Unit 7 - Diarrhoea and Nutrition
Medical Education: Teaching Medical Students about Diarrhoeal Diseases

World Health Organization 1992
http://apps.who.int/iris/handle/10665/40343

download pdf

INTERACTION OF DIARRHOEA AND UNDERNUTRITION CAUSES OF NUTRITIONAL DECLINE DURING DIARRHOEA Reduced food intake Decreased absorption of nutrients Increased nutrient requirements EFFECTS OF FEEDING DURING AND AFTER DIARRHOEA Effect of feeding on diarrhoea Effect of feeding on nutritional status Food given during diarrhoea Food given after diarrhoea stops NUTRITIONAL MANAGEMENT OF DIARRHOEA Feeding during diarrhoea Breast milk Animal milk or formula Soft or solid foods Milk intolerance Feeding during convalescence Vitamin A deficiency and diarrhoea MANAGEMENT OF DIARRHOEA IN CHILDREN WITH SEVERE UNDERNUTRITION Assessment of hydration Rehydration therapy Feeding Associated illness TALKING WITH MOTHERS ABOUT FEEDING DURING DIARRHOEA EXERCISES

UNIT 7 - DIARRHOEA AND NUTRITION

INTERACTION OF DIARRHOEA AND UNDERNUTRITION

Diarrhoea is an important cause of undernutrition. This is because nutrient requirements are increased during diarrhoea, as during other infectious diseases, whereas nutrient intake and absorption are usually decreased. Each episode of diarrhoea can cause weight loss and growth faltering. Moreover, if diarrhoea occurs frequently, there may be too little time to "catch up" on growth between episodes, the result being a flattening of the normal growth curve (Figure 7.1 and Annex 3). Children who experience frequent episodes of acute diarrhoea, or have persistent diarrhoea, are more likely to become undernourished than children who experience fewer or shorter episodes of diarrhoea. In general, the impact of diarrhoea on nutritional status is proportional to the number of days a child spends with diarrhoea each year.

In turn, undernutrition contributes to the problem of diarrhoea. In children who are undernourished as a result of inadequate feeding, previous diarrhoeal episodes, or both, acute diarrhoeal episodes are more severe, longer lasting, and probably more frequent; persistent diarrhoea is also more frequent and dysentery is more severe. The risk of dying from an episode of persistent diarrhoea or dysentery is considerably increased when a child is already undernourished. In general, these effects are proportional to the degree of undernutrition, being greatest when undernutrition is severe.

Thus, diarrhoea and undernutrition combine to form a vicious circle which, if it is not broken, can eventually result in death; the final event may be a particularly severe or prolonged episode of diarrhoea or, when severe undernutrition is present, another serious infection such as pneumonia. Deaths from diarrhoea are, in fact, usually associated with undernutrition. In hospitals where good management of dehydration is practised, virtually all mortality from diarrhoea is in undernourished children.

Diarrhoea is, in reality, as much a nutritional disease as one of fluid and electrolyte imbalance, and therapy is not adequate unless both aspects of the disease are treated. However, in contrast to fluid replacement, nutritional management of diarrhoea requires good feeding practices both during the illness and between episodes of diarrhoea, when the child is not sick. When this is done, and undernutrition is either prevented or corrected, the risk of death from a future episode of diarrhoea is greatly reduced.

This unit describes the factors responsible for nutritional decline during diarrhoea and considers how this effect can be reversed, and nutritional status maintained or improved, by appropriate feeding during and after a diarrhoeal episode.

CAUSES OF NUTRITIONAL DECLINE DURING DIARRHOEA

Reduced food intake

Nutrient intake may decline by 30% or more during the first days of acute diarrhoea as a result of:

anorexia, which may be especially marked in children with dysentery;

vomiting, which may discourage attempts at feeding;

withholding of food, which may be based on traditional beliefs about the treatment of diarrhoea or on recommendations by health personnel to "rest the bowel"; and

giving foods with reduced nutrient value, such as gruel or soup that is over-diluted; this may be done with the belief that a diluted food is easier to digest.

