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"cessful use of a chicken-based diet for the

: m e n t of severely malnourished children with
persistent diarrhea: A prospective, randomized study
iiiii!ii~

Samuel Nur/co, AID, dosdAlberto Garchz-Aranda, AID,Euyenia Fiahbein, RN, and
AIartha In& Pdrez-Ztiffiya, RD

Objective: To evaluate the efficacy of a chicken-based diet for the treatment of persistent diarrhea in severely malnourished children.

Stud}" design: Prospective, randomized, double-blind study that compared a chickenbased diet with elemental (Vivonex) and soy (Nursoy) diets. Hospitalized children with
third-degree malnutrition and persistent diarrhea, aged 3 to 36 months, were included.
Diets were isocaloric and given nasogastrically at 150 ml/kg per day in progressively
increasing concentrations.
Results: Fifty-six children were included (18 received Vivonex, 19 Nursoy, 19 chicken). They had a mean age of 6.4 _+4.4 months, a mean weight of 3604 _+1232 gm, and a
mean weight-for-age percentage of 51.4% _+7.2%. Sixty-four percent had associated
conditions on admission to the hospital. Forty-one children (73.2%) were successfully
treated (13 Vivonex, 13 Nursoy, 15 chicken). There were no differences in diarrheal
outcomes, and all groups had significant weight gain. Failure was independent of the
diet and was associated with the presence of infection on admission. There was a significantly higher nitrogen balance in the children from the chicken group (358.2 _+13
mg/kg per day) than in those receiving Vivonex (226.6 +_61) or Nursoy (291.4 _+111.6;
p < 0.05) groups.
C o n c l u s i o n s : The chicken-based diet was as effective as Vivonex or Nursoy. It is well
tolerated, inexpensive, and widely available and thus represents an effective and inexpensive alternative to the treatment of severely malnourished children with persistent
diarrhea. (J Pediatr 1997;131:405-12)

From the Departnwat of Pediatric GaaO'oenterologyand Nutrition Hospital l@mtil de Mdrico Federico Gdme;4Mexico CitN
d/fexico.
Supported in part b2- the Applied Diarrheal Disease Research Project at Harvard University, by means of a
cooperative agreement with the U.S. Agency for International Development, and in part by National Institutes
of Health grant T32-DK 07703.
Submitted for publication April 3, 1996; accepted Dec. 17, 1996.
Reprint requests: Samuel Nurko, MD, Pediatric Gastroenterology, Children's Hospital, 300 Longwood Ave.,
Boston, MA 02115.
~Dr. Nurko is now in the Combined Program in Pediatric Gastroenterology and Nutrifon, Children's Hospital,
Boston, Mass.
Copyright 9 1997 by Mosby-Year Book, Inc.
0022-3476/97/$5.00 + 0 9/21/79985

Persistent diarrhea confnues to be a major
health problem in developing countries 1"3
and is often associated with a deterioration
in nutritional state. 1'3'4The nutritional rehabilitation of children with PD and severe
malnutrition is difficult and usually requires
hospitalization 4 and specialized care. l's
Initially the introduction of parenteral nutrition improved the outcome of PD in these
children. 6'7 Recent studies have shown that
specialized enteral feeding during the diarrhea] episode results in improved nutritional outcomes. 1'4'8 Therefore the enteral administration of elemental and semielementat
diets, with supplementation with parenteral
nutrition when needed, has become the
standard therapy. 5-z'9 These specialized enteral feedings, however, are very expensive,
usually unpalatable, and not readily available in many areas of the world. 1,4,8

Recent work suggests that malnourished patients with PD may be capable of
tolerating more complex diets, 1'4'8 so efforts are being undertaken to find inexpensive, available, and culturally acceptable diets.l'8' 10,11 Because milk is not well
tolerated by children with PD when given
as a full diet, 1'4'12 alternatives have been
suggested. 1"4'8"10'1I Soy-based formulas
are still used extensively, but their efficacy continues to be controversial. 4'8
Chicken-based diets have been empirical-

