Prognostic factors in hospitalized children with persistent diarrhea: implications for diet therapy

A dietary algorithm for management of persistent diarrhea in developing countries, using locally available foods, is yet to be standardized. We identified factors related to poor outcome among 75 malnourished hospitalized male patients aged 3-48 months with persistent diarrhea (> or = 14 days) treated on soy and cereal-based diet (Diet I). The 28 patients with stool output > 60 g/k body weight on the sixth or the seventh treatment day were considered diarrhea treatment failures on Diet I. In the univariate analysis, breast feeding (p < 0.001), carbohydrate malabsorption based on low stool pH or reducing substances > 0.5% (p = 0.03), initial 24-h purge rate (p = 0.001), pneumonia (p = 0.003), or probable septicemia (p = 0.03) were associated with diarrhea treatment failures. Although 16 of these 28 patients responded to systemic antibiotics without dietary modification, all but one of the remaining recovered on a chicken puree, glucose, and oil formulation. Twenty-six children had weight loss after 7 days on Diet I as compared with the postrehydration weight. These children had lower mean age (p = 0.05), lower food intake in the first 24 h (p = 0.05) and during the initial 7 days (p < 0.01), and a higher initial excretion of enteroaggregative Escherichia coli (32 vs. 8%; p = 0.01). In the logistic regression model, significant risk factors for diarrhea treatment failures were initial purge rates, carbohydrate malabsorption, and intercurrent systemic infection; only low food intake was associated with significant risk for weight loss. The significant association of diarrhea treatment failures with carbohydrate malabsorption suggests that in the initial diet itself, part of polysaccharide be substituted with sucrose or glucose to obtain the right balance between osmolarity and energy density. Our data suggest that prompt identification and treatment of systemic infection is critical, as its eradication achieved recovery in more than half of the treatment failures without a dietary change.