Decreased absorption of nutrients

Overall nutrient absorption is also reduced by about 30% during acute diarrhoea, the impairment being greater for fats and proteins than for carbohydrates. Greater impairment can occur in undernourished children with persistent diarrhoea, reflecting more extensive damage to the gut mucosa. Decreased absorption of nutrients is caused by:

damage to the absorptive (villous) epithelial cells, which reduces the total absorptive surface of the bowel;

disaccharidase deficiency, owing to impaired production of enzymes by the damaged microvilli. (When severe, this can cause malabsorption of disaccharide sugars, particularly as lactose.);

reduced intestinal concentrations of bile acids, which are required for fat absorption; and

rapid transit of food through the gut, leaving insufficient time for digestion and absorption.

Increased nutrient requirements

Nutrient requirements are increased during diarrhoea owing to:

the increased metabolic demands made by fever;

the need to repair the damaged gut epithelium; and

the need to replace serum protein lost by exudation through the damaged intestinal mucosa, as occurs in dysentery.

EFFECTS OF FEEDING DURING AND AFTER DIARRHOEA

To prevent growth faltering, good nutrition must be maintained both during and after an episode of diarrhoea. This can be achieved by continuing to give generous amounts of nutritious foods throughout the episode and during convalescence. In general, the foods that should be given during diarrhoea are the same as those the child should receive when he or she is well. This approach is based on evidence that, during diarrhoea, the major proportion of most nutrients is digested, absorbed, and used, and that, during convalescence, substantial recovery of lost growth is possible. The effects of feeding on both the diarrhoeal illness and the child's nutritional status are considered below.

Effect of feeding on diarrhoea

The notion that feeding should be reduced or stopped during diarrhoea reflects a common belief that giving food will cause stool output to increase and thus make the diarrhoea worse, but this is not usually the case. For example:

Breast milk is usually well tolerated during diarrhoea; children who continue to breast-feed during diarrhoea actually have reduced stool output and a shorter duration of illness than children who do not breast-feed.

Feeding hastens repair of the intestinal mucosa, and stimulates early recovery of pancreatic function and production of brush-border disaccharidase enzymes. This leads to earlier recovery of normal digestion and improved absorption of nutrients.

Children on mixed diets, e.g., cow's milk, cooked cereal, and vegetables, do not have increased stool output. However, those taking only animal milk or formula may have a slight increase in stool volume.

In general, feeding is well tolerated during diarrhoea, the major exception being clinically significant intolerance of lactose and occasionally protein in animal milk. This is unusual in acute diarrhoea, but can be a significant problem in children with persistent diarrhoea (see below and Unit 6).

Effect of feeding on nutritional status

Food given during diarrhoea

Although absorption of nutrients is reduced during acute diarrhoea, a substantial proportion is digested and absorbed, as mentioned above. It is not surprising, therefore, that children given full-strength feedings throughout a diarrhoeal episode gain weight at a near-normal rate, whereas those with a restricted intake gain much less or frequently lose weight. Figure 7.3 shows the growth pattern of children given either a reduced or a full caloric intake during the first four days of an acute episode of diarrhoea. The figure shows that weight gain 8 days after starting treatment was greatest in those who received a normal caloric intake throughout their illness, and less in those whose feeds were reduced during the first 2-4 days of treatment. Moreover, there was no appreciable difference in the amount of diarrhoeal stool passed when children were fed half-strength (55 kcal/kg/day) or full-strength (110 kcal/kg/day) diets. Based on studies such as this, it is now clear that there is no basis for reducing food intake during diarrhoea. Instead, full-strength feeding should be continued so that growth faltering and worsening of nutritional status can be prevented, or at least minimized.

Even when a child is given as much food as possible during diarrhoea, some growth faltering may occur, especially if the child has marked anorexia. Moreover, many children are undernourished prior to developing diarrhoea and they will remain at increased risk of frequent, severe, or prolonged diarrhoeal episodes until their nutritional status improves. The goal of feeding after diarrhoea stops is to correct undernutrition and to achieve and sustain a normal pattern of growth. This is best done by ensuring that the child's normal diet provides adequate amounts of energy and other required nutrients. This is most important for children older than 4-6 months of age receiving a mixed diet. The foods recommended for such children during diarrhoea (see below) are also appropriate for normal feeding when the child is well. It is also helpful to give increased amounts of energy-rich food during the first few weeks of convalescence, when children are usually very hungry and may readily consume 50% or even 100% more calories than usual and grow at several times their normal rate.

