Comparison of safety of glucose oral rehydration solution and maize oral rehydration therapy for home management of diarrhoea in Kenya

Safety margins and variability in the composition of glucose and maize-based oral rehydration therapy (ORT) prepared by mothers in a rural district of Western Kenya, are reported here. In a 2-year longitudinal field study, packets containing glucose ORS and a home solution made with maize and table salts, were provided to the mothers of 6180 children in Kakamega District in two separate sub-locations. Experienced and trained field workers supported by community registered nurses provided training for the preparation and use of ORT during weekly visits to every household. On four occasions separated by 4-6 months, a 5 per cent random sampling was done of the home-prepared solutions actually used for the treatment of children with diarrhoea. The water used for preparing ORT was also sampled. Samples of 174 glucose-based ORT, 148 maize-salt ORT, and 201 samples of water were analysed. Only 2 per cent of the maize-based ORT were above 120 meq/1 sodium (i.e., the safe range of sodium concentration) compared to 17.8 per cent for glucose solutions (p < 0.001). Home water samples contained substantial amounts of salt, which could unpredictably affect the final composition of the ORT solutions. We conclude that maize-salt ORT had a better margin of safety than glucose-based ORS.     

Glycine supplemented oral rehydration solutions for diarrhoea.

Two glycine supplemented oral rehydration solutions (ORS) and a standard ORS with sodium 60 mmol/l were compared for treatment of diarrhoeal dehydration in children. The solutions contained glycine 110 mmol/l and glucose 110 mmol/l (ORS60-Gly110), glycine 60 mmol/l and glucose 80 mmol/l (ORS60-Gly60), and glucose 144 mmol/l only (ORS60), respectively. The patients receiving ORS60-Gly110 had poor weight gain and increased stool and urine volumes after rehydration compared with the other two groups. The patients receiving ORS60-Gly60 had similar stool and urine volumes as those receiving standard ORS60. It is concluded that excess glycine in relation to sodium in an ORS may lead to osmotic diarrhoea, and a high amount of absorbed glycine may result in osmotic diuresis with poor net rehydration. Altogether, the present study failed to find any improvement (''Super-ORS'') by addition of glycine to an ORS containing 60 mmol/l of sodium.     

Safe oral rehydration of hypertonic dehydration

Eighteen infants with severe hypernatremic dehydration secondary to acute gastroenteritis were rehydrated during the 1st day with an oral glucose electrolyte solution containing 60 mmol sodium/L at a mean rate of 120 ml/kg/24 h. These 18 children were safely treated with oral therapy alone. No convulsions were observed during treatment. The mean decrease in natremia was 0.32 mmol/L/h, which compared favorably with the mean fall in natremia of 26 other infants in similar initial conditions who were treated intravenously. The present study lends additional support to the opinion that a slow decrease in plasma sodium (less than 0.5 mmol/L/h) helps to avoid seizures during treatment. As no other untoward effects were observed, this study also confirms that oral solutions given at a slow rate can effectively replace intravenous fluids in the majority of such children.     

Hydrolysed wheat based oral rehydration solution for acute diarrhoea.

A randomised three cell study was carried out in 78 children with acute diarrhoea to evaluate the relative efficacy of oral rehydration solution (ORS) made from partially hydrolysed wheat grain, cooked rice powder, or glucose. Twenty six patients with comparable age, body weight, duration of diarrhoea, and degree of dehydration were studied in each of the three groups. Initial rehydration was carried out by using intravenous Dhaka solution within one to two hours followed by administration of oral rehydration solution. The mean ORS intake during the first and second 24 hours of treatment in patients with cholera receiving wheat-ORS and rice-ORS was significantly less compared with those receiving glucose-ORS. The stool output during the same period in patients receiving wheat-ORS and rice-ORS was significantly less compared with those receiving glucose-ORS. Similar trends in both ORS intake and stool output were observed during the next 24 hours.     

Breast feeding and hypernatremic dehydration. 3 case studies

Despite the well-recognized advantages of breast-feeding, a rare but life-threatening complication may occur with failure to thrive resulting in severe malnourishment or hypernatremic dehydration. We report 3 more cases. Two of them with severe hypernatremic dehydration and cachexia were treated using peritoneal dialysis rather than intravenous fluids in order to rapidly correct the severe metabolic acidosis but slowly the serum osmolarity. Although insufficient breast-milk volume appears to prevail over positive sodium balance in the pathway to hypernatremic dehydration, high sodium concentrations were found in breast milk as previously reported. However, the discovery of a low lactose content inversely related to that of sodium in breast-milk, suggests more complex disturbances in lactation and may draw up new hypothesis in the pathogenesis of this challenging syndrome.     

Hydrolyzed lactalbumin-based oral rehydration solution for acute diarrhoea in infants

The addition of different organic substrates to standard glucose oral rehydration solution (G-ORS) has been shown to improve the intestinal absorption of sodium and water, and thereby decrease stool losses. Therefore, we evaluated, in infants with acute diarrhoea, the safety and efficacy of three oral rehydration solutions (ORS) which had the same concentrations of electrolytes (with sodium 60 mmol/l) but different substrates of proteins and carbohydrates. One solution (LAD-ORS) contained hydrolyzed lactalbumin (LAD) with maltodextrin and sucrose, a second (MS-ORS) was identical but without LAD and a third (G-ORS) was standard glucose ORS. The three solutions were compared in a double-blind, randomized trial in 74 hospitalized well-nourished children in Panama and the United States. All three oral rehydration solutions were equally efficacious and safe in these children, 54% of whom were infected with rotavirus. There was no suggestion that hydrolyzed lactalbumin or maltodextrin provided any advantage over glucose-ORS in terms of stool output or in duration of diarrhoea. We conclude that all three solutions are efficacious in the therapy of acute diarrhoea in infants.     

