Corn syrup sugars: in vitro and in vivo digestibility and clinical tolerance in acute diarrhea of infancy

Splanchnic bed metabolism of glucose in preterm neonates

BACKGROUND

Glucose is a major oxidative substrate for intestinal energy generation in neonatal animals; however, few data in preterm infants are available. Early administration of enteral nutrition, including glucose, may be an effective strategy to support intestinal adaptation to extrauterine life in preterm neonates.

OBJECTIVE

The purpose of the present study was to quantify the first-pass uptake and oxidation of glucose by the splanchnic tissues (intestine and liver) in human neonates.

DESIGN

Eight preterm infants [birth weight ( +/- SD): 1.19 +/- 0.22 kg, gestational age: 29 +/- 1 wk] were studied while they received 2 different enteral intakes (A: 40% enteral, 60% parenteral, total glucose intake = 7.5 +/- 0.5 mg. kg(-1). min(-1), and B: 100% enteral, total glucose intake = 7.8 +/- 0.4 mg. kg(-1). min(-1)). Splanchnic and whole-body glucose kinetics were measured by use of dual-tracer techniques.

RESULTS

During both feeding periods, approximately one-third of dietary glucose intake was utilized during the first pass by the splanchnic tissues. More than three-quarters of this utilized glucose was oxidized in both periods (79 +/- 36% with A and 84 +/- 45% with B). Whole-body glucose oxidation was substantial under both circumstances: 72 +/- 5% and 77% +/- 6% of the glucose flux was oxidized during partial (A) and full (B) enteral feeding, respectively.

CONCLUSIONS

Approximately one-third of dietary glucose is utilized during the first pass by the splanchnic tissues, irrespective of the dietary intake. Most of the utilized glucose is used for energy generation.

Absorption of lactose, glucose polymers, or combination in premature infants

STUDY OBJECTIVE

To determine the digestion and absorption of lactose, a combination of lactose and glucose polymers, and glucose polymers alone in infants born at 28 to 42 weeks of gestation.

DESIGN

Each infant received the three carbohydrate solutions (85 gm/L concentration) in random order.

SETTING

Tertiary care urban children's hospital.

INTERVENTIONS

A double-lumen perfusion catheter was placed in the duodenum-jejunum. Absorption was defined as the disappearance of the carbohydrate and all its components (e.g., for lactose: galactose, glucose).

MEASUREMENTS AND MAIN RESULTS

Absorption of lactose was less than that of the lactose-glucose polymer combination and the glucose polymers alone. There was no relationship between lactose absorption and postnatal age, whereas absorption of the lactose-glucose polymer combination and the glucose polymers alone correlated with age. Lactose absorption was not related to the number of days that the infants received full-strength feedings or the total number of days of feeding before the study, whereas absorption of both the lactose-glucose polymer combination and the glucose polymers alone was related to both. Absorption of the three solutions was not related to gestational age or to the number of days before the initial feeding. Lactose absorption was greater in infants who received formula alone than in infants fed formula together with human milk.

CONCLUSIONS

Premature infants do not digest and absorb lactose as well as glucose polymers. However, lactose does not impair the absorption of glucose polymers. Lactose assimilation is not affected by maturation, but the type of diet may affect lactose digestion and absorption. In contrast, digestion and absorption of glucose polymers are related to both postnatal age and diet.

High-calorie, rice-derived, short-chain, glucose polymer-based oral rehydration solution in acute watery diarrhea

