Community case management of childhood diarrhea in a setting with declining use of oral rehydration therapy: findings from cross-sectional studies among primary household caregivers, Kenya, 2007

We sought to determine factors associated with appropriate diarrhea case management in Kenya. We conducted a cross-sectional survey of caregivers of children < 5 years of age with diarrhea in rural Asembo and urban Kibera. In Asembo, 61% of respondents provided oral rehydration therapy (ORT), 45% oral rehydration solution (ORS), and 64% continued feeding. In Kibera, 75% provided ORT, 43% ORS, and 46% continued feeding. Seeking care at a health facility, risk perception regarding death from diarrhea, and treating a child with oral medications were associated with ORT and ORS use. Availability of oral medication was negatively associated. A minority of caregivers reported that ORS is available in nearby shops. In Kenya, household case management of diarrhea remains inadequate for a substantial proportion of children. Health workers have a critical role in empowering caregivers regarding early treatment with ORT and continued feeding. Increasing community ORS availability is essential to improving diarrhea management.     

Assessment of the effectiveness of oral rehydration therapy against severe diarrheal dehydration.

A hospital based case-control study for assessing the effectiveness of oral rehydration therapy (ORT) preparation against severe dehydration due to diarrhea was conducted at the Infectious Diseases Hospital, Jakarta, Indonesia. A total of 202 children aged 24 months or less who attending the hospital were suffering from acute watery diarrhea were recruited in the study. Those who were severely dehydrated as assessed by WHO criteria were accounted as cases; those who were non-severely dehydrated were accounted as controls. There were 59 cases and 143 controls. A questionnaire was used to interview all study subjects' mothers about ORT usage and various risk factors. Mothers who used ORT were asked to show how they prepared either oral rehydration solution (ORS) or sugar salt solution (SSS). Effectiveness of ORT against severe diarrheal dehydration was based on the formula for assessment of vaccine efficacy by using the odds ratio (OR). With the use of the logistic regression method, an adjusted OR was obtained after controlling various confounders. The effectiveness of ORT against severe diarrheal dehydration was 72.1% for proper ORT preparation and was decreased to 63.2% when ORT was improperly prepared.     

Use of commercially available oral rehydration solutions in Lima, Peru

Caregivers' practices concerning oral rehydration of young children during diarrheal illness were investigated in a periurban community of low socioeconomic level in Lima, Peru. Data of 330 caregivers of children aged 6-36 months were analyzed; 72.7% of all caregivers would give commercially available oral rehydration solutions (ORSs). However, only 58.6% of those caregivers with children that had experienced diarrhea during the previous week stated that they had used commercially available ORSs, a significantly lower percentage. The main reason for not using commercially available ORSs was that caregivers did not know about them. Of all recipes caregivers provided for homemade ORS, none contained the recommended concentrations of sugar and salt. Educating caregivers about availability, benefits, and use of commercially available ORSs as well as correct preparation of homemade ORS is urgently needed.     

Knowledge of diarrhea and socioeconomic factors in relation to the use of oral rehydration therapy in Samut Songkhram Province, Thailand

A study to determine the association between the use of oral rehydration therapy (ORT) by mothers who had children under five years old with diarrhea and their knowledge of diarrhea was conducted in 19 health centers and a hospital at Muang District, Samut Songkhram Province. It was found that in general there was significant association between the use of ORT and mother's knowledge of diarrhea. This significant association was still evident after considering socioeconomic factors such as age, occupation, education and economic status. It was also noted that mothers with high knowledge of diarrhea gave ORT to their children under five with diarrhea two times more frequently than mothers with low knowledge of diarrhea. The present study confirms the impact of knowledge of diarrhea on the use of ORT.     

