Refeeding with Free Lactose Milk ( A1 - 110 ... - Paediatrica Indonesiana

Paediatrica Indonesiana 15 : 191 — 197. July — August 1975.

191

From the Department of Child Health, Medical School, University of Indonesia, Jakarta.

Refeeding with Free Lactose Milk ( A1 - 110 Nestle ) in Children Suffering from Gastroenteritis and Dehydration

by

SUHARJONO, SUNOTO, ASWITHA BOEDIARSO, HENTYANTO HENDARDJI and SOEG1HARTO.

Abstract Forty one infants suffering from diarrhoea hospitalized in the Department of Child Health, Medical School, University of lndonesia/Dr. Tjipto Man gunhusumo General Hospital, Jakarta, from August 15, 1973 to January 15, 1974 were refed with ’’free lactose milk”. The result is as follows : 1. From the point of view of increase of body w eig h t: 27 (65.8 2 ( 4.9 12 (29.3 2

% ) out % ) out % ) out

of41cases of41cases of41cases

were were were

From the point of view of stopping the diarrhoea : 25 (60.9 % ) out of 41 cases were excellent. 10 (24.5 % ) out of 41 was good. 6 (14.6 % ) out of 41 cases were poor. Reotsived 2nd M ay 1975.

excellent. good. poor.

192

SUHARJONO ET AL

water 2.9 gm calories 480 or 670 cal/L . Starting the regim entation and adaptation w e used d ilu tion of 1 /3 this formula which w as increased daily until ilt reached th e proper dilu tion adapted to the requirem ent of the child. A ntibiotic treatm ent and refeeding A fter 3 consecutive days th e proper w ith normal milk formula consisting dilution of Al-110, S.G.M. (a local of high content of lactose often glilve milk formula product) w as substitu unsatisfactory results. ted 2 tim es daily, Al-110 remained 4 In treating Protein Calorie Malnu tim es a day; the follow ing day, fu r trition and/or gastroenteritis in chil ther on S.G.M. 4 tim es and Al-110 2 dren, a lactose free or low lactose tim es and usually on th e third diay d iet m ight be more reasonable (Su- mainly S.G.M. form ula was given. harjono et al., 1971). The purpose The composition of SGM in 100 of this study is to know the effect grams of powder is as follows: protein 20 gm o f free lactose milk formula on refa t 11 gm feeding in children suffering from glucose 28 gm gastroenteritis. other carbohydrates 22 gm salt 5 gm water 3 gm j Materials and methods calories 428 or 514 cal/L . Forty one children suffering from The antibiotic used routinely was gastroenteritis and dehydration, hos Neomycin© 50 mg /k g body weight pitalized in the Department of Child Health Dr. Ciipto Mjangunkusumo Ge for 5 consecutive days if leucocytes neral Hospital, Jakarta, belonged to 2 + (10 — 20 leucocytes per high power field) were found on micros th is study. copic examination of the stools. On refeediing after termination of Follow up study concerning frequ the intravenous fluid therapy, Al-110 ency of stools and increase of body (NESTLE) milk formula was orally weight was carried out for a period applied which was free of lactose. of 2 to 3 weeks of hospitalization. The main composition of this formula Criteria of the results used are as in 100 grams of powder is as follows: follows: 22 gm protein Increase of body w eight is consi 21 gm fat dered excellent if th e ratio between 50.8 gm glucose montfMy increase of., body weight on 3.3 gm salt the Al-110 and the-normal standard Small bowell biopsy from children with gastroenteritis often demon strates histologically the presence of villous atrophy (Walker Smith, 1969, 1972) which may lead to secondary sugar intolerance (Dahlqvist et al., 1970; Sunoto et al., 1973).

