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The BRAT diet for acute diarrhea in children: Should it be used?
Abstract
Oral rehydration and prompt feeding remain the cornerstones of therapy for acute diarrhea. Although many studies support the importance of enteral nutrition in recovery from diarrhea, there are few data concerning the efficacy of specific food types. One type of diet often prescribed during acute diarrhea is the Banana, Rice, Applesauce and Toast (or Tea) BRAT diet. We review the limited data that address the safety and efficacy of diets with bananas, rice, and other dietary components in treating diarrhea. In addition, we review the nutritional content of this restrictive diet and find it lacking in energy, fat and several micronutrients. Prompt feeding and age appropriate food should continue as the standard of nutritional care during acute diarrhea.
... To recover quickly from diarrhea, there is one prescribed diet i.e., bananas, rice, applesauce, and toast (BRAT). For infants and children with disturbed stomachs, BRAT is especially helpful to give the stomach some relief by reducing the amount of stool produced (Duro and Duggan 2007). Since iron helps to combat anemia, vitamin C and copper in bananas facilitate the appropriate absorption of iron (Kumar et al. 2012). ...
Banana fruit is produced and consumed worldwide and belongs to the Musa genus. They are accessible for the entire year and affordable to everybody. It is a source of starch, fibers, minerals (magnesium, calcium, potassium, phosphorus, and manganese), and vitamin B6. Raw and mature bananas are used as a source of important compounds, such as carotenoids, phenolics, biogenic amines, and phytosterols. It has numerous health benefits, for instance, enhances brain health, improves heart health, good for bones, enhances digestive health, valuable for diabetes, brightens the teeth, strengthens the immune system, and helps to treat diarrhea, migraines, and anemia. They are also helpful against cancer and useful in skin and hair care. They can be easily processed into value-added products, which include flour, puree, chips, brew, jam, wine, vinegar, and sauce. Banana produces huge waste in the form of peels, pseudostems, inflorescence, leaves, fruit stalk, and rhizome, which can be used for several applications (medicinal use, as biosorbent, as fiber source, as bio-fertilizers, and livestock feed). Additionally, in recent years, banana peel extract has been utilized for nanoparticle synthesis. Overall, this chapter discusses the health benefits, value-added products, and other significant uses of bananas.
... BRAT diet containing banana, rice, applesauce, and toast or tea was reported to be prescribed during diarrhea. However, this restrictive diet lacks fat, protein, micronutrients, and energy [40]. The intervention diet during diarrhea must be balanced in nutrients, supplemented with antidiarrheal ingredients, and devoid of nutritional components that may enhance diarrhea. ...
Background
Diarrhea and malnutrition are major health problems in developing countries. Inflammation, high oxidative stress, poor nutritional status and fatty liver were encountered during such diseases. Patents for diarrhea and malnutrition management (WO2007/130882A2, WO00/37106A1, WO2014/152420 and CA2987364A1) were published.
Objective
The objective was to introduce anti-diarrhea functional foods with preventive effect on malnutrition.
Methods
Two processing techniques were applied for preparing functional foods (formula 1 ingredients were made into cookies followed by grinding; formula 2 ingredients were pre-cooked, dried and mixed in powder form) that evaluated in rat model of diarrhea with malnutrition (DM). Formula 2 was also assessed when mixed with nucleotides. The ingredients were edible plants possess anti-diarrheal effect with high protein sources (legumes and casein).
Results
Induction of diarrhea with malnutrition, high oxidative stress, inflammation, accumulation of liver fat and histopathological changes were demonstrated in DM control compared to normal control. The functional foods produced variable improvement in growth curves, food efficiency ratio, hemoglobin, hematocrit and plasma zinc, protein, albumin, globulin, lipase activity and MDA. Formula 1 showed superior in improving intestinal histopathology while formula 2 was more efficient in elevating plasma iron. Formula 2 with nucleotides was the best in improving growth curves, alkaline phosphatase and reducing liver fat. Intestinal mucosa reduced glutathione and nitrite showed efficient significant reduction on treatment with formula 2 with or without nucleotides. The formulas showed anti-diarrheal effect through improving feces weight and moisture content.
