Role Of Nutritional Management During & Beyond Diarrhea
Diarrhea remains one of the most common causes of mortality in children under five years of age in India. Latest NFHS-5 data suggests prevalence of diarrhea in the 2 weeks preceding the survey to be 9.2% in children under 5 years of age. However, various individual studies suggest the prevalence of diarrhea to be 20-40% in children under 5 years of age.
Diarrhea leads to villous atrophy, reduced absorption and increased requirements of micro-and macro-nutrients. At this instance, nutritional management plays a significant role to reduce the duration and severity of the diarrhea episodes. The current article discusses the role of nutritional management during diarrhea.
The problem of infection and malnutrition in economically emerging and developing countries like India are equally escalated. Several clinical findings suggest that the relationship between malnutrition and infections can be considered as bidirectional.
Bidirectional Relationship of Infection and Malnutrition
Nutrition being an essential aspect of life is linked to multiple components, systems, and biological processes including infection. Thus, malnutrition can alter the host immune function and adversely affect the skin and mucous barrier, which increases the risk of infection. Infection, in turn, affects nutritional status by three distinct ways:
- It reduces the dietary consumption as well as intestinal absorption.
- It increases catabolism of the nutrients.
- It causes sequestration of nutrients responsible for tissue generation and growth.
An inadequate dietary intake during infection results in weight loss, reduced immunity, mucosal damage, invasion by pathogens, and impaired growth and development in children. Nutrition in a sick child is more intensified by diarrhea, malabsorption, loss of appetite, diversion of nutrients for the immune response, and urinary nitrogen loss, all of which lead to nutrient losses and further damage to defense mechanisms.
Etiology and Nutritional Losses in Diarrhea
Pathophysiologically, diarrhea can be classified into four types:
- Secretory Diarrhea: It transpires when there is production of bacterial toxins (Clostridium difficile, E. coli, etc.), or augmented bile acids succeeding an ileal resection. This does not subside with restriction of food intake.
- Osmotic Diarrhea: It is triggered by the incidence of solutes in the gastrointestinal tract that is mal-absorbed inhibiting water and electrolyte absorption and leads to an osmotic upshot/effect. Mal-digestion of certain food substances, e.g. milk or certain laxatives are the common causes.
- Diarrhea secondary to malabsorption: Malabsorption can be a result of many disorders like Crohn's disease, celiac disease and etc. Many of these disorders result in diarrhea. This diarrhea is chiefly triggered by excessive amount stool volume increase follows fatty acid malabsorption due to unabsorbed fat in the stool.
- Exudative Diarrhea: It is related to the impairment of intestinal mucosa which leads to the release or oozing of mucus, blood, and nutrients from cells due to inflammation or injury.
- Diarrhea secondary to altered bowel motility: Excessive bacterial growth followed by subsequent bile salt deconjugation is encouraged when there is a delay in transport in the small bowel. The resultant fat malabsorption and increased colonic secretion results in triggering this form of diarrhea.
Nutritional Risk Factors for Diarrhea
Nutritional status can stimulate the severity of diarrheal diseases. The nutritional risk factors can be broadly categorized into three different categories.
- Anthropometric Measures: Several studies reflect a possibility that infants or children may have an early illness, an enteric infection, environmental allergies or immunodeficiency syndromes which might have been the cause of malnutrition and diarrhea. In such cases, malnutrition is a result of a prior infection and not the current ones. Presence of such anthropometric measures in diarrhea has always been challenging to investigate.
- Child Feeding Practices: Malnourished children are more susceptible to diseases such as diarrhea, malaria, pellagra and many more. Therefore, feeding practice is a crucial risk factor for diarrhea. Poor feeding practices, like inadequate breastfeeding, inappropriate food (lack of nutrient dense, energy dense, diet diversity, appropriate consistency and quantity) contribute to malnutrition. In several clinical studies, it has been observed that continued breastfeeding reduces risks of diarrhea and other infections than infants who were insufficiently breastfed or there was cessation of nutrient & energy dense food. WHO recommends that a child should not be devoid of feed beyond 6 hours.