405

After these components were blended together. randomized. 406 The study was performed at the Hospital Infantil de 1Vidxico Federico Gdmez in Mexico City. 1'4 we evaluated the efficacy of a chicken-based diet for the treatment of PD in severely malnourished children. METHODS Patients In this prospective. 3 ml vegetable cooking oil. All diets were prepared in the pedi- . Table I.gN solution) to achieve 4 mEq of sodium per kilogram of body weight per day and potassium chloride to achieve 3 mEq/kg/day were also added. Sodium chloride (0. Thirddegree malnutrition was defined by using the Gdmez criteria for weight for age (<60% of the National Center for Health Statistics 50th percenfle). starting at 150 ml/kg per day in a concentration that provides 47. To prepare the chicken-based diet.5 gm table sugar. PISA).5% weight/volume) s'9 (Table I). micronutrients.6 kcal/dl (22. boiled chicken breast. PISA). 4'13-1s Chicken has the advantage of being considered by mothers and health personnel in Mexico 16'17 and other areas of the world as a safe food for children with diarrhea or malnutrition. 4 mEq/kg per day. coconut. a small amount of highly purified safflower oil. Wyeth Laboratories) in the treatment of severely malnourished hospitalized children with PD. At the maximum concentration (Table I) the following ingredients per deciliter of diet were used: 8 gm boiled. glucose and glucose oligosaccharides. 5 Vivonex contains crystalline amino acids. table sugar.5% per day to a maximum concentration of 85. tuberculosis). Composition of the diets at the maximum concentration Study Design DIETS ly and successfully used for the treatment of malnourished infants with PD when elemental or soy diets have not been available.THE JOURNAL OF PEDIATRICS SEPTEMBER 1997 NURKO ETAL. chronic illness (e. sucrose. The soyformula used was Nursoy. 3 mEq/kg per day. and minerals. and vitamins.8 kcal/dl (12. The mainstay of therapy for PD and severe malnutrition at the Hospital Infantil de Mgxico has been the elemental diet Vivonex Standard.. Sodium chloride and potassium chloride were also added to the formula to ensure administration of sodium.7 ml of magnesium sulfate (10% solution. dibasic sodium phosphate). acquired immunodeficieney syndrome. congenital malformation.5% weight/volume) and advancing slowly by 2. minerals. double-blind study a local chicken-based diet was compared with both an elemental diet (Vivonex Standard. and vitamins.7 ml of dibasic sodium phosphate (PISA. the following minerals were added: 5 ml calcium gluconate (10% solution. Norwich Eaton) and a soy-based formula (Nursoy. 5 The chicken-based diet was designed with the use of tables of food composition 19'20 and consists of easily available and simple ingredients: cooking oil. Finally. minerals. The protocol was approved by the local ethical review committee and by the Harvard School of Public Health Committee on the Use of Human Subjects in Research. a severe condition requiring intensive care. Informed consent was obtained from all parents. and potassium. and 10. 2 Patients with the following characteristics were excluded: exclusively breast fed. which contains soy protein. safflower and soy oils. an abdominal condition that would preclude enteral feedings. we and others have shown that Vivonex is effective if it is given in progressively increasing concentrations. we calculated the total volume needed per day (150 ml/kg). Patients between 3 and 36 months of age hospitalized with third-degree malnutrition of the marasmatic type with PD were included. 4'1a'14 Because the optimal nutritional therapy for severely malnourished patients with PD is still controversial. or lack of parental consent. s'9 For use in children with PD. and 1. 2. electrolytes. is PD was defined as three or more loose stools for 14 days or longer. boiled water was added to achieve the total volume required. comminuted chicken breast.g.

