Nutritional Management of Infants with Diarrhea

Government of Pakistan enacted the local code of Pakistan on 26th October, 2002 called Protection of Breastfeeding and Young child Nutrition Ordinance 2002

Subsequently the rules for the implementation of the local code were issued on 2nd November, 2009

The local code of Pakistan only allows scientific and factual communication on to Healthcare Professionals on the Infant Formula Products

The scientific and factual communication to the health workers can be done through a detailing force, scientific events like Symposia and RTDs involving Healthcare Professionals ONLY

Todays event is in line with the provision of communicating scientific and factual information to healthcare professionals with the core objective of enhancing the knowledge of the health workers Local Code of PakistanWishing you all a great learning session today

Breastfeeding is best for babiesInformation for HCPs only1Role of low lactose & low osmolality for fast recovery from diarrheaIMPORTANT NOTICE:The World Health Organization (WHO*) has recommended that pregnant women and new mothers be informed of the benefits and superiority of breast-feeding in particular the fact that it provides the best nutrition and protect babies from diarrhea and other illness. Mothers should be given guidance on the preparation for, and maintenance of lactation, with special emphasis on the importance of a well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle-feeding or other foods and drinks should be discouraged since it will have a negative effect on breastfeeding as well as health of the infants. Similarly, mothers should be warned of the difficulty of reversing a decision not to breast feed. Before advising a mother to use an infant formula on the recommendation of a healthcare professional, she should be advised of the social and financial implications of her decision: for example, if a baby is exclusively bottle-fed, more than one can (450g) per week will be needed, so the family circumstances and costs should be kept in mind. Mothers should be reminded that breast milk is not only the best nutrition, but also the most economical food for infants. If a decision to use an infant formula is taken, it is important to give instructions on correct preparation methods, emphasizing that un-boiled water, unsterilized bottles or incorrect dilution can all lead to illness of the infants. Feeding with a cup and spoon is safer than bottle feeding.*See: International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Assembly in Resolution WHA 34.22, May 1981 as well as the Protection of Breast Feeding and child nutrition ordinance 2002 and rules 2009 Pakistan

Breastfeeding is best for babiesInformation for HCPs onlyFeeding Challenges in Infants with DiarrheaThere are times when feeding becomes a challenge to infants and young children because of certain special conditions. This is particularly true when babies are not breastfed, diarrhea is one such condition and poses a big threat to the growth and well being of infants and children.

Breast milk is the best choice for infantRodriguez-Palmero M. ClinPerinatol. 1999 Jun;26(2):335-59. Kramer MS. Cochrane Database Syst Rev. 2002;(1):CD003517. Chandra RK. ActaPaediatr Scand. 1979 Sep;68(5):691-4. Howie PW. BMJ. 1990 Jan 6;300(6716):11-6.Breastfeeding is best for babiesInformation for HCPs onlySelf explanatoryIn his "Memorial on the Nutrition of Infants", printed in 1870, Henri Nestl wrote:

"During the first months, the mother's milk will always be the most natural nutriment, and every mother, able to do so, should herself suckle her children".

More than 140 years later, this principle is still true and we are more than ever committed to support & promote breastfeeding.

Nestl's Commitment in Encouraging Breast FeedingBreastfeeding is best for babiesInformation for HCPs onlyNestle has a strong commitment towards encouraging Breast feeding, we believe that mothers milk is the best food for infantsBurden ofDiarrheal DiseasesDiarrheal diseases remain a public health problem, throughout the world, with approximately 1.5 billion episodes per year1Mortality from diarrhea is progressively decreasing but incidence of diarrhea is still high during the first 2 years of life2Incidences for diarrheal episodes per child per year from three reviews of prospective studies in developing areas, 1955-20000-5 m6-11 m1 year2 years0123451955-19791980-19891990-2000No. of episodes per person per year2. Kosek M, Bern C, GuerrantRL.The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. Bull World Health Organ. 2003; 81(3): 197-204.1. Kaferstein, F. (2003). Food borne diseases in developing countries: aetiology, epidemiology and strategies for prevention. International Journal of Environmental Health Research 13, S161-168.Breastfeeding is best for babiesInformation for HCPs onlyOver the last decades, progress in oral rehydration therapy has decreased the mortality from diarrhea. However, despite considerable advances, diarrheal disease remains a public health problem, with 2 2.5 million childhood deaths worldwide per year.Although mortality from diarrhea has decreased, the incidence of diarrhea remains very high and stable over time at >3.2 episodes per child per year or 4.8 episodes per child per year from 6 11 months. Causes of Deathin Children under 5More than half of these deaths are associated with malnutrition 3Breastfeeding is best for babiesInformation for HCPs only

3. WHO-UNICEF Child Health Epidemilogy Reference Group (CHERG) Estimates 2013.Diarrhea is a world health problem especially in the developing countries. In Pakistan if we include the Neonatal deaths because of diarrhea, it is still the leading cause of death among infants below 1 year old.

