Unit 7 - Diarrhoea and Nutrition
Medical Education: Teaching Medical Students about Diarrhoeal Diseases
UNIT 7 - DIARRHOEA AND NUTRITION
OF DIARRHOEA AND UNDERNUTRITION
Diarrhoea is an important cause of undernutrition. This is because nutrient
requirements are increased during diarrhoea, as during other infectious
diseases, whereas nutrient intake and absorption are usually decreased. Each
episode of diarrhoea can cause weight loss and growth faltering. Moreover, if
diarrhoea occurs frequently, there may be too little time to "catch up" on
growth between episodes, the result being a flattening of the normal growth
curve (Figure 7.1 and Annex 3). Children who experience frequent episodes of
acute diarrhoea, or have persistent diarrhoea, are more likely to become
undernourished than children who experience fewer or shorter episodes of
diarrhoea. In general, the impact of diarrhoea on nutritional status is
proportional to the number of days a child spends with diarrhoea each year.
In turn, undernutrition contributes to the problem of diarrhoea. In children
who are undernourished as a result of inadequate feeding, previous diarrhoeal
episodes, or both, acute diarrhoeal episodes are more severe, longer lasting,
and probably more frequent; persistent diarrhoea is also more frequent and
dysentery is more severe. The risk of dying from an episode of persistent
diarrhoea or dysentery is considerably increased when a child is already
undernourished. In general, these effects are proportional to the degree of
undernutrition, being greatest when undernutrition is severe.
Thus, diarrhoea and undernutrition combine to form a vicious circle which, if
it is not broken, can eventually result in death; the final event may be a
particularly severe or prolonged episode of diarrhoea or, when severe
undernutrition is present, another serious infection such as pneumonia. Deaths
from diarrhoea are, in fact, usually associated with undernutrition. In
hospitals where good management of dehydration is practised, virtually all
mortality from diarrhoea is in undernourished children.
Diarrhoea is, in reality, as much a nutritional disease as one of fluid and
electrolyte imbalance, and therapy is not adequate unless both aspects of
the disease are treated. However, in contrast to fluid replacement, nutritional
management of diarrhoea requires good feeding practices both during the illness
and between episodes of diarrhoea, when the child is not sick. When this is
done, and undernutrition is either prevented or corrected, the risk of death
from a future episode of diarrhoea is greatly reduced.
This unit describes the factors responsible for nutritional decline during
diarrhoea and considers how this effect can be reversed, and nutritional status
maintained or improved, by appropriate feeding during and after a diarrhoeal
NUTRITIONAL DECLINE DURING DIARRHOEA
Reduced food intake
Nutrient intake may decline by 30% or more during the first days of acute
diarrhoea as a result of:
anorexia, which may be especially marked in children with dysentery;
vomiting, which may discourage attempts at feeding;
withholding of food, which may be based on traditional beliefs about the
treatment of diarrhoea or on recommendations by health personnel to "rest the
giving foods with reduced nutrient value, such as gruel or soup that is
over-diluted; this may be done with the belief that a diluted food is easier to
Decreased absorption of nutrients
Overall nutrient absorption is also reduced by about 30% during acute
diarrhoea, the impairment being greater for fats and proteins than for
carbohydrates. Greater impairment can occur in undernourished children with
persistent diarrhoea, reflecting more extensive damage to the gut mucosa.
Decreased absorption of nutrients is caused by:
damage to the absorptive (villous) epithelial cells, which reduces the
total absorptive surface of the bowel;
disaccharidase deficiency, owing to impaired production of enzymes by the
damaged microvilli. (When severe, this can cause malabsorption of disaccharide
sugars, particularly as lactose.);
reduced intestinal concentrations of bile acids, which are required for fat
rapid transit of food through the gut, leaving insufficient time for
digestion and absorption.
Increased nutrient requirements
Nutrient requirements are increased during diarrhoea owing to:
the increased metabolic demands made by fever;
the need to repair the damaged gut epithelium; and
the need to replace serum protein lost by exudation through the damaged
intestinal mucosa, as occurs in dysentery.
