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Editor,—Murphy’s paper1 “intended to provide evidence based recommendations about . . . clinical management of infants and children with acute gastroenteritis”. Based on six references he concluded that “Many studies have now indicated that there is no advantage . . . of . . .gradually increasing the feed concentration during the recovery phase after gastroenteritis.”
Unfortunately one of these references concluded differently2; another compared refeeding with no refeeding3; and a third dealt with the issue of refeeding with and without cows’ milk.4 Therefore, three of the six references are unsuitable for his purposes. In the remaining papers, all patients were started on oral feeds after a classic but currently unacceptable prolonged period (1 to 2.8 days) of starvation.5-7 One of them showed that, during the first 24 hours, vomiting was less frequent in the “regrading” group (0/14v 11/32; p = 0.02, Fisher exact test).5
None of these studies compared immediate with gradually increased feed concentration after a short period (4–6 hour) of rehydration as recommended by the European Society of Pediatric Gastroenterology and Nutrition.8
Dr Murphy comments:
The practice of increasing feed concentration stepwise (regrading) following an episode of acute gastroenteritis is in effect one of withholding nutrition. The burden of proof therefore lies with those who advocate the use of such regimens. I am grateful to Dr da Mota for pointing out the error in quoting the study by Placzek and Walker-Smith, which did indeed find some evidence in support of regrading. The remaining five studies were appropriate. Although not all were controlled trials of regrading, they did “indicate” that there was unlikely to be an advantage to this practice. Each examined the outcome with a feeding regimen that either restricted or regraded feeds in the early phase of recovery, and generally little advantage was seen. By implication, if not direct evidence, regrading does not seem to be a strategy likely to be of benefit. Although Rees and Brook reported less frequent vomiting in the first 24 hours in a regraded group, there was no difference in hospital length of stay. Evidence to support the use of regrading is therefore very limited.