Managing diarrhea- Current nutrition perspectives.pptx

1. Managing diarrhea-
Current nutrition
perspectives
DR.

2. IMPORTANT NOTICE: MOTHER’S MILK IS BEST FOR
THE BABY
Breastfeeding provides the best nutrition and protection from illnesses of infants. For infants, breast milk is all that is needed for the first 6 months. Breastmilk is the best and
most economical food for baby.
Warning / Caution: Infant milk substitute is not the sole source of nourishment of an infant. Careful and hygienic preparation of infant milk substitute is most essential for health.
Lactose- free infant milk substitute should only be used in case of diarrehea due to Lactose intolerance. Lactose- free infant formula should be withdrawn, if there is no
improvement in symptoms of intolerance.
Continued use of infant milk substitute should not be recommended to avoid any difficulties in reverting to breastfeeding of infants after a period of feeding by infant milk
substitute. In the event recommending infant milk substitute in addition to breastmilk or its replacement during the first 6 months, keep the costs in mind before recommending use
of infant milk formula. Un-boiled water, un-boiled bottles or incorrect dilution can make a baby ill. Always advise to follow instructions exactly.
Unnecessary introduction of partial bottle-feeding or other foods and drinks will have negative effect on breastfeeding.
Characteristics of breastmilk : Immediately after delivery, breastmilk is yellowish and sticky. The milk is called Colostrum, which is secreted during the first-week of delivery.
Colostrum is more nutritious than mature milk because it contains more proteins, more anti-infective properties, which are of great importance for the infant’s defense against
dangerous neo-natal infections. It also contains higher levels of Vitamin ‘A’.
Advantages of breastfeeding : (A) Breastfeeding is much cheaper than feeding an infant milk substitute as the cost of extra food needed by the mother is negligible as
compared to cost of feeding infant milk substitute; (B) Breastmilk is always available; (C) Breastmilk needs no utensils or water (which might carry germs) or fuel for is
preparation; (D) Mothers who breastfeed usually have longer periods of infertility after child birth than non-lactators.
Management of breastfeeding, as under:
I. Breastfeeding
A. Immediately after delivery enables the contraction of the womb and helps the mother to regain her figure quickly.
B. Is successful when the infant suckles frequently and the mother wanting to breastfeed is confident in her ability to do so.
II.In order to promote and support breastfeeding the mother's natural desire to breastfeed should always be encouraged by giving, where needed,
practical advice and making sure that she has the support of her relatives.
iii. Adequate care for the breast and nipples should be taken during pregnancy.
iv. It is also necessary to put the infant to the breast as soon as possible after delivery.
v. Let the mother and the infant stay together after the delivery, the mother and her infant should be allowed to stay together (in hospital, this is called "rooming- in").
vi. Give the infant Colostrum as it is rich in many nutrients and its anti-infective factors protect the infants from infections during the few days of its birth.
vii. The practice of discarding Colostrum and giving sugar water, honey water, butter or other concoctions instead of Colostrum should be very strongly discouraged.
viii. Let the infants suckle on demand.
ix. Every effort should be made to breastfeed the infants whenever they cry.
x. mother should keep her body and clothes and that of the infant always neat and clean.
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3. outline
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Diarrhea
Principles of therapy
Goals of nutritional management
Lactose malabsorption in diarrhea
Nutrition management in different situations
Recommendations
Summary

4. Definition
Three clinical types of diarrhoea::
Acute watery
diarrhoea – lasts
several hours or days
Acute bloody
diarrhoea – also called
dysentery
Persistent diarrhoea –
lasts 14 days or longer
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https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease
Koletzko S, Osterrieder S. Acute infectious diarrhea in children. Dtsch Arztebl Int. 2009;106(33):539–548.
Diarrhea is defined as the passage of three or more loose or liquid stools per
day (or more frequent passage than is normal for the individual). Frequent
passing of formed stools is not diarrhea, nor is the passing of loose, "pasty"
stools by breastfed babies.

5. Epidemiology
Childhood diarrhea is a major public
health burden in India.
Diarrhea is third most common cause
of death in children under five years
of age in India.
Infants and toddlers typically suffer
from acute infectious gastroenteritis
once or twice per year.
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Incidence of Diarrhea in Infants.3
1. Koletzko S, Osterrieder S. Acute infectious diarrhea in children. Dtsch Arztebl Int. 2009;106(33):539–548.
2. Shah, D., Choudhury, P., Gupta, P. et al. Indian Pediatr (2012) 49: 627.
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
0
2
4
6
8
10
12
14
16
18
20
<6
months
6-11
months
12-23
months
24-35
months
36-47
months
48-59
months
Incidence (%)

6. Causes of diarrhea
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Koletzko S, Osterrieder S. Acute infectious diarrhea in children. Dtsch Arztebl Int. 2009;106(33):539–548.
Viruses
• Rotaviruses, noroviruses, and adenoviruses responsible for
about 70% of the cases.
• Rotavirus responsible for about 40% of cases of acute
diarrheal illness in the first 5 years of life.
• Noroviruses and adenoviruses responsible for a further
30% cases.
Bacteria
• In about 20% of affected children, a bacterial pathogen can
be identified in the stool (Campylobacter jejuni, yersinia,
salmonella, shigella, pathogenic E. coli, or clostridium
difficile)
Parasites
• Parasites are the cause in fewer than 5% (lamblia,
cryptosporidia, Entamoeba histolytica, and others).

