Prolonged diarrhea in infancy - University of Cape · PDF filePersistent Diarrhea Nutritional...

Persistent Diarrhea

Nutritional care

Cape Town Sept-Oct 2015

GOES

Basic physiology

Fluids handling in the GIT

bull Small intestine ndash 8-9 liter pass through the Treitzligament

bull 2 liters from intake

bull 7 liters of GIT secretions

bull Large intestine ndash 1 lit fluids reach the ICV

bull Rectum ndash 200 gr are excreted in stool

Basic physiology

bull Stool volume is dependent on fluid content

ndash Water and electrolytes absorption

ndash Fluids secretion

ndash Gut motility

Enterocyte intracellular signalling leading to intestinal secretion

cAMP cGMPCa

cytoskeleton

Basic physiology

Regulation of fluid and electrolytes transport is under the control of regulatory mechanisms

bull Entero-endocrine system

bull ENS

bull Gut flora

bull Gut Immune system

Millennium Development

Goal 4 and 5 by 2015

127 million deaths in 1990 to 63 million in 2013

Definitions acute and chronic or persistent diarrhea

bull WHO ldquopassage of loose or watery stools at least three times in a 24 h periodrdquo

bull ESPGHANESPID a decrease in the consistency of stools (loose or liquid) andor an increase in the frequency of evacuations

ndash Acute diarrheas abrupt onset resolve within 14 days and are mostly caused by infections

ndash Persistent diarrhea episode of diarrhea lasting 14 days or longer (WHO)ndash Chronic diarrhea diarrhea lasting more than 14-30 daysndash Other chronic diarrheas mainly due to congenital defects of digestion

and absorption

Prevalence

bull PD in developed countries bull Prevalence 3-5 or even less

bull Major causes celiac disease food allergy diet induced IBDentericinfections different disorders

bull PD in developing countries bull Prevalence 5-25

bull Major causes serial enteric infections associated with malabsorption malnutrition micronutrients deficiency and immunodeficiency

Persistent diarrhea in developing countries

Infectious disease

Lactose intolerance

Malnutrition

Delayed intestinal mucosa recovery

Bacterial overgrowth

Chronic entropathy

ImmunedeficiencyHIV

Micronutrientdeficiencies

AnorexiaFood withdrawal

Dietarysensitisation

PD = Environmental Enteropathy

bull PD EE a condition characterized by morphologic changes in the gut of inhabitants of developing countries

bull EE is characterized by ndash Intestinal inflammation

ndash Partial villous atrophy

ndash Epithelial cell degenerative changes

bull Functional disturbances in EE includendash Reduced absorption

ndash Increased turnover of intestinal cells

ndash Increased mucosal permeability

ndash Generalized activation of the innate and adaptive immune system

Environmental Enteropathy

Young (less than 6 months)MalnutritionMale genderFeeding practice Micronutrient deficienciesDiarrheal severityChronic diseasesImmunodeficiency HIVAIDS

Selected etiologic agentsUse of antibiotics for AGESocioeconomic status Young mothers

PROLONGED PERSISTENTDIARRHEA

Risk factors for persistent prolonged diarrhea

Araya M et al Acta Paediatr Scand 1991Catassi C et al Pediatr Gastroenterol Nutr 1999

Persistent diarrhea socio-demographic and clinical profile of 264 children seen at

a referral hospital in Addis Ababa

bull 5762 children with all forms of diarrhea 264 (5) had PD

bull PD children characteristics

ndash 83 were below 18 months of age

ndash The peak occurrence was between the ages of 7 to 12 months

ndash 86 had associated malnutrition

ndash 83 lt 4 months were either fully or partially weaned

ndash Watery diarrhea with no dehydration was the main feature

ndash 7 of the patients had dysentery

ndash Average family income was low but literacy level seem to have had no effect

Ethiop Med J 1997 Jul35(3)161-8

Etiologic studies of 130 prolonged episodes of acute diarrhea

Moore SR et al Gastroenterology 2010 October 139(4) 1156ndash1164

Diarrhea attack rates of acute (lt7 days)

prolonged (ge7 and lt14 days) and persistent (ge14

days) episodes per child-year by age


Infants with ProD were twice as likely to develop PD

Diarrhea morbidity accounted for acute (lt7 days) prolonged (ge7 and lt14

days) and persistent (ge14 days)