NUTRITIONAL MANAGEMENT OF DIARRHOEA

The vicious circle by which diarrhoea and undernutrition interact can be broken by correct feeding practices. This requires that health workers advise mothers on the best way to feed their children normally, teach them the importance of continued, full-strength feeding during diarrhoea, and assist them in their efforts to follow this advice. There are four parts to the correct nutritional management of diarrhoea:

assessing the nutritional status of the child,

appropriate feeding during the diarrhoeal episode,

appropriate feeding during convalescence, with follow-up, and

effective communication of dietary instructions to the mother.

The first of these is considered in Unit 3; the remaining three topics are discussed below.

Feeding during diarrhoea

Specific feeding recommendations are determined by the child's age and pre-illness feeding pattern. These are discussed below.

Breast milk

During diarrhoea, breast feeding should not be reduced or stopped, but allowed as often and for as long as the infant desires it. Breast milk should be given in addition to the ORS solution, recommended home fluid, or other fluids given to replace stool losses.

Animal milk or formula

The usual animal milk or formula should be continued. In infants under 6 months of age who are not yet taking soft foods, the milk should be diluted with an equal volume of water for two days. If dehydration develops, milk feeds should be stopped for 4-6 hours during rehydration, and then resumed. This approach is fully satisfactory for most infants. Special lactose-free or hydrolyzed-protein formulas should not be used routinely; they are expensive and of no special value for most infants and children with acute diarrhoea.

Soft or solid foods

If the child is 4 months or older and already taking soft or solid foods these should be continued. Infants 6 months or older should be started on soft foods, if this has not already been done. If dehydration develops, these foods should be stopped for 4-6 hours during rehydration, and then resumed. At least half of the dietary energy should come from foods other than milk. Children should be given frequent small meals, (e.g., six or more times per day) and they should be encouraged to eat. Guidelines for the selection of appropriate foods are:

• use well-cooked local staple foods that can be easily digested, such as rice, corn, sorghum, potatoes, or noodles;
  
• give the staple food in a soft, mashed form; for infants use a thick pap; if cereal gruels or soups are given to prevent dehydration, other energy-rich foods must be given to ensure adequate caloric intake;
  
• increase the energy content of the staple food by adding 5-10 ml of vegetable oil per 100-ml serving; red palm oil is especially good because it is also a rich source of carotene;
  
• mix the staple food with well-cooked pulses and vegetables; if possible, include eggs, meat, or fish;
  
• give fresh fruit juice, green coconut water, or mashed ripe banana to provide potassium; and
  
• avoid foods and drinks with a high concentration of sugar (e.g., commercial soft drinks, fruit drinks) or salt (e.g., commercial soups).

Milk intolerance

A few children with acute diarrhoea, especially young infants, show symptoms of intolerance of animal milk, even when the guidelines for milk feeding are followed. This usually occurs when animal milk or formula is the only food given. Milk intolerance occurs more frequently among children with persistent diarrhoea (see Unit 6). It almost never occurs in children whose only milk is breast milk.

The clinical manifestations of milk intolerance are:

a marked increase in stool volume and frequency when milk feeds are given, and a comparable decrease when they are stopped, and

worsening of the child's clinical condition; signs of dehydration may also develop.

When milk intolerance is due to lactose malabsorption, the stool pH is low (less than 5.5; it turns litmus paper from blue to pink) and it contains a large amount of reducing substances (unabsorbed sugars). A test for reducing substances involves adding 8 drops of fresh liquid stool to 5 ml of Benedict's Solution and boiling the mixture for 5 minutes; an orange-brown colour indicates that the stool contains more than 0.5% reducing substances. Clinitest (R) tablets can also be used, but not most testing tapes (e.g., Testape (R)) or Combistix (R), because they detect glucose.

