Page 103 - 15Diarrhoeaandvomiting

Diarrhoea and vomiting caused by gastroenteritis in children under 5 years

and solid feeds. The GDG considered that cessation of breastfeeding even for a few hours
could pose significant difficulties for mother and child (for example, discomfort and possible
risk to maintaining breastfeeding). For these reasons, breastfeeding should continue if possible
throughout the period of rehydration.
With regard to milk formula feeds and solid foods, different considerations apply. Such feeds
could result in a reduced rate of gastric emptying. Delayed emptying might increase the risk of
vomiting and consequently of ORT failure. The GDG considered that the nutritional significance
of any milk or solid food taken in the 3–4 hour rehydration phase of therapy is likely to be small.
The GDG therefore agreed that feeds other than breast milk should be discontinued during the
rehydration phase of fluid therapy. An exception to this could be made in children without red
flag symptoms or signs of dehydration (see Table 4.6). If such children do not take an adequate
amount of ORS solution they could be given supplementary feeds with their usual fluids –
generally milk or water. However, they should not be given any fruit juices or carbonated drinks
as these are often of high osmolarity and can worsen diarrhoea.

Recommendation on feeding during rehydration
During rehydration therapy:

• continue breastfeeding
• do not give solid foods
• in children with red flag symptoms or signs (see Table 4.6), do not give oral fluids other
than ORS solution
• in children without red flag symptoms or signs (see Table 4.6), do not routinely give oral
fluids other than ORS solution; however, consider supplementation with the child’s usual
fluids (including milk feeds or water, but not fruit juices or carbonated drinks) if they
consistently refuse ORS solution.

6.2 Feeding following rehydration

The timing of the re-introduction of nutrition, whether as milk feeds or solid foods, may be
important. Prolonged withholding of food may result in malnutrition. It is also clear that the
presence of nutrients in the gut promotes mucosal health and absorptive function. It is important
to appreciate that diarrhoea often persists for days but this does not usually indicate clinically
significant malabsorption. A more important indicator of recovery is the achievement of
appropriate weight gain.
The common practice of diluting feeds during the process of re-introduction could have adverse
consequences for recovery. It has also been suggested that the use of specialised soy protein
or protein hydrolysate formulas may reduce the risk of complications during recovery from
gastroenteritis. Lactose-free or lactose-reduced formulas have been recommended to reduce the
risk of diarrhoea from lactose malabsorption.

Solid foods may be important during the recovery phase, not only in the prevention of malnutrition
but also in promoting mucosal recovery. There have been suggestions that specific foodstuffs
could also promote recovery. In some cultures, the use of specific foods such as rice and cereal-
based foods has been promoted. The evidence available regarding such practices was identified
in order to inform recommendations.

Clinical questions
• Does early versus late re-introduction of feed affect outcomes?
• What milk or other liquid feeds should be allowed?
• Should solid foods be allowed? If yes, what foods should be allowed?
• What are the indications for use of a specialised formula?

Out of 71 retrieved papers, 28 were found to be suitable for inclusion and addressed maintenance
feeding following the rehydration phase of therapy. Five RCTs compared the effect of early versus
late reintroduction of feed on clinical outcome while six RCTs described graded re-feeding
versus full-strength re-feeding regimens. One RCT described the addition of fruit juices to the

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