f I

REFEEDING WITH FREE LACTOSE MILK

monthly increase according to age is more than 1. The increase is consi dered good if the ratio is approxi m ately 1, and poor if the ratio is less than 1. In evaluating the frequency o f the stools the result was regarded as excellent if the stool become al ready pasty on the second to third day o f th e formula and diarrhoea did not recur on the introduction of SGM. The result was good if stool become already pasty on the third to fifth day and did not recur or only slightly loose stools appeared on the intro duction of th e SGM. If diarrhoea was still present after fifth day the result was considered poor. Result The result of the trials base on criteria mentioned before can be seen in Table 1. From the results it is re vealed that 'the stopping of diarrhoea w as: excellent 25 (60.9% ), good 10 (24.5% ) and poor 6 (14.6% ) out of 41 (100% ) cases. The increasing of body weight w as: excellent 27 (65.8% ), good 2 (4.9% ) and poor 12 (29.3% ) out of 41 (100%) cases. Discussion Disaccharidases are found within the brushborder lining the luminal surface of the intestinal epithelium (M iller and Crane, 1961) and there fore are able to be affected in any disorder in which the intestinal mucose sis damaged. Damage of the in

193

testinal mucosa, could result in secon dary disaccharide intolerance (Dahlqvist et, al., 1970; Sunoto et a l., 1973); however th is abnormality could be reversible due to the reversibility of the damage of the mucosa in children suffering from gastroenteritis (Wal ker Smith, 1972, 1973). Norm ally lac tose is present in lower concentration as compared with other brushborder disaccharidases (D ahlqvist et al., 1964) and is also th e last to recover completely following dam age (Plotkin and Isselbacher, 1964). Consequently, lactase deficiency is the m ost im portant type of secondary dilsaccharidase deficiency and there fore free iadtose or low lactose milk formula should be preferably intro duced as primary refeeding ¡ini diarr hoea! children. From the present study good to excellent result in refeeding -diarrhoea! children w ith free lactose milk formula are obviously obtained. Only 12 out bf 41 showed poor result ,in increasing body weight, 3 .suffered from PCM, 1 from Down’s syndrome and congenital heart dise ase and 1 from tuberculous meningi tis. These accompanying disease m ight be play a role too in the cause of th e poor results. Twenty seven other patients with excellent results showed increase of body w eight of 300 to 750 gm a week. Comparing with the result of previ ous trial on refeeding with low lactose milk (LLM) produced by a local fa c tory, the difference w as statistically

194

TABLE 1 : E ffeot of free lactose m ilk (Al-110 NestleJ hydration.

No.

1.

Patient

D

Duration of hospita lization (days)

5%

4300

10 1 7 8

2. 3. 4.

A M M

11 10 91/0

4600 6300 7050

5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

L H K A D M H J M N

4 9 5 4 8 t> 4 7 8 8

4100 6900 5300 3300 4800 4450 4750 6150 4700 6350

15. 16.

F M

1 y2 9

3100 6000

D = Diarrhoea (Stopping) Gr = Growth

Increase of B.W. during hospitali zation (gm )

Period after which diarrhoea stops (days) 2

550 50

2 1 1

8 7 8 8 8 7 8 8 13 9

350 450 500 380 200 -- . 350 — 650 300

1 1 1 1 5 6 1 4 3 2

4 8

— 700

4 2

P = Poor G = Good E = Excellent

—

R e s u 1t s Accompanying disease

Tubercolous meningitis PCM, Br. Pnia Br. Pnia —

Br. Pnia Convulsions —

— — PCM PCM, Br. Pnia PCM Convulsion, — Br. Pnia Encephalitis —

—

E

D

G

—

D,Gr — D,Gr — — D D,Gr D,Gr D,Gr D,Gr — — D,Gr — D,Gr

— — —

— Gr — —

D —

D,Gr — — ---D,Gr —

P

Gr — —

Gr —

— — — D D,Gr — Gr

—

— D,Gr —

SUHARJONO ET AL

A ge (mo)

Body weight (B.W.) on admission (gm)

on refeeding children suffering from g astro-enteritis atnd de

TABLE 1 (continued).

No.

Patient

H S H E

21. 22. 23. 24. 25.