PD affect nutritional status

Impact of acute (lt7 days) prolonged (ge7 and lt14 days) and persistent (ge14 days) diarrhea on

anthropometry


first acute (n=308) prolonged (n=145) and persistent (n=62)

Effects of repeated diarrheal episodes on childhood growth curves

Gastroenterology 2010 October 139(4) 1156ndash1164

1007 children with 597638 child-days of diarrhea surveillance

Optimal nutritional therapy is generallyconsidered the cornerstone

of its management

PD is a nutritional disorder

Approach to infant with chronic diarrhea in developing countries

bull Persistent diarrhea following an acute infection is the predominant type of diarrhea

bull Diagnostic resources are often limited

bull Algorithmic approach to diagnosis and management is practical and usually effective

Evaluation steps


bull Initial assessment of hydration and nutritional status

bull Specific testing for pathogens and empiric therapy if necessary

bull Evaluation for extraintestinal infections

bull Evaluation of nutritional status and nutritional rehabilitation

Watery vs Bloody Diarrhea

Classify the diarrhea based on its appearance

bull Watery diarrhea cholera or rotavirus in young children

bull Bloody diarrhea most cases of acute bloody diarrhea are caused by Shigella spp (45 to 67 ) and Campylobacter (35 to 37) Entamoebahistolytica fewer than 3Children presenting with bloody diarrhea are at

particularly high risk for morbidity and mortality

Laboratory testing

bull Fluids electrolytes and dietary management are not dependent on etiology

bull Simple bedside laboratory tests may be helpful in cases of PD to identify severe malabsorption

bull Testing the stool for pH and glucose using a urine

bull A stool glucose of greater than 2+ or a pH lt 50 suggests malabsorption

Specific laboratory testing is not essentialfor the management

of persistent diarrhea in developing countries

Laboratory testing

bull In selected cases especially for bloody diarrheabull Stool cultures Shigella spp and Campylobacter

bull For children with persistent watery stoolsbull Stool microscopy trophozoites or cysts of E Histolytica

bull Fecal antigen for giardia infection rotavirus

bull Dark-field or phase contrast microscopy to identify V cholera

raquo Antimicrobial therapy generally is not necessary for individuals with mild symptoms so there is no benefit to specific testing for these patients

Treatment approach to infant with chronic diarrhea in developing countries

bull Inpatient treatment is advisable

bull Children with moderate severe malnutrition

bull Presence of dehydration

bull Systemic infections

bull Infants younger than 4 months


bull Correction of hydration status

bull Nutritional management plan

bull Treatment of infections

bull Micronutrientsrsquo supplementation






Micronutrients and Vitamins Deficiencies

bull Children with chronic diarrhea and malnutrition are often deficient in

bull Vitamin A zinc folic acid copper and selenium

bull Micronutrients deficiencies bull Impair immune system function

bull Delay mucosal recovery

Micronutrient and vitamin supplementation are part of nutritional rehabilitation

Micronutrients deficiency

Micronutrients and Vitamins

bull The WHO recommendsbull Two times the RDA for folate vitamin A iron copper

and magnesium for two weeks

bull In children with concomitant measles infection or ophthalmologic signs of Vitamin A deficiency should be treated with a high dose of vitamin A

Zinc supplementation

bull The WHO recommends zinc supplementation for children with diarrhea in developing countries

bull 10 mg daily for infants up to 6 months of age bull 20 mg daily for older infants and children for 14 days

bull Meta-analyses showed that zinc supplementation reduced the severity and duration of acute and persistent diarrhea in childrenndash Zinc supplementation in the persistent-diarrhea trials

bull Reduced by 24 probability of continuing diarrhea (95 CI 9 37) bull Reduced by 42 treatment failure or death (95 CI 10 63

