Page 113 - 15Diarrhoeaandvomiting

Diarrhoea and vomiting caused by gastroenteritis in children under 5 years

the milk-free group and one in the cow’s milk group. There was no difference in the duration of
diarrhoea between the two groups. There was a significant difference in the mean weight gain
at day 4 and at recovery in favour of the cow’s milk formula group (P < 0.05 for both). [EL = 1−]

Following admission to a hospital in Venezuela, 73 male infants (age range 3–14 months) with
acute non-bloody gastroenteritis (more than four watery stools in the previous 24 hours, and of
less than 96 hours’ duration) and mild or moderate dehydration were recruited in a trial. Criteria
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for exclusion were shock, malnutrition, more than two breastfeeds per day, ORT failure in the first
8 hours or other underlying disease requiring treatment at admission. The children were assessed
and rehydrated appropriately over 4 hours with WHO ORS solution and then randomised (using
block randomisation and sealed envelopes) to either cow’s milk (n = 37) or an experimental
soup (59% hydrolysed plantain, 27% chicken meat with skin, 14% coconut oil) (n = 36). The
two groups had similar characteristics at the start of the study except that children in the cow’s
milk group had consumed significantly more water 48 hours prior to admission and had had a
significantly longer duration of diarrhoea. The infants were followed up for 1 month by trained
observers and the main outcome measures were duration of diarrhoea and weight increase after
admission at 48 hours and at discharge. There were no differences in these outcomes between
the two groups. [EL = 1−]

Evidence summary

There is lack of good-quality evidence to inform this question. Results from the included studies
suggested that there was no statistically significant benefit of using a non-lactose formula (whether
treated cow’s milk or soy formula) over a lactose-containing formula in the re-feeding period
following rehydration. There was also insufficient evidence for any other special formula to make
a definitive statement. Two comparative RCTs of soy formula suggested that early compared with
late re-feeding with soy formula reduced the duration of diarrhoea but had no effect on overall
weight gain.

GDG translation from evidence to recommendation for Section 6.2

Early versus late re-introduction of feed
The GDG noted that studies comparing early and late reintroduction of feeding used different
time scales and endpoints so that there was a lack of comparable evidence with which to answer
this question.
The GDG considered that it is important to avoid malnutrition in children with gastroenteritis.
Given that there was no evidence of harm with the early re-introduction of cow’s milk, milk
formula or solid foods, and that there was a trend towards increased weight gain in the studies
identified, early re-introduction of feeding is appropriate.

Reintroduction of milk or other liquids
Historically, a common practice following rehydration in formula-fed infants has been to give
diluted milk and then gradually increase the concentration to full strength (regrading). However,
the available evidence shows no benefit from this approach and the GDG believes that giving
full-strength formula is likely to be beneficial in terms of nutrition and weight gain.
Fruit juice is sometimes given by parents during gastroenteritis. However, the evidence suggests
that this prolongs diarrhoea.

Reintroduction of solid foods
The GDG noted that certain dietary restrictions were sometimes advised in the early phase
following rehydration. However, the only relevant evidence available related to a few very specific
diets and no clear benefit or adverse effects were identified. The GDG agreed that reintroduction
of solid foods following rehydration is to be recommended. The diet offered should be palatable
and acceptable to both child and family.

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