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Viewpoint Indian Pediatrics 2001; 38: 396-400 |
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Dietary Regimen for Persistent Diarrhea in Infants Under Four Months |
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Case fatality rate with Persistent Diarrhea (PD) peaks under 7 months(1,2). Dietary algorithm for PD have included children >4 months of age(3-5). Patwari et al.(1) recommend diets with breastmilk for infants <6 months. Since most are associated with lactational failure, it encourages the use of expensive lactose free formulae. We evaluated a dietary regimen for PD in children under 4 months of age.
We included patients of PD <4 months, admitted between June 1997 to September 1999. All underwent septicemic screening. Rehydration and antibiotics were given when needed. The stablization period ended when the child could take orally. This was noted as Zero time and the child weighed. The dietary regimen comprised of the diets A1, A2 and B in this order, except for cases >2 months of age where starter diet A2 was followed by diet B. Diet A1 included breastfeeding and if required (baby hungry after 30 minutes of suckling), top milk supplementation. Efforts to improve lactation, namely, reassurance, plenty of fluids, lactogogues and lactaid were carried on simultaneously. Improvement in lactation was considered if the mother felt engorgement of breast and top milk requirement decreased with adequate weight gain in infant. Top milk supplementation was stopped where babies were satiated and gaining weight adequately on breastfeeding alone. Relactation was successful if exclusive to high partial breastfeeding level was achieved. Exclusive breastfeeding (EBF) was only breastfeeding with or without water. Partial breastfeeding (PBF) was defined if top milk was added. When top milk supplementation comprises >80%, 2080% and <20% of the total feeds the PBF level was classified as low (LPBF), medium (MPBF) and high partial (HPBF), respectively (National Task Force Breastfeeding Hospital Initiative 1992). Diet A2 was a low lactose, energy dense, milk cereal diet prepared with Suji (semolina) or puffed rice powder (5 g), milk (50 ml), sugar (5 g) and oil (1 ml) cooked with water to a capacity of 100 ml, giving energy density of 1 kcal/g and lactose load of approximately 5 g/150 kcal of the feed. Diet B was a milk free diet containing the same ingredients (in double quantity), where the milk was replaced by 5g of egg albumin if the cereal used was puffed rice, giving an energy density of 0.7-0.8 kcal/g. Diets A2 and B were inexpensive and could be easily fed. Dietary shifts in the absence of sepsis, was as per the following criteria: (i) Appearance of dehydration 24 hours after Zero time; (ii) Frequency of more than 15 stools/day; (iii) No weight gain on any 2 of days 5, 6 and 7 (from Zero time) despite intake of >100 kcal/kg/day for 3 consecutive days; and (iv) Weight on day 7 <Zero time weight despite >100 kcal/kg/day for 3 consecutive days. Recovery was defined as cessation of diarrhea (<3 stools/day) plus weight > zero time weight or 2 consecutive days of weight gain of >20 g/day. All were encouraged to take >150 kcal/kg/day. Those who did not recover on Diet B were considered treatment failures and were shifted to egg albumin/chicken puree, glucose with oil or intravenous glucose. Patients with sepsis were given systemic antibiotics. Children were discharged on the diet they improved on. On follow up at 2 weeks a record of diarrheal days since discharge, feeding history and weight was made. SPSS (Version 7.5) and Epi-info 6.04 were used to analyze the data.
Twenty-nine cases of PD, 21 (78.5%) <2 months and 6 (26.8%) <1 month), were included. Twenty five of 29 were males. Of the 15 hospital deliveries, 11 were low birth weight. The data at admission (Table I) reveals that levels of BF were LPBF to nil in 65.5%. In the 6 infants <1 months 4 were on MPBF and 2 on LPBF. Twelve of the 15 subjects between 1 to 2 months were having no to LPBF. Majority (72.4%) were receiving commercially available lactose free formulae at admission. After a mean stabilization period of 23.86 ±17.19 (95%CI 17.32-30.40) hours the mean frequency of stools in last 24 hours at Zero time was 15.68±7.31 (95% CI 18.47-12.91). Twenty one (72.4%) cases received antibiotics at admission on clinical evidence, while 3 were given antibiotics when peripheral blood smear showed bandemia. Urine culture of 8 (27.5%) cases (all male) grew organisms. Blood culture was sterile in 24 and contaminated in 5 cases and none had lower respiratory tract infection.
