Table 2

Gradual introduction of feeding versus normal feeding in children with gastroenteritis

Citation, countryStudy groupStudy type (level of evidence)OutcomeKey resultsStudy weaknesses
Dugdale et al (1982), Australia59 inpatients older than 6 months (average 22 months) with acute gastroenteritis were given clear fluids and then allocated either to half strength milk for 24 h and then full strength milk and food or immediate normal milk and foodRCTHospital stay (days)Immediate group 4.7; graduated group 5.4, p>0.5Small numbers
? length of clear fluids
WeightDuring first 24 h of refeeding immediate group lost 0.02 (0.25) kg and the graduated group lost 0.14 (0.21), p> 0.05
Haque et al (1983), Saudi Arabia150 inpatients, all stages of dehydration between 1 month and 2 years of age randomised to three different feeding regimens:
(1) clear fluids (6–24h) then gradual 1/4 strength milk reintroduction
(2) clear fluids (6–24h) then full strength milk
(3) continuing full strength milk
RCTIncrease in weight at discharge(1) 0.4 (0.1)
(2) 0.8 (0.2)
(3) 1.2 (0.7)
Not stat significant
Large proportion malnourished
Diarrhoea length (days)(1) 3.0 (1.4)
(2) 3.0 (1.3)
(3) 3.8 (1.2)
Not stat significant
Vomiting length (days)(1) 1.0 (1.1)
(2) 1.8 ( 1.3)
(3) 1.6 (1.2)
Not stat significant
Length in hospital (days)(1) 3.1 (1.4)
(2) 3.6 (1.2)
(3) 3.8 (1.2)
Not stat significant
Placzek and Walker-Smith (1984), UK48 inpatients less than 18 months of age with gastro enteritis, >5% dehydration were after 24 h of GEM allocated to immediately full strength milk or gradual reintroductionRCTComplicated clinical course = recurrence of ether severe vomiting or watery diarrhoea with 2% or more reducing substances70% (16 ) of full strength group uncomplicated; 96% (24) of gradual group uncomplicatedSmall numbers
Alternate allocation = randomisation 20% not thriving
Rajah et al (1988), South Africa72 male black inpatients between 6 weeks and 2 years with prolonged dehydrating gastroenteritis (needing more than 72 h IV fluids) assigned to 4 different feeds; partially modified cows’ milk formula, a lactose free casein containing formula, a lactose free soy protein formula, a lactose free whey- hydrolysate formulaRCTStool weights in 3 days following formula changeSignificant drop in stool weight
AL110 p<0.01
Alfare p<0.05
Alsoy p<0.05
No change with Lactogen
Only male black children
Bhan et al (1988), India60 outpatients <5% dehydration between 3 and 24 months were fed either cereal based formula(A) or cows’ milk (B)RCTDuration of diarrhoea post intervention (days)Gr A 11.0 (10.0) > gr B 7.6 (10.8) NS p>0.05Small numbers
Difficulty comparing two preparations
Selection criteria (close to hospital)
? compliance to treatment at home
Mean weight gain (g/kg/24h)GrA 2.0 (4.2) < grB 5.8(7.8) significant p<0.05
Conway and Ireson (1989), Leeds200 well hydrated inpatients, formula fed, ages 6 weeks to 12 months, acute gastroenteritis
Gr1: 24h dextrolyte and gradual reintroduction of SMA gold
Gr2: special full strength HN25 untill stools normal, gradual substitution by SMA gold
Gr3: continued full strength SMA gold cap
Gr4: continued formula S
RCTTime to dischargeGr1 6.9 (3.2); Gr2 6.9 (1.9); Gr3 6.9 (2.2); Gr4 7.1 (3.6); NS117 had ORS before treatment, so is this immediate or delayed full strength feeding
Duration of diarrhoea (h)Gr1 64 (53.7); Gr2 47 (53.7); Gr3 68 (43.6); Gr4 51 (41.5) NS
Severity of diarrhoeaGr2 0.8 (1.7) < Gr3 1.8 (1.5), p=0.05; group1 1.6 (1.7), gr4 1.4 (1.9) intermediate positions
Weight gainDay 2 Gr2,3,4 > Gr1 p=0.01; remains significant on day 5 p=0.05
Ooi et al (1989), Singapore70 inpatients mild/ moderate dehydration, age 1 week to 50 months, either graduated milk feeds or full strength soy feedCTDuration of hospitalisation (days)Soy 2.8; milk group 2.5, not statistically differentSmall numbers
?effect on symptoms
?received clear fluids
Armitstead et al (1989), UK68 children, admitted or gastroenterology casualty, bottle fed, mild acute gastroenteritis dioralyte 24h plus:
(1) gradual milk reintroduction
(2) full strength milk
(3) rapid regrade to whey hydrolysate formula
RCTHospital stay (days)Gr1 4 (0.2); gr2 3.6 (0.6); gr3 3.5 (0.4) NS? sufficient number
Bottlefed only (sponsored by Nestlé)
Most mild dehydration
Reducing substancesNone in all three groups
Weight gainDay 1–4: gr1 −0.35 (0.5); gr2 +0.65 (0.6); gr3 +0.15(0.2)
Stool frequencyDay 1–4: grp1 4–2.2; grp2 3.7–1.6; grp3 4.3–2.5
Haffejee (1990), South Africa309 hospital patients age 3days to 28 months, acute diarrhoea, all stages of dehydration
Formula fed children were randomised to their formula or soy based formula; breast fed children continued this and were divided in breast feeding only and breast feeding plus supplement
RCTRecovery time (hrs) when hydration, weight and nature of stools were normalFormula 70.5 (60.3); breast 60.9 (44.8); breast plus supplement 64.8 (43.3); soya 61.4 (43.5) p>0.05 NS?blinded
No patient chracteristics (race, % dehydration)
Lifschitz et al (1991), USA8 children <5 months, mild to moderate dehydration, addition of 13C labelled rice at 6–22h and repeat at 14–17d later. Breath test measurementCT13C in breath when ill and after recoveryApparent absorption not different, 13 C diarrhoea 86.6%- recovery 94%. NSSmall numbers
Boys only
Mild/moderate dehydration only
Hoghton et al (1996), UK59 outpatient children <3 years old, <7 d gastroenteritis, <5% dehydrated; either immediate modified feeding + ORT (2) or ORT only for 24–48h after which modified food (no milk/wheat) (1)PRCT, single blindMedian duration of diarrhoeaGrp1 66.5 h; grp2 56h p=0.4 not significantSmall numbers
Mild dehydration only
Parents assessed and charted symptoms (bias)
Median % weight changeGrp 1 0.005- grp 2 0.96 p=0.24 NS
Complication rateSimilar, NS
Sandhu et al (1997), Europe230 weaned European children under the age of 3 admitted to hospital; rehydrated with ORS for 4 hours, then Group A: immediate normal diet, Group B 20h of ORS then normal diet, breast feeding continued throughoutRCTWeight gainAfter rehydration weight gain grA 95g, grB 2g p=0.01; during hospitalisation grA> 200g, grB < 100g p=0.001; weight gain similar by day 5 and 14No severely dehydrated children
ComplicationsNo significant diffences re complications