Conclusion
Studied functional foods showed anti-diarrheal effect and malnutrition improvement with different degrees.
... This diet imply the combination of certain foods containing dietary fibers with low nutritional status; however, these foods are supposed to be well tolerated by children's gastro-intestinal tract, during diarrheal episodes. BRAT diet is frequently used as a short-term solution for a good nutritional management (13). ...
Diet has a major role in the treatment of acute diarrhea in children, along with a minimal drug therapy, but not necessarily using antimicrobials. Children can successfully pas a diarrheal episode with diet and symptomatic treatment.
It is important to know how to properly choose foods to introduce in ill children diet. There is a lack of statistical data in our region regarding dietary treatment in child diarrhea. This study was realized by completing a questionnaire regrading nutritional management in children with diarrhea. 110 persons from Dobrogea region completed this questionnaire. We analyzes demographic and clinical issues, people preferences in choosing different foods appropriate to this pathology and minimal knowledge about medication.
Our results evidenced that general population knowledges regarding nutritional management of acute diarrheal disease in children and infants are appreciable. Foods like rice, toast, applesauce/baked apple, mint/figs/bilberry leaves teas, vegetables soup, bananas were found among people preferences, proving appropriate information. Antimicrobial drugs misusage is not reported, 83 out of 110 people avoiding them.
This chapter will discuss a case of diarrhea/constipation. Diarrhea and constipation are functional bowel disorders (FBDs) of the mid or lower gastrointestinal (GI) tract. These FBDs result from intestinal motility dysfunction and/or changes in intestinal fluid absorption, which in turn leads to bloating, discomfort, and occasionally, abdominal pain. Certain dietary choices aggravate these conditions, leading to serious complications. Management of diarrhea/constipation usually requires the use of medications and/or lifestyle modifications. The presently discussed case involved factors that exacerbated the conditions of diarrhea/constipation. This case serves as an example of the role of medical nutrition therapy in managing FBDs (particularly diarrhea and constipation). Moreover, this case will allow the dietetic professional to assess the causes of diarrhea/constipation in order to plan for the nutrition intervention and educate the patient about the dietary manipulations required to reduce their symptoms.
Treatment principles are presented as the emphasis is made on the oral rehydration and the appropriate nutrition.
Infectious diarrhea is both a local and a global concern. Illnesses can range from mild inconveniences to life-threatening epidemics. Although diarrhea can be caused by a vast array of pathogens, the cornerstone of prevention is provision of a safe food and water supply, application of basic hygiene principles, and the development and administration of vaccines. The cornerstone of treatment is rehydration. Selection of specific antimicrobial therapy should be based on disease presentation and epidemiologic factors.
The authors compared the safety and efficacy of a ready-to-use, premixed, rice-based oral rehydration solution (R-ORS) with a glucose-based oral rehydration solution (G-ORS), each containing 75 mmol/L sodium, in Mexican children with acute diarrhea for less than 5 days.
Methods: One hundred eighty-nine boys 3 to 24 months old admitted to the hospital with acute diarrhea and signs of dehydration were randomly assigned to receive either G-ORS or R-ORS. Intake and output were measured every 3 hours.
Results: In the group treated with R-ORS, significantly fewer patients required supplemental intravenous fluids during the rehydration phase compared to the G-ORS group (1%v 8.7%; P < 0.01). Mean stool output, percent weight gain, ORS intake, urine output, and number of patients who vomited during rehydration were similar in the two groups. The mean total stool output after the first 24 hours of maintenance phase was significantly lower in the R-ORS group than in the G-ORS group.
Conclusions: The authors found rice-based ORS to be safe, and its use reduced the rate of intravenous fluid therapy in comparison with the use of a glucose-based ORS.
