GLOBAL ISSUES IN PEDIATRIC NUTRITION Nutrition Vol. 14, No.

10, 1998

Nutritional Management of Acute Diarrhea

PETER B. SULLIVAN, MA, MD, FRCP, FRCPCH

From the Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Oxford, UK

ABSTRACT
Despite recommendations from several bodies such as the World Health Organization and others that feeding should be
continued during diarrhea, the practice of withholding food during the early stages of diarrhea is still widespread. This contributes
to a deterioration in patients’ nutritional state. The principal controversy in the nutritional therapy of acute gastroenteritis centers
on the relative risks of cows’-milk feeds. The two things that need to be considered in determining the optimum approach to
feeding the child with acute diarrhea are the optimum timing for feeding children in relation to the onset of and recovery from
symptoms and, secondly, the effects of specific food ingredients in the diet. Recent studies have demonstrated that the vast
majority of young children with acute diarrhea can be successfully managed with continued feeding of undiluted non-human
milk. Routine dilution of milk and routine use of lactose-free formula are not necessary, especially when oral rehydration therapy
and early feeding (in addition to milk) form the basic approach to the clinical management of diarrhea in children. Confounding
factors are the severity of the diarrhea, coexistent malnutrition, and young age (! 1 y); such infants are much more likely to have
complications from early feeding with undiluted milk and some would advocate use of specifically designed lactose-free formula
in such children. Children who are fed exclusively with human milk and those who receive solid foods with or without human
milk may safely continue to receive their usual diets during diarrhea. Those who are fed exclusively with non-human
milk— especially when very young and with severe diarrhea or malnutrition—should be closely observed if they continue to
consume milk or they should receive a special formulation (e.g., a cereal-milk mixture or fermented milk product). The use of
nutrient-dense mixtures of common foods may be advisable to promote compensatory growth in those who lose weight during
illness or because of anorexia or malabsorption. Nutrition 1998;14:758 –762. ©Elsevier Science Inc. 1998

Key words: diarrhea, infantile diet therapy, diarrhea therapy, diarrhea complications, nutrition

INTRODUCTION: EPIDEMIOLOGY tion10,11 of diarrhea. Despite the fact that the benefit of rice-based
Diarrheal diseases are major causes of morbidity, with attack ORS has been clearly demonstrated in cholera-induced diarrhea,
rates ranging from 2–12 or more illnesses per person per year in its value in non-cholera diarrhea has been questioned.12 However,
developed and developing countries. In addition, diarrheal ill- it has also been suggested that replacing the glucose in ORS by
nesses account for an estimated 12 600 deaths each day in children rice, wheat hydrolysates, or dehulled legumes offsets the negative
in Asia, Africa, and Latin America.1 effect of diarrhea on the nutritional status of the patient.8,13,14

THE IMPORTANCE OF REHYDRATION THERAPY IN NUTRITIONAL CONSEQUENCES OF ACUTE DIARRHEA

MANAGEMENT Repeated episodes of acute diarrhea have significant nutritional
Many diarrheal deaths are caused by dehydration, and diarrheal consequences, and persistent diarrhea associated with malnutrition
disease control programs have emphasized the importance of has emerged as a significant health problem for children in devel-
appropriate fluid and electrolyte therapy. Since the widespread oping countries, with an estimated 3 million deaths per year in
availability of oral rehydration solution (ORS), deaths from acute children under 5 y of age. Descriptive epidemiology indicates that
diarrheal disease have been significantly reduced.2 The need for an 3–20% of episodes of acute diarrhea in children in developing
ORS that not only treats dehydration caused by acute diarrhea countries become persistent and cause about one-third to one-half
more effectively but also decreases stool volume and duration of of all deaths from diarrhea.15–17 Nutritional compromise following
diarrhea has been an impetus for research into alternative solu- acute diarrhea is often due to poor dietary practices, malabsorp-
tions. Much research has focused on the use of glucose polymers tion, and reduced nutrient intake.
derived from corn or rice powders as a replacement for glucose in
“STARVATION THERAPY”
the standard ORS.3–7 Results have shown that such rice-based
ORS is as effective as glucose-based ORS, with the additional Despite recommendations from bodies such as the World
advantages of reducing the amount5,8,9 and sometimes the dura- Health Organization and others18 that feeding should be continued

Correspondence to: Peter B. Sullivan, MA, MD, FRCP, FRCPCH, Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Oxford
OX3 9DU, UK.

