Diet management in congenital diarrheas and enteropathies - general concepts and disease-specific approach, a narrative review.

Congenital diarrheas and enteropathies (CODE) are a group of rare, heterogenous, monogenic disorders that lead to chronic diarrhea in infancy. Definitive treatment is rarely available, and supportive treatment is the mainstay. Nutritional management in the form of either specialized formulas, restrictive diet, or parenteral nutrition support in CODE with poor enteral tolerance is the cornerstone of CODE treatment and long-term growth. The evidence to support the use of specific diet regimens and nutritional approaches in most CODE disorders is limited due to the rarity of these diseases and the scant published clinical experience. The goal of this review was to create a comprehensive guide for nutritional management in CODE, based on the currently available literature, disease mechanism, and the PediCODE group experience. Enteral diet management in CODE can be divided into 3 distinct conceptual frameworks: nutrient elimination, nutrient supplementation, and generalized nutrient restriction. Response to nutrient elimination or supplementation can lead to resolution or significant improvement in the chronic diarrhea of CODE and resumption of normal growth. This pattern can be seen in CODE due to carbohydrate malabsorption, defects in fat absorption, and occasionally in electrolyte transport defects. In contrast, general diet restriction is mainly supportive. However, occasionally it allows parenteral nutrition weaning or reduction over time, mainly in enteroendocrine defects and rarely in epithelial trafficking and polarity defects. Further research is required to better elucidate the role of diet in the treatment of CODE and the appropriate diet management for each disease.

Protective Effect of Low Molecular Weight Seleno-Aminopolysaccharide on the Intestinal Mucosal Oxidative Damage.

Low molecular weight seleno-aminopolysaccharide (LSA) is an organic selenium compound comprising selenium and low molecular weight aminopolysaccharide (LA), a low molecular weight natural linear polysaccharide derived from chitosan. LSA has been found to exert strong pharmacological activity. In this study, we aimed to investigate the protective effect of LSA on intestinal mucosal oxidative stress in a weaning piglet model by detecting the growth performance, intestinal mucosal structure, antioxidant indices, and expression level of intracellular transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2) and its related factors. Our results indicated that LSA significantly increased the average daily gain and feed/gain (p < 0.05), suggesting that LSA can effectively promote the growth of weaning piglets. The results of scanning electron microscope (SEM) microscopy showed that LSA effectively reduced intestinal damage, indicating that LSA improved the intestinal stress response and protected the intestinal structure integrity. In addition, diamine oxidase (DAO) and d-lactic acid (d-LA) levels remarkably decreased in LSA group compared with control group (p < 0.05), suggesting that LSA alleviated the damage and permeability of weaning piglets. LSA significantly increased superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSH-Px), and total antioxidant capacity (T-AOC) levels, but decreased malondialdehyde (MDA) level, indicating that LSA significantly enhanced the antioxidant capacity and reduced oxidative stress in weaning piglets. RT-PCR results showed that LSA significantly increased GSH-Px1, GSH-Px2, SOD-1, SOD-2, CAT, Nrf2, HO-1, and NQO1 gene expression (p < 0.05). Western blot analysis revealed that LSA activated the Nrf2 signaling pathway by downregulating the expression of Keap1 and upregulating the expression of Nrf2 to protect intestinal mucosa against oxidative stress. Collectively, LSA reduced intestinal mucosal damage induced by oxidative stress via Nrf2-Keap1 pathway in weaning stress of infants.

Congenital Glucose-Galactose Malabsorption: A Case Report.

Congenital glucose-galactose malabsorption (CGGM) is a rare cause of intractable infantile diarrhea, with only a few hundred cases recognized worldwide. This life-threatening disorder must be considered in the differential diagnosis of an infant who presents with diarrhea and dehydration that fails to respond to standard therapy. The clinical and diagnostic course of an infant with recurrent episodes of watery diarrhea and hypernatremic dehydration found to be homozygous for a rare variant in the SLC5A1 gene, c.187C>T (p.R63X) is described.