Be aware, however, that milk intolerance is often overdiagnosed. Stool volume and frequency may increase slightly when children with diarrhoea are fed aggressively; reducing substances may also appear in the stool and faecal pH may become low. However, as long as the child is doing well clinically (i.e., is gaining weight, eating, alert, and active), these findings are not a cause for concern.

To manage milk intolerance:

Continue breast-feeding;

For infants under 4-6 months of age who take animal milk:

replace cow's milk or formula with yoghurt or a similar fermented milk product, or dilute milk or formula milk with an equal volume of water (if possible, add 8 g sugar to each 100 ml to maintain energy content); provide small feeds every 2-3 hours;

if there is no improvement after two days, the infant should be referred to a centre where specialized treatment is possible. A lactose-free or milk-free diet may be required.

For infants and children who normally take soft foods with animal milk:

reduce the amount of lactose in the diet by giving diluted animal milk, as described above, or by replacing milk with yoghurt or a similar fermented milk product;

also provide at least half of the caloric intake as non-milk foods, e.g., well-cooked cereals and pulses with added vegetable oil. Give these foods mixed with milk;

if after two days there is no improvement, stop all animal milk products, replacing them with other energy-rich, protein-containing foods. Finely minced chicken meat is effective, but relatively expensive.

Continue the treatment for milk intolerance for two days after diarrhoea has stopped, then reintroduce the usual milk or formula gradually over 2-3 days.

Feeding during convalescence

The foods recommended for feeding during diarrhoea should be continued after diarrhoea stops, and extra food should be given, to support "catch up" growth. A practical approach is to give the child as much as he or she can eat and to provide an extra meal each day for two weeks. If the child is undernourished or is recovering from persistent diarrhoea, this should be continued for a longer period, until the undernutrition is corrected. The child's usual diet should be reviewed and the mother advised on how she can improve its quality. Ideally, the child should be seen regularly for follow-up so that his or her weight can be monitored and encouragement and advice on feeding given to the mother. If possible, a growth chart should also be used, especially if the child is undernourished, and follow-up continued until a normal rate of growth is established (see Annex 3). If these steps are not possible, the importance of giving extra food during convalescence and improving the quality of the child's normal diet should still be stressed to the mother; the best and sometimes the only opportunity to do this is when the child is being treated for diarrhoea.

Vitamin A deficiency and diarrhoea

During diarrhoea, vitamin A absorption is reduced and greater amounts are used from body stores. In areas where vitamin A deficiency is a public health problem, diarrhoea can cause a rapid depletion of vitamin A stores, leading to acute vitamin A deficiency and symptoms or signs of xerophthalmia. Sometimes blindness develops rapidly. This is a particular problem when diarrhoea occurs during or shortly after measles, or in children who are already severely undernourished; it may also be a problem in children who have persistent diarrhoea or frequent episodes of diarrhoea.

Symptoms and signs of vitamin A deficiency should be sought in children with diarrhoea who live in an area where vitamin A deficiency is a significant problem (see Unit 3). If night blindness is present or there are any signs of xerophthalmia, 200 000 units of vitamin A should be given by mouth; infants should receive 100 000 units. This dose should be repeated the next day and again after four weeks. Children who have severe undernutrition or have had measles within the past month should receive a single dose of vitamin A, as above (unless a dose has been given within the past month). In areas where vitamin A deficiency is a problem, mothers should be urged to give their children foods rich in carotene, the precursor of vitamin A: these include yellow or orange fruits and vegetables, and dark-green leafy vegetables.

MANAGEMENT OF DIARRHOEA IN CHILDREN WITH SEVERE UNDERNUTRITION

Diarrhoea is a serious and often fatal event in children with severe undernutrition. Although the main objectives in treating such patients are the same as for better nourished children, certain aspects of patient evaluation and management need to be modified or given particular attention. These are described below. The diagnosis of severe undernutrition is described in Unit 3.