Bhutta ZA Am J Clin Nutr 2000

Mean difference in duration of

acute and persistent diarrhea

Lukacik M et al Pediatrics 2008121326-336

Correction of dehydration acidosis electrolyte abnormalities hypoglycemia

and treatment of concomitant infections should be the first priorities





Dietary management

Dietary management should be addressed ASAP

bull Most children need at least 150 kcalskgday 10 calories from protein (50 from an animal source)

bull There is no need to limit fat intake

bull Breastfeeding should be continued whenever possible

bull Secondary lactase deficiency should be thought for and addressed

Nutritional compromise is present in most cases of persistent diarrhea in developing countries

Nutrients Absorption During Acute and Chronic Diarrhea

Thobani S et al Pediatric enteral nutrition 1994

Predicted Catch-Up Growth at Different Energy Intakes

Optimal protein intake

All balances turn positive on intakes above 22 g of proteinkg per day (350 mg Nkgday)

General Rehabilitation Principles

bull Provide daily caloric intake of 150-200 kcalkgdaybull Caloric density of 80-100 kcal100 gbull Protein intake (10-15 of energy 3-6 g proteinkgday)bull Osmolality should not exceed 350 mOsml

Brown KH Acta Pediatr Scand Suppl 1991

Elemental diets Milk-based diets

Chicken-based feedsTraditional local diets

What to feed

EN PN

Available ProductsDeveloped Countries

bull Home-made recipes

Developing countries

ldquo1113 children with the PD syndrome of infancy were successfully treated with human milk All the infants who were severely malnourished had deteriorated while fed on a wide range of highly modified formulas (extensively hydrolysed and chicken based)

Despite its high lactose content human milk has nutritional and immunological properties that may reverse many of the factors thought to cause PD syndromerdquo

Available Formulae

Cowrsquos milk based Formulae

Soy based formulae

Hydrolysed protein based formulae

Amino acid (Elemental diets) based Formulae

The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk

However some of these children may be lactose intolerant possibly contributing to the high rate of unfavorable treatment outcomes

What is the role of lactose Free diets

Solomons NWet al Am J Clin Nutr 1984

The routine reduction of lactose content from a milk-based diet for severe protein-energy

malnutrition offers no advantages

Severely malnourished diarrhea (n=196 3-60 months)

(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)

BMC Pediatrics 2010

(255) had evidence of lactose intolerance (stool reducing substance ge 1 + [05] and stool pH lt 55)ndash Kwashiorkor (p = 0032)

ndash Perianal skin erosion (p = 0044)

ndash High mean stool frequency (p =lt 0001)

ndash Having ge2 diarrhoea episodes in the previous 3 months (p = 0007)

ndash Young age of 3-12 months

ndash Lack of up to-date immunization

ndash Persistent diarrhoea vomiting dehydration and abdominal distension

ndash Exclusive breastfeeding for less than 4 months

ndash Worsening of diarrhoea on initiation of therapeutic milk

BMC Pediatrics 2010

Dietary managementLactose free diet

bull Secondary disaccharidase lactase deficiencies suspected

bull A low-lactose diet may be necessary

bull Milk based feeds

ndash Mixing milk with cereals small frequent feedings

ndash Lactose-free formulas are an alternative

ndash Use yogurt

bull Non-milk based feeds

ndash Use other source of protein egg or pureed chicken

Available lactose-free formulae


Soy based formulae


Amino acid (Elemental diets) based Formulae frequently employed in developed countries in the therapy

of PD and intestinal disease especially when dietary protein sensitivity is suspected

Randomized controlled trial of an exclusive diet of amino acid-based elemental feed (AAF) compared with standard nutritional rehabilitation (based on skimmed milk and then soya) for PDM

Treatment was given for 4 weeks in the malnutrition ward of a University Teaching Hospital in a single-blind study (n=200 106 HIV +)

155 completed the study 39 died 6 lost to follow up

Weight gain was greater in the AAF group (median gain WA z-score was 123 089ndash157) compared with the control group (087 047ndash125 p = 0002)

Diarrhea frequency and global recovery scores improved equally in both treatment groups and mortality did not differ

