Historical review of the treatment of children with gastroenteritis makes interesting reading and suggests that until the 1930s children with diarrhea were not routinely starved. An 1893 Vade Mecum states, “diet should be given sparingly, consisting of non-irritating articles—gruel, rice, arrowroot, Neave's food prepared with extra quantity of milk, old rice well cooked with milk. Best diet is milk-and-limewater, iced if feverish”(1).
This practice changed in 1926 when Powers (2) described the major procedures in the treatment of “intestinal intoxication” as fluid administration, blood transfusion, withholding food for a period of time, and feeding at the end of the period of starvation in gradually increasing amounts. Therapeutic starvation became the established practice in addition to intravenous fluid therapy.
Theoretic advantages of continued feeding are maintained growth, minimized protein and energy deficits, reduced stool losses, and reduced functional and morphologic hypotrophy associated with “bowel rest”(3–5). Theoretic disadvantages of continued feeding are lactose intolerance leading to osmotic diarrhea, dehydration, and acidosis (6); risk of absorption of macromolecules, such as cow milk antigen, because of an impaired mucosal barrier, resulting in possible further mucosal damage (enteropathy); and even systematic immune response and food sensitization (7,8).
Clinical studies from the 1940s and 1950s showed that infants and children treated with an early or free-feeding regimen had better weight gain and did not have prolonged diarrhea when compared with patients treated with starvation and gradual refeeding (9,10). However, these studies were overlooked, and children continued to be starved for 24 to 48 hours (11).
After the advent of oral rehydration therapy, the practice of bowel rest was questioned. In 1979, Rees and Brook (12), working at the Central Middlesex Hospital, London, published a study that suggested grading feed, starting with one-fourth strength and gradually going up to full strength was unnecessary. Studies by Dugdale et al. (13) and Placzek and Walker-Smith (14) gave similar results. In 1985, a study by Khin-Maung (15) clearly showed that continuing breast-feeding during acute diarrhea was beneficial. A number of studies including excellent studies by Isolauri et al. (16,17) suggested that after initial oral rehydration therapy, full feeding appropriate for age is well tolerated with no adverse effects in children older than 6 months. Excellent studies by Brown et al. (18,19) clearly showed advantages of continued feeding on clinical and nutritional outcomes. Taking all these clinical investigations together, two risk factors, however, suggested caution: age (children younger than 6 months) and severity of diarrhea (children who are more dehydrated and more acidotic, have a higher rate and amount of vomiting, and have a higher number of stools) (20). The outcome of realimentation appears to be closely linked to the success of initial rehydration therapy.
Although glucose-based oral rehydration therapy effectively treats and combats dehydration, it does not stop diarrhea. In the 1980s, much research and thought was devoted to search for a “super” oral rehydration solution (ORS) that would reduce stool losses. Glucose-polymer (21) amino acids including glycine (22,23) were studied but did not prove significantly beneficial in a European clinical setting. Rice-based ORS gave encouraging results (24) but a metaanalysis of 13 clinical trials concluded that the benefit of rice-based ORS is “sufficient to warrant use in patients with cholera but is considerably smaller in noncholera diarrhoea”(25). A study by Santosham et al. (26) showed that feeding with boiled rice or rice-based formula immediately after oral rehydration therapy was as efficient as treatment with rice ORS alone for 24 hours. The emphasis appeared to return to early feeding. A small study based in Bristol, United Kingdom, of 40 patients (27) and an Eastern European study (28) involving infants of 0 to 1 year of age further confirmed that early feeding was safe, with no increase in vomiting or lactose intolerance, and resulted in better weight gain. The results of other studies suggested that dilution of cow's milk formula was not even necessary for dietary management of acute diarrhea in infants younger than 6 months (29–31).
ESPGHAN STUDY ON EARLY FEEDING
The establishment of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Working Group on acute diarrhea followed an ESPGHAN workshop entitled “Optimal Composition of Oral Rehydration Solution for the Children of Europe” held in Copenhagen in 1988 (32). It was thought that the group would provide an ideal setting for multicenter studies. “Early feeding in Childhood Gastroenteritis” was the groups first clinical study and the results were published in 1997 (33).
