Page 102 - 15Diarrhoeaandvomiting

Nutritional management

In the first RCT, conducted in Burma, 117 52 children admitted to hospital for acute watery diarrhoea
of less than 48 hours’ duration were recruited. The children were aged 6–24 months, had
moderate or severe dehydration and had been normally breastfed. Excluded from the study were
children with concomitant illness, bottle-fed children, and those who had received antibiotics
before admission. After enrolment, the children were randomised (by random numbers) to
receive either ORS solution alone (n = 26) or ORS solution plus breastfeeding (n = 26) during
the first 24 hours in the hospital. In the second 24 hours, all children received breastfeeding
and ORS solution. Children requiring IVT were given IV rehydration fluids until they had no
clinical signs of dehydration and they were then randomly allocated to receive one of the two
rehydration regimens. Sample size was calculated prior to the study but no details were given
about concealment of allocation.

The baseline demographic characteristics of the two groups were similar, including the number
of children requiring IV fluids and the number of children having Vibrio cholerae detected in
stool swabs. Children receiving breastfeeding plus ORS solution had, on average, passed five
fewer stools than those receiving ORS solution alone (12.1 ± 1.1 versus 17.4 ± 2.3; P < 0.05) and
this difference was statistically significant. These children also required significantly less amount
of ORS solution (ml per patient) during the early phase of diarrhoea (1570 ± 113 ml versus 2119
± 192 ml; P < 0.05). However, there were no statistically significant differences between the two
groups regarding duration of diarrhoea in hospital, stool output (ml/kg) or vomitus output (ml per
episode). [EL = 1+]
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A case–control study conducted in India recruited 379 infants with acute gastroenteritis of less
than 24 hours’ duration. This study is described in detail in Section 4.1. Cases were defined as
infants with moderate or severe dehydration (n = 243), while controls had no or mild dehydration
(n = 136). More than one-quarter of cases and 21% of control children had cholera. Univariate
analysis identified various factors associated with increased risk of dehydration but, after
controlling for confounding variables, only two factors were found to be significantly associated:
withdrawal of breastfeeding during diarrhoea (OR 6.8; 95% CI 3.8 to 12.2; P < 0.001) and not
giving ORS solution during diarrhoea (OR 2.1; 95% CI 1.2 to 3.6; P = 0.006). [EL = 2+]

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Another case–control study conducted in Bangladesh considered withdrawal of breastfeeding
during acute diarrhoea as a risk factor for dehydration. Children were selected for study if their age
was between 1 and 35 months, if they had watery diarrhoea for 6 days or less at first presentation
and if they had been breastfeeding up to the time of onset of diarrhoea. The cases comprised
285 moderately and severely dehydrated children and 728 children with no clinical signs of
dehydration were recruited as controls. Detailed information about the population characteristics
and the study methodology is provided in Section 5.1. After controlling for confounding factors
(lack of maternal education, history of vomiting, high stool frequency, young age and infection
with Vibrio cholerae), the risk of dehydration was five times higher in infants whose mothers
stopped breastfeeding compared with infants whose mothers continued to breastfeed following
the onset of diarrhoea (OR 5.23; 95% CI 1.37 to 9.99; P = 0.016). [EL = 2+]

Evidence summary
Results from one RCT with EL = 1+ show that there was a significant reduction in the number
of stools passed in the hospital in children receiving breastfeeding along with ORS solution
compared with children receiving only ORS solution. However, no statistically significant
differences were found between the two groups for the duration of diarrhoea or the amount
of stool and vomitus. Two case–control studies did not address the question directly but their
results indicated that continuation of breastfeeding during gastroenteritis was associated with a
reduced risk of becoming dehydrated. No study was identified which looked at the effectiveness
of continuing feeding with the other types of foods during rehydration.

GDG translation from evidence to recommendation
The GDG was aware of advice in other guidelines that encourages continuation of breastfeeds
during rehydration but cessation of other milk and solid feeds. The GDG recognised that there
was some evidence suggesting that breastfeeding actually confers benefit in terms of a reduction
in the number of diarrhoeal stools, but no such evidence was available for other milk feeds

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