- Micronutrient Status: Malabsorption and maldigestion of certain micronutrients might lead to an immune deficiency which can result in poor intestinal integrity, repair which may lead to diarrhea. For example, zinc deficiency results in mucosal injury and delayed intestinal repair mechanisms. It has been observed that vitamin A supplement decreased the severity of diarrhea in children. Similarly, zinc supplementation reduces the incidence of diarrhea at a remarkable rate.
WHO and IAP Recommendations for Nutritional Management During Diarrhea
Indian Academy of Pediatrics (IAP) has provided certain recommendations for diarrhea which are stated as follows:
• Persistent diarrhea: Low osmolarity and low lactose diet are initially recommended for kids. If diarrhea still persists, then the kids should be put on a lactose-free diet.
• Severe malnutrition (Hospital-based management): Feeding should be initiated shortly with a diet containing osmolarity less than <350 mosm/L with the content of lactose not exceeding above 2-3g/kg/day
World Health Organization (WHO) has provided certain recommendations for dietary management during diarrhea as follows:
• Medium chain triglycerides (MCT):
The WHO recommends nourishing of fats or oils during diarrhea to boost the nutrient concentration of diet and to provide maximum energy when there is constrained absorption capacity. MCT can be used as an adjuvant nutritional therapy as they increase the calorie value, improve absorption, digestibility.
• Low osmolarity oral rehydration therapy:
Modified low osmolarity Oral Rehydration Solution (ORS) has a total osmolarity of 245mmol/L and reduced level of glucose and sodium. It has been considered as one of the chief advantages as it decreases the need for unscheduled IV therapy, lower the stool output, reduce the risk of hypernatremia and vomiting.
• Zinc supplementation:
Zinc plays an important role in cell growth and differentiation, protein synthesis, immune function and intestinal transport of water and electrolytes and gut integrity. Its supplementation along with ORS has proven to reduce the duration and severity of diarrheal episodes. Furthermore, they also lower the possibility of subsequent infections over 2-3 months.
Importance of Nutrition Intervention During & Beyond Diarrhea
Nutritional intervention plays a vital role in the management of diarrhea as well as faster recovery after the episodes of diarrhea. It is important to minimize the adverse effects of the illness on nutritional status. As there is an excessive loss of water and nutrients in diarrhea, keeping the patient hydrated and provision of proper nutritional replenishment is of prime importance. In addition, it helps in normal intestinal mucosal renewal and absorptive and digestive functions.
Proper nourishment must be confirmed, and dietary restrictions should not be implemented on account of reducing diarrheal losses. The normal diet should be continued once the child is hydrated. In case of mild to moderate dehydration, food should be offered four to five hours once the child is rehydrated. The infants who are on formula should be taken to their usual formula diet to maintain the nutrient needs upon rehydration.
Lactose-free or avoiding lactose formulas usually is not recommended, until otherwise necessary in certain situations. According to a meta-analysis of 29 clinical trials constituting 2215 patients, there is no necessity of lactose-free milk formula in the majority of children. Nevertheless, certain infants with malnutrition or severe dehydration recover more quickly when given lactose-free formula. A recently published case report illustrates cases of four diarrheal infants who were successfully maintained on low lactose formula to maintain the energy and nutrient values without complete avoidance of lactose. Thus, more research regarding the same is required.
Overall, the treatment of acute diarrhea has relied upon simple and effective therapy of oral rehydration and nutritional support in form of nutrient & energy dense feeds. Similarly, micronutrient replenishment, optimal dietary regimens, and proper precautions are enough in many children older than 6 months with persistent diarrhea. Therefore, early nutritional intervention plays a significant role in management of diarrhea thereby reducing the frequency and severity of diarrhea and further reducing the chances of its re-occurrence.
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