In this review article, we have discussed vital and crucial role that diet plays in promoting health and wellbeing among diarrhea. We have also highlighted the need for medical professionals to advocate for improved ORT (Oral rehydration Therapy), continuous feeding, and use of probiotics and micro nutrients in the management of diarrheal diseases for children below 5 yrs of age.
Globally, diarrhea continues to remain one of the leading causes of mortality among children (1). In 2010 alone, diarrheal illness accounted for an estimated 12,600 deaths world wide. These account for 11% of overall deaths that occurred among children who were below five years. About 80% of these deaths occurred in African and south east Asian regions Fig.1 (2).
Fig. 1: Pie chart of death among children below 5 years.
WHO recommended guidelines on management and treatment of diarrhea in children acknowledge breast feeding as a successful and notable milestone in early stage among infants. Oral rehydration salts (ORS) and nutritional improvements probably have a greater impact on curbing mortality rates rather than the incidence of diarrhea itself. Children in the developing nations who are not breast fed, a lactose free diet may be useful for a speedy recovery (3).
Additionally, antibiotics are beneficial in certain types of diarrhea in children but in some cases it may cause antibiotic associated diarrhea (AAD). Recently it has been observed that the use of probiotics and/or fermented foods such as yogurt can also be beneficial. However, for manufacturing of yogurt, proper proportion of protein, fat, lactic acid, ethanol, microorganism and yeast are required (4).
Nutritionists from the Standard Health Care suggest use of high potassium foods and liquids that include diluted fruit juices, potatoes, bananas etc for reducing diarrheal illness among children. Additionally, use of high sodium foods like broth, soups, spout drinks, salted crackers, and fruit juices (with high fructose), grapes, honey, dates, nuts, figs, soft drinks and prunes can also help in reducing diarrheal illness.
Despite all such measures in controlling mortality relating to diarrheal disease, the chances of its occurrence remain unacceptably high. Focus continues to remain on comprehensive diarrheal disease management strategy introduced through dietary changes, right to health for children, addressing social determinants of health like environmental sanitation and clean drinking water, promotional campaigns with respect to breast feeding and on-going research in the field of cost-effective intervention is hence crucial in reducing the burden of diarrhea among children.
Dietary Management: Traditional Strategies and Current Trends
Rehydration therapy constituents-past and present
Conventional guidelines for management of diarrhea by the ministry of health and family welfare, Government of India, recommend low osmolarity oral rehydration salt solution (ORS), zinc and continued feeding of energy dense feeds in addition to breastfeeding. Oral rehydration therapy (ORT) with ORS remains the cornerstone of appropriate case management of diarrheal dehydration in children (5). Oral rehydration therapy with an inexpensive glucose and electrolyte solution as promoted by the World Health Organization has reduced substantially the number of deaths from dehydration due to diarrhea. However, recent research suggests prolonged use of
Recent advances in diarrheal management have emerged and most of such research has focused on the use of glucose polymers derived from rice powders as a replacement therapy. It has also been suggested that replacing glucose with rice or wheat hydrolysates or legumes can offset the negative effect of diarrhea as seen in the nutritional status of the patient, but much more research insight is needed in finding better management strategies (6).
The Starvation Therapy versus Breast Feeding during Diarrhea in Infants
The traditional reluctance in continue feeding during diarrhea stems, in part, from observations that children with acute diarrhea may have loose stool of incompletely digested nutrients. Damage to the gastrointestinal mucosa can alter some of the normal digestive and absorptive processes, and the absorption of macronutrients and total energy seems to vary as per the amounts of food consumed (7). Thus, for many years, episodes of diarrhea were treated by withholding feeds. The practice of withholding even breast feed was encouraged to such an extent that lactose deficiency occurred.
Recent studies have confirmed the advantage of continuing breast-feeding during the treatment of acute diarrhea. Breast milk has better gastrointestinal tolerance, its relatively low osmolarity, antimicrobial activity, enzymatic, and hormonal effects, or a combination of these factors. The fact that breast milk provided in small but frequent doses may also be advantageous. The breast-fed infant who has diarrhea should continue to be nursed.