EFFECTS OF FEEDING
DURING AND AFTER DIARRHOEA
To prevent growth faltering, good nutrition must be maintained both
during and after an episode of diarrhoea. This can be achieved by continuing to
give generous amounts of nutritious foods throughout the episode and during
convalescence. In general, the foods that should be given during diarrhoea
are the same as those the child should receive when he or she is well. This
approach is based on evidence that, during diarrhoea, the major proportion of
most nutrients is digested, absorbed, and used, and that, during convalescence,
substantial recovery of lost growth is possible. The effects of feeding on both
the diarrhoeal illness and the child's nutritional status are considered below.
Effect of feeding on diarrhoea
The notion that feeding should be reduced or stopped during diarrhoea
reflects a common belief that giving food will cause stool output to increase
and thus make the diarrhoea worse, but this is not usually the case. For
Breast milk is usually well tolerated during diarrhoea; children who
continue to breast-feed during diarrhoea actually have reduced stool
output and a shorter duration of illness than children who do not
Feeding hastens repair of the intestinal mucosa, and stimulates early
recovery of pancreatic function and production of brush-border disaccharidase
enzymes. This leads to earlier recovery of normal digestion and improved
absorption of nutrients.
Children on mixed diets, e.g., cow's milk, cooked cereal, and vegetables,
do not have increased stool output. However, those taking only animal milk or
formula may have a slight increase in stool volume.
In general, feeding is well tolerated
during diarrhoea, the major exception being clinically significant intolerance
of lactose and occasionally protein in animal milk. This is unusual in acute
diarrhoea, but can be a significant problem in children with persistent
diarrhoea (see below and Unit 6).
Effect of feeding on nutritional status
Food given during diarrhoea
Although absorption of nutrients is reduced during acute diarrhoea, a
substantial proportion is digested and absorbed, as mentioned above. It is not
surprising, therefore, that children given full-strength feedings throughout a
diarrhoeal episode gain weight at a near-normal rate, whereas those with a
restricted intake gain much less or frequently lose weight. Figure 7.3 shows the
growth pattern of children given either a reduced or a full caloric intake
during the first four days of an acute episode of diarrhoea. The figure shows
that weight gain 8 days after starting treatment was greatest in those who
received a normal caloric intake throughout their illness, and less in those
whose feeds were reduced during the first 2-4 days of treatment. Moreover, there
was no appreciable difference in the amount of diarrhoeal stool passed when
children were fed half-strength (55 kcal/kg/day) or full-strength (110
kcal/kg/day) diets. Based on studies such as this, it is now clear that there
is no basis for reducing food intake during diarrhoea. Instead,
full-strength feeding should be continued so that growth faltering and worsening
of nutritional status can be prevented, or at least minimized.
Even when a child is given as much food as possible during diarrhoea, some
growth faltering may occur, especially if the child has marked anorexia.
Moreover, many children are undernourished prior to developing diarrhoea and
they will remain at increased risk of frequent, severe, or prolonged diarrhoeal
episodes until their nutritional status improves. The goal of feeding after
diarrhoea stops is to correct undernutrition and to achieve and sustain a normal
pattern of growth. This is best done by ensuring that the child's normal
diet provides adequate amounts of energy and other required nutrients. This
is most important for children older than 4-6 months of age receiving a mixed
diet. The foods recommended for such children during diarrhoea (see below) are
also appropriate for normal feeding when the child is well. It is also helpful
to give increased amounts of energy-rich food during the first few weeks
of convalescence, when children are usually very hungry and may readily consume
50% or even 100% more calories than usual and grow at several times their normal
The vicious circle by which diarrhoea and undernutrition interact can be
broken by correct feeding practices. This requires that health workers advise
mothers on the best way to feed their children normally, teach them the
importance of continued, full-strength feeding during diarrhoea, and assist them
in their efforts to follow this advice. There are four parts to the correct
nutritional management of diarrhoea:
assessing the nutritional status of the child,
appropriate feeding during the diarrhoeal
appropriate feeding during convalescence,
with follow-up, and
effective communication of dietary instructions to the mother.