Oral zinc provision in acute diarrhea.

PURPOSE OF REVIEW: The clinical management of acute diarrhea is based on the use of oral rehydration salts and appropriate nutrition. In addition, the WHO and The United Nations Children's Fund recommend zinc supplementation for diarrhea in children below 5 years. This article aims at reviewing recent literature on the effects of oral zinc for treating acute diarrhea in children. RECENT FINDINGS: Recent studies confirm that zinc supplementation has a benefit in children below 5 years with acute diarrhea in countries at medium or high risk of zinc deficiency. A few small trials have reported a benefit of zinc in children at low risk of zinc deficiency, with heterogeneity in results. No recent study has explored the effects of zinc in children younger than 6 months, and in this age group previous research refuted any benefit from zinc. SUMMARY: Current literature supports the use of oral zinc in treating diarrhea in children older than 6 months, especially if at risk of zinc deficiency, such as children with poor diets exposed to recurrent gastrointestinal infections. More research is needed to confirm findings in children at low risk of zinc deficiency. Currently there is no evidence that zinc benefits children younger than 6 months.

Lactose-free milk for infants with acute gastroenteritis in a developing country: study protocol for a randomized controlled trial.

BACKGROUND: Acute gastroenteritis is a major cause of pediatric morbidity and mortality, accounting for 15% of all childhood deaths worldwide. In developing countries, diarrheal diseases continue to be a major public health burden. Evidence from developed countries suggests that intake of lactose-free milk during diarrheal episodes may reduce the duration of the illness in pediatric inpatients. It is unknown whether lactose-free milk reduces the severity or duration of acute gastroenteritis in infants treated in outpatient settings in developing countries where diarrhea is more severe, and results in higher morbidities and mortalities. We hypothesize that lactose-free milk intake during acute gastroenteritis would significantly decrease the duration and severity of diarrhea in infants presenting to the Emergency Department (ED), as compared with lactose-containing milk. METHODS/DESIGN: An open-label randomized clinical trial. STUDY POPULATION: 40 infants with acute gastroenteritis, age between 2 and 12 months, presenting to the ED, will be randomized to control or intervention group. INTERVENTION: Lactose-free milk, whereas the control group will continue on regular infant formula for a total of 7 days. Infants will be followed up for 7 days. OUTCOME MEASURES: Diarrhea duration, weight loss, illness clinic visits, hospitalization rate, parental satisfaction, and time to symptom resolution. STATISTICAL ANALYSIS: Descriptive and regression analysis will be conducted under the intention-to-treat basis by using SPSS version 21. DISCUSSION: Acute gastroenteritis is a public health burden for developing countries, with a significant impact on infant morbidity and mortality. Provision of infant formula that may reduce the duration and severity of diarrhea can decrease this burden in countries with limited healthcare resources, like Lebanon. The findings from this study are anticipated to provide evidence-based dietary recommendations for ambulatory infants with acute diarrhea in developing countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT02246010; September 2014.

Zinc and Vitamin Supplementation in an Under-5 Indigenous Population of Guatemala: Influence of Lay Health Promoters in Decreasing Incidence of Diarrhea.

BACKGROUND: Malnutrition is an urgent problem in the developing world, especially for children under 5 years of age. The article describes the utilization of a standard of practice designed to prevent illness in a malnourished, under-5 indigenous population and reinforced by weekly basic health messages taught by lay community health promoters. METHOD: The two villages were chosen for observation after administration of the standard of care among the Maya-Kíché, the most numerous Mayan group in Guatemala. The standard of practice, 20 mg of daily oral zinc, was administered for 10 days in the home and followed by daily vitamin supplementation that continued throughout the 3 months of the project. All patients received four monthly clinic visits, with one of the village groups receiving weekly health promoter visits. RESULTS: Data evaluated after the quality improvement project showed significant differences in adherence to the zinc regimen (χ(2) = 3.677, p ≤ .05) as well as lower rates of diarrheal illnesses (χ(2) = 5.850, p ≤ .05), with both of these improved in the health promoter group. DISCUSSION: This study suggests that the training and implementation of para-health professionals from the lay community in response to specific health care needs could be considered a best practice in developing countries. IMPLICATIONS: Public health professionals are key to health promoter training and direction, and their importance in the global setting cannot be understated.