Amadi B et al J Trop Pediatr 2005

AAP

bull 3 month feeding study

bull Growth significantly improved in subjects with CD fed EleCare WAz

bull Symptoms also improved

bull EleCare in improving symptoms in pediatric subjects with CD

ldquoHome Maderdquo Solutions

bull Milk based

bull Chicken meat based

bull Combinations with cereals

bull Total elimination of milk is not required in the initial treatment of patients with

bull In addition milk-cereal mixtures are easy to prepare in the household

bull Further dietary modification may be restricted to those children whose treatment fails with such diets

Pediatrics 1996981122-1126

116 children 3 to 24 months of age with diarrhea

Probability of continuing diarrhea by dietary group

Dietary manipulations during PD

Even among those children for whom lactose avoidance may be necessary nutritionally complete diets comprised of locally available ingredients can beused at least as effectively as commercial preparations

Feeding Yogurt during PD Prospective randomized study (n=102) (age 6-36 months) with PD Traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for 7 days and then in combination with K-Y for 7 days

Bhutta ZA et al Acta Paediatr Suppl 1992

Milk Load Yogurt Load9 boys 7-29 months with chronic diarrhoea


bull Milk based



Successful use of a chicken-based diet for the treatment of severely malnourished children with PD RCT

bull RCT chicken-based diet elemental (Vivonex) and soy

bull 56 children severe malnutrition PD aged 3 to 36 months

bull Isocaloric diets NGT 150 mlkg per day

J Pediatr 1997 Sep131(3)405-12

Nurko S Garciacutea-Aranda JA Fishbein E Peacuterez-Zuacutentildeiga MI


bull Forty-one children (732) were successfully treated

ndash 13 Vivonex 13 Nursoy 15 chicken

ndash No differences in diarrheal outcomes

ndash All groups had significant weight gain


J Pediatr 1997 Sep131(3)405-12


bull Treatment failure was independent of the diet and was associated with the presence of infection on admission

bull There was a significantly higher nitrogen balance in the chicken group (3582 +- 13 mgkg per day) than in those receiving Vivonex (2266 +- 61) or Nursoy (291-4 +- 1116 p lt 005) groups

bull CONCLUSIONS

ndash The chicken-based diet was as effective as Vivonex or soy

ndash Was well tolerated inexpensive and widely available

ndash Represents an effective and inexpensive alternative to the treatment of severely malnourished children with PD

J Pediatr 1997 Sep131(3)405-12


bull 460 children with persistent diarrhea age 4-36 months

bull Bangladesh IndiaMexico Pakistan Peru Viet Nam

bull Malnourished (WAz -303 plusmn 086)

bull Severe associated conditions (45 required rehydration infections)

bull The overall success rate of the treatment algorithm was 80

bull The recovery rate among all children with only diet A was 65 and was 71 for those evaluated after receiving diet B

bull The children at the greatest risk for treatment failure

ndash Acute associated illnesses (cholera septicaemia and UTI)

ndash Required intravenous antibiotics

ndash Highest initial purging rates

bull The short-term treatment of persistent diarrhea can be accomplished safely and effectively in the majority of patients using an algorithm relying primarily on locallyavailable foods and simple clinical guidelines

bull This study should help establish rational and effective treatment for persistent diarrhoea


bull Milk based



Rice based diet compositionl

Akbar MS et al J Trop Pediatr 1993

Management Approach to PD Using Low-Cost Rice Based Diet in Severely Malnourished Children in

Bangaladesh

Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia

Time to improvement of diarrhea in patients using rice-based diet

Cumulative recovery from persistent diarrhea with a rice-based diet


LGG in the Treatment of PD in Indian Children

Basu S et al J Clin Gastroenterol 2007

All patients with PD admitted over a period of 2 years (n=235) Age= 42 plusmn 20 years none had severe PEM Randomized to receive ORS alone (n=117) or ORS plus LGG powder (n=118) containing 60 million cells twice daily for a minimum period of 7 days or till diarrhea has stopped

bull Participants who regularly prepare special feeds at home were observed preparing two feeds with equivalent nutrient composition a 2-ingredient (2-IF protein free powder water) and 6-ingredient feed (6-IF glucose polymer micronutrient powder 50 fat emulsion NaCl KCl water)) under research-conditions and 8 weeks later under home-conditions

bull The same feeds (2-IF and 6-IF) prepared by a trained feed-maker served as controls

