The role of oral electrolyte-glucose solutions in hydration for children--international and domestic aspects

The History of Intravenous and Oral Rehydration and Maintenance Therapy of Cholera and Non-Cholera Dehydrating Diarrheas: A Deconstruction of Translational Medicine: From Bench to Bedside?

The "bench to bedside" (BTB) paradigm of translational medicine (TM) assumes that medical progress emanates from basic science discoveries transforming clinical therapeutic models. However, a recent report found that most published medical research is false due, among other factors, to small samples, inherent bias and inappropriate statistical applications. Translation-blocking factors include the validity (or lack thereof) of the underlying pathophysiological constructs and related therapeutic paradigms and adherence to faulty traditional beliefs. Empirical discoveries have also led to major therapeutic advances, but scientific dogma has retrospectively retranslated these into the BTB paradigm. A review of the history of intravenous (I.V.) and oral therapy for cholera and NDDs illustrates some fallacies of the BTB model and highlights pitfalls blocking translational and transformative progress, and retro-translational factors, including programmatic modifications of therapeutic advances contradicting therapeutic paradigms and medical economic factors promoting more expensive and profitable medical applications inaccessible to resource-limited environments.

Recent Advances of Oral Rehydration Therapy (ORT)

Diarrheal disease is one of the leading causes of worldwide morbidity and mortality, especially in children. It causes loss of body fluid, which may lead to severe dehydration, electrolyte imbalance, shock and even to death. The mortality rate from acute diarrhea has decreased over the last few decades. This decline, especially in developing countries is largely due to the implantation of the standard World Health Organization-oral rehydration solution (WHO-ORS). However, the use of standard ORS has been limited by its inability to reduce fecal volume or diarrhea duration. Subsequently, this has led to various attempts to modify its compositions. And these modifications include the use of reduced osmolarity ORS, polymer-based ORS and zinc supplementation. Some of these variations have been successful and others are still under investigation. Therefore, further trials are needed to progress toward the ideal ORS. In this article, we briefly reviewed the pathophysiologic basis of the ORS, followed by the standard WHO-ORS and several modifications to improve the ORS.

Contributions of Native Americans to the global control of infectious diseases

For over a half of a century, Native American populations have participated in numerous studies regarding the epidemiology, prevention and treatment of infectious diseases. These studies have resulted in measures to prevent morbidity and mortality from many infectious diseases. The lessons learned from these studies and their resultant prevention or treatment interventions have been applied around the world, and have had a major impact in the reduction of global childhood morbidity and mortality.

Diagnosis of bacterial enteric infections in children in Zambia

BACKGROUND

The bacterial pathogens commonly responsible for diarrhea in children under the age of 5 in Zambia were identified and the most effective methods of diagnosis of such infections in laboratories with limited resources, such as those in developing countries, are recommended.

METHODS

Stool samples were collected from children under the age of 5 years who visited the Diarrhoea Training Unit (DTU) of Zambia University Teaching Hospital in Lusaka, Zambia, between May 1992 and May 1993. A total of 639 children were evaluated for the presence of bacterial infection using standard culture media. The prevalence of bacterial pathogens was compared with that reported from other developing countries.

RESULTS

Pathogenic strains of Escherichia coli were isolated from 95 (14.9%) children, Shigella species from 65 (10.2%) children, and Vibrio cholerae from 21 (3.3%) children. The presence of visible blood in the feces was an early indicator of the presence of shigellosis.

CONCLUSIONS

E. coli, Shigella species and Vibrio cholerae were the major causes of bacterial diarrhea in the Zambian children studied. Research is required to determine the prevalence of such enteropathogenic strains. The use of adequate diagnostic procedures is indispensable to appropriate management. The recommendations have been prepared as a manual for the identification of enteropathogenic bacteria to be used in laboratories with limited resources, such as in developing countries.

Oral rehydration therapy

Oral rehydration therapy (ORT) with glucose-electrolyte solutions has been considered to be one of the greatest therapeutic advances of this century. ORT is effective in acute diarrheal disease of diverse etiology. The most widely used oral rehydration solution (ORS) worldwide is that recommended by the World Health Organisation (Na 90, K 20, glucose 111 and citrate 10 mmol/L). Attempts to improve the efficacy of ORS have been made by using complex substrates (rice and other cereals) in place of glucose, and by reducing osmolality by decreasing glucose and sodium concentrations in monomeric ORS. ORS may have wider applications in the management of patients with the short bowel syndrome and in post-surgical patients.

