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It has become clear that rotavirus is the most common cause of gastroenteritis in children less than 2 years of age living in either developed or developing countries.

  • In some children a clinical episode indistinguishable from acute gastroenteritis is followed by Persistant diarrhoea, so called post-gastroenteritis syndrome
  • This is more likely to occur in developing countries, where pre-existing malnutrition and enteropathies may lead to Persistant diarrhoea in 8-20% of children initially presenting with acute gastroenteritis.
  • Secondary lactose intolerance may occur, and many children exhibit an intolerance to cows' milk protein and often several other proteins
  • Management is pragmatic, and comprises mainly of nutritional support. Most children in developed countries survive, but in developing countries mortality is still high.

Nutritional support in Persistent diarrhea:

Persistent diarrhea in children needs special therapeutic diets. Foods chosen should be easy to digest and absorb (to avoid osmotic effect), contain adequate nutrients, and be low on allergenicity, energy-rich, and acceptable to the child. Complex carbohydrates (starches) should be used to avoid hyper-osmolarity and reduce the problem of lactose mal-digestion

Considerable success in the management of chronic diarrhea has been reported using a modular diet (MD), with gradual increments in every nutrient toward a full-strength formula. A Modular Diet is superior to a Semi-Elemental formula in the treatment of chronic diarrhea of infancy.

Findings suggest that hypo-osmolar ORS has beneficial effects on the clinical course of dehydrating acute watery diarrhea in severely malnourished (marasmic) children. Furthermore, children did not become hypo-natraemic after receiving hypo-osmolar ORS. STUDIES:

“Foods chosen should be easy to digest and absorb (to avoid osmotic effect), contain adequate nutrients, and be non-allergenic, energy-rich, and acceptable to the child. Complex carbohydrates (starches) should be used to avoid hyperosmolality and reduce the problem of lactose maldigestion”

Dialogue on Diarrhoea, issue 37 June 1989; A WHO & UNICEF REPORT.

“Because human preterm milk as the sole source of nutrients is deficient in several essential nutrients, especially protein and minerals, the Expert Panel concluded that the most appropriate source of essential nutrients is fortified preterm milk of documented nutritional composition. However, because the quantities of mothers’ preterm milk are unreliable and often inadequate, formulas designed to meet the requirements of preterm-LBW infants can serve as a more uniform and adequate source of nutrients to support optimal growth.”

J. Nutr. 132: 1395S-1577S, 2002.

Stool output (52.3 v 96.6 g/kg/day), duration of diarrhea (41.5 v 66.4 hours), intake of ORS (111.5 v 168.9 ml/kg/day), and fluid intake (214.6 v 278.3 ml/kg/day) were significantly less in the hypo-osmolar group than in the standard ORS group. Percentage of weight gain on recovery in the hypo-osmolar group was also significantly less (4.3 v 5.4% of admission weight) than in the standard ORS group. A total of 29 (91%) children in the standard ORS group and 32 (100%) children in the hypo-osmolar group recovered within five days of initiation of therapy. Mean serum sodium and potassium concentrations on recovery were within the normal range in both groups.

Arch Dis Child 2001;84:237-240 ( March )

Diarrhoea was significantly shorter (3 vs 7 days;P<0.01) and nutritional recovery started earlier (5 vs 9 days;P<0.01) in MD group; (2) median weight gain in the SF group was 100 g/week, compared to 171 g/week in MD group (P<0.05); (3) in two patients from the SF group, diarrhoea persisted, but they achieved complete recovery when changed to MD.

European Journal of Pediatrics; Volume 155, Number 12 / November, 1996

Caloric information per feed is usually not accurately known and hence it is difficult to determine the exact calories being provided. Non-homogenized solid material may blocks fine bore feeding tubes, a problem which is less with commercially available feeds. Lactose intolerance is common in malnourished patients and if lactose, derived from milk, is ingested, diarrhea results. Milk-based kitchen feeds can be made lactose-free by using only pulses, starches and cereals.