Effect of provision of daily zinc and iron with several micronutrients on growth and morbidity among young children in Pakistan: a cluster-randomised trial.

BACKGROUND: Powders containing iron and other micronutrients are recommended as a strategy to prevent nutritional anaemia and other micronutrient deficiencies in children. We assessed the effects of provision of two micronutrient powder formulations, with or without zinc, to children in Pakistan. METHODS: We did a cluster randomised trial in urban and rural sites in Sindh, Pakistan. A baseline survey identified 256 clusters, which were randomly assigned (within urban and rural strata, by computer-generated random numbers) to one of three groups: non-supplemented control (group A), micronutrient powder without zinc (group B), or micronutrient powder with 10 mg zinc (group C). Children in the clusters aged 6 months were eligible for inclusion in the study. Powders were to be given daily between 6 and 18 months of age; follow-up was to age 2 years. Micronutrient powder sachets for groups B and C were identical except for colour; investigators and field and supervisory staff were masked to composition of the micronutrient powders until trial completion. Parents knew whether their child was receiving supplementation, but did not know whether the powder contained zinc. Primary outcomes were growth, episodes of diarrhoea, acute lower respiratory tract infection, fever, and incidence of admission to hospital. This trial is registered with ClinicalTrials.gov, number NCT00705445. RESULTS: The trial was done between Nov 1, 2008, and Dec 31, 2011. 947 children were enrolled in group A clusters, 910 in group B clusters, and 889 in group C clusters. Micronutrient powder administration was associated with lower risk of iron-deficiency anaemia at 18 months compared with the control group (odds ratio [OR] for micronutrient powder without zinc=0·20, 95% CI 0·11-0·36; OR for micronutrient powder with zinc=0·25, 95% CI 0·14-0·44). Compared with the control group, children in the group receiving micronutrient powder without zinc gained an extra 0·31 cm (95% CI 0·03-0·59) between 6 and 18 months of age and children receiving micronutrient powder with zinc an extra 0·56 cm (0·29-0·84). We recorded strong evidence of an increased proportion of days with diarrhoea (p=0·001) and increased incidence of bloody diarrhoea (p=0·003) between 6 and 18 months in the two micronutrient powder groups, and reported chest indrawing (p=0·03). Incidence of febrile episodes or admission to hospital for diarrhoea, respiratory problems, or febrile episodes did not differ between the three groups. INTERPRETATION: Use of micronutrient powders reduces iron-deficiency anaemia in young children. However, the excess burden of diarrhoea and respiratory morbidities associated with micronutrient powder use and the very small effect on growth recorded suggest that a careful assessment of risks and benefits must be done in populations with malnourished children and high diarrhoea burdens. FUNDING: Bill & Melinda Gates Foundation.

Calcium ameliorates diarrhea in immunocompromised children.

Treatment of infectious diarrheas remains a challenge, particularly in immunocompromised patients in whom infections usually persist and resultant diarrhea is often severe and protracted. Children with infectious diarrhea who become dehydrated are normally treated with oral or intravenous rehydration therapy. Although rehydration therapy can replace the loss of fluid, it does not ameliorate diarrhea. Thus, during the last decades, there has been continuous effort to search for ways to safely stop diarrhea. Herein, we report 3 immunocompromised children who developed severe and/or protracted infectious diarrhea. Their diarrheas were successfully "halted" within 1 to 2 days following the administration of calcium.

