Principles of management of persistent diarrhea

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In general the management of persistent diarrhea in malnourished children represents a blend of the principles of management of diarrhea and malnutrition. Associated malnutrition may be quite severe in affected children, necessitating rapid nutritional rehabilitation, often in hospital. Given

Oral rehydration therapy

This is the preferred mode of rehydration and replacement of on-going losses. While in general the standard WHO oral rehydration solution (ORS) is adequate, recent evidence indicates that hypo-osmolar rehydration fluids49,50 as well as cereal-based oral rehydration fluids may be advantageous in malnourished children. In general replacing each stool with about 50-100 ml ORS is safe.

Principles of management of persistent diarrhea 197

Persistent diarrhea

(diarrhea > 14 days with malnutrition

Assessment, resuscitation and early stabilization

Intravenous and/or oral rehydration (hypo-osmolar)

Treat electrolyte imbalance

Screen and treat associated systemic infections

Continued breast feeding Reduce lactose load by

  • Milk-cereal (usually rice-based) diet or
  • Replacement of milk with yogurt

Micronutrient supplementation (zinc, vitamin A, folate)

Recovery

Parental guidance to sustain feeding at home

Follow-up

Growth monitoring

Failure to recover

Continued or recurrent diarrhea Poor weight gain i

Reinvestigate for infections Comminuted chicken diet or green banana diet Elemental feeds i

Continued diarrhea and dehydration

Reinvestigate in the framework of the so-called 'intractable diarrhea of infancy'

Intravenous hyperalimentation

Figure 12.3 Therapeutic approach to the management of persistent diarrhea.

Enteral feeding and diet selection

Irrespective of the cellular mechanisms and structural alterations in malnourished children with persistent diarrhea, the end result is one of altered brush-border and luminal enzymes, with con sequent malabsorption. Despite the aforementioned alterations in digestive and absorptive mechanisms, analysis of studies of metabolic balance in children with persistent diarrhea indicates that satisfactory carbohydrate, protein and fat absorption can take place on a variety of diets.12,38

It is exceedingly rare to find persistent diarrhea in exclusively breast-fed infants, and with the exception of situations where persistent diarrhea accompanies perinatally acquired HIV infection, breast feeding must be continued. Most children with persistent diarrhea are not lactose intolerant, although administration of a lactose load exceeding 5 g/kg per day is associated with higher purging rates and treatment failure. In general therefore withdrawal of milk and replacement with specialized (and expensive) lactose-free formulations is unnecessary. Alternative strategies for reducing the lactose load in malnourished children with persistent diarrhea include the addition of milk to cereals as well as replacement of milk with fermented milk products such as yogurt. These dietary interventions have now been extensively evaluated in several studies in South Asia, and found to be of equivalent efficacy to expensive formulations.51,52

Rarely, when dietary intolerance precludes the administration of cow's milk-based formulations or milk, it may be necessary to administer specialized milk-free diets such as a comminuted or blenderized chicken-based diet or an elemental formulation.53 It must be pointed out that, although effective in some settings,54 the latter are unaffordable in most developing countries. In addition to rice-lentil formulations such as khitchri, the addition of green banana or pectin to the diet55 has been shown to be effective in the treatment of persistent diarrhea.

The usual energy density of any diet used for the therapy of persistent diarrhea should be around 1kcal/g, aiming to provide an energy intake of a minimum of 100kcal/kg per day, and a protein intake of 2-3g/kg per day. In selected circumstances when adequate intake of energy-dense food is problematic, the addition of amylase to the diet through germination techniques may also be helpful.

Micronutrient supplementation

It is now widely recognized that most malnourished children with persistent diarrhea have associated deficiencies of micronutrients including zinc, iron and vitamin A. This may be a consequence of poor intake and continued enteral losses, and requires replenishment during therapy.56 While the evidence supporting zinc administration in children with persistent diarrhea is persuasive, it is likely that these children have multiple micronutrient deficiencies. Concomitant vitamin A administration to children with persistent diarrhea has been shown to improve outcome57,58 especially in HIV-endemic areas.59 It is therefore important to ensure that all children with persistent diarrhea and malnutrition receive an initial dose of 100 000U of vitamin A and a daily intake of at least 3-5 mg/kg per day of elemental zinc. While the association of significant anemia with persistent diarrhea is well recognized, iron replacement therapy is best initiated only after recovery from diarrhea has started and the diet is well tolerated.

Follow-up and nutritional rehabilitation in community settings

Given the high rates of relapse in most children with persistent diarrhea, it is important to address the underlying risk factors and institute preventive measures. These include appropriate feeding (breast feeding, complementary feeding) and close attention to environmental hygiene and sanitation. This poses a considerable challenge in communities deprived of basic necessities such as clean water and sewage disposal.

In addition to the preventive aspects, the challenge in most settings is to develop and sustain a form of dietary therapy using inexpensive, home-available and culturally acceptable ingredients that can be used to manage children with persistent diarrhea. Given that the majority of cases of persistent diarrhea occur in the community and that parents are frequently hesitant to seek institutional help, there is a need to develop and implement inexpensive and practical home-based therapeutic measures.12 Recent data indicate that it may be entirely feasible to do so in community settings.60,61

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