Evans S et al Arch Dis Child 201398184-188

Nutrition Content of Modular Feeds How Accurate is Feed Production

Biochemical nutrient analysis was inaccurate for both feeds but was better for the 2-IF

Preparation errors included

Incorrect use of equipment poor recipe adherence and ingredient measurement mistakes

Even in control-feeds there was equipment inaccuracy poor ingredient emulsification and residues left in mixingmeasuring containers

Fewer errors occurred with powdered than liquid ingredients


Dietary manipulations during PDOutcomeDietIntervention

No significant effect for stool output or weight Significant reduction in the risk of treatment failure 27

Regular vs fermented formulaLiquid feeds reduced lactose vs regular lactoseTouhami M 1992

For both statistically significant effect of these formulas compared to milk for treatment failure2 semi-elemental formulas showed statistically significant effect on weight gain compared to milk

1lactase-treated milk with regular milk 2 lactose-free semi-elemental vs regular milk

Liquid feeds lactose-free vs lactose-containing Penny ME 1989Romer H 1989

No statistically significant effects of the soy-based formula were shown in the single study reporting on duration [2] or in the pooled results from both studies for stool output weight gain or treatment failure

1 Soy-based formula vs a mixture of rice lentils and yogurt2Same with added diluted buffalo milk to the mixed diet

Lactose-free liquid feeds versus lactose-containing mixed diets Bhutta ZA 1991Bhutta Z 1994

The duration (3)] and on stool output (3) weight gain (4) and treatment failure (5) among moderately or severely malnourished children showed no statistically significant effects of commercial diets compared to home-available diets

Commercial were rice- soy-based lactose-free whey-based or amino acid-based formulas lactose-hydrolyzed milkThe home-available included a rice lentil and yogurt mixture with or without diluted buffalo chicken-containing and cowrsquos milk

Commercially vs home-available ingredientsNurko S 1989Penny ME 1989Romer H 1989Bhutta ZA 1991Bhutta ZA 1994Godard C 1989In precarious setting infants malnurished infants gt6months

can be safely rehabilitated with home made products of high nutritional value

Practical Decisions

Decide on the route of administration GUT

Decide on the type of formula

Decide on concentration volume and rate of delivery

Decide on oral vs EN vs PN

Monitoring

Delivery of Enteral Nutrition

Continuous delivery of EN Increase gradually feeding volume up to target Increase concentration of the formula up to 1kcalml Target intake 150 kcalkgday

Continuous evaluation of tolerance to EN Presence of vomiting worsening of diarrhea Abdominal discomfort or distension Stool volume reducing substances fat and pHWeight gain and biochemical indicators of nutritional rehabilitation





Initiate Parenteral Nutrition in the presence of significant enteral

intolerance


Vomiting diarrhea

Dehydration refeeding

Technical complications

Infectious complications

Complications of Enteral Nutrition

Conclusions and Recommendations

bull In developing countries most cases of persistent diarrhea are caused by a combination of enteric infections under-nutrition and impaired immune system function


bull The first step in evaluating a child with persistent diarrhea is to diagnose dehydration malnutrition and associated non-enteric infections

bull The next step is to classify the diarrhea based on its appearance as bloody diarrhea is most likely caused by Shigellawhich confers a worse prognosis and requires antimicrobial treatment

bull Laboratory testing of stool is not essential


bull The first step in treatment is to stabilize children with severe infection or dehydration according to standard protocols


bull The main component of treatment is nutritional rehabilitation many children have a secondary carbohydrate intolerance and respond better to a low-lactose diet


bull It is recommended that all children with chronic diarrhea be treated with zinc supplementation (Grade 1B) and vitamin A


bull Empirical antibiotic treatment is not generally recommended (Grade 1B)

bull In children with bloody diarrhea empiric therapy directed against Shigella is suggested (Grade 2B)

bull Antimicrobial treatment is also suggested for patients with severe symptoms and suspected or proven cholera (Grade 2B)

