IX NATIONAL CONFERENCE OF PEDIATRIC INFECTIOUS DISEASES, CHENNAI, OCT 2006

Dr. Panna Choudhury
Consultant Pediatrician, Maulana Azad Medical College and associated Lok Nayak Hospital,
New Delhi

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Diet in infectious diseases plays an important role primarily due to metabolic changes in the body as a consequence of fever (>37.4oC). Metabolic changes however vary in proportion to the elevation of body temperature above normal and the duration of fever. Following changes are needed to be taken into account.

There is a 13% increase with every 1oC rise in body temperature. This change is more significant in children suffering from acute fever.

• Glycogen and adipose tissue stores decrease significantly because of increased energy expenditure.


• The rate of protein catabolism increases depending upon the severity of infection and the duration of fever. There are increased losses in long continuous fevers than in short duration fevers. Protein breakdown is especially marked in fevers such as typhoid, malaria, poliomyelitis and tuberculosis. This leads to increased nitrogen wastes and places an additional burden on the kidneys.


• There is loss of body fluid in the form of excessive sweat and urine formation. The sweating occurs in response to high fever while the volume of urine is increased to eliminate nitrogen wastes.


• There is increased loss of minerals like sodium, potassium, chloride etc., through sweat, urine and vomiting leading to electrolyte imbalances.


• The absorption of nutrients like protein, minerals and vitamins decreases

The above changes are accompanied by a loss of appetite resulting in low intake of food which leads to loss of weight. If fever is prolonged, the patient may become severely emaciated.

During high fever, there is an aversion towards foods in the form of anorexia, nausea and vomiting. The diet should be planned with the following objectives: (i) to maintain adequate nutrition; (ii) to restore positive nitrogen balance; (iii) to provide relief from symptoms; (iv) to correct and maintain water and electrolyte balance; and (v) to avoid irritation of intestinal tract.

To achieve the above objectives, it is important to know the recommended dietary allowances (Table 1) which are as follows:

Age	Weight (Kg)	Net energy Kcal/day	Protein g/d	Fat g/d	Calcium mg/d	Iron mg/d
0-6 mo 6-12 mo 1-3 yrs 4-6 yrs 7-9 yrs 10-12 yrs (b) 10-12 yrs (g)	5.4 8.6 12.2 19.0 26.9 35.4 31.5	108/kg 98/kg 1240 1690 1950 2190 1970	2.05/kg 1.65/kg 22 30 41 54 57	- - 25 25 25 22 22	- - 400 400 400 600 600	- - 12 19 26 34 19

Adapted from Dietary Guidelines for Indians. New Delhi, Indian Council of Medical Research, 1998).

The nutrient intake in febrile state should be modified as follows:

Energy : Since, there is a rise in body temperature; BMR may be increased by as much as 50%. Restlessness also increases the energy expenditure. Therefore, it is recommended to increase the energy intake by 10-20%. Initially, during the acute stage, a patient may be able to consume only 50% of the requirement, but the energy intake should be gradually increased with recovery and improved tolerance.

Protein : The requirement of protein is related more to the severity and duration of the infection rather than to the height of the fever. Since there is excessive destruction of tissues, the protein intake should be increased to 1.5 to 2 times the normal. For efficient utilization of protein, energy intake should be adequate. To minimize the tissue loss, protein foods of high biologic value such as milk and eggs should be used liberally as they are most easily digested and absorbed.

Carbohydrates : A liberal intake of carbohydrates is suggested to replenish the depleted glycogen stores of the body. Moreover, intake of carbohydrates exerts a protein sparing action. Well cooked, easily digestible carbohydrates like simple starch, glucose, honey, cane sugar etc. should be included as they require much less digestion and are well assimilated. As glucose is less sweet, it can be used not only to provide the required sweetness, but also to increase the energy content of the diet.

Dietary fiber : In diseases involving lesions in the intestinal tract like diarrhea and typhoid, all forms of irritants have to be eliminated from the diet. All harsh, irritating fiber should, therefore, be avoided in the diet, as it is a mechanical irritant.

Fats : Fats are required mainly to increase the energy intake. However, in presence of diarrhea, fats only in the emulsified form like cream, butter, whole milk, egg yolk should be included in the diet, as they are easily digested and well tolerated by patients. In the early stage, intake of fat may aggravate nausea and so its intake should be restricted. Fried foods which are difficult to digest should be avoided.

