.
3. http://www.ncbi.nlm.nih.gov/books/NBK54100/
Nucleotide supplementation has beneficial effects on
the growth of the intestinal epithelium.3

39. Summary and Conclusion
In India, childhood diarrhea accounts for third most common
cause of death in under five age group
Diarrhea results in villous atrophy and decreased absorption of
micro-and macro-nutrients. The lactase-containing epithelial
cells may be lost , leading to secondary lactase deficiency.
There is increased nutritional requirement during diarrheal
episode and energy dense foods are recommended.
Presence of lactose intolerance can lead to prolongation of
diarrhea and milk containing products may worsen diarrhea.

40. Summary and Conclusion
Use of a low lactose diet enables milk consumption even during
diarrhea which constitutes a major portion of an Infant’s diet.
Lactose free formulations should be reserved for severe lactose
intolerance where the trial with low lactose diet has failed
Use of Zinc, Medium-chain triglycerides (MCTs), Maltodextrins
and Nucleotides along with early refeeding is a novel approach
in the nutritional management of diarrhea.

41. Thank you