Nutrition 14:758 –762, 1998

©Elsevier Science Inc. 1998 0899-9007/98/$19.00
Printed in the USA. All rights reserved. PII S0899-9007(98)00078-1
NUTRITIONAL MANAGEMENT OF ACUTE DIARRHEA 759

during diarrhea, the practice of withholding food during the early TABLE I.
stages of diarrhea is still widespread.19 In non-secretory diarrhea,
fasting decreases the volume of stool output. Thus, for many years CONSIDERATIONS WITH RESPECT TO STUDY DESIGNS AND
episodes of diarrhea were treated by withholding feeds; the mis- METHODOLOGIES
conception in both the lay and medical communities being that
“resting” the digestive tract was necessary for intestinal repair and I. Subjects
that some foods— especially milk— could not be tolerated in a. Age
children with diarrhea. Such children frequently underwent one or b. Nutritional status
more days of starvation as a part of the initial treatment and were c. Severity and duration of illness
then fed very cautiously in a way that further contributed to a d. Drug therapy
deterioration in their nutritional state. The practice of withholding II. Location of study
food and milk from children is unfortunate as, in fact, most a. Hospital
children will tolerate significant amounts of milk. Even breast Children tend to be sicker but better supervised
feeding may be discouraged in the belief that lactase deficiency b. Ambulatory
occurs in diarrheal disease to such an extent that it will exacerbate Part hospital-based and part community-based
diarrhea. Moreover, substitution of nutritional foods with dilute c. Community
preparations of low nutritional value is also commonplace and has Children may be less sick and less well supervised
numerous adverse consequences. III. Type of milk
Some of the adverse consequences of food withholding on gut a. Human
function include delayed intestinal repair with a decreased crypt b. Bovine
cell production rate, and decreases in enzymatic activity, mucosal c. “Humanized” formula
protein content, and nutrient absorption.20 –23 Willumsen et al.24 d. Formula processing (spray drying, UHT)
demonstrated the increase in intestinal permeability (as shown by IV. Method of feeding
dual sugar permeability testing with lactulose and mannitol) that a. Quantity
occurs in children with acute diarrhea. Moreover, fasting is known b. Dilution
to maintain this increased permeability, whereas early feeding c. Frequency of feedings
promotes reduction in permeability and hastens recovery.25 Sim- d. Feeding technique (ad libitum, nasogastric tube)
ilarly, early feeding leads to better enterocyte healing and main-
tenance of disaccharidase activity.26 UHT, ultra-high temperature.
RESEARCH ON FEEDING CHILDREN WITH ACUTE DIARRHEA
The question of how to refeed infants recovering from acute
diarrhea in order to avoid potential problems with carbohydrate or and in Guatemala.32 Rapid return to full feeding appropriate for
protein intolerance continues to challenge investigators in this age is associated with better weight gain and significantly shorter
field. Studies have considered the timing for feeding children with duration of diarrhea compared with gradual reintroduction of
acute diarrhea and the effects of specific dietary components. Such foods.33
studies as have been carried out often differ considerably in design Children with acute diarrhea, especially when this is accom-
and methodology (Table I) and this must be taken into account panied by systemic infection, dehydration, and metabolic acidosis,
when interpreting their often diverse conclusions. are unwell, and anorexia is common. Nevertheless, most of these
What, then, is the ideal approach to dietary therapy for diar- children will eat nutritionally significant amounts of food. To
rhea? Is it continued feeding during the acute stage of the illness counteract anorexia, palatable food should be given at frequent
or reduced feeding during illness with a compensatory “over intervals, and liquid foods are often better accepted than solid
feeding” during convalescence? The two things that need to be foods. Anorexic children, however, may need to be fed by naso-
considered, therefore, are the optimum timing for feeding children gastric tube. Food should be high in energy with a high nutrient
in relation to the onset of and recovery from symptoms, and density. Starch is the carbohydrate of choice, as foods with high
secondly, the effects of specific food ingredients in the diet. concentrations of mono- and disaccharides will increase the os-
molality of the food and potentially exacerbate the diarrhea. Local
Optimum Timing for Feeding Children with Acute Diarrhea foods are ideal and may be animal- or vegetable-based diets and
The beneficial effects of early feeding were demonstrated 50 y may also include cereals, pulses, sugar, and vegetable oil.
ago by Chung and Viscorova27 who demonstrated an increase in Effects of Specific Food Ingredients in the Diet
nutrient absorption in malnourished patients with diarrhea when
their daily nutrient intake was increased. Half a century later in Breast-feeding. Breast milk has a greater concentration of
1997, a multicenter study on behalf of the European Society for lactose than cows’ milk and yet seems to be tolerated well.
Pediatric Gastroenterology and Nutrition working group on acute Reasons for this include the facts that breast milk has a lower
diarrhea concluded that complete resumption of a child’s normal osmolality, a higher enzyme content, and contains hormonal (e.g.,
feeding, including lactose-containing formula after 4 h rehydration epidermal growth factor) and antimicrobial factors. Furthermore,
with ORS, led to significantly higher weight gain after rehydration breast milk tends to be given more frequently and in smaller doses
and during hospitalization, and did not result in worsening of than humanized formula milk by bottle.34 Overall, breast-fed
diarrhea, prolongation of diarrhea, or more lactose intolerance infants are better protected against reduced nutrient intake during
when compared with a late feeding group given the normal feed at acute diarrhea than are bottle-fed infants.35 Thus, it is now widely
24 h.28 accepted that breast-feeding should be continued in infants with
Several randomized controlled trials have compared continued acute diarrhea. Such infants have been shown both to have a
versus interrupted feeding18,29 and in none of these were adverse reduced stool output and to need less ORS.36,37 Breast-fed chil-
clinical effects of early or continuous feeding reported. Studies dren with rotavirus diarrhea have a significantly shorter duration
showing that routine dilution of milk formula had no beneficial of diarrhea when compared with non-breast-fed children fed soy
effect on clinical course of illness have been shown in the UK30,31 formula. A cardinal principle of the management of acute diar-
760 NUTRITIONAL MANAGEMENT OF ACUTE DIARRHEA