Mortality Country Fact SheetCauses of death in children under-5Breastfeeding is best for babiesInformation for HCPs only

UNICEF report;Pneumonia and diarrhoea: Tackling the deadliest diseases for the worlds poorest childrenDiarrhea is a world health problem especially in the developing countries. In Pakistan if we include the Neonatal deaths because of diarrhea, it is still the leading cause of death among infants below 1 year old.

Incidence of diarrhea in developing countries

4.8 episodes per yearIncidence of diarrhea in developing countriesBreastfeeding is best for babiesInformation for HCPs onlyDiarrheaFrequent passing of formed stools is not diarrhea.Stools of decreased consistency and increased volume due to imbalance of secretion & absorption of water & salts in the intestineLoose or watery stools at least 3 times a day.Consistency matters more than frequency.Breastfeeding is best for babiesInformation for HCPs only

Diarrheal diseases is still one of the most prevalent and important health concern of developing countries, though the survival rate has increased but the incidence is still high.Diarrhea ClassificationBased on DurationAcute Diarrhea Short in duration (less than 2 weeks)Cows milk proteinSoy milk proteinPost infectious gastroenteritisOther food sensitive enteropathiesPersistent Diarrhea (2 weeks or more)Intestinal Infections (Viral, Bacterial, Parasitic)Celiac DiseaseMalnutritionAntibiotic TreatmentBreastfeeding is best for babiesInformation for HCPs onlyDiarrhea is a world health problem especially in the developing countries. In Pakistan if we include the Neonatal deaths because of diarrhea, it is still the leading cause of death among infants below 1 year old.

Complications of DiarrheaDehydrationGastrointestinal complications:Secondary carbohydrate malabsorptionProtein intolerance (Chronic)Persistent diarrhea (Chronic)Nutritional complications:Malnutrition & Stunted growth (Chronic)Transient lactose intolerance secondary to infective diarrhea is common in developing countriesGupta R, Gupta S; Indian J Med Sci; 1993 Jan; 47(I):1-7Breastfeeding is best for babiesInformation for HCPs onlyInfants under the age of 1 year are specially susceptible to the effects of diarrhea and develop dehydration quite early. Prolonged episodes of diarrhea leads to malnutrition and stunted growth.LactoseThe natural sugar found in the breast milkLactose helps promote: Healthy gut flora1,2 Better calcium absorption3,4 Softer stools1- Bullen et al, J Med Microbiol 1977;10:403-4132- Yoshioka et al, Pediatrics 1983;72:317-3213 -Ziegler et al, J pediatr garstroenterol Nutr 1983;2:288-2944 - Abrams et al, Am J Clin Nutr 2002;76:442-446Breastfeeding is best for babiesInformation for HCPs onlyThe nutrients in breast milk are easily digested and absorbed. Since lactase is the most developed enzyme at birth, the carbohydrate in breast milk is predominantly lactose. Lactose is important to support the growth of babies: promotes calcium absorption for bones and teeth formation provides an acidic environment in the intestines encouraging growth of good bacteria serves as a physiologic (natural) laxative for softer stoolLactose Intolerance Inability or failure to digest lactose Caused by enzyme deficiency lactase Is a clinical syndrome manifested by abdominal pain, bloating flatulence and diarrhea.50 77% of infants and children hospitalized with acute diarrhea have lactose intolerance**Moreira CR Fagundus Neto U Arq Gastroentero 1997; 34:262 - 269J Pediat 1971 Nov;79(5):760-7Breastfeeding is best for babiesInformation for HCPs onlyLactose intolerance is a condition when lactose cannot be digested because of the lack or absence of the enzyme, lactase. This condition pertains only to the deficiency of the lactase enzyme in the villi.LactoseIntolerance

