• Reducing the risks
• News
  • ORT in high fashion
  • Reviews
  • US paediatricians recommend ORT
  • Wall charts published
• Bangladesh
  • Better food for the same money
• Causes and control of chronic diarrhoea
  • A vicious cycle
• Practical advice series
  • Feeding and chronic diarrhoea
• Questions and answers
• Letters
  • ORT and infants
  • Demystifying ORT
  • Diarrhoea: a problem everywhere
  • Kwashiorkor and potassium

DDOnline Diarrhoea Dialogue Online Issue 10 August 1982 Page 1 2

Reducing the risks

The="#page4">main article in this issue by Professor G. C. Cook on the causes and control of chronic diarrhoea could arouse dismay among readers working in isolated places where drug supplies are scarce and referral possibilities very limited. Nevertheless they should not lose heart, for there is still a great deal that they can do to break the vicious cycle of chronic diarrhoea. Simple preventive measures

Preventive measures - better child hygiene. It may be true that drugs are essential to cure established parasitic infections. However, improved environmental and personal hygiene together with more health education and advice about good nutrition can all combine to considerably reduce the risks which lead to the need for drugs and expert treatment.

Helping people to help themselves

Could he eat better for the same money? See="#page3">page three Diarrhoea Dialogue's main purpose has always been to show how people can protect themselves against diarrhoeal disease. Early oral rehydration ought to be the immediate family reaction when acute diarrhoea occurs. This not only stops unnecessary deaths from dehydration but reduces the chances of malnutrition becoming associated with the infection. Several items in this issue stress the importance of early and proper feeding in diarrhoea and the value of breastfeeding young children. Similar nutritional principles apply to adults as well as children, especially where the nutritional status of the whole population is marginal.

Value of an early warning Earlier issues of Diarrhoea Dialogue have also stressed the importance of recognizing the cause as well as the effect. Wherever environmental health is poor, simple epidemiological techniques and the kind of diagnostic tests that can be carried out in the laboratory of a small hospital or large health centre will warn about the presence of organisms such as Entamoeba histolytica and Giardia lamblia. The new diagnostic wall charts from the Ross Institute (see="#page2">page two) will be useful aids in this detective work. Outbreaks of these infections can then be quickly controlled or, better still, prevented. To extend this possibility, the="dd11.htm">next issue of Diarrhoea Dialogue will take laboratory techniques at all levels of health care as its main theme. W.A M C. and K.M.E.

• Causes and control of chronic diarrhoea
• Fighting malnutrition in Dacca
• Questions and answers

DDOnline Diarrhoea Dialogue Online Issue 10 August 1982 1 Page 2 3

ORT in high fashion

The July issue of VOGUE magazine contains an excellent description of the universal value of oral rehydration therapy in treating diarrhoea. The article was written by Dr Michael O'Donnell after a visit to Thailand. Breastfeeding is now the fashionable thing to do; we hope that oral rehydration will become equally acceptable everywhere. Reviews

Oral rehydration therapy: an issue of growing controversy
Booth I W and Harries J T 1982
Journal of Tropical Paediatrics, 28: 116-123 Knowledge about the causes and management of acute diarrhoea has greatly increased over the last 15 years leading to better understanding rather than controversy about the main issues. Since the above article was published, an important paper (reviewed below) has shown that, even in well-nourished children in the United States, the WHO/UNICEF formula is safe and effective when used correctly. This is not to say that it is necessarily the only effective oral rehydration solution (see="#page7">page seven). The growing acceptance of oral rehydration therapy worldwide was also reflected in the findings of a meeting held in Baltimore, USA earlier this year (see="#US">below). Obviously, several points need further study; for example, which is the most suitable carbohydrate for an oral rehydration fluid in a particular area and what is the role of food in the treatment of diarrhoea? Oral rehydration therapy of infantile diarrhoea.
A controlled study of well-nourished children hospitalized in the United States and Panama.
Santosham M et al 1982 New England Journal of Medicine, 306: 1070-1076 This significant study among 146 well-nourished children admitted to hospital with acute diarrhoea in the United States and Panama supports the efficacy of oral rehydration therapy and the WHO concept of a single formula as being universally applicable. Additional water was given on demand after the first 24 hours or earlier if the diarrhoea ceased. Vomiting or hypernatraemia did not cause problems and the results show that the expense and discomfort of intravenous therapy is difficult to justify. US paediatricians recommend ORT

Paediatricians, epidemiologists and public health workers, all with extensive worldwide experience, who met at Johns Hopkins University in March 1982 recommended oral rehydration therapy as a safe, effective and inexpensive method of treating acute diarrhoea in both developed and developing countries. Agreement was reached on the controversial issues of:

• appropriate composition and methods of use of oral electrolyte glucose solution for rehydration; maintenance of hydration during diarrhoea; and prevention of dehydration.
• feeding advice during acute and sub-acute enteritis.