L N M E S

26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

A S T M M H D D A S

5% 9 7 3 1 2 6 24 5 4 2% 5 1 7 6% 7% 11 18 2%


5800 8200 7100 4200

12 7 7 7

2100 2700 4750 6750 3550

12 14 8 7 5

4000 3600 4500 2700 6200 5400 6800 7500 3500 2400



7

8 8 8 7 7 7 7 7 10

500

_

400 400

_

350 200

—

300 350 400 350 1050 350 450 500 850

Period after which diarrhoea stops (days) 6 3 1 1 1 9 1 7 2 4 1 1 1 2

«O _> 1 1 1 4

R e su lts Accompanying disease

_ --. — Sepsis Convulsions Sepsis

_

PCM PCM Down’s syndrome, VSD

— Br. Pnia

— ■ ---

OMA Pharyngitis Pharyngitis Pharyngitis PCM, OMA

E

G

_ — — — — D,Gr D,Gr — — _ D,Gr —

D,Gr D

— — Gr D,Gr D,Gr D,Gr D,Gr Gr D,Gr D,Gr D,Gr —

P D,Gr

—

Gr

:-— --D,Gr

—

D,Gr Gr

_

—

D D

Gr

— — __ D

— — —

D

— — — — — — --— — Gr

R E F E E D IN G W IT H F R E E LACTOSE M ILK

17. 18. 19. 20.

Age (mo)

Body w eight (B.W.) on admission (gm )

P = Poor G = Good E = Excellent

195

TABLE 1 (ccmitinued).

No.

Patient

A ge (mo)

Body weight (B.W.) on admission (gm )



Period after which diarrhoea stops (days)

L F

2 8

3100 6800

5 7

_ 300

4 3

38.

H

8

8500

8

1350

3

39. 40. 41.

E Y T

7 4 2%

6600 5500 4360

6 7 7

50 300 420

1 3 3


E = Excellent G = Good P = Poor

E

G l P

OMA OMA, Candi diasis Convulsions OMA OMA Br. Pnia OMA

_ Gr

D D

Gr —

Gr

D

—

D Gr Gr

— D D

Gr — —

SUHARJONO ET AL

36. 37.

R e s u 1t s Accomroanvinsr disease

REFEEDING WITH FREE LACTOSE MILK

not significant. Chi LLM, 7 (77%). out of 9 patients showed good to excellent results din stopping the diarrhoea but only 4 (44%) showed excellent results

197

in (increasing body weight, as judged by the same criteria (Sutedjo e t a t, 1974).

REFERENCES 1. DAHLQVIST, A.: Method for assay of intestinal disaccharidases. Analyst. Biochem. 7 : 18 (1964). 2. DAHLQVIST, A., LIMBERG, G, MOEUWISSE, G. and ACKERMAN, M.: Intestinal Dipeptidases and D isac charidases in children with Malabsor ption. A cta Paediatr. Scand. 59 : 621 (1970). 3. MILLER, D. and CRANE, R.K.: The D igestive Function of tne Epithelium disaccharide hydrolysis in the isolated border portion of intestinal epithelial cells. Biochem. biophys. A cta 52 : 293 (1961). 4. PLOTKIN, G.R. and ISSELBACHER, K .J.: Secondary Disaccharidase deficiency in adult celiac disease (non tropical sprue) and other m alab sorption states. N. Engl. J. Med. 271 : 1033 (1964). 5. SUHARJONO, SUNOTO, ASWITHA DAMAYANTI, SADIKIN DARMAW AN and COTTON, D.G.: Small In

testinal Biopsy in Protein Calorie Mal nutrition and Coeliac Children. P ae diatr. Indones. 11 : 7 (1971) Special Issue. 6. SUNOTO, SUHARJONO and SU T E DJO : Two years study of sugar intolerance in Indonesian Children. Pediatr. Indones. 13 : 241 (1^73). 7. SUTEDJO, SUHARJONO, ASW ITHA BOEDIARSO, SUNOTO and DADI, E.M.: E ffect of Low Lactose Milk (LLM-Sari Husada) on R efeeding of Diarrhoeal infants. Presented a t the F irst Asian Pediatric Congress, Mani la, 30th April — 4th May, 1974. 8. WALKER SMITH, J.A.: Small bowel morphology in Childhood. Med. J. Aust. 1 : 382 (1969). 9. WALKER SMITH, J.A., PATERSON. H. and KEATING, S. : Evaluation of a N ew Feeding Formula for Sugar Malabsorption. Med. J. Aust. 2 : 107 (1973). 10. WALKER SMITH, J.A.: Gastroente ritis. Med. J. Aust. 1 : 329 (1972).