Because of intrinsic differences in diet composition. The beginning and end of the stool collection time were marked by the fecal excretion of orally administered activated charcoal. The onset of nutritional recoverywas considered to be when the diarrhea ceased and there was consistent weight gain for at least 48 hours. Only the nutritionist who prepared the formula was aware of group assignment. if there was clinical deterioration that precluded further enteral therapy. Wheaton. 5 To confirm Successful separation of stool and urine in girls. was begun when the maximum concentration was achieved. as manifested by return of liquid stools. Cessation of diarrhea was defined as the passage of formed stool not followed by liquid stools for at least 24 hours. (2) It was reduced if Clinitest results showed 4% or if there was an increase of 75% or more in the stool output (>20 m]/kg). A 72-hour nitrogen balance test was performed at the end of the second week. Daily supplementation with 1 mg folie acid. Continuous enteral feedings with Vivonex were then added to the total parenteral nutrition and advanced every 24 hours as tolerated. the percentage of total calories provided as protein. If there was evidence of intolerance. All measurements were obtained by trained nutritionists. The posthydration weight. s The nitrogen balance was measured by the micro Kjeldahl method. CLINICAL PROCEDURES Nude weight was obtained on admission and daily thereafter. and before discharge. and their accuracy was validated before the beginning of the study. The study was designed to use Vivonex as the standard against which the other formulas were compared. All intake and output were recorded. 21 Patients were then fasted overnight. were placed on metabolic beds or cots for separation of stool from urine. D-xylose concentration. Once patients achieved full enteral feedings. the diet concentration was either maintained or decreased as follows: (1) It was kept unchanged if there was evidence of 2% or 3% positive reducing substances (before or after hydrolysis) or if there was an increase in stool output of more than 50% (>20 ml/kg). 1 ml multivitamin (PolyVi-Sol). they were started on a regimen of Vivonex. When full concentration of the diet was achieved. at the end of 2 weeks. Milk-tolerant patients continued their rehabilitation with lactose-contalning formula or whole milk. we performed a separate analysis for all the variables associated with the stool collection at the end of the study. with p H less than 5 and greater than 2% reducing substances in the stool.NURKO ET AL. or if the formula could not be advanced to full concentration. 10 ml/kg. Weights were obtained at the same time every morning with an electronic scale (ScalesTronLx. they continued to receive Vivonex for another 2 weeks and nutritional rehabilitation continued as outlined previously. The maximum concentration of the diets is shown in Table I. The next morning the assigned diet was started if the patient was well hydrated and there were no other contraindications to feeding. total parenteral nutrition alone was initiated and was then continued u n t l the patient was stabilized and gaining weight. All patients had baseline laboratory values obtained at admission. and concentrations were advanced every 48 hours. Patients. and advanced to fullstrength milk if tolerated. If patients had been receiving Nursoy or chicken. If the patients with treatment failure had originally been receiving Vivonex or were unable to continue with enteral feedings. stool and urine cultures. THE JOURNAL OF PEDIATRICS Volume 13 I. After the milk challenge. Successful treatment was declared if the formula could be advanced to the highest concentration and there was cessation of the diarrhea at the end of the study. a milk-flee diet was instituted. 22 Tests for p H and reducing and nonreducing substances in stool were performed daily. If patients showed evidence of lactose malabsorption. On admission to the hospital. full concentration was achieved by the ninth day (Table I). Recumbent length was obtained with a specially designed board on admission. The diet was started at the lowest concentration at a volume of 150 ml/kg per day. was considered the baseline weight. 407 . both male and female. Hydration was maintained during that time with intravenously administered fluids.) and were accurate to at least 10 gm. and stool tests for ova and parasites. After 7 days of the maximum diet concentration. starting 4 days after the maximum diet concentration had been achieved. and elemental iron. which was continued until discharge. When treatment was declared a failure. PROTOCOL Patients were randomly assigned to treatment by using a table of random numbers. nurses. and residents remained masked to the type of diet because aluminum foil was used to cover the formula bag and tubing. The investigators. Number 3 atric nutrition kitchen of the hospital under the supervision of a trained nutritionist. the code was broken. No differences between sexes were found (data not shown). Treatmentfai[are was declared if the patient had 5% or more dehydration during the administration of the diet. Blood culture specimens were obtained only if indicated. carbohydrate. complex-balanced diet. Ill. patients were hydrated according to World Health O r g a n i z a t i o n / U N I C E F guidelines with the use of a standard glucose-electrolyte solution. electrolyte concentrations. laboratory studies included complete blood cell count. If no intolerance occurred. or fat varied (Table I). if diarrhea persisted at the end of the study. depending on the age. all patients restarted a complete age-appropriate. 6 mg/kg. so all three diets were given nasogastrically at progressive isocalorie concentrations. it was maintained for an additional 7 days. obtained on the morning of the start of the feedings. so all data were pooled. The nasogastric tube was inserted by trained nursing staff. patients underwent a challenge with whole cow milk: we administered half-strength whole cow milk.

