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6 Nutritional management

Introduction
Prior to the onset of gastroenteritis, children will be receiving nutrition from a range of sources.
They may be breastfeeding, taking an infant formula or other fluids, or they may also be taking
various solid foods. Recommendations regarding feeds must take into account this variation.
Breastfed infants tend to feed frequently and in smaller volumes at each feed, and gastric emptying
may be more rapid compared with those who are formula-fed. Breastfed infants may also be
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better able to self-regulate their feed volume.
Healthcare professionals and parents are usually most concerned about fluid management or the
alleviation of symptoms. However, the nutritional aspects of management are also important.
The aim of this chapter is to clarify the evidence surrounding nutritional management so that
appropriate and consistent recommendations may be made. Cultural differences may be
important here and should be taken into account when considering the advice given.
Anecdotally, there is wide variation in the advice given to parents regarding continuation or
resumption of feeds, and regarding the types of fluids and solid foods that should be given.
Advice offered has ranged from continued feeding to discontinuation of all nutrition for 24 hours
or even longer. It has been common practice to recommend initial dilution of milk following
its reintroduction. Some have recommended the use of specialised therapeutic feeds such as
lactose-free milks, and soya or protein hydrolysate-based formulas. Some of this advice has
been based on empirical considerations. For example, transient mucosal lactase deficiency is a
common phenomenon with gastroenteritis and this has led to widespread use of use of lactose-
free formulas. However, much of the advice offered regarding nutrition may not have had a
secure evidence base.

6.1 Feeding during rehydration

Current recommendations commonly suggest that during the rehydration phase of therapy
breastfeeding should continue but other food (for example, formula feeds or solid foods) should
be discontinued until the child is rehydrated. 17,19,116 This period of rehydration usually lasts for
about 3 or 4 hours.

Clinical question
Should children with gastroenteritis continue the following types of feeding during the
rehydration phase of therapy?
a) breastfeeding
b) cow’s milk formula feeding
c) mixed feeding (bottle/formula and breastfeeding)
d) solid food/weaning food

Out of 30 retrieved papers, three studies were found to be suitable for inclusion and all of them
had looked at breastfeeding during rehydration. For the other sub-questions related to formula
feeding, mixed feeding and solid or weaning foods, the evidence was not considered suitable or
relevant to answer the questions in a manner consistent with the standards required for guideline
development.

Evidence overview
The first study was an RCT from Burma assessing the effects of breastfeeding during acute diarrhoea
on clinical outcomes, while the other two papers were case–control studies (from India and
Bangladesh) investigating the risk of dehydration associated with discontinuation of breastfeeding.

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