Home' Australian Pharmacist : October 2011 Contents Vol.30–October#10,2011
Early versus delayed re-feeding for children
with acute diarrhoea
By Dr Hanan Khalil
The purpose of this evidence summary
is to present the best available
evidence for early versus delayed
re-feeding for children with acute
diarrhoea based on a systematic
review by the Cochrane collaboration.1
For the full review see: http://dx.doi.
Acute diarrhoea is one of the major
causes of morbidity and preventable
deaths in children, especially in
The most common causes of diarrhoea
in children are due to infectious agents
such as viruses, bacteria and parasites.
Acute diarrhoea is usually associated
with nausea, vomiting and abdominal
cramping. Acute watery diarrhoea is
rapidly dehydrating and can be life-
threatening unless fluid therapy is
started quickly.3 On the other hand,
feeding is usually delayed during and
after the diarrhoeic episode for fear
of exacerbating the symptoms and
worsening the course of the illness.
To date, early oral rehydration has been
studied extensively and has always been
recommended for the management
of dehydration in children with acute
diarrhoea at its earliest onset. The timing
and type of re-feeding, however, has not
been fully examined and is the subject
of this review.1
Characteristics of the
The participants studied for the
systematic review were children (up to
10 years of age) with acute diarrhoea.
Acute diarrhoea was defined as an
increased frequency of defecation
(three or four times in 24 hours), with
a duration of 14 days or less at the
time of presentation.
The interventions considered in this
review compared early re-feeding
versus late re-feeding. Early re-feeding
is defined as introduction of food
within 12 hours from the start of
rehydration. Continuous breastfeeding
during rehydration was included in
this group. The late re-feeding group
was defined as introduction of food
more than 12 hours after the start
of rehydration. Several outcome
measures were considered in this
review. These were divided into
primary and secondary outcomes.
Primary outcomes included duration of
diarrhoea (hours) from admission until
cessation of diarrhoea. Secondary
outcomes included total stool output
(mL/kg) during the first 24 hours and
48 hours after start of rehydration,
percentage weight gain 24 hours after
start of rehydration and at resolution
of diarrhoea, unscheduled IV fluid
therapy and cases of vomiting.
Twelve studies were included in
the review with a total of 1,283
participants. 757 were in the early
feeding group and 526 children were
in the late re-feeding group. The 12
studies were conducted in 16 different
countries. Ten trials were conducted in
a hospital setting, while two studies
enrolled patients from outpatient
Quality of the research
All 12 studies included were
randomised controlled trials. Nine of
them had adequate allocation method
and the other three did not describe
the allocation method. Only one
study reported single blinding. The
participants included in the other 11
trials were not blinded and it is unclear
if the caregivers or outcome assessors
• A shorter duration of diarrhoea was
observed with early re-feeding in
two trials and with late re-feeding
in one trial, while for four trials the
outcome was similar in both groups.
• A significant heterogeneity was
observed between the studies
comparing the total stool output
during the first 24 and 48 hours after
the start of dehydration.
• There was no difference observed
in weight gain at the 24th hour after
start of rehydration and at resolution
of illness between both groups.
• There were no significant differences
in both groups in the number of
participants who needed IV fluids.
There was no evidence to suggest
that early re-feeding increases the risk
of unscheduled IV fluid use, episodes
of vomiting and development of
persistent diarrhoea. No conclusion
could be made regarding the duration
Implications for research
Further studies are needed to
investigate whether the timing of
re-feeding has any effect on the
duration of diarrhoea, the total stool
output and weight gain in childhood
1. Greorio GV, Dans LF, Silvestre MA. Early versus delayed
refeeding for children with acute diarrhoea. Cochrane
Database of Systematic Reviews 2011, Issue 7. Art. No.:
2. Kosek M, Bern C, Guerrant RL. The global burden of
diarrhoeal disease, as estimated from studies published
between 1992 and 2000. Bull World Health Organ. 2003;
3. Santosham M, Keenan EM, Tulloch J, et al. Oral
rehydration therapy for diarrhoea: an example of reverse
transfer of technology. Paediatrics. 1997; 100:e10.
4. Management of severe malnutrition: a manual for
physicians and other senior health workers [online].
Geneva: WHO; 1999. At: www.who.int/nutrition/
Dr Hanan Khalil is the Director of the
Centre for Chronic Disease Management,
a collaborating centre of the Joanna Briggs
Institute, Faculty of Medicine, Nursing and
Health Sciences, Monash University, and
a reviewer for the consumer group of the
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