Gradual introduction of feeding is no better than immediate normal feeding in children with gastro-enteritis
Date First Published:
February 8, 2002
Last Updated:
May 2, 2003
Report by:
Dr Nico Grunenberg, GP (Coupar Angus, Fife)
Three-Part Question:
In [children with gastro-enteritis] is [gradual introduction of feeding better than immediate normal feeding] with regards to [symptom control and time to resolution]?
Clinical Scenario:
A mother with her 11 month old daughter attends the surgery. The child has gastro-enteritis and is mildly dehydrated. Mum has been starving the child the last 24 h as "everything comes back up". She has read this and also to avoid milk feeds in her health manual at home. Having read a paper once on continueous milk feeding as opposed to gradual regrading of milk, I decide to look which approach would be better.
Search Strategy:
Medline 1966-09/01 using the OVID interface.
Search Details:
[exp Gastroenteritis] AND [exp bottle feeding OR exp breast feeding OR exp feeding methods OR "feeding".mp] LIMIT to human AND (newborn infant OR infant OR preschool child OR child).
Outcome:
145 papers were found of which 133 were irrelevant or of insufficient quality. The remaining 12 are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Refeeding after acute gastroenteritis: a controlled study. Dugdale A, Lovell S, Gibbs V, et al. 1982, Australia | 59 inpatients older than 6 months (average 22 months) with acute gastro enteritis were given clear fluids and then allocated either to half strength milk for 24 h and then full strength milk and food or immediate normal milk and food | RCT | Weight | During first 24 h of refeeding immediate group lost 0.02 (0.25) kg and the graduated group lost 0.14 (0.21) p> 0.05 | Small numbers ? length of clear fluids |
| Hospital stay (days) | Immediate group 4.7; graduated group 5.4 p>0.5 | ||||
| Is it necessary to regraduate milk after acute gastoenteritis in children? Haque KN, Al-Frayh A, El-Rifai R. 1983, Saudi Arabia | 150 inpatients all stages of dehydration between 1 month and 2 years of age randomised to three different feeding regimens 1) clear fluids (6-24h) then gradual 1/4 strength milk reintroduction 2) clear fluids(6-24h) then full strength milk 3) continuing full strength milk |
RCT | Length in hospital (days) | 1) 3.1 (1.4); 2) 3.6 (1.2); 3) 3.8 (1.2) Not stat significant | Large proportion malnourished |
| Increase in weight at discharge | 1) 0.4 (0.1); 2) 0.8 (0.2); 3) 1.2 (0.7) Not stat significant | ||||
| Diarrhoea length (days) | 1) 3.0 (1.4); 2) 3.0 (1.3); 3) 3.8 (1.2) Not stat significant | ||||
| Vomiting length (days) | 1) 1.0 (1.1); 2) 1.8 ( 1.3); 3) 1.6 (1.2) Not stat significant | ||||
| Comparison of two feeding regimens following acute gastroenteritis in infancy. Placzek M, Walker-Smith JA. 1984, UK | 48 inpatients less than 18 months of age with gastro enteritis, > 5% dehydration were after 24 h of GEM allocated to immediately full strength milk or gradual reintroduction | RCT | Complicated clinical course = recurrence of ether severe vomiting or watery diarrhoea with 2% or more reducing substances | 70% (16) of full strength group uncomplicated; 96% (24) of gradual group uncomplicated | Small numbers Alternate allocation = randomisation 20% not thriving |
| The effect of feeding four different formulae on stool weights in prolonged dehydrating infantile gastroenteritis. Rajah R, Pettifor JM, Noormohamed M, et al. 1988, South Africa | 72 male black inpatients between 6 weeks and 2 years with prolonged dehydrating gastro-enteritis (needing more than 72 h IV fluids) assigned to 4 different feeds; partially modified cow's milk formula, a lactose free casein containing formula, a lactose free soy protein formula, a lactose free whey- hydrolysate formula | RCT | Stool weights in 3 days following formula change | Significant drop in stool weight AL110 p<0.01; Alfare p< 0.05; Alsoy p< 0.05; no change with Lactogen | Only male black children |