Dietary management of childhood diarrhea in low- and middle-income countries: a systematic review.

BACKGROUND: Current WHO guidelines on the management and treatment of diarrhea in children strongly recommend continued feeding alongside the administration of oral rehydration solution and zinc therapy, but there remains some debate regarding the optimal diet or dietary ingredients for feeding children with diarrhea. METHODS: We conducted a systematic search for all published randomized controlled trials evaluating food-based interventions among children under five years old with diarrhea in low- and middle-income countries. We classified 29 eligible studies into one or more comparisons: reduced versus regular lactose liquid feeds, lactose-free versus lactose-containing liquid feeds, lactose-free liquid feeds versus lactose-containing mixed diets, and commercial/specialized ingredients versus home-available ingredients. We used all available outcome data to conduct random-effects meta-analyses to estimate the average effect of each intervention on diarrhea duration, stool output, weight gain and treatment failure risk for studies on acute and persistent diarrhea separately. RESULTS: Evidence of low-to-moderate quality suggests that among children with acute diarrhea, diluting or fermenting lactose-containing liquid feeds does not affect any outcome when compared with an ordinary lactose-containing liquid feeds. In contrast, moderate quality evidence suggests that lactose-free liquid feeds reduce duration and the risk of treatment failure compared to lactose-containing liquid feeds in acute diarrhea. Only limited evidence of low quality was available to assess either of these two approaches in persistent diarrhea, or to assess lactose-free liquid feeds compared to lactose-containing mixed diets in either acute or persistent diarrhea. For commercially prepared or specialized ingredients compared to home-available ingredients, we found low-to-moderate quality evidence of no effect on any outcome in either acute or persistent diarrhea, though when we restricted these analyses to studies where both intervention and control diets were lactose-free, weight gain in children with acute diarrhea was shown to be greater among those fed with a home-available diet. CONCLUSIONS: Among children in low- and middle-income countries, where the dual burden of diarrhea and malnutrition is greatest and where access to proprietary formulas and specialized ingredients is limited, the use of locally available age-appropriate foods should be promoted for the majority of acute diarrhea cases. Lactose intolerance is an important complication in some cases, but even among those children for whom lactose avoidance may be necessary, nutritionally complete diets comprised of locally available ingredients can be used at least as effectively as commercial preparations or specialized ingredients. These same conclusions may also apply to the dietary management of children with persistent diarrhea, but the evidence remains limited.

The duration of diarrhea and fever is associated with growth faltering in rural Malawian children aged 6-18 months.

Nutrition support programs that only focus upon better complementary feeding remain an insufficient means of limiting growth faltering in vulnerable populations of children. To determine if symptoms of acute infections correlate with the incidence of growth faltering in rural Malawian children, the associations between fever, diarrhea, and cough with anthropometric measures of stunting, wasting, and underweight were investigated. Data were analyzed from a trial where 209 children were provided with adequate complementary food and followed fortnightly from 6-18 months of age. Linear mixed model analysis was used to test for associations. Diarrheal disease was inversely associated with changes in height-for-age Z-score (HAZ), mid-upper arm circumference Z-score (MUACZ), and weight-for-age Z-score (WAZ). Fever was also inversely associated with changes in MUACZ and WAZ. These results suggest that initiatives to reduce febrile and diarrheal diseases are needed in conjunction with improved complementary feeding to limit growth faltering in rural Malawi.