The use of oral rehydration solutions in children and adults

The observation that the intestinal Na⁺-glucose cotransporter remains intact in most diarrheal illnesses led to development of the life-saving, low-cost technology of oral rehydration salt (ORS) solutions. The primary therapeutic role of ORS solutions is in prevention and treatment of dehydration during management of acute gastroenteritis. Successful oral rehydration therapy involves early use of ORS with maintenance or timely resumption of regular feeding. Since the inception of the oral rehydration approach more than three decades ago, the widespread use of ORS solutions has revolutionized the management and outcomes of acute gastroenteritis in children and adults. The efficacy of the World Health Organization ORS solution and of commercial ORS formulations has been enhanced by reducing osmolarity. Newer formulations of ORS are under active investigation, with promise of added benefits, including promotion of intestinal healing. This article reviews fluid and electrolyte transport in the gastrointestinal tract, the pathophysiologic mechanisms of acute diarrhea, and the basis and formulation of current and newer ORS solutions. Guidelines for efficacious use of ORS in the management of acute gastroenteritis and short gut syndrome are also provided.     

Rice-powder salt solution in the treatment of acute diarrhea in young children.

Dehydration is the most common cause of death in diarrheal patients. Early oral rehydration therapy (ORT) can prevent or reverse dehydration from diarrhea in almost almost all cases. Shortages of oral rehydration salt (ORS) packets in certain areas remain a major problem of the Diarrheal Diseases Control Program of Thailand. To find an effective solution that can be prepared locally, a randomized trial of oral rehydration solutions was conducted. A rice-powder salt solution containing rice-power 30 g/l and salt 3.5 g/l (RPSS) was evaluated in a group (n = 23) of infants and young children aged between 4 months and 5 years with mild or moderate dehydration from acute watery diarrhea, and the results were compared with those who received WHO recommended glucose electrolyte solution (WHO-ORS) (n = 21), and glycine supplemented WHO-ORS (G-ORS) (n = 20). The efficacies of WHO ORS and G-ORS were found to be similar. The RPSS was found to be more effective than WHO-ORS and G-ORS as shown by a significantly lower stool frequency, lower rate of stool output, a significantly shorter duration of diarrhea, and a smaller intake of rehydration fluid. Promotion of the effective rice-salt solution could increase early implementation of ORT in many rural communities.     

Effective treatment of diarrhoeal dehydration with an oral rehydration solution containing citrate

To compare the clinical efficacy of oral rehydration salts (ORS) from effervescent tablets containing citrate with the WHO recommended ORS for the treatment of dehydration due to acute diarrhoea, a randomized clinical trial was carried out in 57 adults and 58 children. These patients had mild or moderate degrees of dehydration and acidosis due to acute watery diarrhoea that was caused by enterotoxigenic Escherichia coli in 43-47% of the cases. Efficacies were compared by measuring oral fluid intake, stool output, gain in body weight, decrease in serum specific gravity and correction of acidosis during treatment. Successful rehydration and maintenance of hydration was achieved in 25 adults and 24 children treated with citrate containing ORS and 25 adults and 24 children treated with WHO ORS. The mean intake of ORS/kg body weight in children receiving WHO ORS was greater (p less than 0.05) and correction of acidosis was faster than the citrate group during the initial 24 h of therapy (p less than 0.05). By 48 h, however, both groups showed satisfactory and comparable intake of ORS and correction of acidosis. Thus ORS from effervescent tablets containing sodium citrate base is effective for management of diarrhoea in both adults and children and is a convenient stable form of ORS for use in the home and for travelers.     