To define the benefit of rice oral rehydration salts solution in relation to the glucose based World Health Organisation oral rehydration salts solution for treating and preventing dehydration in patients with severe dehydrating diarrhoea.
Meta-analysis using data from 13 available randomised trials that compared these two formulations.
The studies compared 1367 patients with cholera, severe cholera-like diarrhoea, or acute non-cholera diarrhoea. 668 received the standard WHO solution and 699 the rice based solution.
Each trial report was reviewed to determine patient eligibility, the number of patients who were randomised and the number of these excluded from analysis, details of the randomisation procedure, and the precise timing of the outcome measurements.
Stool output during the first 24 hours; weighted estimates of the difference in mean stool output between treatments.
The rice solution significantly reduced the rate of stool output during the first 24 hours by 36% (95% confidence interval 28 to 44%) in adults with cholera and by 32% (19 to 45%) in children with cholera. The rate of stool loss in infants and children with acute non-cholera diarrhoea was reduced by only 18% (6 to 30%).
The benefit of rice oral rehydration salts solution for patients with cholera is sufficiently great to warrant its use in such patients. The benefit is considerably smaller for children with acute, noncholera diarrhoea and should be more precisely defined before its practical value can be judged.
The effects of purified fiber components and wheat bran on several indices of protein utilization were determined in growing rats. A control diet containing 10% casein was diluted with either cellulose (C), pectin (P), lignin (L), guar gum (G), or wheat bran (W) at fiber levels ranging from 3% to 20%. All fibers except C caused a decrease in net protein ratio (NPR) as compared to the control casein diet. This depression in NPR increased as the dietary fiber level increased. Apparent and true nitrogen digestibilities also decreased with all fibers at all levels. At the highest level of fiber (20%) the depression was greater for G and W and was least for C. NPR when divided by digestibility (analogous to biological value) decreased with P,L, W (all levels) and G (20% level) but not with C. When rats were fed fiber without protein, there was increased excretion of endogenous fecal nitrogen with all fibers at all levels. The results demonstrate that fiber(s) affected protein utilization as measured by NPR, digestibility and endogenous fecal nitrogen excretion and that the negative effect increased with the level of fiber consumed.
One of the intriguing aspects of the acute infectious diarrhoeas is that, while resulting from an infection of the intestinal tract, they only last from a few hours to a few days. The study of the interactions between infectious agents and intestinal epithelium has allowed a better understanding of the cellular and molecular mechanisms that cause the sudden loss of water and electrolytes, the hallmark of acute diarrhoea. These interactions have also led to formulating oral rehydration solutions used worldwide now. They do not, however, allow understanding the short course of most intestinal infections. For that, one has to consider the intestinal epithelium as part of an anatomical and functional system that, including the many types of cells present in the lamina propria, constitutes the intestinal mucosa. Infectious agents interact with the whole of the mucosa, including the cells of the lamina propria. This leads, among other things, to a change in the functions of the epithelial cells and accelerates their turnover. The pathophysiology of the intestinal mucosa leads to better understand the short and benign course of most intestinal infections. It also leads to better understand the physiology of the intestinal mucosa, and the interactions between the body and its nutritional environment.
Malnutrition associated with diarrhea and vomiting can be prevented if the focus of treatment is on nutritional requirements. Some pediatricians inappropriately continue to recommend clear liquids followed by dilute feedings or hypocaloric diets until the diarrhea clears.
Medical records were retrospectively reviewed, and the literature was reviewed.
Severe malnutrition occurred in two children with diarrhea and vomiting who were treated with clear liquids followed by restricted nutrient intake.
Severe malnutrition associated with diarrhea and vomiting can occur when the prescribed treatment is bowel rest followed by hypocaloric diets until diarrhea clears. Malnutrition can be prevented if the focus of treatment is on nutritional requirements. Current American Academy of Pediatrics recommendations for treatment of diarrhea and vomiting are discussed.