Rehydration and nutritional management

Diarrhoea remains a leading worldwide cause of morbidity and mortality. In developing countries alone, 1.5 billion episodes of diarrhoea occur per year in children under 5 years of age and approximately 4,000,000 of these result in death. Early, appropriate therapy decreases the risk of complications and death due to diarrhoea. Regardless of the causative agent, oral rehydration and nutritional management are the mainstays of good management of infants, children and adults with diarrhoea. Diarrhoeal disease control programmes throughout the developing world have adopted the WHO case management plan as a standard. In this chapter, we review the history, successes and shortcomings of various oral rehydration therapies and recommend a case management approach that is similar to the WHO plan. Although ORT is safe, effective, convenient and economical, this therapy has not been universally implemented in health care settings. The challenge for clinical and public health practitioners in developing and developed countries is to identify and overcome the barriers that exist so that all patients with diarrhoea will have the opportunity to receive optimal care.

Oral rehydration therapy

Diarrhea is a major cause of mortality and morbidity affecting infants and children in many parts of the world. Research and understanding of normal and abnormal gastrointestinal physiology allowed the development of oral electrolyte solutions to treat dehydration. These solutions were initially used for treatment of cholera in areas with poor access to medical care and are now used extensively by the WHO. Therapy with OES has expanded to other nonsecretory causes of diarrhea. Two types of solutions are available in the United States. Maintenance solutions contain 40 to 60 mEq per liter of sodium and are used for prevention of dehydration or after rehydration. Rehydration solutions contain 60 to 90 mEq per liter of sodium and are effective for the oral repletion of fluid and electrolyte deficits in both secretory and nonsecretory diarrhea.

Clinical presentation and management of acute gastro-enteritis in in-patient children at King Khalid University Hospital, Riyadh, Saudi Arabia

In a retrospective survey, case notes of all children with acute gastro-enteritis (AGE) admitted to our hospital between 1984 and 1988 were reviewed. The total number of cases was 300. The mean age was 14 months (range 1-60 mths): 67% of cases were boys and 33% girls. Eleven per cent were exclusively breastfed. The clinical presentation was diarrhoea and vomiting in 81%, diarrhoea alone in 15%, and vomiting primarily in 4%. All children had good nutritional status, i.e. both their height and weight were between the 5th and 90th percentile for their age and none showed signs of marasmus or kwashiorkor. Forty-six per cent of the children had AGE without dehydration. Mild, moderate and severe dehydration was present in 41%, 10% and 3% of cases, respectively. Isotonic, hypotonic and hypernatraemic dehydration was present in 95%, 3% and 2% of cases of dehydration, respectively. Sixty-five per cent of cases were given intravenous (IV) fluids. The mean duration of IV administration was 1 day, with a range of 1-7 days. Twenty-two per cent of the children were given oral rehydration solution (ORS) initially, and 13% were given IV plus ORS. None of the children died of gastro-enteritis. It is concluded that there was excessive use of IV fluids, and that there is an urgent need to encourage the use of ORS.

Optimising oral rehydration solution composition for the children of Europe: clinical trials

Clinical trials testing different oral rehydration solutions (ORS) are reviewed. The effects of individual components and their concentrations are analysed in order to establish margins of safety for the composition of the ideal ORS for children in Europe. Glucose is the solute of choice for ORS and concentrations of 70-140 mmol/l are adequate. Glucose may be replaced by sucrose or glucose polymers. "Low" sodium concentrations (35-60 mmol/l) are advised for rehydration and maintenance in acute non-cholera diarrhoea, for children of all ages, including neonates, and for any degree of dehydration except shock. Although intended for children who are not malnourished, the European ORS should have an adequate potassium concentration (20-30 mmol/l), namely the same concentration as found in WHO-ORS. Chloride concentration depends upon other constituents of ORS, namely sodium and potassium, but the range of 30-90 mmol/l is considered to be adequate. Base or base precursors are not required for correction of acidosis except in the severe cases that always need intravenous replacement. A relatively low osmolality seems advisable.