The first of these is considered in Unit 3;
the remaining three topics are discussed below.
Feeding during diarrhoea
Specific feeding recommendations are determined by the child's age and
pre-illness feeding pattern. These are discussed below.
During diarrhoea, breast feeding should not be reduced or stopped, but
allowed as often and for as long as the infant desires it. Breast milk should be
given in addition to the ORS solution, recommended home fluid, or other fluids
given to replace stool losses.
Animal milk or formula
The usual animal milk or formula should be continued. In infants under 6
months of age who are not yet taking soft foods, the milk should be diluted with
an equal volume of water for two days. If dehydration develops, milk feeds should be stopped for 4-6 hours during rehydration, and then resumed.
This approach is fully satisfactory for most infants. Special lactose-free or
hydrolyzed-protein formulas should not be used routinely; they are
expensive and of no special value for most infants and children with acute
Soft or solid foods
If the child is 4 months or older and already taking soft or solid foods
these should be continued. Infants 6 months or older should be started on soft
foods, if this has not already been done. If dehydration develops, these foods
should be stopped for 4-6 hours during rehydration, and then resumed. At least
half of the dietary energy should come from foods other than milk. Children
should be given frequent small meals, (e.g., six or more times per day) and they
should be encouraged to eat. Guidelines for the selection of appropriate foods
- use well-cooked local staple foods that can be easily digested, such as
rice, corn, sorghum, potatoes, or noodles;
- give the staple food in a soft, mashed form; for infants use a thick pap;
if cereal gruels or soups are given to prevent dehydration, other energy-rich
foods must be given to ensure adequate caloric intake;
- increase the energy content of the staple food by adding 5-10 ml of
vegetable oil per 100-ml serving; red palm oil is especially good because it is
also a rich source of carotene;
- mix the staple food with well-cooked pulses and vegetables; if possible,
include eggs, meat, or fish;
- give fresh fruit juice, green coconut water, or mashed ripe banana to
provide potassium; and
- avoid foods and drinks with a high concentration of sugar (e.g., commercial
soft drinks, fruit drinks) or salt (e.g., commercial soups).
A few children with acute diarrhoea, especially young infants, show symptoms
of intolerance of animal milk, even when the guidelines for milk feeding are
followed. This usually occurs when animal milk or formula is the only food
given. Milk intolerance occurs more frequently among children with persistent
diarrhoea (see Unit 6). It almost never occurs in children whose only milk is
a marked increase in stool volume and frequency when milk feeds are
given, and a comparable decrease when they are stopped, and
The clinical manifestations of milk intolerance are:
worsening of the child's clinical condition; signs of dehydration may also
When milk intolerance is due to lactose
malabsorption, the stool pH is low (less than 5.5; it turns litmus paper from
blue to pink) and it contains a large amount of reducing substances (unabsorbed
sugars). A test for reducing substances involves adding 8 drops of fresh liquid
stool to 5 ml of Benedict's Solution and boiling the mixture for 5 minutes; an
orange-brown colour indicates that the stool contains more than 0.5% reducing
substances. Clinitest (R) tablets can also be used, but not most testing tapes
(e.g., Testape (R)) or Combistix (R), because they detect glucose.
Be aware, however, that milk intolerance is often overdiagnosed. Stool volume
and frequency may increase slightly when children with diarrhoea are fed
aggressively; reducing substances may also appear in the stool and faecal pH may
become low. However, as long as the child is doing well clinically (i.e., is
gaining weight, eating, alert, and active), these findings are not a
cause for concern.