Assessment of hydration

Assessment of hydration status in severely undernourished children is difficult, because a number of the signs normally used are unreliable. For example, children with marasmus have loose, lax skin so that skin turgor appears poor, even when they are not dehydrated. On the other hand, skin turgor may appear normal in children with oedema (kwashiorkor), even when they are dehydrated. Likewise, sunken eyes are an unreliable sign in marasmic children; and the apathy of children with kwashiorkor and the irritable, fussy behaviour of those with marasmus make the interpretation of mental state difficult. Absence of tears is difficult to assess in all children with severe undernutrition because they do not readily cry. Signs that remain useful for detecting dehydration include: dry mouth and tongue, and eagerness to drink (for children with some dehydration); or very dry mouth and tongue, cool and moist extremities, and weak or absent radial pulse (for those with severe dehydration). In children with severe undernutrition it is often not possible to distinguish reliably between some dehydration and severe dehydration.

Rehydration therapy

The principal guidelines for rehydrating children with diarrhoea and severe undernutrition are as follows:

Rehydration therapy should take place at a hospital, if possible; if the patient is seen at a health centre or clinic, he or she should be referred to hospital. The mother should be provided with ORS solution and shown how to give it to the child at a rate of 5 ml/kg/hour during the trip (see Figure 6.1).

All fluids should be given by mouth or nasogastric tube. Intravenous infusions should not be used because fluid overload occurs very easily, causing heart failure, and their use also increases the risk of septicaemia; either event is likely to be fatal. Oral rehydration is preferred for children who can drink; otherwise, a nasogastric tube should be used until the child is able to drink.

Rehydration should be done slowly, over a period of 12-24 hours. The approximate amount of ORS solution to be given during this period is 70-100 ml per kg body weight. The exact amount should be determined by the quantity the child will drink and by frequent, careful inspections for signs of overhydration (increasing oedema). The child should remain at the treatment centre until rehydration is completed.

The standard ORS solution should be used. However, additional potassium should be given by mouth, since severely undernourished children are normally potassium-depleted, and this is made worse by diarrhoea. A convenient solution, containing 1 mmol of potassium per ml of solution, can be prepared by dissolving 7.5 g of potassium chloride in 100 ml of water. Four ml of this solution per kg of body weight should be given each day for two weeks, in divided doses mixed with food.

Feeding should be resumed as soon as possible. Starving, even for brief periods, should be avoided. Breast-feeding should continue throughout rehydration and other food should be given as soon as it can be taken. Small amounts can usually be given within 2-3 hours after starting rehydration. The feeding guidelines given below should be followed.

Feeding

Children with severe undernutrition and diarrhoea must be fed very carefully; once rehydration is complete, nutritional rehabilitation should take place, preferably at a treatment centre with expertise in this area. Typically, children must spend 12-14 hours a day at the centre for feeding and supportive care, returning each night to their homes, where frequent feeding is continued. If the child has to be admitted to hospital, the mother should stay with him or her, if possible, to assist with feeding and provide emotional support. For children with kwashiorkor, feeding should be resumed slowly, starting at 50-60 kcal/kg/day and reaching 110 kcal/kg/day after about seven days; feeding usually has to be encouraged owing to the child's lack of interest in eating. For children with marasmus, feeding should be limited to 110 kcal/kg/day for the first week, but food can usually be given ad libitum thereafter. Semi-liquid or liquid foods must be given in numerous small feedings, e.g., every two hours day and night. Initially, eating may be difficult because of stomatitis; in such instances, tube feeding for several days is essential.

A practical diet for initial feeding can be prepared from:

• skim milk powder 8 g
  
• vegetable oil 6 g
  
• sugar 5 g
  
• water to make 100 ml

This contains 100 kcal/100 ml. If possible, the skim milk should be prepared first and fermented to make a yoghurt-like drink before adding sugar and oil. This reduces the lactose content of the diet, so that it is better tolerated. The diet may also be prepared using fresh skim milk (briefly boiled) in place of skim milk powder and water. The oil is an important ingredient, as the diet would otherwise provide insufficient energy.

