Expert Voice

Persistent diarrhea is passage of frequent loose watery stools for ? 14 days. It usually starts as an acute episode and lasts at least 14 days or more. It is estimated that 3 to 20% of the acute diarrhea episodes among children younger than five years become persistent.

The predominant cause of persistent diarrhea (PD) is malabsorption of nutrients particularly of carbohydrates, due to a combination of malnutrition and enteric infection. Prolonged diarrheal episodes with high stool output and reduced oral intake due to associated systemic infection leads to dehydration and growth failure.

Nearly two-third of persistent diarrhea patients can be treated at home through oral rehydration and appropriate dietetic scheme. However, non- breast fed Infants younger than 6 months and children with complications require supervised care in the hospital setting.

Nutritional management continues to be the cornerstone of therapy.

Goals of Nutritional Therapy

1. Commence feeding immediately in order to prevent malabsorption and facilitate mucosal recovery.
2. Continue feeding in order to prevent dehydration and malnutrition leading to growth faltering.
3. Provide adequate nutrients to ensure normal and catch – up growth.
4. Provide micronutrient supplementation to replenish the loss of nutrients.

Simple dietary manipulations can achieve goals of nutritional therapy. Lactose free diets are seldom required except for non-breast fed children below 6 months of age. Randomized controlled trials have proved efficacy of mixed diets using home based common indigenous foods in management of persistent diarrhea. Feeding mixed diets facilitates absorption of 80-95% of carbohydrates, 70% of fat and 75% of nitrogen during diarrhea. Nutritional and dietary intervention involves stepwise elimination and titration of nutrients (particularly carbohydrates) in diet A, B, C and D.

Initial diet a (reduced lactose diet)

Start feeding as soon as the child can eat. There is no role of bowel rest.

1. Total elimination of animal milk is not required routinely; only the daily quantity of animal milk is reduced to 50-60 ml/kg of actual body weight/ day providing not more than 2-2.5g of lactose/kg/day. To reduce lactose concentration in animal milk, diluting it with water is not recommended as it reduces energy density critically. Lactose per unit of milk can easily be reduced by mixing milk with cereals e.g milk or curd rice gruel, milk sooji gruel, or milk dalia.
2. Feed frequently but small volumes. To begin, 6-7 feeds per day should be offered with a total daily energy intake of 75 Kcal/kg of actual body weight / day. Energy intake should be increased gradually upto 150 Kcal/kg over next two weeks if required to achieve weight gain.
3. Many children will eat poorly, until associated serious systemic infection (if any) is treated for 24-48 hr. In such situations, nasogastric feeding may be required in the beginning.

Rationale for the Diet A

1. Clinical trials have clearly shown that reduced lactose diet is better tolerated than lactose free diet, without significantly increasing stool output or risk of dehydration.
2. Milk is the only source of first class protein in vegetarian diet and hence efforts should be made to include milk in the diet even if in small quantity.
3. Lactose reaches the intestine slowly due to delayed gastric emptying and is better toler ated when milk is mixed with cereals, offered frequently in divided feeds and in small volumes.
4. Milk cereal mixtures were found to be more efficacious and acceptable than soy based formulae or curd cereal mixtures.
5. Fat is not contraindicated. In fact, addition of fat further increases calorie density, improves palatability and delays the gastric emptying time. Thus addition of some fat controls diarrhea better.

TYPICAL COMPOSTION OF DIET A

Ingredients	Measures	Approximate quantity
Milk Sugar Oil Puffed rice powder* Water**	1/3 katori ½ level tsp ½ level tsp 4 level tsp ½ katori	40 ml 2 g 2 g 12.5 g to make 100ml
Calories/100g     96 Kcal Proteins/100g     2.4 g

Goals of Nutritional Therapy

1. Commence feeding immediately in order to prevent malabsorption and facilitate mucosal recovery.
2. Continue feeding in order to prevent dehydration and malnutrition leading to growth faltering.
3. Provide adequate nutrients to ensure normal and catch – up growth.
4. Provide micro nutrient supplementation to replenish the loss of nutrients.