Minerals : There is excessive loss of electrolytes like sodium, potassium, and chloride due to increased perspiration. Salty soups, broths, fruit juices, milk, etc should be included to compensate for the loss of electrolytes. In case of hemorrhages, iron supplementation is important to prevent anemia.

Vitamins : As infections and resultant fevers apparently increase the requirement for vitamin A and deplete tissue stores of vitamin C, there is a need to increase the intake of both these vitamins. With the increase in energy requirements the need of B group vitamins also increases. Moreover, the use of antibiotics and drugs interferes with the intestinal bacterial, synthesis of some B group vitamins. So, vitamin supplements may have to be given for some time.

Fluid : In order to compensate for the losses through the skin and sweat and also for ensuring adequate volume of urine for excreting waste, a liberal intake of fluids is very essential. Fluids may be included in the form of beverages, soups, juices, plain water etc.

As the patient is actually ill and anorexic, a high energy, high protein, full fluid diet is recommended in the beginning. Small meals are given at frequent intervals of 2-3 hours. Sufficient intake of fluids and salt should be ensured.
As soon as the fever comes down, a bland, low fiber, soft diet which is easily digested and absorbed should be given to the patient. All mechanically irritating foods like whole grain cereals, whole pulses, raw fruits and vegetables, and chemically irritating foods like spices and other strongly flavored floods should be avoided. Well, cooked, well, mashed, sieved, bland, semisolid foods like khichdi, rice and curd, kheers, custard may be given. Bland, readily digested food affords physiological rest to the alimentary tract. In the beginning, small quantities of food at 2-3 hours interval will provide adequate nutrition without overtaxing the digestive system at anyone time. As the condition of the patient improves, larger meals may be given.

High fiber foods like whole grain cereals and their products e.g., whole wheat flour and cracked wheat, whole pulses and pulses with husk.

Raw vegetables and fruits excluding papaya and banana.

Fried fatty foods such as samosa, pakora, halwa, ladoo etc.

Chemical irritants such as condiment, spice, pickle, relish, chutney and strongly flavored vegetables like cabbage, capsicum, turnip, radish, onion and garlic.

Foods to be included

• Plenty of fluids like juices and soups


• Milk and milk based beverages.
  
• Low fiber foods such as refined cereals and their products, dehusked pulses, well cooked fruits, vegetables in soft and puree form and potatoes.
  
• Foods providing proteins of high biologic value e.g., egg, soft cheese, tender meat, fish, poultry etc.
  
• Plain gelatin based dessert, sugar, honey, jam.
  

Vijay, aged 10 years, was running high fever which was diagnosed as typhoid and subsequently treated with antibiotic therapy. Now his fever is under control and there is also an improvement in his appetite. A day’s diet for him is planned below:

Step I : Recommended Dietary Allowances

-	Normal	Modified
Energy	2190 kcal	+10% = 2420 kcal
protein	54g	+ 50% = 81 g
Vitamin A	600 mcg retinol	-
Vitamin C	40 mg	-

Step II : Food Plan

Exchange	Energy (kcal)	Protein (g)	CHO (g)	Fat (g)
Milk Meat Pulse Cereal Vegetable Fruit Fat Sugar	595 210 100 840 80 120 315 160	28 21 7 24 4 - - -	42 - 17 180 14 30 - 40	35 15 35
Total	2420	84	323	85

Step III : Distribution and type of food

Meal	Type of food	Amount
Early morning	Milk Cereal /biscuits Sugar	175 ml 2 5g
Breakfast	Suji porridge / Upma Bread/cereal flakes with milk Egg Sugar	1 cup 2 pieces / 1 cup 1 5 g
Mid-morning	Paneer sandwich / idli Fruits	2 1
Lunch	Cream of tomato soup Plain Dal / sambhar Cooked rice / plain dosa Potato raita Vegetables	1 cup 1 cup 1.5 cups / 2 pieces ½ cup ½ cup
Tea time	Ice cream / milk shake Dahi vada or uthapam / poha Fruits	1 cup 2½ cup 1
Dinner	Clear soup / rasam Cooked rice / refined cereal products Plain dal / sambhar Non-veg / cottage cheese Stewed apple with custard Vegetables	1 cup 1.5 cups 1 cup 30-50 g 1 cup ½ cup

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