7. Clinical features of Dehydration
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Clinical features of dehydration
Mild Moderate Severe
Irritable
• Irritable
• Weak pulse
• Some reduction in urine volume
• Moribund, apathetic
• Peripheral circulatory failure (cold extremities,
warm body, excessive blanching, weak pulse)
• Marked reduction in urine volume
• Fontanelle depressed
• Eyeballs sunken
• Facies dry and pinched
• Buccal mucosa dry
• Lips parched
• Loss of skin turgor (except in in
hypernatremic variety)
• Fontanelle markedly depressed
• Eyeballs markedly sunken
• Facies markedly dry and pinched
• Buccal mucosa dry
• Lips parched
• Loss of skin turgor (except hypernatremic in
which it may not be variety prominent)
Thirsty • Thirsty • Thirsty
Understanding and Managing Acute Diarrhoea in Infants and Young Children. [Internet] 2019. [Accessed: 18 April, 2019]. Available from: https://hetv.org/resources/acute-diarrhoea.htm.

8. Diagnostic evaluation
Most important diagnostic step is clinical assessment
of the degree of dehydration.
The further diagnostic evaluation concerns the
potential complications.
Good history-taking and physical examination is the
foundation of the diagnostic evaluation.
In severe cases, when complications arise, further
studies must be performed
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Koletzko S, Osterrieder S. Acute infectious diarrhea in children. Dtsch Arztebl Int. 2009;106(33):539–548.

9. History
History-taking should follow a
structured procedure, as the
information obtained will largely
determine the further diagnostic and
therapeutic measures to be taken
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Understanding and Managing Acute Diarrhoea in Infants and Young Children. [Internet] 2019. [Accessed: 18 April, 2019]. Available from: https://hetv.org/resources/acute-diarrhoea.htm.

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Every child should be examined and weighed with clothes off. The extent of
dehydration and fluid loss can be estimated
Physical examination
Koletzko S, Osterrieder S. Acute infectious diarrhea in children. Dtsch Arztebl Int. 2009;106(33):539–548.

11. Further diagnostic testing
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Blood tests and a stool test to determine the infectious organism are generally
unnecessary in mild to moderate cases of diarrheal illness.
Blood tests are generally not necessary in cases of mild or moderate dehydration,
because the results do not influence the treatment.
Blood tests are indicated for severely dehydrated patients and/or those who will
undergo IV rehydration.
• These should include a complete blood count, acid-base status, glucose,
electrolytes, creatinine, and blood urea nitrogen.
• The urine output should be monitored in all patients with severe dehydration,
impaired renal function, or suspected infection with enterohemorrhagic E. coli
(EHEC).
Koletzko S, Osterrieder S. Acute infectious diarrhea in children. Dtsch Arztebl Int. 2009;106(33):539–548.

12. Treatment
strategies
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1. Koletzko S, Osterrieder S. Acute infectious diarrhea in children. Dtsch Arztebl Int. 2009;106(33):539–548.
2. Kapikian AZ. Viral gastroenteritis. JAMA. 1993 Feb 3;269(5):627-30.
3. Dekate P, Jayashree M, Singhi SC. Management of acute diarrhea in emergency room. Management of acute diarrhea in emergency room.
The therapeutic goal is to replace the
fluid and electrolyte losses resulting
from diarrhea and vomiting.
Oral rehydration with ORS given in
frequent, small amounts over 3–4 hours
is successful in more than 90% of cases.
Intravenous fluids are not routinely
recommended except in cases of
persistent vomiting and/or shock.
Nutritional management

13. Principles of therapy
Mild to Moderate Cases
• Fluid, electrolyte and acid-base homeostasis should be preserved and maintained.
• Nutritional status to be restored as early as possible.
• Breast feeding should be continued.
• Antimicrobial agents should be sparingly used and only for specific indications.
• There is no scientific basis for the use of anti-motility or binding agents.
• Associated features such as persistent vomiting, abdominal distension and
convulsions should be managed appropriately.
Severe cases
• The status of dehydration should be determined quickly and emergency treatment
instituted if necessary.
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Understanding and Managing Acute Diarrhoea in Infants and Young Children. [Internet] 2019. [Accessed: 18 April, 2019]. Available from: https://hetv.org/resources/acute-diarrhoea.htm.

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What is the nutritional
recommendation in the
management of infantile diarrhea?
WHO-UNICEF recommends that oral rehydration therapy, zinc
supplementation and energy dense food intake, in addition to
breast-feeding are key actions to reduce diarrhea in infants
Available from: https://www.unicef.org/media/files/Final_Diarrhoea_Report_October_2009_final.pdf. Accessed on November 26, 2016.