The following guidelines were issued for both developing countries and the United States:

1. The WHO formula (ORS) is a suitable oral rehydrating solution regardless of the aetiology or severity of the diarrhoea. The volume to be given should be assessed clinically to replace the estimated deficit.
   
2. Dehydration can be prevented by using ORS together with additional fluids for infants, such as breast milk on demand, or one part plain water to two parts ORS, or juices containing potassium, such as orange juice.
   
3. Where economically and practically feasible, a separate solution may be used preventively or to maintain hydration. Containing less glucose, more sodium, potassium, and bicarbonate or citrate than many commercial oral electrolyte solutions, its intake should be limited to avoid an excess of electrolytes and additional fluids such as plain water and breast milk must be freely given.

Feeding advice

The need to promote optimal nutritional intake during and immediately after episodes of diarrhoea was stressed. The use of ORS promotes appetite and continuation of breastfeeding should be encouraged. Milk formulas containing lactose should be avoided for one or two days and only resumed cautiously. The same applies to cow's milk. Cereals, bananas, potatoes and other carbohydrate-rich foods should be given as soon as possible, especially to children with borderline nutritional status. The group agreed that more knowledge is needed about optimal feeding practices in diarrhoeal disease and recommended the use of locally available foods for this purpose. The recommendations of the meeting were signed on behalf of the group by Dr L. Finberg, Dr P. Harper, Dr H. E. Harrison and Dr R. B. Sack. Wall charts published

In="dd09.htm">issue nine of Diarrhoea Dialogue we mentioned two wall charts, aimed at senior and middle level health workers, being produced at the Ross Institute of Tropical Hygiene in London. The charts have now been published and give 'at a glance' information about the causes of diarrhoea, therapy, transmission routes, epidemiology and control measures.

For further details please write to Dr Isabelle de Zoysa, Ross Institute of Tropical Hygiene, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, U. K.

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Better food for the same money

Katherine Elliott reports on a project in Dacca where nutritional self-reliance is encouraged to combat malnutrition. In Bangladesh, malnutrition kills many small children, almost always in combination with diarrhoeal disease and respiratory and other infections. Xerophthalmia (blinding malnutrition) is common and thousands become blind unnecessarily each year. In 1975, the Save the Children Fund (UK) set up the Children's Nutrition Unit (CNU) in Dacca where Dr Sultana Khanam is now Medical Director. Assessing the child

On arrival, the child is weighed, measured and examined to assess the degree of malnutrition and to establish the presence of any complicating factors needing special treatment other than adequate feeding. Children who are 60 per cent and below their correct weight-for-age, 70 per cent and below their correct weight-for-height, and all cases with nutritional oedema fall within the third degree of severe undernutrition. These, and others with second degree malnutrition and additional complications, are admitted to the 60 bedded Unit, which runs a twenty four hour service. Early rehydration

In the Unit, dehydration is corrected and infections diagnosed and treated accordingly. Feeding begins at once and is carefully planned for maximum catch-up growth. The amount recommended is 150-200 calories per kg of body weight in each 24 hours, including 3gm per kg of high quality protein. In the most severe cases, a nasogastric tube may have to be used but most children, with persuasion, will drink from a cup or can be fed with a spoon. Milk feeds, made from dried skimmed milk reconstituted with additional glucose and oil, are given two-hourly throughout the twenty four hours. This frequency of feeding is essential to avoid hypoglycaemia (low blood sugar). Solid and milk feeds Cooked solid meals are also offered four times a day from the beginning. Locally available foods are prepared appropriately but with salt omitted for those with kwashiorkor oedema. Every plate of food is weighed before and after feeding to calculate the daily calorie intake. A percentage refuse solid food initially but appetite usually quickly returns and all children receive as much as they can eat. The recommended full diet on recovery consists of three cooked meals - breakfast, lunch and supper - together with four milk feeds of 180 ml (six ounces) to be given between meals. Vitamin and mineral supplements are also given. Gross vitamin A deficiency (keratomalacia and xerophthalmia) is treated with intramuscular injections of 100,000 i.u. a day for three days and all receive vitamin A by mouth prophylactically. Anaemia is invariably associated with malnutrition and iron is given by mouth as ferrous sulphate (4-6 mg/kg of body weight per day). In very severe cases, intramuscular iron therapy and blood transfusion may be required. Multivitamin preparations and folic acid are given routinely - also 5-6 mg/kg of potassium and 1 mg/kg of magnesium for the first 10 days. Lugol's iodine helps to correct any iodine deficiency. Involvement of mothers