VaLues are expressed as mean _+SD. W h e n necessary.NURKO ET AL. or acidosis despite adequate hydration. one in the Nursoy group (the patient had primary renal insufficiency). hypoglycemia. Otitis media. hypotension. and pneumonia were treated with appropriate antibiotics. Vivonex was given to . and the Fisher Exact Test was used whenever there were cells with small sizes. version 5. Multivariate and repeated-measures analyses of variance were used to establish differences between the three groups. The statistical analysis was performed with the use of SPSS/PC software and Epi-Info software. Patient characteristics at time of admission INFECTION ON ADMISSION OR DURING HOSPITALIZATION Systemic infection was suspected and treated with broad-spectrum intravenously administered antibiotics if there was a general ill appearance with any of the following signs: temperature instability. one who died before initiation of feedings). Children with dysentery received trimethoprim-sulfamethoxazole. and a difference of 30% in the duration of diarrhea. Statistical analysis We calculated that a sample size of 20 children per group would be needed if we 408 assumed a power of 0. THE JOURNAL OF PEDIATRICS SEPTEMBER 1997 Table II.05. Four were later excluded: two in the Vivonex group (one with acquired immunodeficiency syndrome. 4 Children infected with Giardia larr~lia received metronidazole. transformation of the data was done to fulfill the assumption of normally distributed residuals.80.05. Chi-square tests were used for categorical variables. Significance was assumed when p was less than 0. Descriptive analyses were used to define the presenting characteristics. For the other 56 patients. urinary tract infections. an alpha of 0.01. RESULTS Admission Characteristics A total of 60 patients were initially enrolled in the study. and one in the chicken group (the patient had acute renal failure as a result of dehydration soon after admission). Survival analysis was used to compare the duration of the diarrhea.