In addition, the following mineral and vitamin supplements should be given:

iron - 60 mg of elemental iron/day

folic acid - 100 μg/day

vitamin A - 200 000 units once (100 000 units for infants) in areas where vitamin A deficiency is prevalent. If signs of xerophthalmia are present, the full treatment course described earlier should be given.

vitamin B complex, C, and D - as daily multivitamin drops.

Associated illness

Children with severe undernutrition and diarrhoea frequently have other serious illnesses, especially infections. Most common are pneumonia, septicaemia, otitis media, pharyngitis, tonsillitis, and urinary or skin infections. Severe infection often causes hypothermia rather than fever. Patients should be examined carefully for evidence of infection and given antibiotic therapy. If a site of infection is identified, an appropriate antibiotic should be given. If no site of infection is recognized, a combination of ampicillin and gentamicin given parentally for 5-7 days is appropriate.

TALKING WITH MOTHERS ABOUT FEEDING DURING DIARRHOEA

Most societies have strong cultural beliefs about the feeding of infants and children during and after diarrhoea. Feeding recommendations must be nutritionally sound, but also compatible with the mother's beliefs and resources. In order to give effective dietary recommendations, the doctor must know:

what foods are most commonly used for children at different ages and the nutritional value of these foods when prepared in the usual manner;

what foods are commonly given or specifically restricted during diarrhoea;

what specific combinations can be recommended for energy-rich, low bulk, soft, or semi-liquid diets, using foods that are available, acceptable, and affordable; and

how much food should be given to children with diarrhoea.

The doctor should ask the mother about the child's usual diet and about the food the child has received since diarrhoea began. The advice given should cover feeding both during diarrhoea and after diarrhoea stops; if possible, the recommendations for these two periods should be similar, with emphasis on a balanced, energy-rich diet that is appropriate for the child's age. If the mother does not have or cannot obtain the recommended foods, or is strongly opposed to giving certain items, the doctor should adjust the recommendations to fit her situation. If she does not know how to prepare certain foods, the doctor should ensure that she is given clear instructions and is able to follow them (see "Talking with mothers about home treatment", Unit 4).

The mother will be able to understand and accept dietary advice much better if she is given a dietary prescription. This can be prepared as a printed pamphlet that shows pictures of various foods along with their names and the amounts of each usually given at different ages. If specific staple foods, vegetables, fruits, meats, and oils are circled and the amount of each to be given is indicated, the mother has a handy reminder of how her child should be fed. When dietary advice is given in this form it is also more likely to be taken seriously by the mother.

EXERCISES

1. Which of the following is the most important cause of weight loss during diarrhoea? (There may be more than one correct answer.)

1. Reduced absorption of nutrients
   
2. Increased metabolic demands
   
3. Vomiting
   
4. Anorexia
   
5. Reduced intake of food

2. Which of the following statements about feeding during diarrhoea are correct? (There may be more than one correct answer.)

Feeding during diarrhoea does not appreciably increase stool volume.

Continuing feeding during diarrhoea helps to hasten repair of the intestinal mucosa, thus restoring the production of disaccharidase enzymes.

Food should be withheld when a child has anorexia.

Special foods should be given during acute diarrhoea; the diet is not the same as that recommended when the child is well.

Doctors should insist that mothers follow their advice about feeding, irrespective of the mothers' beliefs about what foods should or should not be given during diarrhoea.

3. Yunus, aged 9 months, is brought to you with watery, non-bloody diarrhoea, which he has had for two days. He has vomited twice. Physical examination shows evidence of some dehydration. You rehydrate him with ORS solution. The mother says that she stopped breast-feeding Yunus when she became pregnant two months ago. Since then, he has been taking cow's milk and eating rice with the rest of the family. When he started to have diarrhoea, she stopped his food.

Which of the following points should be included in your advice to Yunus's mother? (There may be more than one correct answer.)

1. Dilute Yunus's regular milk with an equal volume of water for the next two days; then resume his normal milk feeds.
   
2. Add 5-10 ml of vegetable oil to each serving of well-cooked rice.
   
3. Add well-cooked pulses and vegetables to Yunus's diet; give him an egg, or some fish or meat when possible.
   
4. Gradually resume Yunus's usual diet as the diarrhoea gets better.
   
5. Give an extra meal each day for at least two weeks after diarrhoea stops.

4. Which of the following statements about feeding after diarrhoea are correct? (There may be more than one correct answer.)