Dr. Karanvir Singh, Department of Surgery, Sir Ganga Ram Hospital, New Delhi

Proper choice of diet requires understanding the digestive capacity during persistent diarrhoea. Foods chosen should be easy to digest and absorb (to avoid osmotic effect), contain adequate nutrients, and be nonallergenic, energy-rich, and acceptable to the child.

Dialogue on Diarrhoea, Issue no 37, 1989

What is Lactose Intolerance?: Inability to utilize lactose may be due to lactase deficiency or may be secondary to conditions that produce alterations absorptive surfaces. In the absence of lactase lactose is not hydrolyzed to glucose and galactose. The accumulation of lactose in the intestine causes fermentation, abdominal pain, Cramping and diarrhea. Failure to gain weight is an important symptom in infants. Congenital lactose intolerance is a rare disorder characterized by absent brush border lactase activity. Symptoms occur following ingestion of milk by the infants. A strict lactose free formula is used, several commercial products being available. All products containing lactose in any form whatsoever are rigidly excluded.

GESTATIONAL AGE & SIZE:

  • LOW BIRTH WEIGHT (LBW): At birth, an infant who weighs less than 2500 g
  • VERY LOW BIRTH WEIGHT (VLBW): The infant weighing less than 1500 g
  • EXTREMELY LOW BIRTH WEIGHT (ELBW): The infant weighing less than 1000g
  • Low birth weight may be attributable to a shortened period of gestation, which is PREMATURITY, or a RETARDED INTRAUTERINE GROWTH RATE, which makes the infant small for gestational age (SGA).

NUTRITIONAL MANAGEMENT OF LBW DUE TO PREMATURITY:

Management of low birth weight infants requiring intensive care continues to improve dramatically. Studies indicate that most LBW infants have the potential for long and productive lives. There are many methods by which nutrition can be provided to LBW infants. The infant’s size, age and clinical condition dictate the nutritional requirements and how they can be provided.

Problems of immaturity:

The premature, LBW infants has not had the chance to develop fully in utero and is physiologically different from the term infants. Premature infants are at high nutritional risk because of poor nutrients stores; physiological immaturity; illness, which may interfere with nutritional management and needs, and the nutrient demands required for growth.

Decreased metabolic reserves:

Most fetal nutrient stores are deposited during the last 3 months of pregnancy, therefore, the premature infants begins life in a compromised nutritional state. Because metabolic (energy) stores are limited, nutritional support in the form of parenteral / or enteral nutrition should be initiated as soon as possible. In the preterm infants weighing 1000 gm, fats constitutes only 1% of total body weight, by contrast, the term in infants (3500 gm) has a fat percentage of about 16%. The 1000 gm AGA premature infant, eg, has a glycogen and fat reserves equivalent to about 110 kcal per kg of body weight. With basal metabolic needs of approximately 50 kcal / kg /day, it is obvious that this infant will rapidly run out of fat and carbohydrate fuel unless adequate nutritional support is established. Therefore, the depletion time will be even shorter for preterm infants weighing less than 1000 gm at birth. Nutrient reserves are depleted most quickly by tiny infants who have IUGR as a result of their increased basal metabolic rate.

Nutritional Requirements:

Considering all the above nutritional challenges, a judicious formula which takes care of all the above mentioned concerns is most desirable therapy. Most of the home made diets which are administered by less aware mothers were found to be inadequate in either macro or micro nutrients requirements of these premature infants. Preterm infants should be fed enough to promote growth similar to that of a fetus at the same gestational age, but not so much as to cause nutrient toxicity.