Lactose Dogmatism and Diarrhea
Prolonged or frequent use of diluted milk can have deleterious nutritional effects. However, possibilities of lactose intolerance in high risk young malnourished infants during acute diarrhea are advised to use lactose free supplements. Prolonged use of a lactose containing diet can also result in increase in stool output and small increases in diarrheal duration. Therefore, lactose free formulas have shown some beneficial effects like decreased purging rates, ameliorating dehydration and decreased illness duration. Also, children with mild or no dehydration, and those whose conditions are managed according to appropriate treatment protocols can be treated successfully with lactose containing diets.
Fig.2: Management Strategies of Diarrhea.
Probiotic /mixed diets in diarrhea in Children
Because of lactose intolerance, various efforts have been undertaken to reduce the lactose load in small intestines. The use of yogurt is a good option and acts as a component of rehabilitation diets in the majority of cases of acute diarrhea (8). Significant results have been obtained in management with mixtures based on yogurt that contain its own β-galactosidase. In yogurt, lactose is hydrolyzed to glucose and galactose and its use in place of milk leads to a significant improvement in lactose digestion and reduced clinical symptomatology (9). However, hydrolyzed milk that may or may not be beneficial is not widely available in developing countries, and its higher osmolarity could potentially worsen intestinal fluid loss. Also, Children with acute diarrhea can have deleterious effect on gastrointestinal microbial ecology such as “dysbiosis” (bacterial contamination of the small bowel) (10) and its rectification is part of their nutritional rehabilitation. Inclusion of probiotics like Lactobacillus species, Bifidobacteria, and Saccharomyces boulardii in rehabilitation diets may be a promising well recognized measure to counter dysbiosis (11). In addition, mixed feeding of milk with other staple foods such as rice, cereals or tuber, results in a more absorption of lactose rather than when the milk is given alone. Such foods are usually supplemented with oil so as to increase their caloric density. Other types of such useful mixed diet contain vegetables, such as potatoes, carrots, maize and beans Fig.2 (12). In order to meet the daily caloric requirement, there is a possibility of adequate absorption of macronutrients with the use of the mixed diets. Thus, most studies of mixed diets have also shown a decreased duration of diarrhea, particularly when vegetable proteins were used. This finding could be related to the presence of fiber or other components of the staple foods.
Micronutrients in diarrhea in Children
Zinc supplementation is a new intervention for treating severity and duration of diarrheal episodes in children. Zinc sulfate, acetate, and gluconate are all acceptable zinc salt formulations, of zinc optimal for the national program. Oral zinc administration provides substantial benefit in the reduction of stool output, frequency and duration combined with safety, efficacy, and affordability in acute diarrhea. Thus, it can be concluded that oral zinc supplementation is a simple and effective therapeutic intervention in the management of acute diarrhea. It also plays a critical role in metallo-enzymes, polyribosomes and the cell membrane and cellular functions thereby giving credence to the belief that it plays a central role in cellular growth and in the function of the immune system (13). The possible mechanisms for the effect of zinc may include an improved absorption of water and electrolytes, improvement of gut function and enzyme activities or enhanced immunologic mechanisms (14).
On the other hand vitamin A deficiency, a major public health problem seen in children with diarrhea in many parts of the world is associated with an increased risk of infectious morbidity and mortality (15). It has been suggested, however, that vitamin A intake may reduce the incidence of more severe forms of diarrhea with a negligible effect on milder forms. The possible mechanism for beneficial effect of vitamin A supplementation is not well understood. However, Vitamin A may accelerate epithelial healing and may enhance both humoral and cell-mediated immune responses (16). Some studies have suggested that vitamin A supplementation may not be protective against diarrhea; therefore, further research is necessary before vitamin A supplementation can be universally recommended into diarrheal management.
Additionally, Folic acid has been suggested as a possible beneficial nutrient in the management of diarrhea because it is needed for the regeneration of damaged small-bowel mucosal epithelial cells (17). The role of folate supplementation has to be explored further before any recommendations can be issued.
Recognition of the synergistic relationship between nutrition and diarrhea is a strong force in most of the public health interventions to prevent diarrhea. There is mounting evidence for the cross-talk between diarrhea and dietary management in every way. Renewed interest in dietary management for diarrhea has generated new hopes but there is still much to be learnt regarding use of nutrient-dense food stuffs. Understanding this important aspect of biology is likely to have a major impact on our understanding of diarrheal management in children for better planning and organization of health services.
Author: Fazili I, M. Pharma student at Kashmir University