rhea, therefore, is that the breast-fed infants should continue to romyces boulardii in rehabilitation diets may be a promising
receive breast milk during the episode of diarrhea. means to counter this “dysbiosis.”58 – 62 Several studies have
shown that the administration of probiotic agents may modulate
Cows’-milk feeds. The principle controversy in the nutritional the microbial balance of the host enteric flora and attenuate acute
therapy of acute gastroenteritis centers on the relative risks of episodes of diarrhea.51,63– 66 S. boulardii, for instance, can enhance
cows’-milk feeds.28 Lactose maldigestion may occur as a tempo- expression of intestinal enzymes67 and has been shown to reduce
rary complication of diarrhea in children.38 – 40 In rotavirus gastro- the secretion induced by cholera toxin.68 Lactobacilli species have
enteritis, for example, there is both a decreased expression of been shown to improve intestinal permeability,65 inhibit bacterial
lactase and an increase in absorption of cows’ milk protein anti- attachment and invasion of intestinal cells,69 and, using fermen-
gens potentially leading to food sensitization. tation processes, have been successfully incorporated into reha-
In the early 1980s the World Health Organization recom- bilitation diets.70,71
mended dilute cows’ milk or cows’-milk formula in those infants
who are not breast-fed and the American Association of Pediatri- “Power-flour.” In addition to fermentation of foods to im-
cians recommended the use of lactose-free formula and or dilution prove the microbial ecology in the gut, other processes have been
of cows’ milk in acute diarrhea. More recently, Brown et al.41 applied to enhance the nutritional quality of food in developing
undertook a meta-analysis of 29 randomized controlled trials and countries. One such technique is the use of amylase-digested
concluded that the vast majority of young children with acute starch. Amylase from germinating cereal grains enables the prep-
diarrhea can be successfully managed with continued feeding of aration of a very palatable porridge with a higher energy density
undiluted non-human milk. Routine dilution of milk and routine and lower viscosity than conventional weaning foods.71–74 This
use of lactose-free formula are therefore not necessary, especially food can be combined with fermentation in a way that inhibits
when ORS and early feeding (in addition to milk) forms the basic pathogen growth. These inexpensive technologies are very appro-
approach to the clinical management of diarrhea in infants and priate for developing countries. In a randomized controlled trial,
children. This analysis, however, did not address the confounding Darling et al.71 demonstrated an improved energy intake in infants
effects of severity of diarrhea, degree of malnutrition, or young fed amylase-digested porridge in acute diarrhea. Moreover, in a
age (less than 1 y) in the patients. subsequent study Willumsen et al.24 also demonstrated a signifi-
Lactose-free formulas have been shown to have important cant reduction in intestinal permeability as measured by lactulose:
beneficial effects such as decreased purging rates, ameliorating mannitol excretion in children fed an amylase-digested fermented
dehydration, and decreased illness duration. When cows’ milk was porridge when compared with conventional or amylase-digested
compared with lactose-free soy formula, there was an 85% in- porridge alone. It is interesting to note, however, that these are not
crease in purging rate and a 42% increase in duration of illness “new” technologies but frequently represent traditional modes of
contributing to the increased treatment failure rate; these effects food preparation in developing countries that have been lost as
