Discuss the dietary management of persistent diarrhoea.

Understanding Persistent Diarrhea

Persistent diarrhea differs from acute diarrhea in its etiology and management. While acute diarrhea is often caused by a single pathogen and resolves quickly, persistent diarrhea is frequently multifactorial. Common causes include:

• Infections: Parasitic infections (Giardia, Cryptosporidium), bacterial overgrowth, and viral persistence.
• Malabsorption: Lactose intolerance secondary to intestinal damage, celiac disease, or other malabsorptive disorders.
• Immunodeficiency: Underlying immune deficiencies can predispose to chronic infections and diarrhea.
• Food Allergy/Intolerance: Cow’s milk protein allergy is a common trigger.

Dietary Principles in Management

The primary goals of dietary management are to correct dehydration, address nutrient deficiencies, and promote gut rehabilitation. This is achieved through a phased approach.

1. Rehydration

Oral Rehydration Solution (ORS) remains the mainstay of rehydration therapy. The amount of ORS needed depends on the severity of dehydration and stool output. Continued losses should be replaced meticulously.

2. Energy Requirements

Children with persistent diarrhea often have increased energy needs due to increased metabolic rate and losses. Energy intake should be increased by 10-20% above normal requirements. Sources of energy should be easily digestible carbohydrates and fats.

3. Protein Requirements

Protein is crucial for tissue repair and immune function. Protein intake should be maintained at 1.5-2.0 g/kg/day. Hydrolyzed protein formulas may be considered in cases of suspected cow’s milk protein allergy or malabsorption.

4. Micronutrient Supplementation

Persistent diarrhea leads to significant losses of micronutrients, particularly zinc, iron, vitamin A, and folate. Supplementation is essential:

• Zinc: 10-20 mg/day for children over 6 months.
• Vitamin A: Age-appropriate dose as per national guidelines.
• Iron: Supplementation should be cautiously introduced after initial improvement, as iron can exacerbate diarrhea in some cases.
• Folate: Supplementation is important, especially if there is evidence of megaloblastic anemia.

Feeding Strategies Based on Age

Dietary management needs to be tailored to the child’s age and ability to tolerate feeds.

Age Group	Feeding Strategy
Infants (<6 months)	Continue breastfeeding. If exclusively breastfed, consider supplementing with a lactose-free or hydrolyzed formula. Small, frequent feeds.
6-12 months	Continue breastfeeding. Introduce easily digestible complementary foods like rice porridge, mashed bananas, and cooked vegetables. Avoid sugary drinks and fatty foods.
>12 months	Age-appropriate diet with emphasis on easily digestible foods. Small, frequent meals. Encourage fluid intake.

Specific Dietary Modifications

• Lactose-Free Diet: Consider a trial of lactose-free formula or diet if lactose intolerance is suspected.
• Elemental Diet: In severe cases of malabsorption, an elemental diet (amino acid-based formula) may be necessary.
• Probiotics: Probiotics may help restore gut flora and improve intestinal function, but evidence is still evolving. Lactobacillus rhamnosus GG has shown some benefit.

Monitoring and Complications

Close monitoring is crucial to assess response to treatment. Parameters to monitor include:

• Stool frequency and consistency
• Weight gain
• Electrolyte levels
• Albumin and prealbumin levels (indicators of nutritional status)

Potential complications include:

• Severe malnutrition
• Electrolyte imbalances
• Secondary infections
• Growth retardation