In this study, we have compared the effects of the World Health Organization oral rehydration solution (WHO ORS) and an ORS containing short polymers of glucose (Amylyte ORS) at a high caloric density (five times) and comparable osmolality, on stool output, duration of diarrhea, weight gain and fluid and electrolyte balance, in randomized, open-labeled, controlled clinical trials in five centers. A total of 198 male children (4 months to 10 years) with acute diarrhea ( <72 h after onset) were assigned by random allocation to either WHO ORS or Amylyte ORS at five centers in Asia. Children were stratified according to grade of dehydration (mild, moderate or severe) and the initial purging rates during the first 6 h (low ( < 2 ml/kg/h), moderate (2-5 ml/kg/h) and high ( > 5 ml/kg/h) purgers). The clinical characteristics of the children in the two treatment groups were comparable. Amylyte ORS reduced stool volumes significantly in children with severe dehydration (285.4 +/- 74.2 versus 75.5 +/- 20.0 ml/kg; p < 0.05) and in children with a high initial purging rate (200.3 +/- 42.8 versus 130.5 +/- 9.1 ml/kg; p < 0.05). This was accompanied by a significant (276.4 +/- 14.6 versus 227.6 +/- 11.8 ml/kg; p < 0.01) reduction in ORS requirements in the Amylyte ORS treated group, the effect being greatest in children with severe dehydration (491.5 +/- 108.5 versus 155.7 +/- 27.3 ml/kg; p < 0.01) or high initial purging rates (394.2 +/- 66.2 versus 316.8 +/- 34.8 ml/kg; p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Absorption of glucose polymers from rice in oral rehydration solutions by rat small intestine

BACKGROUND

This study aims to determine the effect of replacing glucose in oral rehydration solution (ORS) with starch hydrolysates from rice on absorption in the small intestine and levels of glucose in portal venous blood and on disaccharidase levels and morphometric measurements in intestines of rats.

METHODS

ORS containing standard composition of salts and 2% glucose (WHO ORS) or 2%, 5%, or 10% starch hydrolysates were infused into duodena of 60 Sprague-Dawley rats (250-350 g). Portal venous blood glucose levels were determined at 0, 30, 60, 90, and 120 minutes.

RESULTS

Significantly larger areas under the curve of glucose absorption (AUCs) were produced by ORS containing 10% unfractionated starch hydrolysates (123.2 +/- 3.8), 2%, 5%, and 10% starch hydrolysates with long-chain ( > 9 molecules) glucose polymers (109.5 +/- 10.6, 109.3 +/- 7.4, and 115.3 +/- 7.1, respectively), and 5% and 10% starch hydrolysates with short-chain (2-9 molecules) glucose polymers (124.4 +/- 6.1 and 128.1 +/- 6.8). ORS with 2% and 5% unfractionated starch hydrolysates and 2% short-chain glucose polymers produced AUCs comparable with those of WHO ORS (96.48 +/- 5.7). Disaccharidase levels and morphometric measurements were not significantly different.

CONCLUSIONS

Starch hydrolysates from rice containing glucose polymers can be used in ORS in higher concentrations than glucose to provide higher caloric density without increased osmolality.

An optimal rice-based oral rehydration solution: the effect of different concentrations of amylase on production of short chain polymers of glucose

As part of a plan to develop a rice-based oral rehydration solution containing short polymers of glucose instead of glucose, we determined the concentration of amylase that would yield the largest amount of short chain polymers. Thai rice (25 g) was boiled with 500 ml of distilled water for 30 min. Of 200 ml supernatant rice water obtained, 100 ml were digested with different amounts of amylase after cooling to 50 degrees C for 60 min, boiled for 5 min, and centrifuged (10,000 g, 25 degrees C) for 60 min. The resulting supernatant (80 ml) was freeze-dried; 1.75 g of the powder obtained were dissolved in 3.5 ml of water, passed through a Bio-Gel P2 column to separate short chain polymers (2-9 molecules of glucose) and long chain polymers (> 9 molecules of glucose), which were identified by spectrophotometry (lambda = 190 nm) or by high performance liquid chromatography. Ten mg of amylase (equivalent to 12,000 modified Wohlgemath units) per 100 ml of rice water was optimal for the production of short polymers of glucose from rice.

Impact of rice based oral rehydration solution on stool output and duration of diarrhoea: meta-analysis of 13 clinical trials

OBJECTIVE

To define the benefit of rice oral rehydration salts solution in relation to the glucose based World Health Organisation oral rehydration salts solution for treating and preventing dehydration in patients with severe dehydrating diarrhoea.