Utilidad de las proteínas de pollo y de soja en ratas nutridas o desnutridas con diarrea inducida por lactosa / Utility of chicken and soybean protein in well-nourished or undernourished rats with lactose-induced diarrhea

En el tratamiento nutricional de la diarrea infantil se han utilizado con éxito preparaciones líquidas que contienen pollo combinado con cereales y/o tubérculos, que se preparan en la institución de hospitalización o en la casa. En un estudio anterior, se comparó la efectividad de fórmulas con proteínas de pollo o aislado de soja en el tratamiento de la diarrea infantil. El objetivo de este trabajo fue estudiar en ratas con o sin diarrea, la utilización de las proteínas y la disponibilidad de nutrientes de dietas preparadas con pollo o aislado proteico de soja, para determinar si los resultados obtenidos en los niños eran comparables a los obtenidos en ratas. Dado que la diarrea y la desnutrición frecuentemente están presentes de manera simultánea, también se estudiaron grupos de animales con o sin diarrea previamente desnutridos. Los resultados mostraron que durante la diarrea las ratas desnutridas fueron igualmente eficientes que las nutridas en utilizar los nutrientes presentes en las dietas con pollo o soja, por lo que no experimentaron un deterioro nutricional mayor que las nutridas. Adicionalmente, la severidad de la diarrea fue similar en las ratas asignadas a las dietas con pollo o soja. Asimismo, las ratas con diarrea consumieron, crecieron, absorbieron y retuvieron menos de los macronutrientes dietarios que las ratas control. Sin embargo, este efecto de la diarrea fue similar en las ratas que consumieron proteína de soja o de pollo. Como estos resultados coinciden con los obtenidos previamente en niños con diarrea aguda, se concluye que la proteína de soja es tan efectiva como la de pollo en el manejo nutricional de la diarrea y que la diarrea producida con lactosa en ratas es un modelo apropiado para el estudio de las consecuencias nutricionales de la misma.

In the nutritional treatment of diarrhea, good results have been obtained using liquid formulas with chicken meat together with cereals and/or starchy vegetables, prepared at home or at the clinic. In a previous study, formulas prepared with chicken meat or isolated soybean protein were tested in the treatment of infantile diarrhea. In order to determine if the results obtained in children could be reproduced in rats, the objective of the present study was to evaluate the effectiveness of the same diets in the nutritional treatment of well-nourished as well as undernourished rats with lactose induced diarrhea. The results showed that all the rats with diarrhea absorbed and retained less of the dietary nutrients and consequently, grew less than their counterparts without diarrhea. However, the absorption and retention measured in the nourished as well as in the undernourished rats were similar, indicating that a short period of malnutrition previous to the diarrhea episode, did not affect rats' absorption capacity. In addition, similarly to the results previously obtained in children, the rats with lactose induced diarrhea utilised equally well the dietary nutrients present in the chicken as well as in the soybean protein based diets. These results confirmed the value of isolated soybean protein in the nutritional treatment of diarrhea and showed that lactose induced diarrhea in rats is an appropriate model to study the nutritional consequences of diarrhea.

Diarrea funcional como causa de diarrea crónica / Functional diarrhea as cause of chronic diarrhea

La diarrea funcional se presenta con frecuencia en la práctica pediátrica, y generalmente no se asocia a alteraciones nutricionales, pero sí a esquemas dietéticos incorrectos. Se actualiza su importancia clínica, se hace énfasis en la patogenia, diagnóstico y en los métodos de tratamiento. Consideramos que es la causa más frecuente de diarrea crónica inespecífica y que el interrogatorio dirigido según los criterios de Roma es útil para su diagnóstico. La mayoría de los pacientes con esta enfermedad en la infancia deben ser tratados en la atención primaria

The functional diarrhea is frequent in the pediatric practice and in general it is not associated with nutritional alterations, but to incorrect dietary schemes. Its clinical significance is updated and its pathogenesis, diagnosis and treatment methods are emphasized. Authors considered that the functional diarrhea is the more frequent cause of unspecific chronic diarrhea and the questioning directed according the Rome criteria is very useful for its diagnosis. Most of patients presenting with this disease during childhood must to be treated in primary care services

Green banana-supplemented diet in the home management of acute and prolonged diarrhoea in children: a community-based trial in rural Bangladesh.