LactaseDeficiency

Congenital Lactase DeficiencyPrimary Lactase DeficiencySecondary Lactase DeficiencySecondary Lactase Deficiency is common in Acute Diarrhea**Trounce JQ, Waller Smith JA, Arch. Dis. Child H 1985;60:986-99Brown KH, Black RE, Penny L, Am.J Clin. Nutr 1980;33:2226-7 NORMAL VILLIDAMAGED VILLIBreastfeeding is best for babiesInformation for HCPs onlyLactose intolerance refers to any of the following 3 conditions:Primary (Congenital) lactase deficiency is a relatively rare, lifelong condition when there is the complete absence of the lactase enzyme. Primary lactase non-persistence refers to the normal, age-related decrease in lactase activity. Most humans gradually lose the intestinal enzyme lactase after infancy (generally after weaning) and with it the ability to digest lactose.Secondary lactase deficiency is the most common type of lactose intolerance due to injury to the intestinal mucosa. It is a frequent and common presentation in infants under the age of 6 months. Since lactase is a brush border enzyme, any condition that injures the intestinal mucosa induces a decrease in lactase activity. Lactase is the first enzyme to be affected and the last to recover, and it has been shown that the specific activity of lactase declined with increasing degree of mucosal injury in children 24 months of age or younger.Acute diarrheaOsmotic diarrheaBacterial fermentationMono-saccharidesIncreased osmolarityDisaccharides intoleranceIntestinal mucosal damageColicInfectionsSwagarty DL Jr, Walling AD, Klein RM, Am Family Phy. 2002 May 1; 65(9):1845-50Andrade JAB, Moreira C, Fogundes Neto U. J.Pediatr.2000;76(Suppl.2):5119 - 26Acute diarrhea - mucosal injury - lactose intolerance Vicious circle may prolong diarrhea recoveryVicious Circle of DiarrheaBreastfeeding is best for babiesInformation for HCPs onlyWhen diarrhea strikes, the risk for malnutrition increases. This is because, by itself, diarrhea causes nutrient and water loss. Then theres a tendency to withhold food due to fear that it will aggravate the diarrhea. Hence, diarrhea often leads to malnutrition. Malnutrition weakens the immune system and makes the infant more susceptible to infections that can, again, lead to diarrhea. Diarrhea is typically more persistent and severe in infants and young children with malnutrition than in children who are not malnourished.So it important to stop the vicious cycle with appropriate nutritional management. Otherwise, the vicious cycle may worsen the statistics on infant mortality. Secondary Lactase Deficiency threatens Childs adequate Nutrition Withholding of food specially milk Compensation of Nutrient and Water losses due to Diarrhea Prevention of MalnutritionManagement ofLactose intoleranceBreastfeeding is best for babiesInformation for HCPs onlyManagement ofLactose intoleranceIn children who have acute diarrhea, adequate nutrition is still possible despite lactase deficiency or Lactose intoleranceAppropriate management of lactose intolerance is elimination of lactose from diet...*Nizami SQ, Bhutta ZA, Molla AM, J Trop Pedi 1996 June; 42(3):133-7Carbohydrate source is of prime importance in controlling diarrhea during lactose intoleranceBreastfeeding is best for babiesInformation for HCPs onlyIn lactose intolerant cases adequate nutrition can be maintained by removing lactose from the diet, however, it is very important that they continue to receive CHO in a different form so that their growth and development continues. Many families use homemade feeds:Diluted infant formulaDiluted cows milkRice-based feedsHow are infants with diarrhea fed in low-income families?Nutritionally inadequateBreastfeeding is best for babiesInformation for HCPs onlyCriteria for selectingRight Nutritional FormulaBreastfeeding is best for babiesInformation for HCPs onlyWhile selecting a lactose free diet, it is of paramount importance that it must fulfills the criterias listed here. Low lactoseLow osmolalityLow out-of-pocket for faster recovery from diarrhea

Breastfeeding is best for babiesInformation for HCPs onlyLACTOGEN Recover Triple L conceptAn adequate answer to an unmet need

Low lactose content to address transient lactose intolerance

Low osmolality to prevent acceleration of loose stools therefore helping faster recovery of mucosa

Low out-of-pocket to give access to appropriate nutrition to a much wider patient population

Breastfeeding is best for babiesInformation for HCPs only

LACTOGEN Recover is 25 times lower in lactose than a standard infant formulaLower than any currently-available infant formula

10Regular IFLACTOGEN Recover Low in Lactose

Breastfeeding is best for babiesInformation for HCPs only

LACTOGEN RecoverLactose Intolerance:Diarrhea leads to injury of the intestinal mucosa and destruction of villiInjured intestinal mucosa produces less of the enzyme lactase which normally digests lactose (milk sugar)High lactose content in the intestine leads to:gas production due to excessive fermentationIncrease of motility due to lowering PH as a result of high lactic acid production loose stools acceleration due increase of osmotic pressureand therefore worsening of the diarrhea

LACTOGEN Recover Why a Low lactose content?

Breastfeeding is best for babiesInformation for HCPs onlyBetter weight gain:Low lactose formula given during the re-feeding period improved weight gain when compared to a standard, diluted infant formula*

LACTOGEN Recover Why a Low lactose content?

