Rationale for Early Feeding in Childhood Gastroenteritis

Historical review of the treatment of children with gastroenteritis makes interesting reading and suggests that until the 1930s children with diarrhea were not routinely starved. An 1893 Vade Mecum states, “diet should be given sparingly, consisting of non-irritating articles— gruel, rice, arrowroot, Neave’s food prepared with extra quantity of milk, old rice well cooked with milk. Best diet is milk-and-limewater, iced if feverish” (1). This practice changed in 1926 when Powers (2) described the major procedures in the treatment of “intestinal intoxication” as fluid administration, blood transfusion, withholding food for a period of time, and feeding at the end of the period of starvation in gradually increasing amounts. Therapeutic starvation became the established practice in addition to intravenous fluid therapy. Theoretic advantages of continued feeding are maintained growth, minimized protein and energy deficits, reduced stool losses, and reduced functional and morphologic hypotrophy associated with “bowel rest” (3–5). Theoretic disadvantages of continued feeding are lactose intolerance leading to osmotic diarrhea, dehydration, and acidosis (6); risk of absorption of macromolecules, such as cow milk antigen, because of an impaired mucosal barrier, resulting in possible further mucosal damage (enteropathy); and even systematic immune response and food sensitization (7,8). Clinical studies from the 1940s and 1950s showed that infants and children treated with an early or free-feeding regimen had better weight gain and did not have prolonged diarrhea when compared with patients treated with starvation and gradual refeeding (9,10). However, these studies were overlooked, and children continued to be starved for 24 to 48 hours (11). After the advent of oral rehydration therapy, the practice of bowel rest was questioned. In 1979, Rees and Brook (12), working at the Central Middlesex Hospital, London, published a study that suggested grading feed, starting with one-fourth strength and gradually going up to full strength was unnecessary. Studies by Dugdale et al. (13) and Placzek and Walker-Smith (14) gave similar results. In 1985, a study by Khin-Maung (15) clearly showed that continuing breast-feeding during acute diarrhea was beneficial. A number of studies including excellent studies by Isolauri et al. (16,17) suggested that after initial oral rehydration therapy, full feeding appropriate for age is well tolerated with no adverse effects in children older than 6 months. Excellent studies by Brown et al. (18,19) clearly showed advantages of continued feeding on clinical and nutritional outcomes. Taking all these clinical investigations together, two risk factors, however, suggested caution: age (children younger than 6 months) and severity of diarrhea (children who are more dehydrated and more acidotic, have a higher rate and amount of vomiting, and have a higher number of stools) (20). The outcome of realimentation appears to be closely linked to the success of initial rehydration therapy. Although glucose-based oral rehydration therapy effectively treats and combats dehydration, it does not stop diarrhea. In the 1980s, much research and thought was devoted to search for a “super” oral rehydration solution (ORS) that would reduce stool losses. Glucose-polymer (21) amino acids including glycine (22,23) were studied but did not prove significantly beneficial in a European clinical setting. Rice-based ORS gave encouraging results (24) but a metaanalysis of 13 clinical trials concluded that the benefit of rice-based ORS is “sufficient to warrant use in patients with cholera but is considerably smaller in noncholera diarrhoea” (25). A study by Santosham et al. (26) showed that feeding with boiled rice or rice-based formula immediately after oral rehydration therapy was as efficient as treatment with rice ORS alone for 24 hours. The emphasis appeared to return to early feeding. A small study based in Bristol, United Kingdom, of 40 patients (27) and an Eastern European study (28) involving infants of 0 to 1 year of age further confirmed that early feeding was safe, with no increase in vomiting or lactose intolerance, and resulted in better *E. Isolauri, J. A. Walker-Smith, G. Banchini, M. Van Caillie-Bertrand, J. A. Dias, S. Guandalini, J. H. Hoekstra, M. Juntunen, S. Kolacek, D. Marx, D. Micetic-Turk, M. C. A. C. Razenberg, H. Szajewska, J. Taminiau, Z. Weizman, C. Zanacca, and R. Zetterström. Address correspondence and reprint requests to Dr. B. K. Sandhu, Institute of Child Health, Royal Hospital for Children, St. Michael’s Hill, Bristol BS2 8BJ, United Kingdom. Journal of Pediatric Gastroenterology and Nutrition 33:S13–S16 © October 2001 Lippincott Williams & Wilkins, Inc., Philadelphia