were noted to be less when milk was diluted.42 Some studies they were gradually replaced by recent methods.
(although it is noteworthy that these tended to include cases with
more severe diarrhea) show an increased severity of diarrhea Milk-cereal mixtures. Mixtures of accessible staple foods are
amongst children who receive diets containing milk or lac- safe to use during diarrheal illness and are associated with purging
tose.43– 46 Conversely, other studies detected no such differences rates that are usually less than those observed with milk or
between treatment groups.37,47,48 Thus, adverse complications soy-based diets. The fiber and resistant starch content of such diets
seem to be more likely to occur in children (especially when their are high and these probably combine with fecal water and encour-
diarrhea is more severe) who receive a milk diet containing lactose age increased colonic bacterial proliferation. In a randomized
during diarrhea than in children who receive milk- or lactose-free controlled trial, Brown et al.46 showed a wheat-noodle and milk
diets. There is, therefore, an argument for the use of a specifically diet to be safer in terms of decreased diarrheal duration and
designed lactose-free formula, especially in high-risk young mal- decreased stool output than milk diets in the dietary management
nourished infants with severe diarrhea.49 Nevertheless, in devel- of acute diarrhea. Cereals may reduce the apparent diarrheal
oped countries today lactose intolerance appears to be uncommon duration either through actual reduction in diarrheal fluid losses
and the use of lactose-free formula in the vast majority of children or by improving the stool consistency.75 Goepp et al.76 fed in-
is not justified.50 fants with a rice-syrup solid containing ORS and a rice formula,
and noted a quicker resolution of acute diarrhea than those fed
Yogurt. Although it is generally believed that non-human the standard regime consisting of glucose ORS and a soy-based
milk can safely be used as a component of rehabilitation diets in formula.
the majority of cases of acute diarrhea,41 superior results have
been obtained in management with mixtures based on yogurt, CONCLUSION
which contains its own !-galactosidase.51,52 In yogurt, lactose is
hydrolyzed to glucose and galactose and its use in place of milk In conclusion, children who are fed exclusively with human
leads to a significant improvement in lactose digestion and re- milk and those who receive solid foods with or without human
duced clinical symptomatology.53,54 milk may safely continue to receive their usual diets during
diarrhea. Those who are fed exclusively with non-human milk—
Probiotic therapy. Children in developing countries usually especially when very young and with severe diarrhea or malnu-
live in a highly contaminated environment that from an early age trition—should be closely observed if they continue to consume
exerts a significant effect on gastrointestinal microbial ecology. milk or they should receive a special formulation (e.g, cereal-milk
Bacterial contamination of the small bowel—“dysbiosis”—is a mixture or fermented milk product). The use of nutrient-dense
well-recognized feature of diarrhea in such children55–57 and its mixtures of common foods may be advisable to promote compen-
rectification is part of their nutritional rehabilitation. Inclusion of satory growth in those who lose weight during illness or because
probiotics like Lactobacillus species, Bifidobacteria, and Saccha- of anorexia or malabsorption.
NUTRITIONAL MANAGEMENT OF ACUTE DIARRHEA 761

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