15. Goals of nutritional management
• To temporarily restrict the amount of animal milk (or lactose) in the
diet
• To provide a sufficient intake of energy, protein, vitamins, and minerals
• To facilitate the repair process in the damaged gut mucosa
• To improve nutritional status
• To avoid giving foods or drinks that may aggravate the diarrhea
• To ensure adequate food intake during convalescence
• To correct any malnutrition
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Diarrhea and Dehydration. [Internet] 2016. [Accessed: April 18, 2019]. Available from: https://www.aap.org/en-us/Documents/Module_6_Eng_FINAL_10182016.pdf

16. Lactose malabsorption in acute diarrhoea
The lactase enzyme that breaks down lactose is present at the tips of the intestinal villi which
makes it extremely vulnerable to intestinal injury and disorders
Acute diarrhea can cause damage to the lactase-containing epithelial cells present on the
tips of the intestinal villi, thus causing lactose malabsorption
The new epithelial often lack sufficient lactase activity, which will further exacerbate the
lactose malabsorption, with subsequent prolongation of the diarrheal episode
Disruption of the intestinal barrier during diarrhea often predisposes the infant to lactose
intolerance temporarily because of the loss of epithelial cells that contain lactase.
The osmotic effects of undigested lactose draw fluid into the intestinal lumen causing loose
stools
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1. Nabulsi M, et al Lactose-free milk for infants with acute gastroenteritis in a developing country: study protocol for a randomized controlled trial. Trials. 2015;16:46.
2. Sethi G, et al. Low lactose in the nutritional management of diarrhea: Case reports from India. Clinical Epidemiology and Global Health. 2018 Dec 1;6(4):160-2.

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Nutrition during diarrhea
Reduction in
food intake
Decrease in
absorption of
nutrients
Increase in
catabolism of
nutrient
reserves
Increased
energy
requirements
during
recovery by
~25% of the
RDA
^During recovery, an intake of at least 125% of recommended dietary allowances (RDA) should be attempted with nutrient dense food, and this should continue until the child reaches preillness weight and ideally until the child achieves a normal nutritional status1 In OP
Ghai’s Essential Pediatrics, 8th Edition; 2015, chapter 11; page 295
https://www.ncbi.nlm.nih.gov/books/NBK219100/

18. Nutrition management in different
situations?
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Exclusive
Breastfed
Continue breastfeeding
Breast feeding+ top
feeding
Continue breastfeeding +
lactose free nutrition
Exclusively top fed
Lactose free nutrition is
beneficial
Ideal but may be
difficult to meet
the additional
25% requirement
Lactose free
nutrition will
help meet the
additional 25%
requirement
Suggested feed
Predominant feed of
child
Rehydration first and then re-feeding with lactose- free nutrition should be started

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COCHRANE ANALYSIS- 2013
In young children with acute diarrhoea who are not predominantly breast-fed, changing to a lactose-free diet may result in
the earlier resolution of acute diarrhoea, and reduce treatment failure
Santosham M, Goepp Julius et al. Pediatrics 1991;87:619-622.

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Global recommendation for lactose free nutrition in
Infantile diarrhea
Recommended:
Avoid lactose-
containing milk in
children with
persistent post-
infectious diarrhoea
(diarrhoea lasting
more than 14 days)
when they fail a
dietary trial of milk
or yogurt
Lactose intolerance
occurs in some infants
as a result of acute
gastroenteritis; and
lactose free formulas
are recommended for
post diarrheal
refeeding in patients
who have signs and
symptoms of clinically
significant lactose
intolerance
Breast-feeding should
not be interrupted and
in non-breast-fed
infants and young
children, lactose-free
feeds can be
considered in the
management of
gastroenteritis. Active
therapy may reduce
the duration and
severity of diarrhea

21. Role of Zinc
• Zinc supplementation is a critical new intervention for treating diarrheal episodes in
children.
• Administration of zinc along with new low osmolarity oral rehydration solutions /
salts (ORS), can reduce the duration and severity of diarrheal episodes for up to
three months
• The World Health Organization (WHO) and UNICEF recommend:
• A dosage of 20 mg of elemental zinc per day in age group six months -to five years,
in the management of diarrhea.
• Oral zinc administration provides substantial benefit in the reduction of stool output,
frequency, and duration, combined with safety, efficacy, and affordability in acute
diarrhea
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1. Bajait C, et al. Role of zinc in pediatric diarrhea. Indian J Pharmacol. 2011 May;43(3):232-5.

22. KEY TAKE
AWAYS….
üDiarrhea can be associated with the development
of secondary lactose intolerance
ü The most important management strategy for
diarrhoea in infants is rehydrate with ORS,
replenish with zinc and refuel with energy-dense
food and continued breastfeeding
ü There is an increase in energy requirement by
25% in infantile diarrhoea
ü Breastfeeding should be continued during
diarrhoea
ü Lactose-free nutrition is clinically shown to be
effective in reducing the duration and severity of
diarrhea
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