Although standard glucose-based oral rehydration therapy corrects the dehydration caused by cholera, it does not reduce the diarrhea. Short-chain fatty acids, which are produced in the colon from nonabsorbed carbohydrates, enhance sodium absorption. We conducted a study to determine the effects of an orally administered, nonabsorbed starch (i.e., one resistant to digestion by amylase) on fecal fluid loss and the duration of diarrhea in patients with cholera.
We randomly assigned 48 adolescents and adults with cholera to treatment with standard oral rehydration therapy (16 patients), standard therapy and 50 g of rice flour per liter of oral rehydration solution (16 patients), or standard therapy and 50 g of high-amylose maize starch, an amylase-resistant starch, per liter of oral rehydration solution (16 patients). The primary end points were fecal weight (for every 12-hour period during the first 48 hours after enrollment) and the length of time to the first formed stool.
The mean (+/-SD) fecal weights in the periods 12 to 24 hours, 24 to 36 hours, and 36 to 48 hours after enrollment were significantly lower in the resistant-starch group (2206+/-1158 g, 1810+/-1018 g, and 985+/-668 g) than in the standard-therapy group (3251+/-766 g, 2621+/-1149 g, and 2498+/-1080 g; P=0.01, P= 0.04, and P=0.001, respectively). From 36 to 48 hours after enrollment, fecal weight was also significantly lower with the resistant-starch therapy than with the rice-flour therapy (985+/-668 g vs. 1790+/-866 g, P=0.01). The mean duration of diarrhea was significantly shorter with the resistant-starch therapy (56.7+/-18.6 hours) than with standard therapy alone (90.9+/-29.8 hours, P=0.001) or the rice-flour therapy (70.8+/-20.2 hours, P=0.05). Fecal excretion of starch was higher with the resistant-starch therapy (32.6+/-30.4) than with the standard therapy (11.7+/-4.1 g, P=0.002) or the rice-flour therapy (15.1+/-8.4 g, P=0.01).
The addition of a resistant starch to oral rehydration solution reduces fecal fluid loss and shortens the duration of diarrhea in adolescents and adults with cholera.
Because of the beneficial intestinal effects of dietary fibers, we have evaluated the therapeutic effects of green banana or pectin in children with persistent diarrhea.
In a double-blind trial, 62 boys, age 5-12 months, were randomly given a rice-based diet containing either 250 g/L of cooked green banana (n = 22) or 4 g/kg pectin (n = 19) or the rice-diet alone (control, n = 21), providing 54 kcal/dL daily for 7 days. Stool weight and consistency, frequency of vomiting and purging, and duration of illness were measured.
Most children (60%) had no pathogens isolated from stools, 17% had rotavirus, 5% Vibrio cholerae, 4% Salmonella group B, and 11% had enterotoxigenic Escherichia coli infections. By day 3 posttreatment, significantly (P < 0.001) more children recovered from diarrhea receiving pectin or banana than controls (59%, 55%, and 15%, respectively). By day 4, these proportions correspondingly increased to 82%, 78%, and 23%, respectively, the study diet groups being significantly (P < 0.001) different than controls. Green banana and pectin significantly (P < 0.05) reduced amounts of stool, oral rehydration solution, intravenous fluid, and numbers of vomiting, and diarrheal duration.
Green banana and pectin are useful in the dietary management of persistent diarrhea in hospitalized children and may also be useful to treat children at home.