2 gm/kg per day.THE JOURNAL OF PEDIATRICS NURKO ET AL.5 409 .0 • 9.8 days for Vivonex. 1 Nursoy. and 3.6 to 3.6 to 3. was 8.2%) with Vivonex. respectively (p < 0. 11 (57.4 • 0. and 14. There were no significant differences between the three groups. and 116.14% of the patients (2 patients receiving Vivonex. The intolerance was transient in 19 (56%) of 34 patients. 13 (68.05).3% had a gastrointestinal infection.67 days for Nursoy. 111. Number 3 18.5 • 99.3 days for chicken. The other was discharged on a soy. Sixty-four percent of the patients had associated conditions at the time of admission (Table II).02) and a tendency toward a higher number of children with nutritional recovery in the chicken group (NS). Laboratory Tests The serum albumin concentration decreased significantly in the Nursoy group (from 3.p < 0. One of the failures in the Nursoy group was shown to be a result of allergy to the formula.4%) with Nursoy. and 9 were eventually discharged home on a milk-containing diet regimen. 5.3 gm/kg. and 2 chicken (NS).6 • 45. 3.4%) chicken (NS). and the median duration of diarrhea.l • grrdcll. and biologic values. Intestinal pneumatosis developed in 7.5 • 99. and chicken. Table III shows the outcome characteristics of those patients successfully treated. Five patients (8. Total parenteral nutrition was required in 7 of the 10 patients.1. The Figure shows the results of the survival analysis done to compare the daily probability of continuing with diarrhea among the three groups. There was a significant difference in the amount of protein per kilogram per clay ingested after the full diet was tolerated: 2. respectively.4 • 0. and their mean stay was 50 • 30 days.2 • 8. All patients in each group had an apparent positive nitrogen balance and a similar percentage of absorption. 34 (60. and 1 chicken).7 hours with Vivonex.8%) of the patients receiving Vivonex.5 • 0.6 for the Vivonex.2%): 13 (72.7%) of the 56 patients had some evidence of formula intolerance: 14 (77.3. estimated by the analysis. and 97. Fifty percent had a nongastrointestinal infection. 98. Diarrhea The mean fecal output per kilogram of body weight and the number of bowel movements per kilogram per day in the first 24 hours were similar in all groups (Table II). and bacterial sepsis (K[ebsfe/[apneanwn/ae)early in the hospital course (1). The other 10 patients with treatment failure were successfully managed.3 • 9. 1 Nursoy.and milk-free diet regimen because of allergy.3 • 0.9 with Nursoy.4 gm/kg with Vivonex. and 15 (78. The mean time from initiation of the diet to failure was 85. Volume 13 I. and 4 chicken) had treatment failure. There were also no differences in the mean stool output per kilogram per day or in the day of cessation of diarrhea in comparison with the 41 patients who successfully completed the study (Table III). whereas it did not change significantly in the other groups: 3.5 _+ 0. Nursoy. Their initial clinical and laboratory characteristics are Shown :in Table II. Nutritional Outcome The mean number of total calories per kilogram of body weight per day ingested by each group after the full diet was tolerated was similar: 115. During the study. and 7.9 with chicken) (NS).9%) with chicken (not significant). There was a statistically significant higher nitrogen balance (p < 0.05).9%) died: two who had been receiving Vivonex.6 • 72 hours (60. percentage of retention./ Outcome A successful outcome was seen in 41 patients (73. There was a significant weight gain in all groups and no differences between groups.2 • 0. The other 15 (44%) (5 receiving Vivonex. Nursoy to 19. Nursoy. central line-associated sepsis (2). Table I I L Main outcome characteristics for the 41 patients who successfully completed the stud. There were no differences between groups. and chicken to 19. 6 Nursoy. The patients died of intestinal pneumatosis (2).9%) Nursoy. and chicken groups. and 9 (47.

