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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.
[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).

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Dugdale A 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
Haque K N et al, 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
Placzek M et al, 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
Rajar R 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
Bhan MK 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
Conway S P et al, 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
Ooi B C, 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
Armistead J et al, 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
Haffejee I E , 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)
Lifschitz CH 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
Hoghton MAR 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
Sandhu BK 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

Comment(s)

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.

Clinical 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

1. Dugdale A, Lovell S, Gibbs V, et al. Refeeding after acute gastroenteritis: a controlled study. Arch Dis Child 1982;57(1):76-8.
2. Haque KN, Al-Frayh A, El-Rifai R. Is it necessary to regraduate milk after acute gastoenteritis in children? Tropical & Geographical Medicine 1983;35(4):369-73.
3. Placzek M, Walker-Smith JA. Comparison of two feeding regimens following acute gastroenteritis in infancy. Journal of Pediatric Gastroenterology & Nutrition 1984;3(2):245-8.
4. Rajah R, Pettifor JM, Noormohamed M, et al. The effect of feeding four different formulae on stool weights in prolonged dehydrating infantile gastroenteritis. Journal of Pediatric Gastroenterology & Nutrition 1988;7(2):203-7.
5. 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. Journal of Pediatric Gastroenterology & Nutrition 1988;7(2):208-13.
6. Conway SP, Ireson A. Acute gastroenteritis in well nourished infants: comparison of four feeding regimens. Archives of Disease in Childhood 1989;64(1):87-91.
7. Ooi BC, Lou J, Cheng HK. Acute gastroenteritis in children—aetiology and comparison of two modes of treatment. Annals of the Academy of Medicine, Singapore 1989;18(1):40-2.
8. Armistead J, Kelly D, Walker-Smith J. Evaluation of infant feeding i acute gastroenteritis. Journal of Pediatric Gastroenterology & Nutrition 1989;8(2):240-4.
9. Haffejee IE. Cow's milk-based formula, human milk, and soya feeds in acute infantile diarrhea: a therapeutic trial. Journal of Pediatric Gastroenterology & Nutrition 1990;10(2):193-8.
10. Lifschitz CH, Torun B, Chew F, et al. Absorption of carbon 13-labelled rice in milk by infants during acute gastroenteritis. Journal of Pediatrics 1991;118(4(pt1)):526-30.
11. Hoghton MA, Mittal NK, Sandhu BK, et al. Effects of immediate modified feeding on infantile gastroenteritis. British Journal of General Practice 1996;46(404):173-5.
12. 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. Journal of Pediatric Gastroenterology & Nutrition 1997;24(5):522-7.