To manage milk intolerance:
For infants under 4-6 months of age who take animal milk:
replace cow's milk or formula with yoghurt or a similar fermented milk
product, or dilute milk or formula milk with an equal volume of water (if
possible, add 8 g sugar to each 100 ml to maintain energy content); provide
small feeds every 2-3 hours;
if there is no improvement after two days, the infant should be referred to
a centre where specialized treatment is possible. A lactose-free or milk-free
diet may be required.
For infants and children who normally take soft foods with animal milk:
reduce the amount of lactose in the diet by giving diluted animal milk, as
described above, or by replacing milk with yoghurt or a similar fermented milk
also provide at least half of the caloric intake as non-milk foods, e.g.,
well-cooked cereals and pulses with added vegetable oil. Give these foods
mixed with milk;
if after two days there is no improvement, stop all animal milk
products, replacing them with other energy-rich, protein-containing foods.
Finely minced chicken meat is effective, but relatively expensive.
Continue the treatment for milk intolerance for two days after diarrhoea
has stopped, then reintroduce the usual milk or formula gradually over 2-3 days.
Feeding during convalescence
The foods recommended for feeding during diarrhoea should be continued after
diarrhoea stops, and extra food should be given, to support "catch up" growth. A
practical approach is to give the child as much as he or she can eat and to
provide an extra meal each day for two weeks. If the child is undernourished or
is recovering from persistent diarrhoea, this should be continued for a longer
period, until the undernutrition is corrected. The child's usual diet should be
reviewed and the mother advised on how she can improve its quality. Ideally, the
child should be seen regularly for follow-up so that his or her weight can be
monitored and encouragement and advice on feeding given to the mother. If
possible, a growth chart should also be used, especially if the child is
undernourished, and follow-up continued until a normal rate of growth is
established (see Annex 3). If these steps are not possible, the importance of
giving extra food during convalescence and improving the quality of the child's
normal diet should still be stressed to the mother; the best and sometimes the
only opportunity to do this is when the child is being treated for diarrhoea.
Vitamin A deficiency and diarrhoea
During diarrhoea, vitamin A absorption is reduced and greater amounts are
used from body stores. In areas where vitamin A deficiency is a public health
problem, diarrhoea can cause a rapid depletion of vitamin A stores, leading to
acute vitamin A deficiency and symptoms or signs of xerophthalmia. Sometimes
blindness develops rapidly. This is a particular problem when diarrhoea occurs
during or shortly after measles, or in children who are already severely
undernourished; it may also be a problem in children who have persistent
diarrhoea or frequent episodes of diarrhoea.
Symptoms and signs of vitamin A deficiency should be sought in children with
diarrhoea who live in an area where vitamin A deficiency is a significant
problem (see Unit 3). If night blindness is present or there are any signs of
xerophthalmia, 200 000 units of vitamin A should be given by mouth; infants
should receive 100 000 units. This dose should be repeated the next day and
again after four weeks. Children who have severe undernutrition or have had
measles within the past month should receive a single dose of vitamin A, as
above (unless a dose has been given within the past month). In areas where
vitamin A deficiency is a problem, mothers should be urged to give their
children foods rich in carotene, the precursor of vitamin A: these include
yellow or orange fruits and vegetables, and dark-green leafy vegetables.
OF DIARRHOEA IN CHILDREN WITH SEVERE UNDERNUTRITION
Diarrhoea is a serious and often fatal event in children with severe
undernutrition. Although the main objectives in treating such patients are the
same as for better nourished children, certain aspects of patient evaluation and
management need to be modified or given particular attention. These are
described below. The diagnosis of severe undernutrition is described in Unit 3.
Assessment of hydration
Assessment of hydration status in severely undernourished children is
difficult, because a number of the signs normally used are unreliable. For
example, children with marasmus have loose, lax skin so that skin turgor appears
poor, even when they are not dehydrated. On the other hand, skin turgor may
appear normal in children with oedema (kwashiorkor), even when they are
dehydrated. Likewise, sunken eyes are an unreliable sign in marasmic children;
and the apathy of children with kwashiorkor and the irritable, fussy behaviour
of those with marasmus make the interpretation of mental state difficult.
