Diarrhée aigue chez l’enfant: quel régime adopter?
INTRODUCTION
La diarrhée représente la deuxième cause de mortalité chez l’enfant de moins de cinq. Elle est à l’origine de 525 000 décès d’enfants par an. Elle peut durer plusieurs jours, déshydratant l’organisme et le privant des sels minéraux nécessaires pour la survie. Auparavant, pour la majorité des personnes, la déshydratation sévère et les pertes hydriques étaient les principales causes de décès par diarrhée. Désormais, d’autres causes comme les infections septiques d’origine bactérienne sont probablement à l’origine d’une proportion croissante des décès dus aux diarrhées. Ce sont les enfants en état de malnutrition ou d’immunodépression qui sont le plus exposés au risque de diarrhées engageant le pronostic vital.
La diarrhée est définie par au moins 3 émissions de selles molles ou liquides dans une journée (ou des selles plus fréquentes que ce qui est habituel pour le sujet atteint). Des émissions fréquentes de selles bien moulées ne sont pas une diarrhée, pas plus que des selles molles, «pâteuses», pour des nourrissons allaités au sein. Elle est en général le symptôme d’une infection intestinale pouvant être causée par divers micro-organismes, bactéries, virus ou parasites. L’infection se transmet par le biais de l’eau ou d’aliments contaminés, ou d’une personne à l’autre en cas d’hygiène insuffisante. Même dans les pays industrialisés, la diarrhée aiguë est responsable d’une morbidité importante et d’une mortalité non négligeable. La déshydratation secondaire à une diarrhée aiguë est en effet la principale cause de mort considérée comme évitable dans le recrutement des services de réanimation pédiatrique en France. La réhydratation orale et la réalimentation précoce constituent l’essentiel du traitement de la diarrhée aiguë du nourrisson. La réhydratation orale restaure l’équilibre hydroélectrolytique ; la réalimentation précoce diminue la fréquence et la durée des anomalies de la perméabilité intestinale, et évite une altération de l’état nutritionnel, tout en raccourcissant la durée de la diarrhée. La place du traitement médicamenteux est secondaire.
LA RÉHYDRATATION ORALE
Le traitement de la diarrhée aiguë doit impérativement comporter l’administration d’un soluté de réhydratation orale (SRO) pour éviter une déshydratation, principal risque chez le jeune enfant. Ce dernier s’administre en petites quantités toutes les 20 minutes à la phase aiguë. Depuis les années 1970 dans le tiers-monde, les solutés de réhydratation orale (SRO) ont permis de réduire la mortalité des diarrhées aiguës chez l’enfant de plus de 60 % et de supprimer 80 % des perfusions intraveineuses. Quel que soit l’agent infectieux en cause (virus ou bactérie) et la physiopathologie de la diarrhée, il persiste une capacité d’absorption des électrolytes et donc de l’eau par les entérocytes. Les SRO favorisent cette absorption par la présence concomitante de glucose et de sodium. L’efficacité des SRO est largement prouvée par de nombreuses études et méta-analyses, avec un taux d’échec faible. La composition des SRO a évolué avec le temps et le lieu d’utilisation. La formule initiale de l’Organisation mondiale de la santé (OMS)/Unicef contenait 3,5 g de chlorure de sodium (sodium 90 mmol/l), 2,5 g de chlorure de potassium, 1,5 g de bicarbonate de sodium et 20 g de glucose. L’OMS a révisé en 2004 la composition des SRO et recommande à l’heure actuelle des solutions à osmolarité abaissée à 245 mOsm/l (sodium 75 mmol/l, glucose 13,5 g/l), qui tendent à se rapprocher de plus en plus de celle des SRO disponibles en Europe. Les SRO utilisés en Europe étaient en effet d’emblée moins riches en sodium, car les pertes sodées sont plus faibles dans les diarrhées de cette région du globe.