Ingredients Measures Approximate quantity Egg white / chicken 3 level tsp/ 1 ¾ level tsp 15 g Puffed rice powder* 2 level tsp 7g Glucose ¾ level tsp 3g Oil 1 level tsp 4g Water ¾ katori to make 100ml Calories/100g 78 Kcal Proteins/100g 2.3 g *can be substituted with cooked rice

Preparation: Mix milk, sugar and Puffed rice powder together. Add boiled water & mix well. Add oil and offer the feed to the child.

*Puffed rice powder (murmura) can be substituted by cooked rice or sooji or any other cereal available. Advantage of puffed rice powder or rice flakes (chirwa) is that they are already pre-digested and hence better and absorbed.

**Water is mixed with milk in above diet to balance calories and proteins in the desired volume. Mixing water with milk is not required if higher protein and calorie density was required.

Note: Carbohydrates provided by Diet A are disaccharides (sugar and lactose in milk) and polysaccharides (starch in rice powder).

THE SECOND DIET B (LACTOSE-FREE WITH REDUCED STARCH DIET)

About 50-70% of children improve on the initial Diet A. Some children who do not respond on Diet A are changed to Diet B if free of systemic infection. Diet B is lactose free (milk free) and other form of carbohydrate mixture is also titrated slightly. In the process of making Diet B lactose free (or milk free), milk proteins also get compromised and therefore, milk protein must be replaced by chicken or egg white or commercial protein hydrolysate (if available).

Rationale for Diet B: The lactose free reduced starch diet

1. Some children do not respond well to the initial low lactose diet (Diet A). They may have impaired digestion of starch and lactose as well as other disaccharides.
2. Therefore, disaccharides are completely eliminated i.e. milk (lactose) and sugar. Also, starch (polysaccharide) is reduced and partially substituted by glucose (monosaccharide).
3. Partial substitution of cereal with glucose increases the digestibility without increasing the osmolarity. If all the cereals were to be replaced by glucose, the case would be reversed.

Ingredients	Measures	Approximate quantity
Egg white / chicken Puffed rice powder* Glucose Oil Water**	3 level tsp/ 1 ¾ level tsp 2 level tsp ¾ level tsp 1 level tsp ¾ katori	15 g 7g 3g 4g to make 100ml
Calories/100g     78 Kcal Proteins/100g     2.3 g

Preparation with egg: Whip the egg white well. Add puffed rice powder, glucose, oil and mix well. Add boiled water and mix rapidly to avoid clumping.

OR

Preparation with chicken: Boil chicken, remove the bones and make chicken puree. Mix chicken puree with rice, glucose and oil. Add boiled water to make a smooth paste.

THE THIRD DIET C: (MONOSACCHARIDE BASED DIET)

Overall 80-85% patients with severe persistent diarrhea will recover with sustained weight gain on the initial Diet A or the second Diet B. A small percentage may not tolerate a moderate intake of the cereal in Diet B. These children are given the third diet (Diet C) which contains only glucose as source of CHO and a protein source as egg or chicken. Energy density is increased by adding oil to the diet.

Child who has not tolerated Diet A and Diet B is expected to have lost substantial weight due to continuing diarrhea. Thus, foremost aim at this stage is to control diarrhea immediately. Expecting to stop diarrhea and weight gain at the same time is not possible at this stage. Due to absence of complex carbohydrates and restricted use of glucose, Diet C is low in calories and therefore, cannot ensure weight gain in malnourished child. As soon as diarrhea stops on Diet C, other forms of CHOs are slowly added to ensure gradual weight gain.

Note: Glucose in very high quantity will increase the osmolarity of the diet and result in osmotic diarrhea. Amount of glucose should not exceed 3 – 4 g / 100 ml of feed.

