A Multicentre Study on Behalf of the European Society of Paediatric Gastroenterology and Nutrition Working Group on Acute Diarrhoea: Early Feeding in Childhood Gastroenteritis


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The main aim in managing gastroenteritis in children is the correction of dehydration and maintenance of hydration using an optimal oral rehydration solution (ORS). In 1992 the European Society of Paediatric Gastroenterology and Nutrition (ESPGAN) working group on oral rehydration therapy (ORT) published guidelines for the optimal composition of ORS for Europe (1).The second aim in the management of these children is nutritional repair. The positive effect of continuing breast-feeding during treatment of gastroenteritis with ORS is well established (2). However, debate has continued on the optimal nutritional therapy of non-breast-fed patients, particularly in relation to the reintroduction of oral feeds and the need for specific dietary restrictions (3-19).In 1926 Powers (20) described the major procedures in the treatment of “intestinal intoxication” as administration of fluids, transfusion of blood, with-holding of food for a time, and the administration of food at the end of the period of starvation in gradually increasing amounts. Therapeutic starvation became the established practice, in addition to intravenous fluid therapy. This practice has been changed by oral rehydration therapy, which has gradually brought about the principle of rapid realimentation, with reintroduction of oral feeds immediately after adequate rehydration. The principal controversy in the nutritional therapy of acute gastroenteritis centres on the relative risks of cow's milk feeds (Table 1)(21). First, decreased lactase activity is chiefly associated with rotavirus gastroenteritis, and temporary lactose intolerance is considered an important factor in chronic diarrhoea (22). Second, infants who have rotavirus diarrhoea show an enhanced absorption of cow's milk antigens (23). Foreign proteins transported across an impaired mucosal barrier could evoke local or systemic immune response and food sensitisation (24).Until recently, the results of clinical studies from the 1940s and 1950s showing that infants and children treated with an early or free feeding regimen had better weight gain and no prolongation of diarrhoea compared with patients on starvation and gradual refeeding were overlooked (25,26), and children continued to be starved for 24-48 h (27). Several studies over the last 15 years have shown that there is no need for “regrading” slowly, and after initial ORT, full feeding appropriate for age is well tolerated in children >6 months of age with no adverse effects (6-10,14,18,28). When these clinical investigations are taken together, two risk factors, however, suggest caution: age (children <1 year) and diarrhoeal severity (more dehydrated and acidotic children have a higher rate and amount of vomiting and a higher number of stools) (29). The outcome of realimentation appears to be closely linked to the success of the initial ORT.AIMSThe aim of this study was to compare the effect of ORS (conforming to ESPGAN ORS working group recommendations (1) and “early” or “late” feeding on the duration and severity of diarrhoea, weight gain, and complications (carbohydrate intolerance and vomiting) in weaned European infants.PATIENTS AND METHODSThis was a multicentre study based in twelve European hospitals: Royal Hospital for Sick Children, Bristol, U.K.; Ospedale Maria Nuova, Reggio Emilia, Italy; Department of Clinical Sciences, University of Tampere, Finland; Departimento Universita Di Napoli, Napoli, Italy; The Children's AMC, Amsterdam; Groot Ziekengasthius, `s-Hertogenbosch, The Netherlands; Children's Hospital Zagreb, Republic of Croatia; Maribor Teaching Hospital, Ljubljanska, Slovenia; Department of Paediatrics, Charles University, Czech Republic; Antwerp Children's Hospital, Belgium; Hospital de S. Joao, Porto, Portugal; Katedra Pediatrii Akademii Medycznej, Warszawa, Dzialdowska, Poland; and Soroka Medical Centre, Beer Sheva, Israel.

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