The signs of cure are based on a steady weight gain up to within 75-80 per cent of normal, together with a renewal of activity and interest in the surroundings. Most children are ready for discharge within three to four weeks. They are given BCG vaccine where indicated, and other immunizations are started before they leave and completed in the follow-up clinic. It is very rare indeed for a child to be re-admitted for malnutrition although the family will often return for emergency advice if any illness occurs. The success lies in the close involvement of the mothers who are admitted with their children to the Unit, help with their care and feeding and learn how to continue an adequate diet, using foods which are readily available locally. Breastfeeding mothers are encouraged to continue and it is worth re-emphasizing that all the feeding in the Unit takes place using a cup, plate and spoon. No feeding bottles are ever used. Practical teaching

Children with milder degrees of malnutrition and without complications are seen as out-patients. They and their families are asked to attend each day so that the child's progress can be monitored and the older members can learn about the best kinds of food to buy with the limited money they have available. They are shown how the rice, legumes, vegetables and oil can all be cooked together in the same pot, adding the customary hot spices only after the baby's portion has been taken out. They also learn how much food a small child needs to keep healthy and grow normally, and to make sure the child not only receives but actually eats its fair share. The Unit has an outdoor kitchen where this teaching takes place in a practical but informal fashion. Dr Sultana reckons most mothers learn all they need to know in two or three weeks. Later children in the same family seldom suffer from malnutrition. Patience and enthusiasm The enthusiasm and dedication of all the staff at the CNU inevitably rubs off on the families who attend. Persuading apathetic children to eat demands patience and, for the severely ill, recovery is very much dependent on persevering with the two-hourly milk feeds throughout both the day and night. Such gross malnutrition could be daunting but only about seven per cent of the worst cases die and this is usually within the first 48 hours. Widespread influence The Unit, although crowded and short of resources, is spotlessly clean and well kept, the surroundings are colourful to stimulate the children's interest - and even the weakest child has a toy close by. It is not surprising that the influence of the CNU is widespread within the surrounding community and is an example for other deprived areas.

DDOnline Diarrhoea Dialogue Online Issue 10 August 1982 3 Page 4 5

A vicious cycle

Professor G. C. Cook considers the range of factors that can produce chronic diarrhoea. How do we differentiate between acute and chronic diarrhoea? The division is not precise but, for this article, chronic diarrhoea lasts for at least one month. Acute diarrhoeas always get better more rapidly and their causes and treatments have been reviewed in earlier issues of Diarrhoea Dialogue (1, 2). Major causes of chronic diarrhoea

The vicious cycle associated with chronic diarrhoea shown in the diagram applies in all countries. There is always a need to check that too many purgatives, or antibiotics, have not been given over a long period. Surgical causes are rare in developing countries but general illnesses such as thyrotoxicosis and anxiety neuroses should be considered. The age of a child can be a factor in diagnosing the cause of chronic diarrhoea (for example cows milk protein sensitivity in very small infants; post-weaning malabsorption following repeated infections).