| Comparison of a lactose-free cereal-based formula and cow's milk in infants and children with acute gastroenteritis. Bhan MK, Arora NK, Khoshoo V, et al. 1988, India | 60 outpatients < 5% dehydration between 3 and 24 months were fed either cereal based formula (A) or cows milk (B) | RCT | Duration of diarrhoea post intervention (days) | Gr A 11.0 (10.0) > gr B 7.6 (10.8) NS p>0.05 | Small numbers Difficulty comparing two preparations Selection criteria (close to hospital) ? compliance to treatment at home |
| Mean weight gain (g/kg/24h) | Gr A 2.0 (4.2) < gr B 5.8(7.8) significant p<0.05 | ||||
| Acute gastroenteritis in well nourished infants: comparison of four feeding regimens. Conway SP, Ireson A. 1989, Leeds | 200 well hydrated inpatients, formula fed, ages 6 weeks to 12 months, acute gastroenteritis Gr1: 24h dextrolyte and gradual reintroduction of SMA gold Gr2: special full strength HN25 untill stools normal, gradual substitution by SMA gold Gr3: continued full strenght SMA gold cap Gr4: continued formula S |
RCT | Duration of diarrhoea (hrs) | Gr1 64(53.7); Gr2 47(53.7); Gr3 68(43.6); Gr4 51(41.5) NS | 117 had ORS before treatment, so is this immediate or delayed full strength feeding |
| Time to discharge | Gr1 6.9(3.2); Gr2 6.9(1.9); Gr3 6.9 (2.2); Gr4 7.1(3.6) NS | ||||
| Severity of diarrhoea | Gr2 0.8(1.7) < Gr3 1.8(1.5) p= 0.05 ; group1 1.6(1.7), gr4 1.4 (1.9) intermediate positions | ||||
| Weight gain | Day 2 Gr2,3,4 > Gr1 p=0.01; remains significant on day 5 p= 0.05 | ||||
| Acute gastroenteritis in children—aetiology and comparison of two modes of treatment. Ooi BC, Lou J, Cheng HK. 1989, Singapore | 70 inpatients mild/ moderate dehydration, age 1 week to 50 months, either graduated milk feeds or full strength soy feed | CT | Duration of hospitalisation (days) | Soy 2.8; milk group 2.5, not statistically different | Small numbers ?randomised ?effect on symptoms ?received clear fluids |
| Evaluation of infant feeding i acute gastroenteritis. Armistead J, Kelly D, Walker-Smith J. 1989, UK | 68 children, admitted or gastro-enterology casualty, bottle fed, mild acute gastroenteritis dioralyte 24h plus 1)gradual milk reintroduction 2)full strength milk 3) rapid regrade to whey hydrolysate formula |
RCT | Stool frequency | Day 1-4: grp1 4-2.2; grp2 3.7-1.6; grp3 4.3-2.5 | ? sufficient number Bottlefed only (sponsored by Nestle) Most mild dehydration |
| Reducing substances | None in all three groups | ||||
| Weight gain | Day 1-4 : gr1 -0.35 (0.5), gr2 +0.65(0.6), gr3 +0.15(0.2) | ||||
| Hospital stay (days) | Gr1 4(0.2), gr2 3.6(0.6), gr3 3.5(0.4) NS | ||||
| Cow's milk-based formula, human milk, and soya feeds in acute infantile diarrhea: a therapeutic trial. Haffejee IE. 1990, South Africa | 309 hospital patients age 3days to 28 months, acute diarrhoea, all stages of dehydration Formula fed children were randomised to their formula or soy based formula; breast fed children continued this and were divided in breast feeding only and breast feeding plus supplement. |
RCT | Recovery time (hrs) when hydration, weight and nature of stools were normal | formula 70.5 (60.3); breast 60.9(44.8); breast plus supplement 64.8(43.3); soya 61.4(43.5) P>0.05 NS | ?blinded No patient chracteristics (race, % dehydration) |
| Absorption of carbon 13-labelled rice in milk by infants during acute gastroenteritis. Lifschitz CH, Torun B, Chew F, et al. 1991, USA | 8 children < 5 months, mild to moderate dehydration, addition of 13C labelled rice at 6-22h and repeat at 14-17d later. Breath test measurement | CT | 13C in breath when ill and after recovery | Apparent absorption not different, 13 C diarrhoea 86.6%- recovery 94%. NS | Small numbers Boys only Mild/moderate dehydration only |