Protein:

Lower limits of protein needs in prematurely born neonates have not been adequately studied, yet providing protein in amounts maximizing accretion without excess is a goal in these infants' nutritional care. Protein turnover was studied in eight premature infants of conceptual age 26-37 weeks. Following observations were made:

  • Protein turnover in premature infants is far more rapid than in term infants, children, or adults and is inversely related to conceptual age;
  • Muscle protein turnover constitutes a greater fraction of overall turnover with advancing maturity;
  • Energy and protein intake affect net tissue protein gain significantly in rapidly growing infants and
  • The efficiency of protein synthesis as a function of protein intake is higher in the most immature infants.

Thus amount and quality of protein must be considered when establishing protein requirements for the preterm infant. Amino acid must be provided at a level that meets demands without inducing amino acid or protein toxicity.

Amount: A reference fetus model has been used to determine the amount of protein that would need to be ingested to match the quantity of protein deposited into newly formed fetal tissue (Ziegler et al., 1976). To achieve these fetal accretion rates, additional protein must be supplied to compensate for intestinal losses and obligatory losses in the urine and skin. Based on this method for determining protein needs, the advisable protein intake is 3.5 to 4g/kg/day. This amount of protein is apparently well tolerated by stable infants who are growing rapidly. There is concern, however, that this amount of protein may cause additional stress to sick infants who are not growing.

Type: The quality or type of protein is an important consideration, as premature infants have different amino acid needs than do term infants owing to immature hepatic enzyme pathways. Higher levels of the essential amino acid cysteine are present in the preterm infant, whereas levels of the amino acids phenylalanine and tyrosine, which the preterm infant has difficulty oxidizing, are comparatively lower. Taurine is a sulfonic amino acid that may be important for preterm infants. Human milk is a rich source of Taurine. Protein sources which are rich in above mentioned essential amino acids and non essential amino acids like whey and comminuted chicken should be used to meet the fetal needs.

Lipids:

fat should comprise 40 % to 50 % of the total calories, preferably MCT oils

Carbohydrates:

approximately 40% of the total calories are the standard for the premature infants. Lactose should be preferably avoided due to low lactase activity. Milk based formulas containing lactose as predominant sugar should be avoided for LBW infants. Rather a partially digested starch like “Maltodextrin” assures easy digestibility of carbohydrates without causing the diarrhea.

Minerals & Vitamins:

Premature infants require more vitamins and minerals especially sodium, iron, calcium and phosphorous, due to poor body stores, physiologic immaturity, illness, and rapid growth. Formulas developed especially for preterm infants, contain increased vitamin and minerals concentrations to meet the needs of the infant. Recommendations for enteral administration of vitamins in the premature infants are:

Why transition from TPN / NBM needs aggressive MNT ?
Conditions like Diarrhea, GI surgery, Post surgery, lactose intolerance, when GIT is not used at all or when patient is on TPN and needs to be shifted on oral diet, the kitchen diet create huge problems. Diarrhea, electrolyte imbalance, dehydration, underfeeding & malnutrition are common feature during transition from TPN / NBM to kitchen diet. All these problems delay the recovery process & in some cases it may lead to death (especially in children) & PEM. A specially designed formula which can take care of all the above problems is a transition diet. It facilitates transition from no oral food to full oral diet.

Transition diet can be easily provided in the form of special reconstituted nutrient Formula. It can prevent diarrhea, electrolyte imbalance, dehydration & Underfeeding. This transition diet for a week before kitchen diet prevents GI complications related above indications.

Comminuted chicken, with maltodextrin & WHO recommended Electrolytes Gives a reconstituted formula of osmolality below 200mOsmol /l. A hypo-osmolal feed prevents osmotic diarrhea & hence corrects electrolyte imbalance & dehydration. Calorie density of 0.75 kcal / ml prevents underfeeding, Thus each transition from No oral food to full oral diet is safely achieved by bridging the two extremes by a specially designed nutrient therapy.

Usually after eating a protein diet our body exhibits a allergic reaction to it. Comminuted chicken as compared to other proteins is much less allergenic and hence is known as hypo-allergenic.