Epithelial and other cells of the gastrointestinal mucosa rely on both luminal and bloodstream sources for their nutrition. The term functional food is used to describe nutrients that have an effect on physiologic processes that is separate from their established nutritional function, and some of these nutrients are proposed to promote gastrointestinal mucosal integrity. We review the recent in vitro, animal, and clinical experiments that evaluated the role of several types of gastrointestinal functional foods, including the amino acids glutamine and arginine, the essential micronutrients vitamin A and zinc, and 2 classes of food additives, prebiotics and probiotics. Many of the data from preclinical studies support a strong role for enteral nutrients in gastrointestinal health; in comparison, the data from human studies are limited. In some cases, impressive data from in vitro and animal studies have not been replicated in human trials. Other clinical trials have shown positive health benefits, but some of those studies were plagued by flaws in study design or analysis. The methods available to detect important changes in human gastrointestinal function and structure are still limited, but with the development of more sensitive measures of gastrointestinal function, the effects of specific nutrients may be more easily detected. This may facilitate the development of phase 3 clinical trials designed to more rigorously evaluate the effects of a particular nutrient by focusing on valid and reliable outcome measures. Regulatory changes in the way in which health claims can be made for dietary supplements should also be encouraged.
Acute gastroenteritis remains a common illness among infants and children throughout the world. Among children in the United States, acute diarrhea accounts for >1.5 million outpatient visits, 200,000 hospitalizations, and approximately 300 deaths/year. In developing countries, diarrhea is a common cause of mortality among children aged <5 years, with an estimated 2 million deaths annually. Oral rehydration therapy (ORT) includes rehydration and maintenance fluids with oral rehydration solutions (ORS), combined with continued age-appropriate nutrition. Although ORT has been instrumental in improving health outcomes among children in developing countries, its use has lagged behind in the United States. This report provides a review of the historical background and physiologic basis for using ORT and provides recommendations for assessing and managing children with acute diarrhea, including those who have become dehydrated. Recent developments in the science of gastroenteritis management have substantially altered case management. Physicians now recognize that zinc supplementation can reduce the incidence and severity of diarrheal disease, and an ORS of reduced osmolarity (i.e., proportionally reduced concentrations of sodium and glucose) has been developed for global use. The combination of oral rehydration and early nutritional support has proven effective throughout the world in treating acute diarrhea. In 1992, CDC prepared the first national guidelines for managing childhood diarrhea (CDC. The management of acute diarrhea in children: oral rehydration, maintenance, and nutritional therapy. MMWR 1992;41[No. RR-16]), and this report updates those recommendations. This report reviews the historical background and scientific basis of ORT and provides a framework for assessing and treating infants and children who have acute diarrhea. The discussion focuses on common clinical scenarios and traditional practices, especially regarding continued feeding. Limitations of ORT, ongoing research in the areas of micronutrient supplements, and functional foods are reviewed as well. These updated recommendations were developed by specialists in managing gastroenteritis, in consultation with CDC and external consultants. Relevant literature was identified through an extensive MEDLINE search by using related terms. Articles were then reviewed for their relevance to pediatric practice, with emphasis on U.S. populations. Unpublished references were sought from the external consultants and other researchers. In the United States, adoption of these updated recommendations could substantially reduce medical costs and childhood hospitalizations and deaths caused by diarrhea.
The protective capacities of fresh green (unripe) sweet bananas and of phosphatidylcholine and pectin (banana ingredients) against acute (ethanol- or indomethacin-induced) and chronic (indomethacin-induced) gastric mucosal lesions were evaluated in rats. Banana pulp was mixed with saline and given by gavage, as a pretreatment in a single dose. The identical protocol was used for pectin and phosphatidylcholine solution, and the dosages were adjusted to equal the amount of ingredients in the banana mixture, but higher concentrations were also given. The banana suspension reduced acute lesions, as did pectin and phosphatidylcholine in higher concentrations, but in concentrations as in fresh fruit no protective effects were observed except by pectin against indomethacin injury. In the model of chronic ulcers the banana suspension provided an incomplete and temporary protective effect. We conclude that the protective capacity of fresh green sweet bananas cannot be confined to only one active component. Pectin and phosphatidylcholine may protect gastric mucosa by strengthening the mucous-phospholipid layer, but the mechanism of protection afforded by bananas has to be further elucidated.