TYPICAL COMPOSITION OF DIET C:

Ingredients	Measures	Approximate quantity
Chicken/ Egg white Glucose Oil Water**	2 ½ level tsp / 5 level Tsp ¾ level tsp 1 level tsp 1/2 – ¾ katori	12g / 15 g 3g 4g to make 100ml
Calories/100g     60 Kcal Proteins/100g     3 g

Preparation:

Boil chicken, remove the bones and make chicken puree. Mix chicken puree with glucose and oil. Add boiled water to make a smooth paste.

OR

Whip the egg white well. Add glucose, oil and mix well. Add boiled water and mix rapidly to avoid clumping.

THE FOURTH DIET D: ZERO CARBOHYDRATE DIET

Five percent of persistent diarrhea children may not tolerate even small quantity of glucose as carbohydrate source. By this time, child would have had long duration of diarrhea and will need IV fluids but feeding will still not cease. Diet D is simply chicken blended in water (chicken gruel or soup) with small amount of fat and pinch of salt – this should be offered to the child as much as possible. Diet D is devoid of all carbohydrates. Diarrhea invariably stops within 1 -2 days, following which fat is increased and then slowly start working upwards i.e From Diet D to Diet C to Diet B and to diet A. Remember, it is a very slow process and requires a lot of confidence and patience on the part of physician/ dietician. Reassurance to parents is extremely important as well.

It is important to monitor the child carefully at each stage and make gradual changes in the diet. Delay in titrating the diet, modifying diet too fast, taking short cuts or skipping steps of dietary manipulations will result in failure of nutritional intervention. Not only patience but a intense practical training is required to master the technique of titrating diets and attain nutritional acumen.

Recommendation in exclusively breast-fed infants: Exclusively Breast fed children do not get diarrhea. If infants < 6 months of age reports with diarrhea, then detailed history needs to be elicited regarding intake of any other fluid at any time or feeding improperly reconstituted formula feed with bottle or poor hygiene etc.

Mothers should be encouraged to exclusively breast feed. If breast feed output is less, then either undiluted fresh milk or properly reconstituted formula milk (whatever is applicable) should be advised with proper instructions about volumes to be offered each time, along with all the best practices to be following at this age such as avoidance of bottle feeding , hygiene etc. In developing countries, infants <12 months who are breast-fed during diarrhea and proper complementary feeding on proper time is initiated, gain better weight and rarely develop malnourishing persistent diarrhea.

Normally, non-breast fed children below 6 months of age with diarrhea require lactose free commercial formula since they cannot be started on cereals very early.

Frequently Asked Questions

Q 1: When should the change be made from initial diet (Diet A) to the second diet (Diet B) or Diet B to Diet C

In the absence of initial or hospital acquired systemic infection, the diet should be changed when there is treatment failure defined as:

1. A marked increase in stool frequency (usually more than 10 watery stools/day) any time after at least 48 hours of initiating the diet or,
2. Return of signs of dehydration any time after initiating treatment or,
3. A failure to establish weight gain by day 7.

Q2: For how long should Diet A or Diet B be given?

Unless signs of treatment failure occur earlier, each diet should be given for a minimum period of 3-4 days.

Q3: Why is milk based low lactose diet is better tolerated than lactose free diet?

It is always easier to resume to normal food from low lactose diet rather than from lactose free diet. This may be due the fact that lactase activity is resumed faster with low lactose diet.

Q4: How can I be confident that the child has recovered completely?

Recovery from diarrhea is not simply cessation of liquid stools but achievement of normal as well as catch-up growth. A higher than recommended intake of food during convalescence (when stools start to improve in consistency) is consumed by affected children and it facilitates catch-up growth.

Q5: What should be done for the rare cases with severe glucose malabsorption?

Poor outcome on Diet C may be due to transient glucose malabsorption. This is a rare complication. These patients are identified by presence of reducing substances in stool when glucose is the only carbohydrate in diet as well as in ORS. In such cases, diarrhea ceases promptly on fasting for 24 hours and administration of IV fluids.
The practical approach is to administer IV fluids @ 10% glucose with electrolytes and continue a diet orally which contains chicken or egg white (as source of protein) and oil.