The aim of this study was to compare the effect of ORS (conforming to ESPGAN ORS working group recommendations) (32) and early or late feeding on the duration and severity of diarrhea, on weight gain, and on complications (carbohydrate intolerance and vomiting) in weaned European infants.
A total of 230 patients were enrolled in the study, 134 in the early-feeding group (group A) and 96 in the late-feeding group (group B). Mean age was 13 months, and mean duration of diarrhea was 3.2 days. Most of the patients (80%) had mild dehydration. Patients were weighed and examined, the degree of dehydration assessed, and fluid deficit calculated. Each patient was then rehydrated in the following 4 hours. If allocated to group A, the patients started their usual diet, and if allocated to group B, they continued on maintenance ORS only for the following 20 hours and then began the usual diet. In addition, both groups were offered ORS 10 ml/kg/stool for each watery stool. If a child was breast-fed, breast-feeding was to continue throughout, along with ORS and diet as appropriate.
The amount of ORS taken over the first 4 hours was similar in the two groups; a mean of 46 ml/kg (41–50 ml/kg) for group A and 49 ml/kg (45–52 ml/kg) for group B. Weight gain during this phase was also similar, 85 g for group A and 77 g for group B (P = 0.76).
After Rehydration: 4 to 24 HOURS
During this period, mean weight gain was significantly higher in group A (95 g) compared with group B (2 g) (P = 0.01) (Fig. 1). More ORS was consumed by the nonfeeding group (group B), but the total amount of fluid intake was similar in the two groups. There was no significant difference between the two groups in plasma sodium, potassium, or bicarbonate levels. Net weight gain during hospitalization was significantly higher in group A compared with group B (P = 0.001).
There was no significant difference between the two groups in the incidence of vomiting or watery stools on days 1 to 5. (See Fig. 2 and 3.) The incidence of lactose intolerance for weaned children appears to be extremely low, 6% and 1% in groups A and B before entry into study and nil on day 5 and day 14. No patient had diarrhea or vomiting persisting by day 14. Milk intake was significantly higher in group A on day 2 (P = 0.008) and day 3 (P = 0.02) but became equal by day 4. Four patients in each group required intravenous fluids by day 4. None of these patients had significant lactose intolerance.
The conclusions of this multicenter study were as follows: (1) Complete resumption of a child's normalfeeding, including lactose-containing formula after 4 hours of rehydration with glucose ORS (ESPGHAN-recommended composition) led to significantly higher weight gain after rehydration and during hospitalisation. (2) There was no worsening of diarrhea, no prolonged duration of diarrhea, and no increased vomiting or lactose intolerance in the early-feeding group. The incidence of lactose intolerance in this study was extremely low, and based on this data, restriction of lactose-containing foods for the vast majority of children with gastroenteritis does not appear justified.
RECOMMENDATIONS FOR FEEDING IN CHILDHOOD GASTROENTERITIS
Conventional treatment of acute gastroenteritis in Europe has included a period of starvation, usually 24 hours, but often prolonged (11). This practice continues (34). It has become clear that the withdrawal of food during the management of gastroenteritis is not beneficial. This study, involving a range of hospitals from around Europe, added considerable weight to this evidence. In malnourished children, the nutritional benefits of early feeding have been well illustrated (18). Most of the children in our study were not nutritionally compromised when they developed gastroenteritis, but nevertheless because some of them lost weight, they may have gained nutritional advantage from nutritional supplements in addition to ORS.
This study provides clear evidence that continuation of feeding during gastroenteritis has advantages for the children of Europe (35). Optimal management of mild to moderately dehydrated children should consist of oral rehydration with ORS for the first 4 hours followed by resumption of normal feeding. Supplementing the usual feeds with ORS (10 ml/kg/liquid stool) as necessary can prevent further dehydration. Breast-feeding should be continued throughout.
Gastroenteritis is still not optimally managed in children in Europe (34). Guidelines need to be promoted for optimal management of gastroenteritis, especially to primary care physicians, health-care workers, and parents. Effective promotion and implementation of preventative measures to reduce the prevalence of gastroenteritis, e.g., better hygiene practice in the home and increased breast-feeding, are necessary.
Research is also needed to optimize management of gastroenteritis in children. The working group has carried out a study on the use of probiotics (36) and a study on zinc supplementation is being planned.
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