| Effects of immediate modified feeding on infantile gastroenteritis. Hoghton MA, Mittal NK, Sandhu BK, et al. 1996, UK | 59 outpatient children < 3 years old, < 7 d gastro-enteritis, < 5% dehydrated; either immediate modified feeding + ORT (2) or ORT only for 24-48h after which modified food (no milk/wheat) (1) | PRCT single blind | Median duration of diarrhoea | Grp1 66.5 h- grp2 56h p=0.4 not significant | Small numbers Mild dehydration only Parents assessed and charted symptoms (bias) |
| Complication rate | Similar- NS | ||||
| Median % weight change | Grp 1 0.005- grp 2 0.96 p=0.24 NS | ||||
| A multicentre study on behalf of the european society of paediatric gastroenterology and nutrition working group on acute diarrhoea. Early feeding in childhood gastroenteritis. Sandhu BK Isolauri E, Walker-Smith JA, et al. 1997, Europe | 230 weaned european children under the age of three admitted to hospital Rehydrated with ORS for 4 hours, then Group A: immediate normal diet, Group B 20h of ORS then normal diet, breast feeding continued throughout |
RCT | Weight gain | After rehydration weight gain grA 95g, grB 2g p=0.01; during hospitalisation grA> 200g, grB < 100g p=0.001; weight gain similar by day 5 and 14. | No severely dehydrated children |
| Complications | No significant diffences re complications |
Author Commentary:
Nearly all studies show no significant difference in length of symptoms and hospital stay. Two larger studies showed a significant increase in weight in the initial stages with immediate full strenth feeding. One larger study also showed an increase in severity but not in length of diarrhoea with immedaite feeding. This was associated with faster weight gain. One study showed benefit of lactose free feeds in severe dehydrating gastroenteriris. One smaller study showed more complicated clinical courses with immediate feeding, this was a small study and 20% of the children needed intravenous hydration possibly related to a more severe illness. In two smaller studies children had solids as well and did not do worse.
Bottom Line:
In children with gastroenteritis, gradual reintroduction of feeding is not better than immediate normal feeding with regards to time to resolution and symptom control.
References:
- Dugdale A, Lovell S, Gibbs V, et al.. Refeeding after acute gastroenteritis: a controlled study.
- Haque KN, Al-Frayh A, El-Rifai R.. Is it necessary to regraduate milk after acute gastoenteritis in children?
- Placzek M, Walker-Smith JA.. Comparison of two feeding regimens following acute gastroenteritis in infancy.
- Rajah R, Pettifor JM, Noormohamed M, et al.. The effect of feeding four different formulae on stool weights in prolonged dehydrating infantile gastroenteritis.
- Bhan MK, Arora NK, Khoshoo V, et al.. Comparison of a lactose-free cereal-based formula and cow's milk in infants and children with acute gastroenteritis.
- Conway SP, Ireson A.. Acute gastroenteritis in well nourished infants: comparison of four feeding regimens.
- Ooi BC, Lou J, Cheng HK.. Acute gastroenteritis in children—aetiology and comparison of two modes of treatment.
- Armistead J, Kelly D, Walker-Smith J.. Evaluation of infant feeding i acute gastroenteritis.
- Haffejee IE.. Cow's milk-based formula, human milk, and soya feeds in acute infantile diarrhea: a therapeutic trial.
- Lifschitz CH, Torun B, Chew F, et al.. Absorption of carbon 13-labelled rice in milk by infants during acute gastroenteritis.
- Hoghton MA, Mittal NK, Sandhu BK, et al.. Effects of immediate modified feeding on infantile gastroenteritis.
- Sandhu BK Isolauri E, Walker-Smith JA, et al.. A multicentre study on behalf of the european society of paediatric gastroenterology and nutrition working group on acute diarrhoea. Early feeding in childhood gastroenteritis.