Absence of tears is difficult to assess in all children with severe
undernutrition because they do not readily cry. Signs that remain useful for
detecting dehydration include: dry mouth and tongue, and eagerness to drink (for
children with some dehydration); or very dry mouth and tongue, cool and moist
extremities, and weak or absent radial pulse (for those with severe
dehydration). In children with severe undernutrition it is often not possible to
distinguish reliably between some dehydration and severe dehydration.
The principal guidelines for rehydrating children with diarrhoea and severe
undernutrition are as follows:
Rehydration therapy should take place at a hospital, if possible; if the
patient is seen at a health centre or clinic, he or she should be referred to
hospital. The mother should be provided with ORS solution and shown how to give
it to the child at a rate of 5 ml/kg/hour during the trip (see Figure 6.1).
All fluids should be given by mouth or nasogastric tube. Intravenous
infusions should not be used because fluid overload occurs very easily,
causing heart failure, and their use also increases the risk of septicaemia;
either event is likely to be fatal. Oral rehydration is preferred for children
who can drink; otherwise, a nasogastric tube should be used until the child is
able to drink.
Rehydration should be done slowly, over a period of 12-24 hours. The
approximate amount of ORS solution to be given during this period is 70-100 ml
per kg body weight. The exact amount should be determined by the quantity the
child will drink and by frequent, careful inspections for signs of overhydration
(increasing oedema). The child should remain at the treatment centre until
rehydration is completed.
The standard ORS solution should be used. However, additional potassium
should be given by mouth, since severely undernourished children are normally
potassium-depleted, and this is made worse by diarrhoea. A convenient solution,
containing 1 mmol of potassium per ml of solution, can be prepared by dissolving
7.5 g of potassium chloride in 100 ml of water. Four ml of this solution per kg
of body weight should be given each day for two weeks, in divided doses mixed
Feeding should be resumed as soon as possible. Starving, even for brief
periods, should be avoided. Breast-feeding should continue throughout
rehydration and other food should be given as soon as it can be taken. Small
amounts can usually be given within 2-3 hours after starting rehydration. The
feeding guidelines given below should be
Children with severe undernutrition and diarrhoea must be fed very carefully;
once rehydration is complete, nutritional rehabilitation should take place,
preferably at a treatment centre with expertise in this area. Typically,
children must spend 12-14 hours a day at the centre for feeding and supportive
care, returning each night to their homes, where frequent feeding is continued.
If the child has to be admitted to hospital, the mother should stay with him or
her, if possible, to assist with feeding and provide emotional support. For
children with kwashiorkor, feeding should be resumed slowly, starting at
50-60 kcal/kg/day and reaching 110 kcal/kg/day after about seven days; feeding
usually has to be encouraged owing to the child's lack of interest in eating.
For children with marasmus, feeding should be limited to 110 kcal/kg/day
for the first week, but food can usually be given ad libitum thereafter.
Semi-liquid or liquid foods must be given in numerous small feedings, e.g.,
every two hours day and night. Initially, eating may be difficult because of
stomatitis; in such instances, tube feeding for several days is essential.
A practical diet for initial feeding can be prepared from:
- skim milk powder 8 g
- vegetable oil 6 g
- sugar 5 g
- water to make 100 ml
This contains 100 kcal/100 ml. If possible, the skim milk should be prepared
first and fermented to make a yoghurt-like drink before adding sugar and oil.
This reduces the lactose content of the diet, so that it is better tolerated.
The diet may also be prepared using fresh skim milk (briefly boiled) in place of
skim milk powder and water. The oil is an important ingredient, as the diet
would otherwise provide insufficient energy.
iron - 60 mg of elemental iron/day
In addition, the following mineral and vitamin supplements should be given:
folic acid - 100 mg/day
vitamin A - 200 000 units once (100 000 units for infants) in areas where
vitamin A deficiency is prevalent. If signs of xerophthalmia are present, the
full treatment course described earlier should be given.
vitamin B complex, C, and D - as daily multivitamin drops.
