A critique of oral therapy of dehydration due to diarrheal syndromes

Promotion of Oral Rehydration Therapy Comparing a Homemade Rice-Powder Gruel and Oral Rehydration Salts

Characteristics of the use of two oral rehydration solutions [rice-based gruel (RBG) or oral rehydration salts (ORS)] were assessed in 162 mothers of children under five years of age who presented a first episode of diarrhoea during the study period, in 12 rural villages of Central Mexico. Eighty-six mothers lived in six villages randomly assigned to receive the RBG promotion and 76 lived in six villages assigned to receive the ORS promotion. The intervention strategy, relying on face-to face contact by health auxiliaries who teach mothers about the dangers of dehydration, how to recognize it, and how to prepare and feed an oral rehydration solution, closely resembled that used by the National Program for the Control of Diarrheal Diseases. Before the intervention, 42% of all mothers used RBG and 58% used ORS; 8% of mothers who used RBG and 18% of those who used ORS used the beverage for rehydration purposes. After the intervention, in the villages where RBG was promoted, 57 (66%) of the mothers used RBG and 14 (16%) used ORS. In the villages where ORS was promoted, 9 (12%) of the mothers used RBG and 58 (76%) used ORS. In both groups, all mothers used at least one other beverage (usually herbal tea) during diarrhoea. but the promoted beverages were used first The use of the promoted beverage was higher when mothers had used it before the intervention. Eighty-six percent of mothers who prepared RBG used the promoted concentration of ingredients, whereas all mothers who prepared ORS correctly diluted one package in 1 L of water. After the intervention, 54% and 67% of mothers said they used RBG and ORS specifically to prevent dehydration.

A Programme to Develop Culturally and Medically Sound Home Fluid Management of Children with Acute Diarrhoea

A strategy to develop a programme for the fluid management of acute diarrhoea in childhood, based on culturally and medically sound home-based practices, is presented. The strategy outlined comprised a sequence of studies. The first was an ethnographic description of home practices in the study area, oriented to identify mothers’ beliefs and practices regarding fluid management during acute diarrhoeal episodes, with the aim of selecting one beverage that could be used as a rehydration solution. Once the beverage was selected, the second study consisted of a clinical trial to test the efficacy of this beverage, compared with standard oral rehydration salts (ORS), in rehydrating children with acute diarrhoea. Having proved the clinical efficacy of the beverage, the third study consisted of a public health intervention, in which the use of the homemade beverage was promoted with the specific intention of rehydrating diarrhoea-affected children. Characteristics of the acceptability, preparation, and use of the promoted beverage at the community level were compared with those of ORS. A distinct feature of the strategy outlined was the attempt to follow a “from-the-village” approach to tailor the intervention, taking into account the mothers’ beliefs and practices as well as medical criteria.

Double blind, randomised controlled clinical trial of hypo-osmolar oral rehydration salt solution in dehydrating acute diarrhoea in severely malnourished (marasmic) children

AIMS

To compare the clinical efficacy of hypo-osmolar oral rehydration salt (ORS) solution (224 mmol/l) and standard ORS solution (311 mmol/l) in severely malnourished (marasmic) children having less than 60% Harvard standard weight for age with dehydrating acute watery diarrhoea.

METHODS

In a double blind, randomised, controlled trial, 64 children aged 6-48 months were randomly assigned standard (n = 32) or hypo-osmolar ORS (n = 32).

RESULTS

Stool output (52.3 v 96.6 g/kg/day), duration of diarrhoea (41.5 v 66.4 hours), intake of ORS (111.5 v 168.9 ml/kg/day), and fluid intake (214.6 v 278.3 ml/kg/day) were significantly less in the hypo-osmolar group than in the standard ORS group. Percentage of weight gain on recovery in the hypo-osmolar group was also significantly less (4.3 v 5.4% of admission weight) than in the standard ORS group. A total of 29 (91%) children in the standard ORS group and 32 (100%) children in the hypo-osmolar group recovered within five days of initiation of therapy. Mean serum sodium and potassium concentrations on recovery were within the normal range in both groups.