1. An extra meal should be given each day for at least two weeks.
   
2. Milk should continue to be diluted with an equal volume of water, to reduce the amount of lactose in the diet.
   
3. The foods given should be of the same type recommended for use during diarrhoea, i.e. energy-rich mixtures of a staple food, vegetable oil, pulses, vegetables and, if possible, meat, fish or egg. The usual milk should be given.
   
4. Normal feeding should be resumed gradually, to prevent diarrhoea from returning.

5. Roberto, aged 9 months, has had frequent episodes of diarrhoea. He cries a lot and is restless during the examination. His skin pinch goes back slowly, he drinks eagerly, and his tongue is dry. His mother says he has had diarrhoea frequently, "almost every month". He has been taking cow's milk from a feeding bottle since he was 1 month old and started to take regular food at the age of 8 months. His mother says that he seems to be growing slowly, he does not need larger clothes as often as her previous children did, and he has been wearing the same protective charm bracelet on his wrist since he was 6 months old. Since the diarrhoea started the mother has given him some formula but no solid food "because he was not hungry". Roberto weighs 4.7 kg and has a "skin and bones" appearance. It is obvious that he is severely undernourished. What should be done for Roberto? (There may be more than one correct answer.)

1. He should be rehydrated orally with ORS solution at a rate of 70-100 ml/kg over 12-24 hours.
   
2. Food should be withheld until rehydration is completed.
   
3. If Roberto does not take the estimated volume of ORS, the remainder should be given intravenously as Ringer's Lactate solution.
   
4. Roberto's treatment, including rehydration and nutritional management should be given at a hospital or specialized treatment centre.
   
5. Roberto should be given supplemental potassium (a solution of potassium chloride added to his food) for two weeks.

6. Part 1. Kati is 7 months of age. She is brought to you after two days with diarrhoea and has signs of severe dehydration. You initiate IV rehydration and then obtain further information from her mother. She says Kati was weaned to cow's milk six weeks earlier. She also eats well-cooked rice and vegetables. Kati has continued to receive this diet during her illness. After rehydration you advise Kati's mother on home treatment, namely, feeding with cow's milk, rice, vegetables, and added oil. After two days, Kati's mother returns because Kati is still having frequent watery stools. The mother thinks these usually occur shortly after Kati takes milk. You think Kati may have milk intolerance. What step would help most to confirm this diagnosis?

1. Stop all food for two days and see whether the diarrhoea improves.
   
2. Withhold milk for a 12 hours (while continuing to give other foods) to see whether diarrhoea subsides, then give it again to see whether the diarrhoea promptly worsens.
   
3. Test the stool for pH and reducing substances.
   
4. Give a special soy-based milk and see whether the diarrhoea stops.
   
5. Give an antibiotic and see whether the diarrhoea stops.

Part 2: If the diagnosis of milk intolerance is confirmed, what steps would be appropriate for its treatment? (There may be more than one correct answer.)

1. Give a special soy-based formula until diarrhoea stops.
   
2. Dilute Kati's usual milk with an equal amount of water for two days.
   
3. Provide at least half of Kati's food energy as cooked cereal and vegetables, with added vegetable oil. Mix Kati's milk with these foods.
   
4. Give yoghurt or another fermented milk product in place of milk.
   
5. Replace Kati's milk with fruit juice or tea.

---

ANSWERS

1. E. A-D also occur but only contribute to weight loss if food intake is decreased. When enough food is given weight loss is prevented. 2. A,B 3. B,C,E. Since Yunus is 9 months of age his regular milk does not need to be diluted. 4. A,C 5. A,D,E 6. Part 1 - B. Observation of a close association between diarrhoea and milk feeds is the most important. Testing the stool for pH and reducing substances is only helpful when it is clear that milk makes the diarrhoea worse.

Part 2 - B,C,D

updated: 7 June, 2017