DESIGN

Meta-analysis using data from 13 available randomised trials that compared these two formulations.

SUBJECTS

The studies compared 1367 patients with cholera, severe cholera-like diarrhoea, or acute non-cholera diarrhoea. 668 received the standard WHO solution and 699 the rice based solution.

INTERVENTION

Each trial report was reviewed to determine patient eligibility, the number of patients who were randomised and the number of these excluded from analysis, details of the randomisation procedure, and the precise timing of the outcome measurements.

MAIN OUTCOME MEASURES

Stool output during the first 24 hours; weighted estimates of the difference in mean stool output between treatments.

RESULTS

The rice solution significantly reduced the rate of stool output during the first 24 hours by 36% (95% confidence interval 28 to 44%) in adults with cholera and by 32% (19 to 45%) in children with cholera. The rate of stool loss in infants and children with acute non-cholera diarrhoea was reduced by only 18% (6 to 30%).

CONCLUSIONS

The benefit of rice oral rehydration salts solution for patients with cholera is sufficiently great to warrant its use in such patients. The benefit is considerably smaller for children with acute, noncholera diarrhoea and should be more precisely defined before its practical value can be judged.

Short-chain glucose polymer and anthracene-9-carboxylic acid inhibit water and electrolyte secretion induced by dibutyryl cyclic AMP in the small intestine

Glucose-stimulated sodium absorption is the rationale for treatment with glucose-based oral rehydration solution in diarrhea. Concurrent treatment with pharmacological inhibitors, which specifically block chloride secretion, may be a useful adjunct to oral fluid therapy. To examine this hypothesis, the authors determined the intestinal water and ion transport rates in rat small intestine during the secretory phase induced by perfusion with N6-2'-0-dibutyryl adenosine 3',5'-cyclic monophosphate (dbcAMP), 1.0 mmol/L. A marker (polyethylene glycol 4000) dilution technique was used to evaluate the antisecretory effects of a defined short-chain glucose polymer, D-glucose, and a chloride channel blocker, anthracene-9-carboxylic acid (A-9-C). The results showed that dbcAMP induced small intestinal water and chloride ion secretion rapidly and reliably. The 2.5% concentration of rice short glucose polymer (G2, 22.7%; G3, 28.2%; G4, 14.0%; G5, 16.6%; G6, 11.6%; G7-9, 6.9%) is a better carbohydrate than the 2.5% concentration of D-glucose in reversing secretion of water, chloride, and sodium ions induced by dbcAMP. The combination of A-9-C and the glucose polymer can reverse dbcAMP-induced intestinal secretion and produces significantly (P less than 0.05) better antisecretory effect on water, sodium, and chloride ions than D-glucose with A-9-C.

Alanine-based oral rehydration therapy for infants with acute diarrhea

Twenty male infants less than 1 year of age with acute diarrhea and dehydration were randomly assigned to a study group and studied in blind fashion in a metabolic unit to assess the efficacy of the addition of 30 mmol/L alanine to the standard World Health Organization (WHO) oral rehydration solution (ORS). Patients were exclusively rehydrated with one of two types of ORS during the first 24 hours of treatment. On the second day, oral feedings were started with a lactose-free formula, and ORS was given to replace stool losses. Body weight, ORS, food intake, vomitus, stool, and urine output were recorded at 6-hour intervals. Blood was drawn at the time of admission, after rehydration, and at 24 and 48 hours of hospitalization to monitor blood gases and electrolytes. Rehydration was satisfactory in both groups of patients. ORS that contained alanine did not reduce the purging rates of the infants compared with those who received standard ORS. Clinically no adverse effect of the alanine-based ORS was observed during hospitalization. None of the patients had significant hypernatremia or hyponatremia, and serum amino acid levels were not altered. These data show that the addition of 30 mmol/L alanine to the standard WHO-ORS produces no further improvement in the outcome of the infants with acute diarrhea compared with those fed the standard WHO-ORS.