Studies were performed to determine the mechanism by which short-chain fatty acids increase colonic Na and Cl absorption by determining unidirectional 22Na and 36Cl fluxes across isolated stripped mucosa from the rat distal colon under voltage clamp conditions. Mucosal butyrate (25 mM, in the absence of bicarbonate) significantly enhanced both net Na and net Cl absorption by 7.0 +/- 1.3 and 6.9 +/- 1.0 microEq/h.cm2, respectively, without increasing the short-circuit current. Net Na and Cl absorption in butyrate-Ringer's solution and HCO3-Ringer's solution were identical. Butyrate stimulation of Na (and Cl) absorption was Cl-dependent and prevented by 1 mM mucosal amiloride, an inhibitor of Na-H exchange, but was HCO3-independent and not inhibited by acetazolamide, a carbonic anhydrase inhibitor. In contrast, bicarbonate-stimulated Na (and Cl) absorption was also Cl-dependent and amiloride-sensitive, but was significantly inhibited by acetazolamide. The effect of mucosal butyrate on net Na and Cl absorption was substantially greater than serosal butyrate, which in the presence of bicarbonate did not alter ion transport. The stimulation of Na and Cl absorption by mucosal butyrate was significantly greater than by propionate and acetate, whereas mucosal formate did not alter Na transport. The results of this study permit the following model: short-chain fatty acid stimulation of active Na and Cl absorption involves uptake of the nonionized form of butyrate and the coupling of Na-H and Cl-butyrate exchanges.
Rates of stool output are reduced when cooked rice is incorporated into oral rehydration solutions. We found that a fraction extracted from rice inhibited the response of intestinal epithelial crypt cells to adenosine 3'5'-cyclic monophosphate, a major intracellular mediator of secretion. This response to rice was seen as an inhibition of cell shrinkage and of chloride efflux in fresh suspended guinea pig crypt cells. The active fraction was of low molecular weight (< 1.5 kDa), hydrophobic, and not a peptide or glycoprotein. It may be chloride-channel blocker.
The protective capacities of fresh green (unripe) sweet bananas and of phosphatidylcholine and pectin (banana ingredients) against acute (ethanol- or indomethacin-induced) and chronic (indomethacin-induced) gastric mucosal lesions were evaluated in rats. Banana pulp was mixed with saline and given by gavage, as a pretreatment in a single dose. The identical protocol was used for pectin and phosphatidylcholine solution, and the dosages were adjusted to equal the amount of ingredients in the banana mixture, but higher concentrations were also given. The banana suspension reduced acute lesions, as did pectin and phosphatidylcholine in higher concentrations, but in concentrations as in fresh fruit no protective effects were observed except by pectin against indomethacin injury. In the model of chronic ulcers the banana suspension provided an incomplete and temporary protective effect. We conclude that the protective capacity of fresh green sweet bananas cannot be confined to only one active component. Pectin and phosphatidylcholine may protect gastric mucosa by strengthening the mucous-phospholipid layer, but the mechanism of protection afforded by bananas has to be further elucidated.
To assess the effects of dietary fiber (soy polysaccharide) on the severity, duration, and nutritional outcome of acute, watery childhood diarrhea.
A total of 34 hospitalized Peruvian male infants between 2 and 24 months of age were randomly assigned to receive a soy-protein isolate, lactose-free formula with added soy polysaccharide (group SF, n = 19) or the same diet without added fiber (group S, n = 15). The consumption of formulas, stool amount and consistency, absorption of macronutrients, and change in anthropometric status were measured.
Children in both groups were initially similar with regard to age, nutritional status, and prior duration and severity of diarrhea. Four patients in group SF (21%) and two in group S (13%) failed therapy because of recurrent dehydration or severe purging (P = .67). Formula intakes increased slightly during hospitalization (P = .03), but did not vary by dietary group (P = .73). Stool outputs declined significantly (P < .001) during hospitalization, but there were no significant differences by dietary group in either stool wet weight (P = .83) or dry weight (P = .87). Estimated median durations of liquid stool excretion after hospitalization were 43 hours in group SF and 163 hours in group S (P = .003). There were no significant differences in fractional or net absorption of macronutrients or change in anthropometric status by dietary group.