Breastfeeding is best for babiesInformation for HCPs only* Woweries J, Dressler F. Re-feeding infants with acute enteritis with a hydrolyzed infant formula. Pdiatr Grenzgeb 1997; 36: 137-144. Original title (German): Realimentation bei akuter Suglingsenteritis mit Hydrolysatnahrung.Infants, who were hospitalized dueto acute enteritis, had a positive weight gain when an undiluted, lactose-reduced infant formula was given during the re-feeding period, compared to a standard, diluted infant formula

LACTOGEN Recover Low osmolalityLACTOGEN Recover has a 20% lower osmolality than a standard infant formulaIts osmolality is 35% lower compared to cows milk, as lactose is replaced by low & high DE maltodextrin

Breastfeeding is best for babiesInformation for HCPs onlyRegular IF175220

LACTOGEN RecoverHigh osmolality:Causes excessive movement of water into the intestinal lumen Leading to loose stools and worsening of diarrhea

Low osmolality:Prevents osmotic diarrheaHelps to recover faster from diarrhea

LACTOGEN Recover Why a Low osmolality?

Breastfeeding is best for babiesInformation for HCPs only26Better weight gain:A formula with low osmolality leads to better weight gain in infants with diarrhea and malnutrition*

LACTOGEN Recover Why a Low osmolality?

LACTOGEN Recover: 175 mOsm/kg

Breastfeeding is best for babiesInformation for HCPs onlySignificantly higher weight gain was obtained after feeding a low osmolality lactose-free formula ( 175 mOsm/kg) vs. lactose-free formula with higher osmolality (200 mOsm/kg) to malnourished children with diarrhea*Kukuruzovic RH, Brewster DR. Milk formulas in acute gastroenteritis and malnutrition: a randomized trial. J Pediatric Child Health. 2002; 38(6): 571-7.Diarrhea is highly prevalent in low socioeconomic groups for whom affordability is a major concern LACTOGEN Recover Low out-of-pocket

There is an obvious need for a nutritionally appropriate yet affordable solution

Breastfeeding is best for babiesInformation for HCPs onlyWith zinc:Known to reduce duration and severity of acute and persistent diarrhea**With nucleotides:Known to have trophic effect on intestinal epitheliumContributing to the recovery of the damaged intestinal mucosa*For faster recovery from diarrheaLACTOGEN Recover Additional benefits

Breastfeeding is best for babiesInformation for HCPs only* Slzov D, Sma P, Richter J, Krs O, Zavadilov J. Stimulation of ileal epithelium growth and regeneration by dietary nucleotide extracts. Acta Medica (Hradec Kralove). 2004;47(3):163-6.**. Dardenne M. Zinc and immune function. Eur J Clin Nutr 2002; 56(S3): S20-S23.** Patro B, Golicki D, Szajewska H. Meta-analysis: zinc supplementation for acute gastroenteritis in children. Aliment Pharmacol Ther. 2008 Sep 15;28(6):713-23.WHO Recommended: ***Zinc supplements for 10/14 days, depending on the availability of supplies and national policy, to reduce the severity of the episode and to reduce the incidence of diarrhea episodes in the following 2 to 3 months.***WHO: Diarrhea Treatment Guidelines for Clinic-Based Healthcare Workers

LACTOGEN Recover Triple L conceptAn adequate answer to an unmet need Low lactose

Low osmolality

Low out-of-pocket

For faster recovery from diarrhea

Feeding tableBreastfeeding is best for babiesInformation for HCPs onlyIMPORTANT NOTICEThe World Health Organization (WHO*) has recommended that pregnant women and new mothers be informed of the benefits and superiority of breast-feeding in particular the fact that it provides the best nutrition and protect babies from diarrhea and other illness. Mothers should be given guidance on the preparation for, and maintenance of lactation, with special emphasis on the importance of a well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle-feeding or other foods and drinks should be discouraged since it will have a negative effect on breastfeeding as well as health of the infants. Similarly, mothers should be warned of the difficulty of reversing a decision not to breast feed. Before advising a mother to use an infant formula on the recommendation of a healthcare professional, she should be advised of the social and financial implications of her decision: for example, if a baby is exclusively bottle-fed, more than one can (450g) per week will be needed, so the family circumstances and costs should be kept in mind. Mothers should be reminded that breast milk is not only the best nutrition, but also the most economical food for infants. If a decision to use an infant formula is taken, it is important to give instructions on correct preparation methods, emphasizing that un-boiled water, unsterilized bottles or incorrect dilution can all lead to illness of the infants. Feeding with a cup and spoon is safer than bottle feeding.*See: International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Assembly in Resolution WHA 34.22, May 1981 as well as the Protection of Breast Feeding and child nutrition ordinance 2002 and rules 2009 Pakistan

Breastfeeding is best for babiesInformation for HCPs onlyChart12.12.82.82.854.82.73.141.52.12.4

1955-19791980-19891990-2000N of episodes per person per year

Tabelle11955-19791980-19891990-20000-5m2.12.82.86-11m2.854.81 year2.73.142 years1.52.12.4Ziehen Sie zum ndern der Gre des Diagrammdatenbereichs die untere rechte Ecke des Bereichs.