Persistent and chronic diarrhea and malabsorption: Working group report of the second world congress of pediatric gastroenterology, hepatology, and nutrition

Despite considerable advances in the understanding and management of diarrheal disorders in childhood, they are still responsible for an estimated 2.2 million childhood deaths worldwide (1). In 1980, the World Health Organization calculated that there were >700 million episodes of diarrhea annually in children 4.6 million deaths (2). More recent reviews indicate that although global mortality has decreased, the incidence remains unchanged at >3.2 episodes per child-year (3). These findings indicate the continuing need to focus on the prevention and management of acute and chronic diarrhea in children in developing countries. Diarrheal disorders form a continuum, the majority of cases resolving within the first week of the illness. However, a smaller proportion of diarrheal illnesses may fail to resolve and persist for >2 weeks. Persistent diarrhea (PD) may be defined as the passage of 3 watery stools per day for >2 weeks in a child who either fails to gain or loses weight. PD identifies children with a substantial diarrhea-related morbidity and accounts for between 36% and 54% of all diarrhea-related deaths (4). Many infants and toddlers in developing countries may have frequent recurrent episodes of acute diarrhea or PD, resulting in nutritional compromising and/or predisposing these children to PD. The bulk of epidemiological data on the relationship between acute diarrheal disorders and PD are from studies undertaken > 10 to 15 years ago. There is a paucity of recent data on this subject, especially from non–HIVendemic areas. However, chronic enteropathy and PD have been increasingly recognized as manifestations of advancing HIV infection and AIDS. Address correspondence and reprint requests to Dr. Bhutta (e-mail zulfiqar.bhutta@aku.edu). Research 1. Assessment of mucosal immuno-pathology and molecular and cellular biology of persistent diarrhea in representative populations in developing countries. 2. Studies of small bowel microbiology in PD, especially in at-risk populations e.g., malnourished children and HIV endemic areas. 3. Evaluation of the link of micronutrient deficiencies with PD and their relationship with intestinal repair mechanisms. Intervention 1. Improved facility-based approaches and algorithms for the nutritional management of PD and malnutrition. 2. Diagnosis and management of PD in public health system and primary care (including domiciliary) settings. 3. Scaling-up environmental control measures and safe water and hygiene strategies. Education 1. Continuing medical education strategies to educate medical students and physicians in the recognition, management and prevention of PD. 2. Education of nursing and paramedical personnel in the recognition and management of PD in ambulatory and health system settings. 3. Community and public health education strategies for increased awareness of the prevention of PD and optimal management of acute and prolonged diarrheal episodes. Journal of Pediatric Gastroenterology and Nutrition 39:S711–S716 © June 2004 Lippincott Williams & Wilkins, Philadelphia