Of 22 cases on starter diet A1, 21 were <2 months and 1 >2 months with HPBF at admission. Of the 17 patients where relactation was successful, all recovered. Nine of these were receiving no to LPBF initially. Hence, relactation was achieved in 9 of the 14 cases with no to LPBF. The remaining 5 cases who were shifted to diet A2 were 1-2 months old on nil to LPBF. These could not be relactated but the shift was due to no weight gain till the 7th day. Among the 4 cases who did not recover on diet A2, one left the study with diarrhea persisting and 3 were shifted to diet B. Two of these improved while the third with frequency of >15 stools/day and dehydration left against medical advice. Hence there was 82.8% (95% CI% 67.42-95.48) overall success rate for diets A1 and A2. Relactation was achieved in 77.3% (95% CI 54.2-91.3) cases. Further there was 100% and 66.6% success for relactation <1 month and <2 months age groups, respectively. Two third patients improved each on diet A2 (8/12) and B (2/3). During the hospital stay of 8.41±1.70 (95% CI 7.7-9.1) days the weight gain in the recovered cases was 179.3±161.75 g (95% CI 117.7-240.8). Thus there was 93.1% (95% CI 75.78-98.8) recovery on this dietary regimen. Of the 27 cases that recovered, 20 reported for follow up between 2 to 4 weeks. Only one had 2 diarrheal days since discharge. The mean weight gain was 511.5±294.2 g (95% CI 373.8-649.1) with the mean weight gain per week being 208.75±102.2g (95% CI 160.8-256.6) improving the Z score (0.59±2.33; 95% CI 1.69 to 0.49) as well as weight for length (96.1±13.2%; 95% CI 189.9-102.2) from admission.
All cases were of severe PD, since they had a high frequency (22.4±11.9) of stools/day and 83% needed rehydration. The need for antibiotics was present in 83% of cases, which is higher than that reported for older infants(1). Sibal et al report frequent association of non-gastrointestinal infections in PD <6 months(6). Our evidence was mostly clinical since the majority had received antibiotics before admission. Almost one third of all cases documented urinary tract infection, similar to that reported earlier(6). Early top milk supplementation, which is associated with malnutrition in this age group(7), was universal. Low birth weight was documented in 11 cases. Association of these factors with PD in this age group needs further evaluation. More than 65% of these cases were on very low levels of BF and 72% were receiving commercially available lactose free formulae. That puts a query on the role of lactose free formulae in the management of acute or persistent diarrhea. The high antigenic value of the soya protein in such formulae could induce a hypersensitivity reaction resulting in ongoing intestinal mucosal insult(8). As voiced before, there are practical and financial problems in management of nonbreast fed infants under 4 months of age(1). Khichri (rice and lentil mix) or yougurt based cereal diet recommended(3,4) for older infants with PD are difficult to feed to these younger subjects. Further amylase activity is low at birth but increases 200 fold within 9 months(9). Zoppi et al. have observed 10 fold increase in the pancreatic amylase in prematures after starch feeding(10). Earlier reports(11) of malabsorptive diarrhea following starch feeds in under 6 months, have not been validated. In view of these reports, the present dietary regimen added cereals to make milk energy dense and low lactose. The rationale is that some amount of lactose is needed to stimulate the lactase regeneration. For the same reason lactose free formulae may not be so effective. If even low lactose load is not tolerated, then a milk free diet is useful. Following this dietary regimen in the present study, high success rates for relactation and inexpensive cereal based diet were seen. Relactation success was 100% in those less than 4 weeks of age and 64% for those on nil to LPBF. As suggested earlier, dietary shift should not be arbitrary and an algorithmic approach can make the management more effective(12). It was encouraging that except for 2 cases, the rest (93%) recovered on the present dietary regimen. The case who did not respond on diet B could be having low amylase activity and hence malabsorption due to bacterial fermentation of undigested starch. In such cases use of chicken puree glucose diet can be useful. Hence, we conclude that the need for antibiotics is higher in PD of less than 4 months. Relactation should be tried in all subjects with PD up to 2 months of age. Further simple inexpensive cereal based diets are effective in children under 4 months of age with PD. Contributors: SA conceived the idea of this study, supervised data collection, analyzed and drafted the paper, she will act as the guarantor for the study. SAA and SK handled the data collection and took part in analysis and drafting. Funding: None.
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