Children with severe undernutrition and diarrhoea frequently have other
serious illnesses, especially infections. Most common are pneumonia,
septicaemia, otitis media, pharyngitis, tonsillitis, and urinary or skin
infections. Severe infection often causes hypothermia rather than fever.
Patients should be examined carefully for evidence of infection and given
antibiotic therapy. If a site of infection is identified, an appropriate
antibiotic should be given. If no site of infection is recognized, a combination
of ampicillin and gentamicin given parentally for 5-7 days is appropriate.
MOTHERS ABOUT FEEDING DURING DIARRHOEA
Most societies have strong cultural beliefs about the feeding of infants and
children during and after diarrhoea. Feeding recommendations must be
nutritionally sound, but also compatible with the mother's beliefs and
resources. In order to give effective dietary recommendations, the doctor must
what foods are most commonly used for children at different ages and the
nutritional value of these foods when prepared in the usual manner;
what foods are commonly given or specifically restricted during diarrhoea;
what specific combinations can be recommended for energy-rich, low bulk,
soft, or semi-liquid diets, using foods that are available, acceptable, and
how much food should be given to children with diarrhoea.
The doctor should ask the mother about the child's usual diet and about the
food the child has received since diarrhoea began. The advice given should cover
feeding both during diarrhoea and after diarrhoea stops; if possible, the
recommendations for these two periods should be similar, with emphasis on a
balanced, energy-rich diet that is appropriate for the child's age. If the
mother does not have or cannot obtain the recommended foods, or is strongly
opposed to giving certain items, the doctor should adjust the recommendations to
fit her situation. If she does not know how to prepare certain foods, the doctor
should ensure that she is given clear instructions and is able to follow them
(see "Talking with mothers about home treatment", Unit 4).
The mother will be able to understand and accept dietary advice much better
if she is given a dietary prescription. This can be prepared as a printed
pamphlet that shows pictures of various foods along with their names and the
amounts of each usually given at different ages. If specific staple foods,
vegetables, fruits, meats, and oils are circled and the amount of each to be
given is indicated, the mother has a handy reminder of how her child should be
fed. When dietary advice is given in this form it is also more likely to be
taken seriously by the mother.
1. Which of the following is the most important cause of weight
loss during diarrhoea? (There may be more than one correct answer.)
2. Which of the
following statements about feeding during diarrhoea are correct? (There may be
more than one correct answer.)
Feeding during diarrhoea does not appreciably increase stool volume.
- Reduced absorption of nutrients
- Increased metabolic demands
- Reduced intake of food
Continuing feeding during diarrhoea helps to hasten repair of the
intestinal mucosa, thus restoring the production of disaccharidase enzymes.
Food should be withheld when a child has anorexia.
Special foods should be given during acute diarrhoea; the diet is not the
same as that recommended when the child is well.
Doctors should insist that mothers follow their advice about feeding,
irrespective of the mothers' beliefs about what foods should or should not be
given during diarrhoea.
Yunus, aged 9 months, is brought to you with watery, non-bloody diarrhoea, which
he has had for two days. He has vomited twice. Physical examination shows
evidence of some dehydration. You rehydrate him with ORS solution. The mother
says that she stopped breast-feeding Yunus when she became pregnant two months
ago. Since then, he has been taking cow's milk and eating rice with the rest of
the family. When he started to have diarrhoea, she stopped his food.
Which of the following points should be included in your advice to Yunus's
mother? (There may be more than one correct answer.)
4. Which of the following statements about
feeding after diarrhoea are correct? (There may be more than one correct
- Dilute Yunus's regular milk with an equal volume of water for the
next two days; then resume his normal milk feeds.
- Add 5-10 ml of vegetable oil to each serving of well-cooked rice.
- Add well-cooked pulses and vegetables to Yunus's diet; give him an egg, or
some fish or meat when possible.