Glucose polymers as an alternative to glucose in oral rehydration solutions

Several issues involving glucose-based oral rehydration therapy may limit its acceptability and sustained use. Our studies suggest that defined short-chain glucose polymers (2 to 9 glucose units) are hydrolyzed and absorbed faster than isocaloric solutions of D-glucose in the small intestine of the rat. Glucose polymers, primarily from rice-based solutions, have been shown to be as effective as glucose-based solutions. They offer additional advantages in reducing the amount and duration of diarrhea with lesser volumes of solution, thereby reducing the costs of treatment. Rice-based solutions provide high caloric density and increase the absorption of sodium without an osmotic overload. The result is increased net absorption of glucose, sodium, and water. Glucose polymers from rice or other starches in oral rehydration solutions may be effective, inexpensive, easily used, and safe treatments for acute diarrhea.

Improved water and sodium absorption from oral rehydration solutions based on rice syrup in a rat model of osmotic diarrhea

Rice syrup solids, rice protein, and casein hydrolysate were added to experimental oral rehydration solutions in various combinations and tested in a rat intestinal perfusion system. Chronic osmotic diarrhea was induced in juvenile rats by supplying the cathartic agents, magnesium citrate and phenolphthalein, in their drinking water for 1 week. The experimental oral rehydration solutions were compared with standard oral rehydration solutions containing 20 gm/L or 30 gm/L of glucose and with each other to determine if there were significant differences in net water, sodium, or potassium absorption. An oral rehydration solution containing 30 gm/L of rice syrup solids had a net water absorption rate significantly higher than that of the standard 20 gm/L glucose-based oral rehydration solution (2.1 +/- 0.62 versus 1.5 +/- 0.48 microliters/[min x cm], p less than 0.05). Casein hydrolysate did not significantly affect net water absorption. However, combinations of 30 gm/L rice syrup solids and 5 gm/L casein hydrolysate significantly increased (p less than 0.05) net sodium and potassium absorption compared with the 20 gm/L glucose-based oral rehydration solution but not versus rice syrup solids alone. Oral rehydration solutions containing 30 gm/L rice syrup solids plus 5 gm/L rice protein, and 30 gm/L rice syrup solids plus 5 gm/L casein hydrolysate, had net water absorption rates significantly higher than the rate of a 30 gm/L glucose-based oral rehydration solution (2.5 +/- 0.36 and 2.4 +/- 0.38, respectively, versus 0.87 +/- 0.40 microliters/[min x cm], p less than 0.05). Rice protein and casein hydrolysate, however, did not significantly affect net water, sodium, or potassium absorption when added to rice protein glucose-based oral rehydration solutions. An inverse correlation between osmolality and net water absorption was observed (r = -0.653, p less than 0.02). The data suggest that substitution of rice syrup solids for glucose in oral rehydration solutions will improve water absorption and that rice syrup solids in combination with protein hydrolysates may, in addition, promote better sodium and potassium uptake.

The response to dietary treatment of patients with chronic post-infectious diarrhea and lactose intolerance

The response to dietary treatment of patients with chronic post-infectious diarrhea and lactose intolerance was prospectively studied in 29 infants less than 1 year of age. All had gastroenteritis with diarrhea which persisted for more than 3 weeks. In the hospital, diarrhea continued and lactose intolerance was documented while being fed half-strength cow's milk formula. They were given dietary treatment with one of three formulas used for treatment of diarrhea in infancy. Improvement of diarrhea was more frequently achieved with Pregestimil when given as the initial therapy than with the other two formulas. With Pregestimil nine of 10 patients improved whereas only four of nine infants fed Portagen and one of 10 patients initially treated with soy formula improved. Pregestimil was also effective in three of five patients who initially failed to improve with Portagen and in four of eight patients tried with soy formula with or without carbohydrate. Additionally, in the patients who improved, recovery was more rapidly achieved with Pregestimil than with the other two formulas. Formula failures were due to intolerance to glucose polymers in three patients, possibly to protein in seven infants, and an intolerance to all nutrients in five patients. The improvement of the diarrhea was slower in patients who had evidence of colitis in rectal biopsies regardless of the dietary treatment given, but was not correlated with other variables, i.e., etiology of diarrhea, jejunal histology, or duration of diarrhea prior to treatment. However, as a group, the patients who failed to respond to Pregestimil were younger (less than 3 months of age), had more formula changes and associated infections, and were given more antibiotics; they also had more prolonged diarrhea before treatment and more severe jejunal mucosal lesions and jejunal bacterial overgrowth. The data suggests that Pregestimil seems to be the most effective formula for the treatment of infants with chronic post-infectious diarrhea and lactose intolerance.