A future issue of Diarrhoea Dialogue will deal with parasite-related diarrhoea in more detail. The signs and symptoms vary with the cause but simple observation can give some clues. Diseases of the small intestine, liver and pancreas usually produce continuously large, very soft and sometimes watery stools. With diseases of the large intestine, the stools are usually small and contain blood, mucus and pus - and the diarrhoea may alternate with periods of normal bowel function. Causes associated with the small intestine Tropical malabsorption
In tropical countries, mostly in Asia and Central America and very occasionally in Africa, chronic diarrhoea, associated with malabsorption, occurs in a condition that used to be called 'tropical sprue' but is now referred to as post-infective tropical malabsorption (TM). The problem usually follows acute diarrhoea, and bacteria such as E. coli, Enterobacter cloacae or Klebsiella pneumoniae remain in excessive numbers in the small bowel, probably due to adverse changes in its structure and movements. Large, bulky, fatty, foul smelling stools, which sometimes float in water due to excessive gas bubbles, may occur. If the condition is not treated, there may be severe weight loss and eventually death. All the absorptive functions of the small intestine may be found to be abnormal, if these can be investigated. Where the diet contains a significant amount of fat, examination of the stool will show fat droplets which stain with Sudan III. This is evidence of fat malabsorption or steatorrhoea. Tetracycline (250 mgs three times a day for 14 days) and folic acid (5 mgs three times a day for 28 days) is the appropriate treatment. Dietary causes
A component of food grains (particularly wheat) known as gluten can cause small bowel disease (gluten enteropathy or coeliac disease). The mucosal lining of the gut is more severely affected than in tropical malabsorption and the condition can, on rare occasions, be provoked by tropical exposure. The only effective treatment is to completely remove gluten from the diet; there is no response to antibiotics and folic acid. Hypolactasia is a deficiency of the digestive enzyme which splits lactose, the sugar found in milk. Any condition which damages the mucosal lining of the small intestine can produce hypolactasia. It also occurs any time after three or four years of age as an inherited characteristic among a significant range of populations. Chronic diarrhoea results if large amounts of milk are consumed but the absorption of other foods is not affected. Severe malnutrition (3, 4) can also cause chronic small intestinal diarrhoea. Surgical causes
Removal of a length of the small intestine for a variety of reasons, such as injury, can produce chronic diarrhoea and there may be severe vitamin B12 malabsorption and anaemia. Parasitic causes

Larval stage of strongyloides stercoralis. The most important parasites affecting the small intestine are Giardia lamblia and Strongyloides stercoralis - also Kala-azar in some regions. All can lead to chronic diarrhoea with malabsorption. These will be described in detail in a future issue of Diarrhoea Dialogue.

DDOnline Diarrhoea Dialogue Online Issue 10 August 1982 4 Page 5 6

Tumours and tuberculosis

Certain tumours of the small bowel, e.g. lymphomas, may produce chronic diarrhoea. Tuberculosis of the lower part of the small intestine (ileum) and caecum is an under-diagnosed cause of chronic diarrhoea and malabsorption. It starts with weight loss and low grade fever. Drug treatment for tuberculosis is essential and blockage of the bowel may require surgical intervention. The possibility of T.B. infection must always be kept in mind or the disease may be missed. Causes outside the small intestine
Liver disease, either acute or chronic, can also produce diarrhoea and malabsorption. Hepatitis and cirrhosis are both common in developing countries due to viral infection and to alcohol and other toxic agents. Chronic inflammation of the pancreas with calcification, possibly caused by childhood malnutrition, is not an uncommon cause of chronic diarrhoea and malabsorption in some parts of the developing world - e.g. tropical Africa, southern India and Indonesia. It may be associated with diabetes mellitus, which requires careful treatment with a low carbohydrate diet and special drugs. Any deficiency of pancreatic digestive enzymes can be partly replaced by giving pancreatic extracts by mouth. Causes associated with the large intestine

As described at the beginning, chronic diarrhoea due to factors affecting the large bowel has different characteristics. Using a microscope, pus cells are usually visible in large numbers and are best seen if methylene blue or other stains are used. Parasitic causes

Trophozoites of Entamoeba histolytica in in a fresh stool specimen (left) and the cystic form(right). Entamoeba histolytica and, more rarely, Balantidium coli infections of the large bowel produce chronic, usually intermittent, diarrhoea with blood and mucus in the stools. Using a microscope, trophozoites and cysts can be readily identified in fresh stool specimens. Treatment is with metronidazole (800 mgs three times a day for five days), and diloxanide furoate (500 mgs three times a day for ten days) for those who continue to have cysts in their stools.

Particularly in Egypt and the Sudan, intermittent large-intestinal diarrhoea can result from Schistosoma mansoni and S. japonicum infections. Praziquantel or oxamniquine are now the treatments of choice; older drugs are less effective and also more toxic. In children, heavy infections with Trichuris trichiura may very occasionally produce chronic, bloody diarrhoea and mebendazole (100 mgs three times a day for three days) is the treatment of choice. Infections associated with antibiotics
Antibiotics are widely used in developing countries and antibiotic-associated, pseudo-membranous colitis is an occasional sequel, especially with clindamycin, and lincomycin, but most antibiotics have been incriminated in this condition. Bowel damage is probably caused by the toxin from growth of a bacterium, Clostridium dificile, in the gut. Treatment with other antimicrobials, vancomycin and metronidazole is usually effective.* Inflammatory bowel diseases (ulcerative colitis and Crohn's disease) and diverticulitis are unusual in most developing country populations. They may be started or exacerbated when visitors move from temperate climates to the tropics. Colonic carcinoma is also unusual in tropical populations but should not be forgotten as a treatable cause of chronic bloody diarrhoea. Professor G. C. Cook, Hospital for Tropical Diseases London, UK. (1) Candy D 1981 Finding the guilty organisms. Diarrhoea Dialogue 7: 4-5

(2) Lambert H P 2982 Cautious prescription. Diarrhoea Dialogue 8: 4-5

(3) Cook G C 1980 Tropical gastroenterology. Oxford University Press, Oxford, New York, Delhi.