A comparative trial of rapid oral and intravenous rehydration in acute diarrhoea

37 children under the age of 5 years hospitalized for acute diarrhoea and dehydration were randomized to receive oral or intravenous rehydration during 6 to 12 hours. Rehydration was satisfactory in both groups, with correction of dehydration, metabolic acidosis and sodium deficit at equal rates. The reintroduction of normal feedings was successful in most of the orally rehydrated children after 12 hours, but often unsuccessful in the i.v. therapy group. Consequently the orally rehydrated children showed a 2.9% weight gain by the time of discharge whereas the intravenously treated children did not gain weight in the hospital. The duration of diarrhoea was also shorter in the orally rehydrated children. Thus oral rehydration therapy was equal or superior to even rapid intravenous rehydration therapy in the management of acute diarrhoea in children.     

Lactose feeding during persistent diarrhoea

Lactose intolerance is a recognized complication of some episodes of diarrhoea. Whereas it is of clinical importance in relatively few children with acute diarrhoea it seems to be a more common problem in children presenting with persistent diarrhoea, especially in malnourished children with severe diarrhoea. We describe a recent study which also demonstrated adverse clinical and nutritional consequences in the majority of children with mild but persistent diarrhoea consuming 6 g lactose/kg body weight/d. It is desirable to identify these children who need to reduce their lactose intake in order to limit unnecessary dietary changes which are expensive to implement and/or nutritionally disadvantageous. Admission clinical characteristics were analyzed for their ability to predict clinical outcome in a group of 33 children with persistent diarrhoea taking a lactose-containing diet. The results of tests of stool reducing substances and a lactose breath hydrogen test (LHBT) were analyzed in the same group whose clinical management had been independent of the test results. Eighty-nine percent of children who deteriorated had one of the following characteristics: age <12 months, weight-for-height less than -2 SD below NCHS norms or fever >37°C. Children who unequivocally improved while continuing to take lactose could not be selected without the risk of including children who deteriorated. Neither tests of stool reducing substances nor the LBHT improved the predictive value of simple clinical parameters. Reduction of lactose in the diet of children with persistent diarrhoea who have any of these parameters is recommended, but mixing of milk with cereal or substituting with fermented milk products is preferable to milk withdrawal or dilution with water.     

Role of cereal-based oral rehydration therapy in persistent diarrhoea in children

A total of 2000 children aged under five and 12,500 diarrhoea episodes were studied prospectively for assessing the efficacies of R-ORS and G-ORS and for comparing them with that of a comparison area using drugs for treatment. Efficacy was evaluated in terms of ORS use rate, consumption of ORS per episode, duration of diarrhoea and rate of recovery. The data were analysed to compare the rate of persistent diarrhoea in the three areas. Mean ORS consumption was 946 ± 576 and 1236 ± 766 ml per episode of watery diarrhoea in the R–ORS and G–ORS areas respectively. The mean durations of watery diarrhoea were 3.3 ± 2.1, 5.4 ± 3.5 and 8.8 ± 5.5 days in the R-ORS, G-ORS and comparison area, respectively. The median durations for dysentery were 7, 9 and 12 days in the three areas respectively. The incidences of persistent diarrhoea following watery diarrhoea were 0.4, 3 and 12% in the R-ORS, G-ORS and comparison area respectively, and, following dysentric episodes, 8, 18 and 40%. The results of the study suggest that R-ORS can hasten recovery from both watery diarrhoea and dysenteries, thus reducing the incidence of persistent diarrhoea.     

Randomised double blind study of hypotonic oral rehydration solution in diarrhoea

A hypotonic (osmolality 224 mmol/l, sodium 60 mmol/l) oral rehydration solution (ORS) was compared with an isotonic high glucose ORS (osmolality 304 mmol/l, sodium 60 mmol/l) in children with acute diarrhoea in a randomised double blind study. The stool output and hence the mean consumption of ORS for maintenance hydration was less (p = 0.036) in patients receiving hypotonic (69 ml/kg) than isotonic (97 ml/kg) ORS. Hypotonic ORS was more effective in patients with rotavirus positive than with rotavirus negative diarrhoea.     

Clinical experience with a hypotonic oral rehydration solution in acute diarrhoea

A hypotonic oral rehydration salts (ORS) solution with total osmolality of 224 rnosmol/l was compared in an open clinical trial with an isotonic (osmolality 304 mosmol/l) ORS solution for the treatment of dehydration due to acute diarrhoea. Both ORS solutions had the same electrolyte composition with a Na⁺ concentration of 60 mmol/l. Children given the hypotonic ORS solution ( n = 103) passed significantly fewer diarrhoeal stools, and their diarrhoea and hospital stay were shorter than those of children given the isotonic ORS solution ( n= 135). We conclude that hypotonic ORS ("light" ORS) has clinical advantages over the standard ORS currently used in Finland.     

Can acetate replace bicarbonate in oral rehydration solution for infantile diarrhoea?

In a double-blind trial two groups of 20 infants and young children suffering from diarrhoeal dehydration and acidosis were successfully treated with an acetate and a bicarbonate containing oral rehydration solution. The former was found to be as effective as the latter and was equally acceptable to the patient.