Actuellement, il existe une double tendance vers la réduction des quantités de sodium dans les SRO et vers une harmonisation mondiale, suivant en cela les recommandations non seulement de l’OMS mais aussi de sociétés savantes comme l’European Society of Pediatric Gastroenterology, Hepatology And Nutrition (ESPGHAN). Les SRO « fait maison » ne sont pas adaptés. Le Coca-Cola® ne doit pas être utilisé en raison de son hyperosmolarité, de son absence complète de potassium et quasi complète de sodium. Pour les pays en voie de développement, l’OMS valide une formule d’eau de riz préparée avec du sel. La composition de ces préparations est cependant très imprécise et dépourvue de potassium.
LA RÉALIMENTATION
La réintroduction rapide de l’alimentation permet d’éviter la dégradation de l’état nutritionnel en réduisant les anomalies de la perméabilité intestinale, en facilitant la « réparation » des entérocytes et en maintenant l’activité des disaccharidases, en particulier de la lactase et de la saccharase. La lactase hydrolyse le lactose au niveau de la bordure en brosse des entérocytes, dont les plus matures sont situés au sommet des villosités intestinales, qui constitue la zone la plus facilement altérée par les agents infectieux, au premier rang desquels le Rotavirus. De plus, il semble que le Rotavirus ait une toxicité directe sur l’entérocyte, en inhibant l’adressage de la protéine lactasique vers la bordure en brosse. Une étude conduite par l’ESPGHAN chez 230 nourrissons de 12 à 17 mois (âge moyen : 14 mois) a montré que la réintroduction de l’alimentation du nourrisson après quatre heures de réhydratation orale exclusive est aussi efficace et bien supportée qu’après 24 heures de réhydratation orale exclusive, avec un meilleur gain pondéral encore patent 14 jours après le début de la diarrhée et sans que le taux de complications, en particulier les vomissements, la pérennisation ou la récidive précoce de la diarrhée, ne soit plus élevé.
Réalimentation de l’enfant au sein
Il existe un consensus pour conseiller la poursuite de l’allaitement maternel, en alternant les prises de SRO et les tétées, qui permet une guérison plus rapide de la diarrhée et améliore l’état nutritionnel.
Réalimentation de l’enfant nourri avec une préparation lactée hypoallergénique.
Chez l’enfant recevant une préparation lactée hypoallergénique dite « HA » en raison d’antécédents atopiques familiaux, il faut éviter pendant la période de diarrhée d’utiliser des préparations artificielles avec ou sans lactose contenant des protéines entières, en particulier des protéines du lait de vache ou de soja. Celles-ci représenteraient en effet une augmentation de la charge allergénique pendant une période de perméabilité intestinale accrue.
Réalimentation de l’enfant nourri avec une préparation lactée à base de lait de vache
Le mode d’alimentation au cours de la diarrhée aiguë a longtemps été un sujet de discussions animées. Dès le début du 20e siècle, le jeûne prolongé a été conseillé pour le traitement des diarrhées aiguës du nourrisson, dans le but de faciliter la guérison des lésions intestinales. En fait, dès 1948, Chung et Viscorova ont montré sans aucune ambiguïté que la durée de la diarrhée n’était pas prolongée chez les nourrissons réalimentés précocement, mais cette proposition n’a reçu quasiment aucun écho jusqu’au début des années quatre-vingts. La crainte d’une intolérance au lactose a longtemps conduit à recommander l’exclusion prolongée du lait pendant 24 à 48 heures, voire plus, dans le but d’une « mise au repos » de l’intestin, et l’utilisation exclusive d’un SRO pendant la même période, suivie de la réalimentation du nourrisson, soit avec le lait qu’il recevait avant la diarrhée, reconstitué de façon progressive sur deux à trois jours, soit plus volontiers avec une préparation diététique sans lactose. La diminution de la fréquence de l’intolérance au lactose au cours des diarrhées aiguës habituellement rencontrées dans les pays industrialisés a été soulignée dès 1987. L’intolérance au lactose ne survient en fait que dans moins de 5 % des cas, ce qui signifie que l’utilisation d’une préparation diététique sans lactose n’est que rarement nécessaire. L’intolérance au lactose semble