Hydrolysis and absorption of glucose polymers from rice compared with corn in chronic diarrhea of infancy

Because rice remains the most available carbohydrate in developing countries, where chronic diarrhea is most prevalent, we compared the in vitro hydrolysis and clinical tolerance of rice glucose polymer with those of corn glucose polymer. Rice glucose polymer hydrolysis to D-glucose and short-chain polymers (polymers with two to four glucose units and those with five or more units) was similar to that for corn glucose polymers during incubation with saliva or duodenal aspirates. However, rice glucose polymers yielded more short-chain products than corn glucose polymers during incubation with pooled mucosal homogenates (p less than 0.01). In vivo tolerance testing of 16 infants with chronic diarrhea confirmed that rice glucose polymers were well tolerated and, compared with corn glucose polymers, achieved a higher maximal increase of serum glucose concentration (36.6 +/- 7.3 vs 27.6 +/- 10.3 mg/dl; p less than 0.02), a shorter time to peak serum glucose concentration (34.0 +/- 10.2 vs 52.5 +/- 25.7 minutes; p less than 0.02), and a greater area under the serum glucose response curve at 30 minutes (538 +/- 131 vs 1035 +/- 501 cm; p less than 0.02). We conclude that rice glucose polymers are rapidly hydrolyzed in vitro and in vivo and are more rapidly absorbed than are corn glucose polymers in children with chronic diarrhea.

Glycine, glycyl-glycine and maltodextrin based oral rehydration solution. Assessment of efficacy and safety in comparison to standard ORS

We evaluated the efficacy and safety of an oral rehydration solution containing glycyl-glycine, glycine, and maltodextrin (GGG-ORS), in comparison to the glucose based ORS (standard ORS). The osmolality of the GGG-ORS (305 mOsm/l) and standard ORS (311 mOsm/l) was similar. Ninety-two children presenting with acute gastroenteritis and moderate dehydration, aged 3 months to 3 years, were randomly assigned to receive standard ORS or GGG-ORS. All the patients were successfully rehydrated orally. The two groups were comparable for baseline characteristics including the microbial etiology. Rotavirus (49%, 36%), ETEC (11%, 18%) or a combination of rotavirus and ETEC (15%, 9%) were the main stool pathogens isolated. There was no significant difference in the mean stool output or duration of diarrhoea between the two groups. Patients in the GGG-ORS group had higher urine output (p less than 0.01) and weight gain (p less than 0.05) in the initial 6 hours when feeding was withheld, but no such differences were observed beyond this period. Hypernatremia did not develop in any patient during the study. We conclude that glycine and glycyl-glycine supplemented oral rehydration solution does not have any therapeutic advantage in the treatment of acute gastroenteritis with moderate dehydration caused predominantly by rotavirus.

Disorders of carbohydrate digestion and absorption

The carbohydrate malabsorptive syndromes are frequently seen by pediatricians. The congenital deficiency states are quite rare, but adult type hypolactasia and lactose intolerance following rotavirus infection are recognized with increasing frequency by primary care physicians. Therapy for these disorders involves identification of the offending carbohydrate, removal of the carbohydrate from the diet, and exclusion of other entities that may result in carbohydrate malabsorption but not respond to its removal from the diet. Prognosis for both the primary and secondary carbohydrate malabsorption syndromes is excellent. Compliance with diets for those pediatric patients who will require lifelong therapy remains problematic.