Some preliminary considerations on the sobada: a traditional treatment for gastrointestinal illness in Costa Rica

Although Costa Rica has one of the most effective national health systems in Latin America, popular medicine still persists. The sobada is a traditional healing technique which involves rubbing. Used principally to treat pega, a folk-diagnosed gastrointestinal condition which mainly affects children and old people, it was used by 70% of a random sample of families from the poorer barrios of San José. In recent years Costa Rica's health system has been under great strain because of increased costs and numbers of users. The prevalence and possible resurgence of the sobada may be an adaptation of poor people to national health services which have grown suddenly very large and impersonal and to the recent introduction of oral rehydration in hospital settings.

Oral rehydration therapy--a review

REHYDRATION AND maintenance of adequate fluid and electrolyte balance is the key to the management of the child with acute diarrheal disease. Oral rehydration treatment has been shown to be simple, practical, inexpensive, highly effective and safe for developing as well as for developed countries. A better understanding of the physiological mechanisms implicated in diarrheal illness as well as extensive clinical testing of oral rehydration solutions have lead to the improvement of the composition of electrolyte, carbohydrate and base constituents. The widespread use of oral rehydration therapy may result in a decreased need for hospitalization and less discomfort and complications which are associated with intravenous rehydration therapy.

Evaluation of an oral rehydration solution with Na+ 60 mmol/l in infants hospitalized for acute diarrhoea or treated as outpatients

An oral rehydration solution (ORS) containing 60 mmol/l of Na+ (ORS60) was compared in a randomized trial with the ORS of WHO formula (Na+ 90 mmol/l = ORS90) for the treatment of diarrhoeal dehydration in 66 hospitalized infants aged 3 to 34 months. The infants had a 5 +/- 3% dehydration, and received within 6-10 hours 76 +/- 32 ml/kg of ORS60 or 74 +/- 41 ml/kg of ORS90 corresponding to a sodium input of 4.6 +/- 1.9 mmol/kg and 6.6 +/- 3.7 mmol/kg, respectively. Both treatments were found adequate and equally effective for the correction of dehydration and sodium deficit. The same ORS60 was also compared to a commercial low sodium glucose-electrolyte solution (sodium 35 mmol/l, glucose 3.5 milligrams) for ambulatory treatment of acute diarrhoea in infants. Satisfactory rehydration was achieved within 6 hours in 19 of 23 infants receiving ORS60 as opposed to 6 of 18 infants receiving the commercial solution (p less than 0.001); the poor result with the latter was in most cases attributed to a refusal by the infant to consume the sweetish solution. It is concluded that ORS60 is suitable for the treatment of isotonic diarrhoeal dehydration in hospitalized children as well as outpatients.

Hypernatremic dehydration in children with severe psychomotor retardation

Three cases of hypernatremic dehydration in children with severe psychomotor retardation are described. All the children were receiving processed foods that contained extremely high amounts of sodium and were unintentionally deprived of free water. Salt and water intake must be monitored closely in children who can neither communicate thirst nor regulate their diet.

Honey in the treatment of infantile gastroenteritis

A clinical study was undertaken using honey in oral rehydration solution in infants and children with gastroenteritis. The aim was to evaluate the influence of honey on the duration of acute diarrhoea and its value as a glucose substitute in oral rehydration. The results showed that honey shortens the duration of bacterial diarrhoea, does not prolong the duration of non-bacterial diarrhoea, and may safely be used as a substitute for glucose in an oral rehydration solution containing electrolytes. The correct dilution of honey, as well as the presence of electrolytes in the oral rehydration solution, however, must be maintained.

Oral rehydration therapy of severe diarrheal dehydration

In 1980, 104 infants with seven to 15 percent dehydration due to severe diarrhea and vomiting were hospitalized in Tehran and treated in two separate phases, deficit therapy and maintenance therapy, using two isotonic oral solutions. For deficit therapy, solution A (sodium 80, potassium 20 mmol/l) was administered at a rate of 40 ml/kg per hour until all signs of dehydration disappeared. For maintenance therapy, solution B (sodium 40, potassium 30 mmol/l) was given sip by sip at a rate of about 250 ml/kg per 24 hours until diarrhea stopped. Intravenous fluids were not used, even in severe dehydration and shock. The efficacy and safety of this regimen were confirmed by rapid and successful rehydration and correction of electrolyte abnormalities present on admission.