Behavior of urban based child caretakers in the home treatment of diarrheal diseases

Behaviors of low income urban mothers and child caretakers in the treatment of childhood less than 5 year diarrhea were analysed from a surveillance study conducted between August 1988 and July 1989. Help seeking behaviors of mothers and caretakers for 412 episodes of child diarrhea were as follows: investigators 37.1%, drug stores 18.2%, wait and see or self treatment 17.0%, private clinics 12.6%, near by hospital 10.2%, and local health center 4.9%. Major treatment practices included ORT alone (54%) and ORT plus antibiotics and/or antidiarrheal drug (22%). Overall ORT usage was 76%. Twelve percent of diarrheal episodes no treatment was given to the children. Antimicrobials were believed to be essential in addition to ORT especially when diarrhea was associated with fever, vomiting and bloody stools. Thirty-six percent of invasive diarrhea cases (Shigella, Salmonella, Campylobacter) were treated with antibiotics. Only 18.2% of noninvasive diarrhea received antibiotics, most of this antibiotic use being in rotavirus diarrhea where vomiting and some fever are prominent. Availability of oral rehydration salts (ORS) and good experience with ORT were the key to the extensive use or ORT in this study. A surprisingly small number of mothers and child caretakers (4.9%) sought help from the local health center when their children had diarrhea.     

Training rural health staff for oral rehydration therapy in southern Sudan

From February 1980 to August 1982 a very definite change occurred in the treatment pattern for diarrhoea among the rural health staff in Torit and Kapoeta districts in Eastern Equatoria Province in Sudan. This paper describes a training and supervision programme for promoting use of ORT in diarrhoeal diseases and at the same time discouraging the use of sulphonamides in simple diarrhoea. In the training programme emphasis is put on increasing the knowledge of the health staff both about the medical facts and about communication with their communities. ORS as treatment for diarrhoea has been well accepted by the public, who consider the sugar/salt solution as "good medicine". The use of sulphonamides for diarrhoea has decreased from 75% to 22% of the diarrhoea cases, while use of ORS has increased from 7% to 72% of the diarrhoea cases.     

Rice-flour-based oral rehydration solution for diarrhoeal diseases

Dehydration and electrolyte imbalance, the main causes of morbidity and mortality in diarrheal diseases, have been treated with glucose-based oral rehydration solutions. However, there have been difficulties due to unavailability, cost and unpalatable solutions. 300 children, from age 4 weeks to 12 years, in Jaffna, Sri Lanka, were treated with rice-flour based oral rehydration solution (ORS). This solution was made by boiling 50g. rice flour with 1 liter water and adding a prepackaged salt packet. 50 grams of rice flour is hydrolyzed to produce 35 grams glucose, 4.35 grams protein and 165 kilocalories. 3 children required hospitalization for intravenous therapy, but the rest responded well to the rice flour based ORS. Diarrhea resolved within 2 to 4 days. The rice flour and salt packet together cost Sri Lanka Rs 1.50 (US$0.06), which is significantly less than the glucose based ORS, which costs Sri Lanks Rs 5.00 (US$0.20). Rice-flour based ORS was found to be an inexpensive, palatable, easily available, and an effective alternative to glucose-based formulas.     

Declining impact of oral rehydration therapy in a Papua New Guinea Highlands Province: a case study with implications for Papua New Guinea's National Diarrheal Disease Control Program.

A provincial diarrheal disease control program that was based on the delivery of oral rehydration solution (ORS) from health facilities now places greater emphasis on the management of diarrhea with fluids at home. The change in strategy has been associated with decreasing utilization of health facilities and increasing mortality from diarrheal disease. The declining impact is attributed to the promotion of home-based management with little preparation of the target population for their therapeutic role. National policy recommends home-based management for mild cases of diarrhea and ORS for more severe cases. Our observations in the Southern Highlands Province have important implications for the diarrheal disease control program in Papua New Guinea.     

Private Sector Provision of Oral Rehydration Therapy for Child Diarrhea in Sub-Saharan Africa

Although diarrheal mortality is cheaply preventable with oral rehydration therapy (ORT), over 700,000 children die of diarrhea annually and many health providers fail to treat diarrheal cases with ORT. Provision of ORT may differ between for-profit and public providers. This study used Demographic and Health Survey data from 19,059 children across 29 countries in sub-Saharan Africa from 2003 to 2011 to measure differences in child diarrhea treatment between private for-profit and public health providers. Differences in treatment provision were estimated using probit regression models controlling for key confounders. For-profit providers were 15% points less likely to provide ORT (95% confidence interval [CI] 13–17) than public providers and 12% points more likely to provide other treatments (95% CI 10–15). These disparities in ORT provision were more pronounced for poorer children in rural areas. As private healthcare in sub-Saharan Africa continues to expand, interventions to increase private sector provision of ORT should be explored.     