Soy polysaccharide, while not affecting stool output, macronutrient absorption, or nutritional status during acute, watery childhood diarrhea, significantly and markedly reduced the duration of liquid stool excretion.
This paper reports preliminary results from a study of child feeding practices in a rural area of Zimbabwe. Although Zimbabwe has relatively low infant mortality rates, it still has high child malnutrition rates. Several factors, including sex roles and relations between the sexes, access to resources, food costs and availability, time and energy costs of food production and preparation, and illness beliefs and practices, especially those concerning diarrhea and malnutrition, are examined as possible determinants of feeding practices and nutritional and health status. Results are compared to reports made by the World Bank and the Zimbabwe national nutrition survey. Whereas the World Bank report suggests a problem of late introduction of breastmilk supplements or solids, we found the opposite tendency of early introduction (by 3 months) of supplements. We suggest that mothers' pragmatic attitudes, interacting with certain social, cultural, and economic variables, are important factors influencing their child feeding decisions, especially resisting the use of commercial infant formula, at least in this rural area, and promoting prolonged breastfeeding.
The child with diarrhea should continue to be fed. An evolution in our approach to the nutritional management of children with acute diarrhea has gradually occurred. The American Academy of Pediatrics recently published recommendations for the treatment of children with acute gastroenteritis (Table); these guidelines endorse early feeding of age-appropriate foods, pointing out that this practice does not worsen the diarrhea, may decrease stool output, shorten duration of illness, and improve nutrition. This is a reevaluation of the previous recommendation of gradual reintroduction of milk-based formulas or cow milk beginning with dilute mixtures, indicating that as long as children are monitored for signs of intolerance, a regular age-appropriate diet, including full-strength milk or cow milk formula, can be used safely. Feeding during acute diarrhea should be continued, because a significant amount of nutrient absorption will still occur and thereby allow a better nutritional outcome. These foods should be easily digested and absorbed, be culturally acceptable, cheap, palatable, and lack a deleterious effect on the illness. Breast-feeding should be continued. Children receiving non-human milk should continue with full-strength milk or formula while being observed for signs of lactose malabsorption. If reliable observation is not possible, if the child is malnourished, or if there are signs of severe intolerance, a reduced-lactose or nonlactose formula should be administered. This diet should have an energy density between 0.7 and 1.0 kcal/gm of cooked food. The role of micronutrient supplementation in acute diarrhea is unclear at this time. Diarrheal diseases are a significant cause of pediatric mortality in developing countries, and in industrialized countries, diarrhea is an important cause of office visits to physicians, hospitalizations, and preventable mortality. Therefore there remain significant incentives to optimize the management of diarrhea. It is now clear that depriving the body of nutrition in general and the gut of enteral nutrients in particular entails a variety of adverse consequences. Optimal nutritional therapy, with continued feeding during illness, should be considered a crucial aspect of diarrhea management.
Oral rehydration therapy is used to treat dehydration caused by diarrhoea. However the rehydration solution does not reduce stool loss or length of illness. A solution able to do this may lessen the use of ineffective diarrhoea treatments as well as improve morbidity and mortality related to diarrhoea.
The objective of this review was to assess the effects of rice-based oral rehydration salts solution compared with glucose-based oral rehydration salts solution on reduction of stool output and duration of diarrhoea in patients with acute watery diarrhoea.
We searched the Cochrane Infectious Diseases Group trials register, the Cochrane Controlled Trials Register, Medline, Embase, Lilacs and the reference lists of relevant articles. We also contacted researchers in the field.