l'a'la'ya and it has been suggested that approximately 49% (range.6 mg/dl.9 ml/kg) and third (16.3 + 0.1 mg/dl) or chicken (23.07%) of 13 in the Nursoy group.66 _+8.THE JOURNALOF PEDIATRICS NURKO ET AL. were identified as important factors associated with treatment failure. We confirmed that children with superimposed infections are at a higher risk of treatment failure.61 vs 27.5 vs 54.7 +_ 16. Risk Factors There were significant differences (o < 0. There can be up to a 17-fold increase in the mortality rate. which emphasizes the need to look for and control superimposed infections at the time of admission and nutritional rehabilitation.004) than those who tolerated milk.07).91 gm.80 vs 6. particularly infection with Cryptospor~ium (RR.2 vs 133.65) and the presence of associated infections (RR.9%) compares favorably with rates previously reported in the literature.0 VIVONEX "'.6 _+ 13.9 mmol/L). and the incidence of associated infections (56.0 _+40.28 • 10. 15'16 However.9 _+19. 1'11 This study included a difficult population that is frequently excluded from other clinical trials.9).9 _+0.67) or pneumonia (RR. and are inexpensive. Probabilityof continuingdiarrhea since admission:a comparisonbetween the diets.25. SEPTEMBER 1 9 9 7 A sodium concentration less than 130 mmol/L (relative risk.1 to 14.1% vs 86. 23% to 62%) of diarrhea-associated deaths result from P D and malnutrition. There were no electrolyte abnormalities noted in children of either group. \ \ I - O. 1'8'13 Severely malnourished children with P D usually have a high mortality rate and high treatment failure rates. We have shown in this study that the use of a locally available chicken-based diet is at least as effective as elemental and soy-based diets in the hospital treatment of severely malnourished children with PD. 3. a tendency to be younger (3.1 _+11. and a lower D-xylose concentration at baseline (17. p < 0. sodium concentration (138.8 vs 47.6 \ DISCUSSION \\ "0 ~ 0.61.0 + 0. gngdl with Vivonex. 1. There was no difference in the D-xylose level at the end of the study when both groups were compared (20.28 _+ 1258.24 vs 3659. p < 410 0. There were also differences in stool output on the second (20. and there were . 3. 1. 1.2. and 3.7 mg/dl) than those receiving Nursoy (23.41 to 6.1 months.7 to 3. 13'25 As in previous studies.58 to 6. and in 4 (21.no other significant differences in laborato W values between formulas (data not shown). Those with milk intolerance had a lower admission weight (2900.05) between patients with treatment success and those with treatment failure with regard to the following admission characteristics: albumin concentration (3.4 +_33. ~ ~ I 0. 95% CL.64 + 4. The main components of the chicken-based diet are easily available.42). are culturally acceptable.15.0 0 "" I 12 14 16 Days since admission F~ure.2 mg/dl).7%).3 ml/kg) days.5 mg/dl) (0 < 0. the diets were . la'93 We also did not find any differences in outcome when comparing the treatment failure rates of those children ha~ng the most extreme levels of malnutrition (weight-for-age percentage.2 _+0. CHICKEN \\ - o a \ 0.00 ~_2.07. in 3 (23.004). <40%) with the rates of less malnourished children.89 +_13. p < 0. 1'a'13 The mortality rate found in this study (8. At the end of the study.8 _+ 10. 1. 1.91 +. use of this diet in children with P D has been limited. 3. 95% confidence limits.4 gm/dl).2 I I I I I 2 4 6 B 10 0.4 \ m oe-4 o.B I NUNSOY 9 \ .1%) of 15 in the chicken group. 16'17 Chicken-based diets were also previously used as an alternative for the treatment and rehabilitation of children with malnutrition 1'10'13'14 and acute diarrhea. 4. No other significant differences were found.4 _+ 6.6 vs 2.3 gm/dl with chicken. 95% CL.05) Milk Tolerance Test Intolerance was present in 7 patients (17%): in none of the 13 patients in the Vivonex group. 95% CL. children receiving Vivonex had a significantly higher DxNlose concentration (34.83 _+ 289.53 to 6.09 vs 23.5 _+ 7.