Factors affecting utilization of health care services by mothers of children ill with diarrhea in rural Vietnam

To examine the use of health services for the treatment of childhood diarrhea in three southern provinces of Vietnam, and identified household, maternal, child and health service characteristics associated with this use, a cross-sectional household survey was conducted between November 1998 and January 1999. Women with a pre-school aged child living at home were the primary respondents for the survey questionnaires. Respondents were asked to recall diarrheal disease events experienced by their child during the two weeks prior to interview, and their responses to these events. Prevalence ratios (PR) were used to identify associations between maternal age, education, occupation, ethnicity, knowledge about diarrhea, feeding practises during diarrhea, household residence and economic status, disease severity, use of oral rehydration solution (ORS), time to nearest health care facility and overall satisfaction with local medical services, and the use of health care services for children ill with diarrhea. The two-week period prevalence of childhood diarrhea was 10% and varied by the province and ethnicity of the child's mother. Forty-three percent of mothers reported using ORS during diarrheal episodes. Seventy percent of mothers sought advice or treatment when their child became ill with diarrhea. After controlling for potential confounders in regression models, maternal ethnicity, maternal high school education (in comparison to no education or incomplete primary education), more severe disease and the use of ORS were factors associated with increased utilization of health care services. There was a low level of the utilization of ORS to treat children with diarrhea, especially by ethnic minority mothers. A high percentage of mothers reported low levels of satisfaction with medical services, especially those from ethnic minorities. Mothers from ethnic minorities and those with lower levels of education were less likely to seek advice or treatment. These findings suggest the need for programs to promote the use of ORS and use of appropriate services for the treatment of childhood diarrheal disease. Interventions are needed to improve the access of ethnic minority children to child health care services for the treatment of diarrhea.     

The treatment of acute diarrhea in the third millennium: a pediatrician's perspective

Diarrheal diseases continue to be a major cause of morbidity and mortality worldwide. Although new, potentially useful drugs such as acetorphan are appearing at the horizon, the cornerstone of treatment remains a proper oral rehydration (ORT). Yet, the rates at which ORT is used are still disappointingly low. Despite dramatic progresses in the understanding of the pathophysiology of diarrhea, the list of available drugs is indeed short. Recently however, several new options have appeared that may bear a great potential in the near future. The first is a potential improvement of ORS. It was recently shown that the addition of a resistant starch to oral rehydration solution reduces fecal fluid loss and shortens the duration of diarrhea in patients with cholera. Starches that are resistant to hydrolysis by amylase in fact generate in the colon short-chain fatty acids, which are known to enhance sodium absorption. The second development in treating diarrheal disease is acetorphan (racecadotril). This enkephalinase inhibitor has in fact been shown to be effective in reducing by almost half the stool output of 135 young children with acute diarrhea. Finally, probiotics. In the last few years, they have attracted a great deal of renewed interest, particularly focusing on their effects in treating and preventing diarrheal diseases. Lactobacillus GG proved effective in several clinical trials, mostly randomized and placebo-controlled, in the prevention and/or treatment of acute diarrheal disease in children. We have recently shown (6) the safety and efficacy in its administration in the ORS, especially in Rotavirus-induced diarrheas, in a large multicenter, randomized, double blind and placebo-controlled study conducted on behalf of the ESPGHAN Working Group on Acute Diarrhea.     

Control study of oral rehydration solution (ORS)/ORS + dioctahedral smectite in hospitalized Thai infants with acute secretory diarrhea.

