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Nutritional Management of
Diarrhea
Agenda
What is diarrhea and what are different types?
Intestinal mucosal damage and impact on nutrition
Secondary Lacta...
Acute
watery
diarrhoea
• Severe fluid loss and rapid dehydration in infected
patients which last for few hours or days(<14...
Childhood diarrhea is a major public
health burden in India1
Diarrhea is third most common
cause of death in children und...
Rotavirus is the leading cause of severe
diarrhea in Indian children under five years1
15-30% of diarrheal episodes in
hos...
Vicious circle of diarrhoea-malnutrition
Infection
(viral, bacterial etc.)
Diarrhoea
Intestinal Mucosa damage
/ Villous at...
Impact of diarrhea on nutritional
status
Increased metabolic needs1
Increased protein and nutrient loss1
 Reduction in ...
Decreased nutrient absorption during
diarrheal episodes
Diarrheal episodes result in villous atrophy and intestinal epithe...
Intestinal mucosal damage and its effect
on lactase secretion
 Lactase enzyme is located in the internal lining (Brush bo...
Congenital
Type of lactase
deficiency
Definition Characteristics
Complete absence of
lactase from birth
• Very rare
There ...
Carbohydrate Intolerance in
Indian children with Acute Diarrhea
30.3
39.5
55.7
0
10
20
30
40
50
60
Incidence of
Carbohydra...
Secondary Lactose Intolerance in acute
diarrhea
0
0
0
1
1
1
14
6
90
Lactose-intolerant
Multiple Disaccharide
intolerance
M...
Nutritional Interventions for diarrhea
Current Nutritional advices in Nutritional
Management of Diarrhea
• Breast feeding
• ORS
• Stop milk completely
• Low lact...
• Early reintroduction of
feeds after acute
gastroenteritis risked
exacerbating the
illness, causing
protracted diarrhea
•...
ESPGHAN Recommendations on Early Refeeding
Children who require rehydration should continue to be
fed. Food should not be ...
Role of milk in the diet of the child with
diarrhea
 Milk is the main source of nutrients for the young child
According ...
Impact of High Lactose content (Cow’s
Milk/Regular Formula) in diarrhea
Infection1 Diarrhea
Damage to the
intestinal
mucos...
Feeding Infants with Secondary Lactose-
Intolerance
A lactose restricted diet should be given during the period of seconda...
Reviewing the current options
Breast Milk
The Gold Standard
• Provides important
immune factors
Diluted Cow’s
Milk/Regular...
Clinical Evidence with Low Lactose
Formulae
Recovery of lactose tolerance
after acute diarrhea
% of infants able to tolerate lactose
after acute diarrhea
1. Gabr M, M...
Low Lactose Formula Improves Early Weight
Gain in Infants with Acute Diarrhea
Group A – Lactose free corn syrup formula
Gr...
Comparison of Four Feeding Regimens in Well
Nourished Infants with Acute Gastroenteritis (1/2)
Assessed for
a. Weight chan...
Comparison of Four Feeding Regimens in Well Nourished
Infants with Acute Gastroenteritis (2/2)
Early Weight Gain with Low ...
Low Lactose diet in Persistent Diarrhea
A double-blind prospective trial, which included 64 children, (3-36 months of age)...
Low Lactose diet in Persistent Diarrhea
1. Penny ME, Paredes P, Brown KH. Clinical and nutritional consequences of lactose...
IAP recommendations
Persistent Diarrhea:
• Low Osmolarity and Low Lactose diet are recommended for
children with persisten...
High osmolality foods can aggravate
diarrhea
• Hyperosmolar foods include
– Cow’s milk
– Boiled skim milk
– Hypertonic (10...
Low osmolarity oral rehydration therapy
is recommended
Advantages: Decreased need for
unscheduled IV therapy, Less
stool o...
Maltodextrin
A polysaccharide used in place of glucose in standard ORS
Compared to standard ORS,
maltodextrin when hydroly...
Medium Chain Triglycerides
• The WHO recommends feeding of fats or oils during
diarrhea:
– To enhance the nutrient density...
• Easily hydrolysed and rapidly absorbed
• Can be absorbed even before hydrolysis
• Do not enter the lymph system and they...
Clinical Evidence
MCT: Medium chain triglycerides
1. Tanchoco CC, Cruz AJ, Rogaccion JM, et al. Diet supplemented with MCT...
Zinc Supplementation
1. Khan WU, Sellen DW, University of Toronto, Toronto, Canada. April 2011. Zinc supplementation in th...
Mechanism of Action of Zinc
Inhibits cAMP-induced, chloride-dependent fluid secretion
by obstructing basolateral potassium...
Based on the WHO/UNICEF/IAP
recommendations, Government of India
recommends:1
• Supplementation to be started as soon
as d...
Nucleotides
• Non-protein nitrogenous compounds1
• Supports Immunity: Increased Serum IgA
concentrations
• Favourable effe...
Summary and Conclusion
In India, childhood diarrhea accounts for third most common
cause of death in under five age group
...
Summary and Conclusion
Use of a low lactose diet enables milk consumption even during
diarrhea which constitutes a major p...
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Nutritional management of diarrhea

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Nutritional management of diarrhea

  1. 1. Nutritional Management of Diarrhea
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 13. Nutritional Interventions for diarrhea
  14. 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. 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. 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. 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. 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. 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. 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. 21. Clinical Evidence with Low Lactose Formulae
  22. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 41. Thank you

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