Background Prevalence of malnutrition in Indonesian children keeps increasing despite tremendous efforts to improve nutritional status. Persistent diarrhea (PD) is often found together with malnutrition, causing higher mortality rates. Damaged villi reduces enteric hormone feedback to pancreas, decreasing digestive enzymes for adequate nutrient digestion and absorption, causing pancreas exocrine insufficiency (PEI). Research on pancreas function in Indonesian children is almost non-existent, standard assessment (fecal elastase-1) expensive and requiring modern laboratory equipments not available in low-resource areas where nutrition problems are prominent, reference range not yet available for Indonesian children. Affordable and feasible alternative for assessment of pancreas exocrine function is higly imperative to ensure adequate nutrition digestion.

Objective To develop low-cost assessment method in detecting nutrient maldigestion caused by PEI for low-resource areas in rural Indonesia, to establish Indonesian reference range for fecal elastase-1, to evaluate the magnitude of PEI in PD, and to evaluate whether pancreas enzyme substitution is beneficial for proper nutrient digestion in children with PD.

Method Study in children 6-60 months of age: 30 with PD, 30 with malnutrition, and 120 healthy children. Clinical signs and symptoms, anthropometric measurements, bowel movement pattern, and diet will be obtained from each subject; fecal sample taken for elastase-1, fecal analysis, steatocrit test. Diagnostic test of elements of fecal analysis and steatocrit against elastase-1 as standard test. Children with PD will be enrolled in a double-blind, placebo-controlled, parallel-group study, assigned to pancreas enzyme supplement or placebo for 1 month. Length of diarrhea, fecal fat, and pre-/post- treatment serum prealbumin will be evaluated. Data analysis will be done using SPSS 11.5 for Windows.

Significance This new method will allow care providers in low-resource areas to easily detect nutrient maldigestion potentially lead to malnutrition, enabling early efforts to restore digestive function. This study will also establish reference value of pancreas exocrine function parameters in Indonesian children. Pancreas enzyme supplementation might also be a more targeted alternative to PD, which often found together with malnutrition and usually treated with relatively expensive elemental diet. Indonesia as a developing country with increasing prevalence of malnutrition could largely benefit from an accurate, cost-effective, and non-invasive method to assess and treate pancreas exocrine function in the fight to combat malnutrition.