surtout observée en cas d’infection à Rotavirus ou de malnutrition, et chez le nourrisson de moins de six mois. Dans l’étude de l’ESPGHAN rapportée par Sandhu et al., la prévalence de l’intolérance au lactose n’était que de 3 % à l’inclusion, et aucun enfant n’avait d’intolérance au lactose au 5e jour d’évolution. Une méta-analyse rapportée par Brown et al. colligeant 29 essais cliniques réalisés chez 2 215 patients a montré qu’une très grande majorité des nourrissons atteints de diarrhée aiguë pouvait être réalimentée avec un lait normal, contenant du lactose, et non dilué. Les échecs de la réalimentation étaient certes près de deux fois plus fréquents chez les nourrissons recevant du lactose (22 %) que chez ceux n’en recevant pas (12 %) (p < 0,001). Cependant, cette différence ne concernait que les études incluant des patients ayant une déshydratation sévère et les études publiées avant 1985. La durée de la diarrhée était légèrement augmentée dans le groupe des enfants recevant du lactose par rapport à ceux qui n’en recevaient pas. Cette différence disparaissait chez les nourrissons qui recevaient une alimentation solide concomitante. Le taux d’échec de la réalimentation était légèrement plus élevé chez les enfants recevant un lait avec lactose non dilué (16 %) que chez ceux recevant un lait avec lactose dilué (12 %) (p < 0,002).
Le zinc est essentiel pour la croissance, la synthèse protéique, la fonction cellulaire T et le développement des fonctions intestinales. Une augmentation des pertes intestinales en zinc a été mise en évidence au cours de la diarrhée. L’effet bénéfique d’une supplémentation en zinc sur le nombre et la durée des épisodes de diarrhée a été démontré chez les enfants dénutris dans les pays en développement, d’autant plus nettement que ces enfants présentaient un déficit avéré en zinc. Ainsi, les recommandations actuelles sont d’administrer uniquement un lait sans lactose si la diarrhée est jugée sévère par le pédiatre, si elle entraîne une déshydratation avec la nécessité d’une hospitalisation ou si celle-ci est supérieure à 7 jours. Cette administration du lait sans lactose doit être limitée dans le temps, en général à 8 jours, car l’hypolactasie est transitoire. Le lait antérieur peut être repris sans transition.
Aliments spécifiques et diarrhée aiguë
Des aliments tels que les carottes, les bananes, les pommes, les myrtilles, les coings sont souvent donnés en cas de diarrhée aiguë. Ces aliments sont riches en pectines, des substances végétales de type polysaccharides, qui augmentent le temps de transit orocæcal du fait de leur effet adsorbant. Toutefois, si visuellement les selles sont moins liquides, le risque de déshydratation de l’enfant est le même. Il n’y donc pas lieu de privilégier ces aliments qui ont l’effet d’une éponge. De même, les fruits et légumes crus, ainsi que les jus de fruits consommés avec modération, ne doivent pas être supprimés de l’alimentation. Le riz est souvent un aliment privilégié en cas de diarrhée aiguë. Des études chez l’animal ont montré que des composés du riz amélioraient la réaction immunitaire intestinale de type Th1 et avait un effet inhibiteur sur les canaux chlore CFTR permettant une diminution des sécrétions digestives. De plus, le riz contient également des polymères glucidiques (amylopectines et maltodextrines) qui ont un rôle absorbant. De plus, la libération progressive intra-luminale du glucose favoriserait l’absorption du sel et de l’eau via le cotransporteur sodium/glucose (effet absorbant). Mais encore une fois, même si les selles paraissent moins liquides, le riz ne limite pas le risque de déshydratation. En pratique, en cas de diarrhée aiguë, les régimes spécifiques limitant ou favorisant certains aliments sont inutiles. Il n’existe aucune étude ayant démontré leur efficacité. Ils peuvent par ailleurs être dangereux, car même si l’aspect des selles est moins liquide, le risque de déshydratation est identique. De plus, l’administration prolongée de tels régimes peut conduire à un déséquilibre de l’alimentation. La seule mesure diététique à évaluer est la mise en place d’un lait sans lactose en cas de diarrhée sévère ou prolongée.
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