Dioctahedral smectite, a non systemic antidiarrheal agent, is mucoprotective and absorbs enterotoxins and rotavirus as demonstrated in animal models. Smectite has been successfully used in various countries in children and adults with acute diarrhea. This study was to assess the efficiency of smectite associated with rehydration in infants with acute secretory diarrhea. Sixty-two hospitalized Thai infants, aged 1-24 months, with acute secretory diarrhea were randomly divided into 2 groups receiving (1) oral rehydration solution (ORS) (30 cases), (2) ORS and Smectite (3.6 g/day) (32 cases). Both groups were comparable for age, weight, nutritional status and duration of symptoms before treatment. All 62 infants received lactose free formula and chicken rice soup as the standard diet. Stool frequency, weight change and duration of diarrhea were recorded. The mean duration of diarrhea was 84.7 +/- 48.5 hours in group 1, and 43.3 +/- 25.1 hours in group 2 (p = 0.005). The number of infants with diarrhea was significantly lower in group 2 on Day 1 (p < 0.01) and Day 3 (p = 0.001); furthermore 27% of infants in group 1 and 3% in group 2 had still diarrhea on Day 5. The stool frequency and weight changes were not statistically different in the two groups. No major side effects were observed except two cases of vomiting and hardened stools. It is concluded that (1) Smectite shortens the course of acute secretory diarrhea in Thai infants; (2) smectite may reduce the occurrence of prolonged diarrhea; furthermore (3) in our study dioctahedral smectite was found to be safe in children aged 1 to 24 months.     

Continuous oral hydration or with fractionated doses in acute diarrhea-induced dehydration in children

OBJECTIVE: To evaluate the safety and effectiveness of two oral rehydration techniques. MATERIAL AND METHODS: A randomized clinical trial was conducted at the oral rehydration unit of Hospital Infantil de Mexico "Federico Gomez", between September 1998 and June 1999. Forty patients five-year old and younger children, dehydrated due to acute diarrhea, were given oral rehydration solution (ORS) ad libitum (AL group); another forty patients received ORS in fractionated doses (FD group). Clinical characteristics were similar in both groups. Results are presented as means, standard deviations and medians, according the distribution of simple and relative frequencies. RESULTS: The mean stool output in the AL group was 11.0 +/- 7.5 g/kg/h; as compared to 7.1 +/- 7.4 in the FD group (p = 0.03). ORS intake, rehydration time, and mean diuresis values were similar in both groups (p > 0.05). Six patients in the AL group and five in the FD group had high stool output (> 10 g/kg/h), that improved after administration of rice starch solution. One patient in the AL group and two in the FD group had persistent vomiting that improved with gastroclisis. No patient required intravenous rehydration. CONCLUSIONS: These results suggest that ORS administration ad libitum under supervision, is a technique as safe and effective as the fractionated doses technique, for the treatment of dehydrated children due to acute diarrhea.     

Gum arabic promotes rat jejunal sodium and water absorption from oral rehydration solutions in two models of diarrhea

BACKGROUND & AIMS: We have shown that addition of gum arabic (GA) to a 90 mmol/L sodium-111 mmol/L glucose oral rehydration solution (ORS) enhances its effectiveness for water and electrolyte absorption in normal rats. The present study extends these observations on GA in ORS to two rat models of diarrheal disease. METHODS: Juvenile rats were either treated for 1 week with magnesium citrate-phenolphthalein to produce chronic osmotic-secretory diarrhea or luminally exposed to 10 mmol/L theophylline to induce jejunal secretion. In both models jejunal perfusion was used to assess absorption. RESULTS: Addition of 2.5 or 5.0 g/L GA to ORS increased roughly twofold absorption of sodium, potassium, and water in the model of chronic osmotic-secretory diarrhea. Rats perfused with GA-supplemented ORS showed an expansion of the basolateral intercellular spaces between villus absorptive epithelial cells and the lamina propria, reflecting enhanced water and sodium absorption. Similarly, addition of 2.5, 5.0, or 10.0 g/L GA to the ORS neutralized theophylline-induced abolition of net sodium and potassium absorption and reversed water and glucose malabsorption. CONCLUSIONS: These experimental studies in models of diarrhea suggest that GA may be a useful additive to ORS for the potentiation of water and electrolyte absorption. (Gastroenterology 1997 Jun;112(6):1979-85)     