Randomized trials comparing standard World Health Organization oral rehydration solution with an experimental oral rehydration salts solution in which glucose (20 grams per litre) was replaced by 50-80 grams per litre of rice powder, with the electrolytes remaining unchanged.
Data were extracted independently by a statistician and a clinician.
Twenty-two trials were included. Concealment of allocation was adequate in 15 of these trials. Irrespective of age, people with cholera who were given rice oral rehydration salts solution had substantially lower rates of stool loss than those given oral rehydration salts solution in the first 24 hours. Mean stool outputs in the first 24 hours were lower by 67 millilitres/kg of body weight (weighted mean difference -67.4, 95% confidence interval -94.3 to -41.0) in children, and by 51 millilitres/kg of body weight (weighted mean difference -51.1, 95% confidence interval -65.9 to -36.3) in adults. The rate of stool loss in infants and children with acute non-cholera diarrhoea was reduced by only four millilitres/kg of body weight (weighted mean difference -4.3, 95% confidence interval -9.3 to 0.8).
Rice-based oral rehydration appears to be effective in reducing stool output in people with cholera. This effect was not apparent in infants and children with non-cholera diarrhoea.
Partially hydrolyzed guar gum (Benefiber; Novartis Nutrition, Minneapolis, MN, U.S.A.) is fermented by colonic bacteria liberating short-chain fatty acids (SCFAs), which accelerate colonic absorption of salt and water. The purpose of this study was to evaluate the effect of Benefiber (BF)-supplemented World Health Organization Oral Rehydration Solution (WHO ORS) in the treatment of acute noncholera diarrhea in children.
A double-blind, randomized, controlled clinical trial was performed at ICDDR,B in 150 male children aged 4 to 18 months who had watery diarrhea of less than 48 hours' duration. After admission, children were assigned to receive either WHO ORS or BF-supplemented WHO ORS until recovery. Major outcome measures, such as duration of diarrhea and amount of stool output, were compared between the treatment groups.
Patients receiving BF-supplemented WHO ORS had significantly reduced duration of diarrhea compared with the control group (mean +/- SD, 74 +/- 37 vs. 90 +/- 50 hours, P = 0.03). Survival analysis for duration of diarrhea also showed a reduction the BF-supplemented WHO ORS-treated group (P = 0.025, log rank test). There was also less stool output daily from days 2 through 7 in the patients treated with BF-supplemented WHO ORS compared with that in the children treated with WHO ORS; the reduction was significant on day 7 only.
Benefiber added to standard WHO ORS substantially reduces the duration of diarrhea and modestly reduced stool output in acute noncholera diarrhea in young children, indicating its potential as a new antidiarrheal therapy for acute diarrhea in children.
To compare glucose and rice-based oral rehydration solution with rice-based oral rehydration solution containing recombinant human lactoferrin and recombinant human lysozyme in diarrhea outcomes.
We conducted a randomized, double-blind controlled trial in children with acute diarrhea and dehydration. One hundred and forty children 5 to 33 months old were block randomized to receive low osmolarity WHO-ORS (G-ORS), rice-based ORS (R-ORS), or rice-based ORS plus lactoferrin and lysozyme (Lf/Lz-R-ORS). Intake and output were monitored for 48 h in the ORU, with continued monitoring through home and clinic follow-up for 14 d.
The G-ORS and R-ORS groups did not show any differences in diarrhea outcomes and were therefore combined as the control group. Intent-to-treat analysis showed a significant decrease in duration of diarrhea (3.67 d vs 5.21 d, P = 0.05) in the Lf/Lz-R-ORS group as compared with the control group and a significant increase in the number of children who achieved 48 h with solid stool, 85% vs 69% (P < 0.05). There were no significant differences [corrected] in volume of diarrhea or [corrected] the percentage of children who had a new diarrhea episode after achieving the endpoint.
Addition of recombinant human lactoferrin and lysozyme to a rice-based oral rehydration solution had beneficial effects on children with acute diarrhea.