Manifestations of Gastrointestinal Disease in the Child

710 FIRST PRINCIPLES OF GASTROENTEROLOGY
4.7 Management
Management begins with identifying the underlying factors contributing to
undernutrition and correcting them if possible. In more complex cases it is
very helpful to have a multidisciplinary approach with physician and nurses,
dietitian, social worker and, if indicated, a behavioral psychologist or feeding
specialist. The goal of nutritional management is to promote compensatory
catch-up growth. Children diagnosed with growth failure secondary to protein
calorie malnutrition may need to receive up to 150% of the recommended
daily caloric intake for their expected, (not actual) weight for age. This is usually
achieved by attempting to provide nutrient-dense food. For infants, the caloric
density of formula can be increased and, in toddlers, nutrient density is
increased by enriching preferred food with butter, peanut butter, oil, cheese or
carbohydrate additives. Fruit juice may contribute to poor growth and should
be limited to 240-480 mL/day. Small, frequent feedings should be offered. In
cases of moderate and severe malnutrition, a multivitamin supplement should
be offered. Severe malnutrition should be managed in-hospital, with close
monitoring of electrolytes and fluid balance to prevent refeeding syndrome.
5. ACUTE DIARRHEA IN CHILDREN / J.D. Butzner
5.1 Introduction
A North American child will develop between 6 and 12 episodes of acute
diarrhea before the age of 5. This contributes to approximately 12% of childhood
hospitalizations and approximately 300 deaths per year. Worldwide,
acute diarrheal disease is the leading cause of childhood morbidity and mortality,
accounting for three million deaths each year. Most deaths are caused
by failure to treat acute dehydration properly and to correct electrolyte
imbalances. Studies from both the developing and developed world demonstrate
that hospitalization can be avoided and morbidity and mortality can be
drastically reduced by the prompt introduction of two simple treatments: oral
rehydration therapy and early refeeding. In spite of recommendations to use
oral rehydration therapy and to continue or resume feeding early in mild
to moderate diarrheal illnesses, the use of unsuitable treatments persists.
These include unnecessary intravenous therapy, inappropriate oral fluids
(unbalanced sugar-electrolyte solutions), prolonged starvation with a slow
introduction of limited feeds, and the inappropriate use of antibiotics as
well as antimotility and antidiarrheal agents.
5.2 Pathophysiology of Acute Diarrheal Disease
An understanding of the physiology of intestinal fluid, electrolyte and nutrient
transport provides a basis for understanding the mechanisms of acute diarrheal
disease and successful oral rehydration therapy. Water absorption occurs