(4) Rowland M G M 1981 The diarrhoea-malnutrition complex. Diarrhoea Dialogue 6: 4-5

(5) Harries J T 1982 In The Leonard Parsons Symposium on Chronic Diarrhoea. Ed. McNeish A S University of Birmingham (in press).

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Feeding and chronic diarrhoea After initial rehydration, proper feeding is essential for recovery from chronic diarrhoea. Adequate protein, energy and other essential nutrients must be provided from food to reduce the risk of further episodes of diarrhoea, protein energy malnutrition (PEM) and death. Starvation is never appropriate. Even in chronic diarrhoea some food will be absorbed and is important for bowel function as well as nutrition. Feeding by mouth limits the atrophic changes in the small intestine and pancreas associated with complete withdrawal of oral feeds. It is also psychologically valuable to maintain eating habits. Importance of breast milk Breast feeding should be continued wherever possible, even during initial rehydration, because breast milk provides important immunological protection against infection as well as being the safest, cheapest and most nutritious food for young children with chronic diarrhoea. Where socially acceptable, freshly expressed, donated breast milk or 'wet nursing' can help out if the mother's own supply is insufficient or has been discontinued and cannot be re-established. Cow's milk may damage the intestinal lining causing subsequent intolerance. It should therefore be avoided where alternatives are available but soya-based formulae (e.g. Formula S by Cow and Gate and Prosobee by Mead Johnson), although nutritionally adequate, are expensive. Home made versions, like ground nut milk, and some commercial preparations are not sufficient as the only food source (1). Sucrose (cane and beet sugar) intolerance is thought to be uncommon. Starches, such as rice powder or arrowroot, are well tolerated but again, in chronic diarrhoea, their low protein, mineral and energy content demands very careful supplementation. Supplementary foods Supplementary solids should be given as milk free multi-mixes made from locally available foods selected for high energy and nutrient content. Small portions should be offered five to eight times a day and the child coaxed to eat. Oral fluids to maintain hydration must be continued for as long as diarrhoea persists. Body stores of potassium are depleted in chronic diarrhoea so foods high in potassium are important, for example, bananas, orange and pineapple. Highly spiced foods, e.g. chillies, and large quantities of legumes (peas, beans and dhal) may cause increased stool output. Food should be freshly prepared, ideally for each meal, to reduce the risk of microbial infection. Take great care to protect and preserve food which will be fed later. At the Hospital for Sick Children, London, I frequently use a diet made from commercially prepared comminuted (very finely ground) chicken (2). This can be adapted for developing countries (see Table A). Other mammalian milks are sometimes tolerated by children sensitized to cow's milk protein, but these need modification for infants along the lines given for goat's milk in Table B.

TABLE A
Alternative ingredients for the chicken mixture

If fed as the sole source of nutrition, offer 150 to 200 ml/kg actual weight/day. In a very sick infant the diet can be started at half strength, the sugar introduced to the full dose over three to four days and the oil emulsion added on the fifth to seventh day.

A complete mineral supplement including macro (calcium, phosphorous, magnesium, sodium, potassium) and trace minerals (zinc, copper, iron, etc.) together with the full range of all vitamins are necessary if this diet is used for more than one to two weeks.

TABLE B
Modification of goat's milk for infant feeding

Vitamins A, D, C, B12, folic acid and iron should be supplied from other sources.

If possible, mothers and other relatives should help, not only with the actual feeding, but also with the preparation of any special diet. This will encourage them to continue to provide suitable food after the child returns home. It is important to follow up undernourished children, especially those with chronic diarrhoea. Long-term malnutrition predisposes to further infections creating the vicious cycle of more malnutrition leading to death.

Dorothy Francis, SRD, Group Chief Dietitian, The Hospital for Sick Children, Great Ormond Street, London, UK.

(1) Tripp J H, et al 1979 Infant Feeding Practices: a cause for concern. British Medical Journal 2: 707-709.

(2) Francis D E M 1978 Treatment of Multiple-Malabsorption Syndrome of Infancy. Journal of Human Nutrition 32: 270-278.