Previous studies confirm that children receiving 6. Hendricks KM. In those children. Nutritional management of persistent diarrhea in child- 411 . which suggests that their initial mueosal damage was greater. Vivonex has a much higher carbohydrate concentration (Table I). &26"27providing only about 8% of total calories. 5'6'9'2a'24 Sixty percent of children acquired some signs of intolerance while the diet regimens were being advanced. were younger. the risk of limiting the amount of nutrients in comparison with ad lib oral intake. Alejandra Consnelo. Chicken has a low osmolarity. later. 6. These signs were most likely related to carbohydrate malabsorption. The technical aspects of the placement and management of the feedings requires specialized personnel and equipment. mainly of oligosaecharides. 25 Caution should be exercised in the treatment of those patients in whom increasing stool outputs appear in the first and second day. achieve positive nitrogen balance. 5 the chicken diet requires the addition of minerals. Those children who were milk intolerant at the end of the study had an initial lower admission weight. the majority of the calories are provided by carbohydrate and the protein content is lower. 12 the question that remains unanswered is when milk can safely be reintroduced into the diet of these children. inexpensive. Clear benefits of the chicken-based diet include good tolerance. I It is possible that the chicken-based diet may be another alternative once the usual therapies have failed. &25 Transient intolerance was also seen in children receiving chicken or soy. and Aloniea Covarrubias.formanee o/this study. which suggests that malnourished infants with PD frequently have transient intolerance to other sugars. a factor that does not represent a major obstacle for severely malnourished children with PD. These mineral additions make preparation suitable only in health care facilities. a slower advancement of the dietary regimen may be necessary. The higher nitrogen balance in those receiving chicken indicates that chicken protein has a higher biologic value than soy. 24"27and it has been shown recently that.70/0. and effective nutrients.70/0 of energy as protein achieved a slow compensatory growth. and weight gain in children with PD. 29 It is therefore possible that protein intake with Nursoy was inadequate to allow more rapid accretion of nitrogen at higher energy intakes. severely malnourished children with P D can be successfully managed with a chicken-based diet. with the potential for increasing the severity of their illness.16 Like Vivonex. These data suggest that the protein status and lean body mass of malnourished patients fed soy formulas may be deteriorating slowly despite apparently adequate nitrogen retention. Although the use of milk as the sole nutrient for children with P D has been shown to be deleterious. 25 O f the three diets tested. Bhutta ZA.0% protein calories were compared. 5'9 This difference in protein content may partially explain why children on the chicken-based diet regimen had a significantly higher nitrogen balance than those receiving Vivonex. All diets were administered continuously via nasogastric infusion. nutrient absorption. Some authors have found that nearly 50% of hospital-referred patients with PD do not recover from diarrhea a week after the introduction of a soy formula. which probably accounts for the higher incidence of transient intolerance seen in those patients. a method of feeding that has been shown to have a beneficial effect in control of diarrhea. 4 In the community the treatment of children with PD needs to include continued feeding with locally available. who usually require hospitalization. We express special thanks to the nurses~ residents. Number 3 given at a fixed volume and the caloric density was advanced slowly. Rosaura P~'ez. Dr. availability. We are indebted to all the personnel of the Applied Dialv'heal Disease Research Projectfor rhea" support during the poformance of the study. REFERENCES 1. and cultural acceptance. 5'9 It is then possible that the hydrolyzed amino acids are better absorbed. in p~rtieula6 we thank Gina Toussaint. and show weight gain. 12 and a good correlation between fecal carbohydrates and total fecal output has been shown. Sarah Arvizu. There was no advantage to the use of an elemental or a soy-based diet. s More importantly the child has no control over the amount of food that is being ingested. low cost. because they may be at risk of failure. there were no differences in growth when formulas with 5. Dr. Liliana Worona. and had a lower D-xylose concentration. although we cannot exclude the possibility of intolerance to milk protein. and 8. 29 Other problems have also been associated with the use of soy formulas in these patients. nitrogen balance. 11'14'24We also found a significant decrease in the serum albumin concentration in patients who received Nursoy despite a positive nitrogen balance. In summary. a better amino acid score. and laboratmy personnel of the nutrition ~vardat the Hospital lnfantil de ~Ilxico for their help in the pe. The protein and caloric intakes were similar in children receiving chicken or soy feedings. We found that 83% of patients who successfully finished the study were able to tolerate a full milk load at least after 2 weeks of nutritional rehabilitation. <8'11'1a Two main limitations of the nasogastric route need to be mentioned. and a higher degree of digestibility and bioavailability. 28 Furthermore other studies have documented the adequacy of Vivonex for growth and for treatment of PD. THE JOURNAL OF PEDIATRICS Volume 13 I. 6 Most likely the intolerance was related to lactose malabsorption.5%. We also thank DI: Laurie Fishman and DI: Alan Leiehtnerfor their o'itical reviewof the manuscript andfor lheir helpful su~gestions. Therefore the chicken-based diet represents a good alternative for the treatment of hospitalized children with severe malnutrition and PD. A potential shortcoming of this study is the difference in the macronutrient composition of the diets (Table I). These children were able to tolerate a complex diet. In Vivonex.NURKO ET AL. which increases the risk of overzealous refeeding or intolerance 27 and. in recovering malnourished infants. 8 It has also been suggested that soy-containing diets may produce transient sensitivity and subtle mucosal abnormalities in the intestinal mucosa of children with diarrhea.

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