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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.

Overgrowth of aerobic and anaerobic bacteria in the upper small intestine is a common finding in persistent diarrhea. We hypothesized that a large dose of broad spectrum, nonabsorbable oral antibiotic would hasten recovery from persistent diarrhea by eradicating aerobic bacterial overgrowth. Sixty-eight patients were randomly assigned to treatment with either oral gentamicin (n = 33) or placebo (n = 35) for a period of 6 days. The two groups were comparable in their clinical features, stool weights, duodenal and fecal microflora, during an initial 24 h observation period before randomization. The proportion of patients recovering within 6 days post-treatment was similar in the antibiotic (45.2%) and placebo (50%) groups. The stool weights in the two groups during 24-72, 72-120, and 120-168 h of the study did not differ significantly. The percent mean weight gain (g) at 168 h post-treatment in the antibiotic (1.0 +/- 5.1) and placebo (1.4 +/- 5.3) groups also did not differ significantly (p = 0.8). A similar proportion of antibiotic- (61.3%) and placebo- (60.7%) treated patients had started to gain weight by the last day of the study. We conclude that oral gentamicin was no more effective than placebo in reducing purge rates, in achieving earlier recovery from diarrhea, and in promoting the earlier onset of weight gain in this study.

Children with acute diarrhea and moderate dehydration between 3 months and 5 years of age were randomly assigned to receive treatment with standard WHO oral rehydration solution (ORS) (n = 33) and two other solutions in which the 20 g/L glucose was substituted by 50 g/L of pop rice (n = 31) and 60 g/L of mung bean (lentil) powder (n = 29). Satisfactory oral rehydration, as assessed clinically and by changes in PCV and total serum solids (TSS), was achieved in 90.9% with WHO ORS, 96.8% with pop rice, and 96.6% in the mung bean ORS treated group (p greater than 0.05). The purging rates (ml/kg/h) until recovery were 2.49 +/- 1.5 (pop rice); 2.91 +/- 2.0 (WHO), and 3.41 +/- 1.7 in the mung bean group (p greater than 0.05). The percentage of patients recovering from diarrhea within the 72 h study period was 58.0 (pop rice), 48.4 (WHO), and 44.8 for mung bean group (p greater than 0.05). Though differences in stool volumes and duration in the three groups were not statistically different, there was a trend toward improvement in efficacy with the pop rice ORS in several parameters: greater weight gain, higher percentage decline in TSS, higher urine output despite lower ORS intake, and lower purging rates. The intake of semisolids in the 24-72 h study period was also higher in the pop rice group as compared to the other two groups (p less than 0.05). The number of breast feeds and intake of artificial milk was however similar in all groups (p greater than 0.05).

R-1 anti-reticulin antibodies (ARA) were present in sera of 10 of the 12 children who subsequently fulfilled the ESPGAN diagnostic criteria for celiac disease (CD), but was not found in any children in the age-matched control groups, viz., severely malnourished (n = 20), acute gastroenteritis (n = 23), normally nourished asymptomatic (n = 38), and 42 children with protracted diarrhoea and failure to thrive due to nonceliac causes. ARA was a highly specific (100%) and sensitive (83%) assay for the early diagnosis of CD. A positive ARA assay with an initial subtotal villous atrophy was seen to always suggest CD, and these together would provide a useful basis for instituting gluten-free diets in suspected cases of CD rather than histological findings alone, which may be often present in children in the third world with protracted diarrhoea and associated severe malnutrition.