Oral rehydration therapy in diarrhea. Not just for Third World children

Oral rehydration therapy is an effective, practical, and economical means of treatment for dehydration secondary to diarrhea. The regimen can be used on an outpatient basis with a substantial reduction in both cost and hospital-induced anxiety. It is not necessary to discontinue breast-feeding infants with diarrhea, and early feeding does not prolong the diarrheal illness.

High sugar worse than high sodium in oral rehydration solutions

The literature on oral sugar-electrolyte mixtures for treatment of acute diarrhoea is reviewed. Several trials have shown that the solution proposed by the WHO for developing countries containing inter alia 90 mmol/l of sodium and 111 mmol/l of glucose is safe for short term oral rehydration. When used in this manner there is no risk for development of hypernatraemia. The surplus base of the solution is not essential and, furthermore, other anions e.g. acetate may be substitute for bicarbonate. Other modifications of the WHO formula have also been successfully tried, e.g. sucrose 4% (117 mmol/l) instead of glucose 2% (111 mmol/l). A somewhat lower concentration of sucrose may, however, prove to be better. Most acute childhood diarrhoeas are not mediated by enterotoxin and thus not of the secretory type, but temporary malabsorption is common. Therefore, the amount of carbohydrate in oral sugar-electrolyte mixtures should be limited. Osmotic diarrhoea due to carbohydrate malabsorption is a more likely cause of hypernatraemia in dehydrated children than too much dietary sodium. In developed countries prepacked oral sugar-electrolyte mixtures are mainly designed for moderately sick children treated at home. There is no reason to raise the carbohydrate content of these mixtures above that of the WHO formula, but the sodium content must be lower. For most situations in home treatment 50 mmol/l of sodium will be adequate.

Oral hydration of diarrhoeal dehydration. Comparison of high and low sodium concentration in rehydration solutions

Oral hydration of diarrhoeal dehydration. Acta Paediatr Scand, 72:167, 1983.--Two groups of infants aged 2 to 20 months with moderate to severe dehydration were randomly assigned to either sucrose high sodium (90 mEq/l) or sucrose low sodium (58 mEq/l) solution in a double blind manner. Rehydration was assessed on clinical grounds and confirmed by serial determination of body weight, hematocrit, total serum protein and blood urea nitrogen. Twenty (80%) of 25 patients on sucrose high sodium solution and 20 (77%) of 26 patients on sucrose low sodium solution were successfully hydrated. Only the assigned sucrose-electrolyte solution was given during the average rehydration period of about 7 hours when the serum electrolytes were remeasured. Three patients on high sodium solution developed mild hypernatremia. Slight hyponatremia was encountered in 2 patients on low sodium solution. Purging rate was significantly higher in patients who failed as compared to those who succeeded. The results of this study suggest that oral sugar electrolyte solution with sodium concentration of 90 mEq/l is safe and effective in the majority of infants with diarrhoeal dehydration of diverse causes. However, intravenous fluids must be available particularly for those with a high purging rate as a significant number of them may fail.

Oral rehydration therapy of infantile diarrhea: a controlled study of well-nourished children hospitalized in the United States and Panama

Although oral glucose-electrolyte solutions containing 90 mmol of sodium per liter have been widely used in the treatment of acute diarrhea among under-nourished children in the developing world, they have rarely been studied in well-nourished children. We therefore conducted a controlled randomized study among well-nourished children three months to two years who were hospitalized with acute diarrhea (52 in the United States, and 94 in Panama), to compare the efficacy of this solution with that of one containing 50 mmol of sodium per liter and with standard intravenous therapy. Oral rehydration with both solutions according to protocol was successful in 97 of 98 children (one required unscheduled intravenous therapy), and in 87 (89 per cent) no intravenous therapy was required. All of six children admitted with hypernatremia were successfully treated with oral therapy alone. We conclude that glucose-electrolyte oral solutions containing either 50 or 90 mmol of sodium per liter are effective and safe in the treatment of well-nourished children hospitalized with acute diarrhea, and that they may completely replace the intravenous fluids in the majority of such children.

Oral solutions for gastroenteritis--optimal glucose concentration

About half of all infants and toddlers with infectious diarrhoea of probable virus aetiology and treated with an oral rehydration solution containing 4.6% glucose had faecal glucose greater than or equal to 0.3%. In most of them the faecal concentration of glucose was higher than 0.50%. From the physiological point of view, it seems wise to decrease the glucose concentration substantially from that so often recommended for the treatment of diarrhoea in developed countries.