Oral rehydration solution in the year 2000: pathophysiology,efficacy and effectiveness

The use of oral rehydration solution (ORS) with early refeeding forms the basis of therapy for dehydration secondary to diarrhoea. ORS has produced such positive results in dehydrated patients that no further scientific demonstration is needed to confirm its efficacy. This review presents several issues that remain unsettled or controversial. They include the following.

• 1.1. The mechanism of water handling by the intestine is discussed; this is more complex than initially thought, at the epithelial, cellular and molecular level.
• 2.2. The composition of ORS which has been successfully adapted for the most frequent conditions, except for severely malnourished children, is described.
• 3.3. In contrast to the strong scientific basis and obvious efficacy in rehydration of ORS, its consequences for growth, nutrition and mortality are difficult to demonstrate, unless adequate long-term nutritional support is also provided in addition to ORS.
• 4.4. Finally, discrepancies between the recommendations and the practice of oral rehydration therapy are now well documented. Analysis of the causes of these discrepancies may participate in improving public health campaigns.

     

Does oral rehydration therapy alter food consumption and absorption of nutrients in children with cholera?

In order to estimate consumption of food and absorption of nutrients, a metabolic balance study was conducted in 47 children between 1 and 5 years old, suffering from acute cholera. Twenty-two of the children were treated by intravenous solution (IV) only and 25 others by oral rehydration along with intravenous solution (ORS/IV) when necessary. After initial rehydration a nonabsorbable charcoal marker was fed to the patients followed by a typical Bangladeshi home food of known composition offered ad libitum. Appearance of the first marker in the faeces was taken as zero hour (0 h); at 72 h a second marker was fed. Faeces, urine and vomitus were collected up to the appearance of the second marker. Intake of IV fluid, ORS and any other fluid or food were recorded accurately. Samples of faeces, urine and vomitus were analysed for energy, fat and nitrogen. Consumption of nutrients and absorption in both groups were calculated. There was no significant difference in the intake or absorption of energy or carbohydrate between the two groups. The consumption of fat and protein was slightly, but significantly, lower in the ORS/IV group during the acute stage of diarrhoea than in the IV group. Absorption of nitrogen was significantly lower in the ORS/IV group, but absorption of fat was not significantly impaired. Vomiting was significantly higher in the ORS/IV group. The differences in the consumption and absorption of nutrients between the two groups were transient and came to the same level within 2 weeks after recovery.     

Effects of food with two oral rehydration therapies: a randomised controlled clinical trial.

To evaluate the impact of food on the efficacy of oral rehydration solution (ORS), a randomised, controlled clinical trial was conducted in 182 adults with cholera. After initial rehydration with an intravenous polyelectrolyte solution for four hours, the patients were randomised to receive one of four rehydration therapies: glucose based ORS and no food for the first 24 hours (group A), glucose based ORS plus food from the beginning of treatment (group B), rice based ORS with no food for the first 24 hours (group C), and rice based ORS plus food from start of therapy (group D). Tetracycline was given after 72 hours to all patients. No significant differences in ORS intake, stool output, and duration of diarrhoea were noted between groups A and B and between groups C and D. A substantial and significant reduction in stool output was, however, shown in the groups who received rice based ORS irrespective of feeding. These results show that food does not potentiate the efficacy of either glucose based or rice based ORS in adults with cholera. Rice based ORS compared with glucose ORS substantially reduces purging in cholera patients.