SUMMARY OBJECTIVE: To determine the effectiveness of green banana in the home management of acute (<7 days) or prolonged (≥ 7 days) diarrhoea at the community level. METHODS: A cluster randomized field trial was conducted among 2968 Bangladeshi rural children 6-36 months old. Wards (villages) were randomly assigned to either a standard care group or a standard care plus green banana group where mothers were instructed to add cooked green banana to the diets of diarrhoeal children. Through a village-based surveillance system, diarrhoeal morbidity data (severity, duration, compliance) were collected for 14 days. Treatment effects were determined by analysing cumulative probability of cure by testing Cox proportional hazards models and relative risk (RR). RESULTS: The cumulative probability of cure was significantly (P < 0.001) different in children receiving GB for both acute [hazard ratio (HR) = 0.63 (95% CI: 0.56-0.67)] and prolonged diarrhoea [HR = 0.38 (95% CI: 0.26-0.59)]. The recovery rates of children with acute diarrhoea receiving GB (vs. control) were significantly more by day 3: 79.9%vs. 53.3% [(RR) = 0.47, 95% CI: 0.41-0.55], (P < 0.001) and day 7: 96.6%vs. 89.1% (RR = 0.32; 0.22-0.46), (P < 0.001). Children with prolonged diarrhoea receiving green banana had significantly higher recovery rates by day 10: 79.8%vs. 51.9% (RR = 0.42; 0.23-0.73), (P < 0.001) and day 14: 93.6%vs. 67.2% (RR = 0.22; 0.08-0.54), (P < 0.001). CONCLUSION: A green banana-supplemented diet hastened recovery of acute and prolonged childhood diarrhoea managed at home in rural Bangladesh.

[Feeding infants and young children with acute diarrhea]. / Alimentation au cours des diarrhées aiguës du nourrisson et du jeune enfant.

Acute gastroenteritis remains a common and often severe illness among infants and children throughout the world. The management of a child with acute diarrhea includes rehydration and maintenance fluids with oral rehydration solutions (ORS), combined with continued age-appropriate nutrition. However, although substantial data support the role of continued nutrition in improving gastrointestinal function and anthropometric, biochemical, and clinical outcomes, the practice of continued feeding during diarrheal episodes has been difficult to establish as accepted standard of care. Recommendations for maintenance dietary therapy depend on the age and diet history of the patient. It has been clear for many years that, when affected by gastroenteritis, breastfed infants should be continued on breast milk without any need for interruption and, by that way, will get faster recovery and improved nutrition. Moreover, many well-conducted studies have provided evidence that in formula-fed children not severely dehydrated, a rapid return to full feeding is well tolerated. Lactose intolerance and/or secondary cow's milk allergy are not a clinical concern for the vast majority of patients. In fact early refeeding i.e resumption of normal diet, in amounts sufficient to satisfy energy and nutrient requirements, should be the rule. However, in children younger than 6 months of age, the lack of suitable studies must lead to caution and use of specific lactose-free or extensively hydrolysate formulae, especially in case of severe and/or prolonged diarrhea. Several studies support the use of zinc supplementation or probiotics for acute diarrhea but some doubts persist in infant in developed countries.

Fermented infant formulae without live bacteria.

Infant and follow-on (or "follow-up") formulae fermented with lactic acid-producing bacteria during the production process contain no viable bacteria in the final product due to their inactivation by heat or other means. In this article the ESPGHAN Committee on Nutrition reviews published information on their clinical evaluation. In a systematic literature review, 2 randomized clinical trials including 933 infants were identified as meeting our predefined inclusion criteria. Our analysis reveals that only limited published data are available on the effects of fermented infant formulae. There are indications from 2 studies that some fermented infant formulae may reduce the occurrence or severity of infectious diarrhea in infants. It is recommended that the effects of fermented infant formulae on infectious diarrhea and other relevant outcomes should be assessed in further randomized controlled trials according to current scientific standards. The available data do not allow general conclusions to be drawn on the use and effects of fermented formulae for infants.