Q6: Why is Soya based commercial formula not recommended for diarrhea?

In which situations, they may be recommended? Soya is one of the ten top priority food allergen and is rated next to milk. Children intolerant to milk often develop intolerance to soya as well. Intolerance to soya could be serious as soya induces an allergic response which is about 100 times higher than for many other food allergens. People with a soy allergy are not necessarily allergic to other legumes due to the fact that soya is different than the other legumes in it’s composition.
However, soya based formulas are well tolerated and recommended in galactosemia, drug induced diarrhea, Cow’s milk protein allergies etc.

Q7: Are there any commercial formulas available for treating persistent diarrhea?

Yes, but their role is limited. During transition (rehabilitation phase), it becomes difficult to shift the child from commercial formulation to normal home based diet. But sometimes, there is no choice and one must know about commercial formulas as well.
Commercial formula claiming low lactose (Like diet A) is not available. However, number of Lactose free formulas are available such as soya based formulas (2nd class protein), hydrolysed casein based or whey based formulas (1st class milk protein present but free from lactose), intact milk protein lactose free formulas, semi-elemental lactose free formulas containing milk peptides etc. Avoid soya based formulas for treating persistent diarrhea unless there is suspicion of milk protein allergy.

Q8: What is the role of Commercial formulas for treating Persistent diarrhea?

Instead of home based Diet B, lactose free commercial formula having milk proteins can be used especially in hospital setting where preparation of feed every 2 hourly is not practical and feasible.
Remember: Commercial formulas in young children with persistent diarrhea also need to titrated and used sensibly. Full strength commercial formulas will invariably not tolerated in the initial phase. Do not make a mistake of starting a full strength commercial formula according to the method of reconstitution written on the tin.
Usually, for a child who has not tolerated Diet A and needs to be on Diet B, commercial lactose free formula should always be started with ½ strength without any fortification in order to test the tolerance irrespective of the age of the child.

Q9: what is role of MCT oil in treating persistent diarrhea?

Medium chain triglycerides are better tolerated but it is important to know that MCT oil lack in essential fatty acids (EFA). Prolonged use of MCT oil is not advisable. Sometimes child does not stop purging and it is often not realized that continuing diarrhea is due to EFA deficiency rather than anything else.
It is recommended to use mixed type of fats in every feed to ensure maximum absorption i.e a mixture of saturated (SF), polyunsaturated (PUFA) and monounsaturated (MUFA). Eg; Diet A provides saturated fat from milk; one must fortify Diet A with mixture of refined oil and MCT oil (rather than just MCT oil) to get maximum benefit. Usually, the proportion of refined oil: MCT oil should be 3:1.
Remember: In the intial phase, child can be started on exclusive MCT oil in Diet A or Diet B but not more than one week. Prolonged use of MCT oil has more value in cases of severe fat malabsorption, chylous ascites, lymphangectasia etc.
Do not use MCT oil casually. Use it only when indicated.

Q10: What is the maximum amount of protein which can be given?

One should be very careful about protein. Overdose of protein may lead to protein toxicity and increased renal solute load leading to Nutrition recovery syndrome which could be serious state. In Diet A and B, dietary protein level should not exceed 3 – 3.5 g / kg of actual body weight/ day. In Diet C and D, proteins can be used very liberally since these diets do not contain carbohydrates and most protein get used up as energy.

POINTS TO REMEMBER

1. Always reach the target volume first and then start fortifying diet >1 Kcal/ ml.
2. All persistent diarrhea children require micronutrient supplementation @ 1 -2 RDA for 15 days – 30 days depending on the duration of diarrhea. Vitamin A and Zinc are the most important nutrients to be supplemented.
3. Children with persistent diarrhea need ORS with each passage of watery stool. Proper doses of ORS should be advised. Sicker children may need IV fluids.

Nutritional Management of Persistent diarrhea is very interesting and rewarding if managed in a proper way according to the protocol. Diet A, B, C and D could be designed in multiple ways depending on the requirement of the patients.