Division of Gastroenterology, Hepatology, and Nutrition, Center for Global Child Health, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA.
To highlight recent advances in our understanding of prolonged episodes of acute diarrhea and persistent diarrhea in children. The focus is on the contribution of these illnesses to the global burden of diarrhea, their impact on childhood growth and development, novel epidemiologic links between prolonged and persistent diarrheal episodes, and strategies for their prevention and management.
Although less common than acute diarrhea, prolonged and persistent episodes of diarrhea in childhood constitute a significant portion of the global burden of diarrhea. These episodes also play a key role in the vicious cycle of childhood diarrhea and malnutrition in which undernutrition is both a risk factor and an outcome of diarrhea. Increased efforts to provide WHO-recommended zinc therapy for all children with diarrhea in developing countries will significantly reduce morbidity and mortality. In children who develop persistent diarrhea, yogurt-based or amino acid-based diets may accelerate their recovery.
In addition to increased implementation of strategies already known to effectively prevent and manage acute diarrhea, further research is needed to address the recognition, prevention, and treatment of prolonged episodes of acute diarrhea and persistent diarrhea in resource-limited settings.
"Secondly, we have attempted to disaggregate the effects of various approaches to dietary management by duration of diarrhea at study enrolment, recognizing that persistent post-infectious diarrhea may constitute a related but distinct pathophysiology from that of acute diarrhea, involving prolonged intestinal mucosal injury and delayed mucosal regeneration which increase the risk of chronic malnutrition and growth failure and may also inhibit neurodevelopment . Previously reviewed evidence from community-based cohort studies in Asia, Africa and Latin America suggests that persistent diarrhea accounts for 3% to 20% of all childhood diarrheal episodes [9,49] and between one third to one half of diarrhea mortality . We therefore sought to separately investigate the evidence for the dietary management of this important subset of the total diarrheal burden. "
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
BMC Public Health 09/2013; 13 Suppl 3(Suppl 3):S17. DOI:10.1186/1471-2458-13-S3-S17 · 2.26 Impact Factor
"In about 5–10% of children from developing countries diarrhoea continues for more than 2 weeks (Persistent diarrhoea, PD) with disastrous consequences for the nutritional state of the infant (Moore, 2011). Diarrhoea becomes thus a driver for malnutrition which makes the child more susceptible to another bout of diarrhoea creating a vicious cycle. "
[Show abstract][Hide abstract] ABSTRACT: Food and nutrition have played a crucial role in biological evolution. Lactation in mammals was one key invention. A central role in milk is played by lactose, otherwise an exotic sugar in nature. Lactose digestion needs the induction of specialized gut enzymes. This enzyme is shut off in a precisely timed developmental step leading to lactose malabsorption promoting weaning in the young and ovulation in the mother. The lactose-lactase system could thus regulate optimal birth spacing in land mammals. The domestication of cattle promoted milk as a food item also for adult nutrition. This was only possible by two further key inventions: the concomitant domestication of lactic acid bacteria which ferment the non-digestible lactose to the easily absorbed lactic acid and the mutation to lactase persistence (LP) in adults from dairy societies. This mutation represents one of the strongest selected loci of the human genome. Since no crucial nutritional selective advantage is conferred by LP, its dominance might be the result of indirect effects like the spread of cattle pathogens into humans. Lactase is also temporarily lost in rotavirus and Escherichia coli childhood diarrhoea and persistent diarrhoea is consequently best treated with lactose-free diets.
Solomon Shiferaw, Muna Abdullah, Yared Mekonnen, Abdoulaye Maïga, Akanni Akinyemi, Agbessi Amouzou, Howard Friedman, Aluisio J. D. Barros, Sennen Hounton
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