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.     

Absorption of a hypotonic oral rehydration solution in a human model of cholera.

The development of oral rehydration solutions (ORSs) has been one of the important therapeutic advances of this century. The optimal formulation, however, of ORSs for both cholera and other infective diarrhoeas is still debated. Part of the problem in developing ORSs has been the lack of adequate test systems for the assessment of new formulations before clinical trial. We have developed a jejunal perfusion, cholera toxin induced, secretory model in humans and have compared net water and solute absorption from a hypotonic ORS (HYPO-ORS: sodium 60 mmol/l, glucose 90 mmol/l, osmolality 240 mOsm/kg) and the British Pharmacopoeia recommended ORS (UK-ORS: sodium 35 mmol/l, glucose 200 mmol/l, osmolality 310 mOsm/kg) in six healthy volunteers. A plasma electrolyte solution (PES) was also perfused in all subjects to confirm a secretory state. Only HYPO-ORS reversed sodium secretion to absorption (p < 0.01). Both ORSs promoted net water absorption but this was greatest with HYPO-ORS (p < 0.01). Glucose and potassium absorption rates were similar for both ORSs whereas chloride absorption mirrored sodium absorption and was greatest from HYPO-ORS (p < 0.05). These results, in a biologically relevant model of secretory diarrhoea, suggest it may be possible to achieve improved rates of rehydration by the use of hypotonic ORS with mid range sodium concentrations.     

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.     

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.     

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-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.     

Patterns of use of oral rehydration therapy in Srinagar (Garhwal), Uttaranchal,India

A study was conducted to assess the knowledge of preparing packet oral rehydration solution (ORS) and home-made salt-sugar solution (SSS) among mothers in Srinagar (Garhwal), Uttaranchal. Two hundred and twenty-five mothers were interviewed. Only a small proportion recognized the ORS packets (18.66%) and only 17.77% mentioned the correct method of preparing a solution from a packet (even after reading the instructions on the packet). Homemade SSS was adequately discussed by only 6.22% mothers and they were taught to correctly prepare and administer ORS and home-made SSS. After the educational programme, significant (P < 0.001) improvement in their knowledge was found. Eighty-six per cent knew the correct method of preparing packet ORS and 80.88% the correct method of preparing homemade SSS (P < 0.001). Interventions of this kind should be carried out to improve the knowledge and skills of mothers in treating childhood diarrhoea.     

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.     

A controlled trial comparing the efficacy of rice-based and hypotonic glucose oral rehydration solutions in infants and young children with gastroenteritis

A prospective randomized trial was conducted to compare the efficacy of a rice-based oral rehydration solution (ORS) with glucose ORS in infants and children under 5 years of age with acute diarrhoea and mild to moderate dehydration (< 10%). One hundred children presenting to a large metropolitan teaching hospital were eligible for entry to the study and were randomized to receive rice ORS or glucose ORS. Outcome measures were stool output (SO), duration of illness (DD) and recovery time to introduction of other fluids (RTF) and diet (RTD). Significant differences were found for all outcome measures in favour of the rice ORS group. Mean SO was lower (160 vs 213 mL; P < 0.02), mean DD was reduced (17.3 vs 24.3 h; P = 0.03) and median RTF was decreased (12.7 vs 18.1 h; P < 0.001) in the rice ORS group compared with the glucose ORS group. The median time to introduction of diet and mean length of hospital stay showed similar significant reductions. Our study has shown rice ORS to be an acceptable alternative to glucose ORS in young children and have shown that it is significantly more effective in reducing the course of diarrhoeal illness and the time taken to return to normal drinking and eating habits.     

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.     

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.     

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.     

The management of diarrhoea in young children in a rural community in Zambia

Among 64 mothers in two villages in a rural Zambian population who reported childhood diarrhoea, 41 (64%) sought treatment from a health centre or clinic. Among these, 22 (54%) were given oral rehydration salts (ORS) and 19 (46%) were given medications other than ORS. Among the 23 who did not attend a health centre, 14 gave home remedies which included salt and sugar solution, of which, in five, the medicines used were from traditional healers. Overall, 43 (67.2%) of the mothers used some fluids as the first line of treatment. The fluids were infrequently given and in almost all instances, irrespective of the source of the fluid, no more than 15 ml were given over a 24 h period. Furthermore, among the mothers who used fluids, 28 (65.1%) reported stopping the fluids completely if the child vomited. None of the mothers however reported completely withdrawing food from the children. Age and educational level of the mother were not significant factors (P greater than 0.05). These findings suggest that education of mothers on home management of diarrhoea and the proper use of ORS needs to be re-emphasized and health care personnel need to be fully conversant with currently recommended methods for treatment of childhood diarrhoea.     

Water and solute absorption from hypotonic glucose-electrolyte solutions in human jejunum.