- Gradually resume Yunus's usual diet as the diarrhoea gets better.
- Give an extra meal each day for at least two weeks after diarrhoea stops.
5. Roberto, aged 9 months, has had frequent
episodes of diarrhoea. He cries a lot and is restless during the examination.
His skin pinch goes back slowly, he drinks eagerly, and his tongue is dry. His
mother says he has had diarrhoea frequently, "almost every month". He has been
taking cow's milk from a feeding bottle since he was 1 month old and started to
take regular food at the age of 8 months. His mother says that he seems to be
growing slowly, he does not need larger clothes as often as her previous
children did, and he has been wearing the same protective charm bracelet on his
wrist since he was 6 months old. Since the diarrhoea started the mother has
given him some formula but no solid food "because he was not hungry". Roberto weighs 4.7 kg and has a "skin and bones" appearance. It is obvious
that he is severely undernourished. What should be done for Roberto? (There may
be more than one correct answer.)
- An extra meal should be given each day for at least two weeks.
- Milk should continue to be diluted with an equal volume of water, to
reduce the amount of lactose in the diet.
- The foods given should be of the same type recommended for use during
diarrhoea, i.e. energy-rich mixtures of a staple food, vegetable oil, pulses,
vegetables and, if possible, meat, fish or egg. The usual milk should be given.
- Normal feeding should be resumed gradually, to prevent diarrhoea from
6. Part 1. Kati is 7 months of age.
She is brought to you after two days with diarrhoea and has signs of severe
dehydration. You initiate IV rehydration and then obtain further information
from her mother. She says Kati was weaned to cow's milk six weeks earlier. She
also eats well-cooked rice and vegetables. Kati has continued to receive this
diet during her illness. After rehydration you advise Kati's mother on home
treatment, namely, feeding with cow's milk, rice, vegetables, and added oil.
After two days, Kati's mother returns because Kati is still having frequent
watery stools. The mother thinks these usually occur shortly after Kati takes
milk. You think Kati may have milk intolerance. What step would help most
to confirm this diagnosis?
- He should be rehydrated orally with ORS solution at a rate of 70-100
ml/kg over 12-24 hours.
- Food should be withheld until rehydration is completed.
- If Roberto does not take the estimated volume of ORS, the remainder should
be given intravenously as Ringer's Lactate solution.
- Roberto's treatment, including rehydration and nutritional management
should be given at a hospital or specialized treatment centre.
- Roberto should be given supplemental potassium (a solution of potassium
chloride added to his food) for two weeks.
Part 2: If the diagnosis of milk intolerance
is confirmed, what steps would be appropriate for its treatment? (There may be
more than one correct answer.)
- Stop all food for two days and see whether the diarrhoea improves.
- Withhold milk for a 12 hours (while continuing to give other foods) to see
whether diarrhoea subsides, then give it again to see whether the diarrhoea
- Test the stool for pH and reducing substances.
- Give a special soy-based milk and see whether the diarrhoea stops.
- Give an antibiotic and see whether the diarrhoea
- Give a special soy-based formula until diarrhoea stops.
- Dilute Kati's usual milk with an equal amount of water for two days.
- Provide at least half of Kati's food energy as cooked cereal and
vegetables, with added vegetable oil. Mix Kati's milk with these foods.
- Give yoghurt or another fermented milk product in place of milk.
- Replace Kati's milk with fruit juice or tea.
1. E. A-D also occur but only contribute to weight loss if food intake is
decreased. When enough food is given weight loss is prevented. 2. A,B 3. B,C,E. Since Yunus is 9 months of age his regular milk does not need to be
diluted. 4. A,C 5. A,D,E 6. Part 1 - B. Observation of a close association between diarrhoea and
milk feeds is the most important. Testing the stool for pH and reducing
substances is only helpful when it is clear that milk makes the diarrhoea worse.
Part 2 - B,C,D
updated: 23 April, 2014