Nutritional managementSummary

RecoomendationsFeeding type

Continue without changeBreast feeding

Use full-strength undiluted CM based formula

May do better in PDLactose-free or yogurt

No convincing studiesAmino-acid based formulas

Promising not much studiedWeaning mixtures prepared from local staple

YES in developing countriesMicronutrients supplementation

Basic physiology

Fluids handling in the GIT

bull Small intestine ndash 8-9 liter pass through the Treitzligament

bull 2 liters from intake

bull 7 liters of GIT secretions

bull Large intestine ndash 1 lit fluids reach the ICV

bull Rectum ndash 200 gr are excreted in stool

Basic physiology




ndash Gut motility


cAMP cGMPCa

cytoskeleton

Basic physiology



bull ENS

bull Gut flora










and absorption

Prevalence






Infectious disease

Lactose intolerance

Malnutrition



Chronic entropathy

ImmunedeficiencyHIV











































anthropometry







of its management






Evaluation steps











Laboratory testing







Laboratory testing
















































Dietary management

















What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea





























Basic physiology




ndash Gut motility


cAMP cGMPCa

cytoskeleton

Basic physiology



bull ENS

bull Gut flora










and absorption

Prevalence






Infectious disease

Lactose intolerance

Malnutrition



Chronic entropathy

ImmunedeficiencyHIV











































anthropometry







of its management






Evaluation steps











Laboratory testing







Laboratory testing
















































Dietary management

















What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea






























cAMP cGMPCa

cytoskeleton

Basic physiology



bull ENS

bull Gut flora










and absorption

Prevalence






Infectious disease

Lactose intolerance

Malnutrition



Chronic entropathy

ImmunedeficiencyHIV











































anthropometry







of its management






Evaluation steps











Laboratory testing







Laboratory testing
















































Dietary management

















What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea





























Basic physiology



bull ENS

bull Gut flora










and absorption

Prevalence






Infectious disease

Lactose intolerance

Malnutrition



Chronic entropathy

ImmunedeficiencyHIV











































anthropometry







of its management






Evaluation steps











Laboratory testing







Laboratory testing
















































Dietary management

















What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea





































and absorption

Prevalence






Infectious disease

Lactose intolerance

Malnutrition



Chronic entropathy

ImmunedeficiencyHIV











































anthropometry







of its management






Evaluation steps











Laboratory testing







Laboratory testing
















































Dietary management

















What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea





























Prevalence






Infectious disease

Lactose intolerance

Malnutrition



Chronic entropathy

ImmunedeficiencyHIV











































anthropometry







of its management






Evaluation steps











Laboratory testing







Laboratory testing
















































Dietary management

















What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea






























Infectious disease

Lactose intolerance

Malnutrition



Chronic entropathy

ImmunedeficiencyHIV











































anthropometry







of its management






Evaluation steps











Laboratory testing







Laboratory testing
















































Dietary management

















What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea




































































anthropometry







of its management






Evaluation steps











Laboratory testing







Laboratory testing
















































Dietary management

















What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea

































of its management






Evaluation steps











Laboratory testing







Laboratory testing
















































Dietary management

















What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea

































Evaluation steps











Laboratory testing







Laboratory testing
















































Dietary management

















What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea


































Laboratory testing







Laboratory testing
















































Dietary management

















What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea





























Laboratory testing
















































Dietary management

















What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea







































































Dietary management

















What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea







































What to feed

EN PN






Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea


































Available Formulae


Soy based formulae











BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea





































BMC Pediatrics 2010










BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea






































BMC Pediatrics 2010







ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea



































ndash Use yogurt





Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea































Soy based formulae










AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea



































AAP






bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea


































bull Milk based






Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea
































Pediatrics 1996981122-1126









bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea



































bull Milk based







J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea

































J Pediatr 1997 Sep131(3)405-12








J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea



































J Pediatr 1997 Sep131(3)405-12




bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea
































bull CONCLUSIONS




J Pediatr 1997 Sep131(3)405-12















bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea










































bull Milk based






Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea
































Bangaladesh































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea


























































Practical Decisions





Monitoring









intolerance


Vomiting diarrhea





































intolerance


Vomiting diarrhea





























Vomiting diarrhea





























Prolonged diarrhea in infancy - University of Cape · PDF filePersistent Diarrhea Nutritional...

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