While oral rehydration therapy with glucose-electrolyte solutions is highly effective, the optimal formulation has not yet been defined. Recent clinical studies suggest that stool volume, and thus water losses, may be reduced if glucose is replaced by a polymeric substrate which reduces osmolality. It is possible that the efficacy of glucose monomer based oral rehydration solutions (ORS) will also improve if osmolality is decreased. Using jejunal triple lumen perfusion in healthy adult volunteers net water and solute absorption were studied from three hypotonic solutions with different sodium concentrations (46, 60, 75 mmol/l) but identical glucose concentrations (90 mmol/l), thus allowing osmolality to rise (210, 240, and 270 mOsm/kg, respectively). Results from these solutions (ORS 45:210, ORS 60:240, and ORS 75:270) were compared with the World Health Organisation oral rehydration solution (WHO-ORS). Greatest water absorption was seen with ORS 60:240 (p less than 0.01). Sodium absorption from ORS 60:240 and WHO-ORS was similar and greater than sodium absorption from ORS 45:210 (p less than 0.05). Potassium and glucose absorption were greater from ORS 60:240 than from any of the other hypotonic solutions (p less than 0.05) and were equal to absorption from WHO-ORS). These results in a short segment of healthy human jejunum suggest that hypotonic ORS containing monomeric glucose may increase water absorption.     

Treatment of rotaviral gastroenteritis with Oiwei Baizhu powder

AIM To observe the effects of Qiwei Baizhu Powder ( QWBZP) on rotaviral gastroenteritis in children and in animal models.``METHODS Enrolled patients were divided into two groups, and one group was treated with oral rehydration solution(ORS) and the other treated with oral liquid of QWBZP. Neonate mice were orally infected with 50 μLrotavirus suspension (4 × l0s PFU/mL) and treated with ORS or oral liquid of QWBZP, respectively.``RESULTS Eighty-three cases of rotaviral gastroenteritis treated with QWBZP revealed a better efficacy than that treated with ORS (x2 - 10.8T, P<0.05). The contents of sodium and glucose as well as number of patients with positive human rotavirus antigen in stool in QWBZP group were all less than that in ORS group. In animal models,QWBZP was found effective in treating rotavirus gastroenteritis in neonate NIH mice, as compared with control groups. In QWBZP group, the mortality of infected mice was decreased by 73.3%, the body weight of infected mice was increased, the contents of sodium and glucose as well as number of mice with positive rotavirus antigen in feces were significantly reduced, and the pathological changes such as damage of small intestinal mucosa and villi were also obviously alleviated.``CONCLUSION QWBZP has effects on improving the absorptive function of small intestine, shortening the duration of diarrhea and rotavirus shedding from stool and alleviating the pathological changes of small intestine induced by rotavirus.``     

Treatment of rotaviral gastroenteritis with Qiwei Baizhu powder

AIM To observe the effects of Qiwei Baizhu Powder(QWBZP)on rotaviral gastroenteritis in children and inanimal models.METHODS Enrolled patients were divided into twogroups,and one group was treated with oral rehydrationsolution(ORS)and the other treated with oral liquid ofQWBZP.Neonate mice were orally infected with 50μLrotavirus suspension(4×10~8 PFU/mL)and treated withORS or oral liquid of QWBZP,respectively.RESULTS Eighty-three cases of rotaviral gastroenteritistreated with QWBZP revealed a better efficacy than thattreated with ORS(X~2=10.87,P<0.05).The contents ofsodium and glucose as well as number of patients withpositive human rotavirus antigen in stool in QWBZP groupwere all less than that in ORS group.In animal models,QWBZP was found effective in treating rotavirusgastroenteritis in neonate NIH mice,as compared withcontrol groups.In QWBZP group,the mortality of infectedmice was decreased by 73.3%,the body weight ofinfected mice was increased,the contents of sodium andglucose as well as number of mice with positive rotavirusantigen in feces were significantly reduced,and thepathological changes such as damage of small intestinalmucosa and villi were also obviously alleviated.CONCLUSION QWBZP has effects on improving theabsorptive function of small intestine,shortening theduration of diarrhea and rotavirus shedding from stool andalleviating the pathological changes of small intestineinduced by rotavirus.     

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.

     

Oral rehydration solution safely used in breast-fed children without additional water

Sixty-four children of age 3 months to 2 years were treated for diarrhoea in a rural treatment centre with oral rehydration solution (90 mmol/l Na+); plain water was not supplied during rehydration. All children continued breast-feeding during the therapy. Serum sodium levels after 24 h of intake indicated that 61 children had serum sodium level below 148 mmol/l and three were above (range 150-151). None of the children developed clinical signs or symptoms of hypernatremia. The use of additional water may not be necessary during rehydration therapy of breast-fed children.