CONCLUSION

Our findings suggest that hypo-osmolar ORS has beneficial effects on the clinical course of dehydrating acute watery diarrhoea in severely malnourished (marasmic) children. Furthermore, children did not become hyponatraemic after receiving hypo-osmolar ORS.

Changes in human ecology and behavior in relation to the emergence of diarrheal diseases, including cholera

Human populations throughout the world can be found in diverse conditions. A proportion of the population of developing countries lives in deprived conditions characterized by ramshackle housing, lack of piped water and sanitation, and widespread fecal contamination of the environment. Enteric infections, particularly due to bacterial pathogenes, are readily transmitted under these circumstances. In contrast, the majority of inhabitants of industrialized countries live in a sanitary environment that generally discourages the transmission of enteric pathogenes, particularly bacteria. In both these ecologic niches, changes in human ecology and behavior are leading to the emergence of certain enteric infections. Relevant factors in developing areas include urbanization (leading to periurban slums), diminished breastfeeding, and political upheaval that results in population migrations. In industrialized areas, large-scale food production (e.g., enormous poultry farms), distribution, and retailing (e.g., fast-food chains) create opportunities where widespread and extensive outbreaks of food-borne enteric infection can ensue if a breakdown in food hygiene occurs.

Mortality rates in displaced and resident populations of central Somalia during 1992 famine

Famine and civil war have resulted in high mortality rates and large population displacements in Somalia. To assess mortality rates and risk factors for mortality, we carried out surveys in the central Somali towns of Afgoi and Baidoa in November and December, 1992. In Baidoa we surveyed displaced persons living in camps; the average daily crude mortality rate was 16.8 (95% CI 14.6-19.1) per 10,000 population during the 232 days before the survey. An estimated 74% of children under 5 years living in displaced persons camps died during this period. In Afgoi, where both displaced and resident populations were surveyed, the crude mortality rate was 4.7 (3.9-5.5) deaths per 10,000 per day. Although mortality rates for all displaced persons were high, people living in temporary camps were at highest risk of death. As in other famine-related disasters, preventable infectious diseases such as measles and diarrhoea were the primary causes of death in both towns. These mortality rates are among the highest documented for a civilian population over a long period. Community-based public health interventions to prevent and control common infectious diseases are needed to reduce these exceptionally high mortality rates in Somalia.

Health beliefs related to diarrhea in Haitian children: building transcultural nursing knowledge

Regardless of where they live or under what circumstances, mothers throughout the world seem to have a compelling desire to provide the best possible health care for their children (Huston, 1979). Haitian mothers living in the Dominican Republic were no exception. The health beliefs and practices of these mothers related primarily to diarrhea among their children which demonstrated a concern and resourcefulness that is commendable. The results of this study clearly indicate the importance of transcultural nurses conducting culturally relevant research as a basis to develop sound health programs in developing countries. Diarrhea was identified as the single most important threat to a child's health in these communities. That mothers did not know about the correct ingredients and/or proportions for oral rehydration solutions (Western views) was of interest. Although the Dominican government makes some commercial packets of ORS, most of the women interviewed did not have ready access to this product. This finding reflected the need for transcultural nurses to offer to teach mothers how to make ORS using the sugar, salt, and water they had available. Since the mothers' perception that diarrhea was a dangerous threat to their children's health, was verified by childhood mortality statistics in the bateys, it would seem that ORS could make a significant impact on the health status of the children. Breastfeeding also was a major health belief factor associated with the treatment of diarrhea. Even though the majority of mothers believed breast feeding should be continued if a child had diarrhea, a number believed it should be discontinued. Nurses working with CHWs will need to emphasize the importance of breastfeeding and help them to develop creative ways of communicating this information to the mothers. The second most dangerous threat to the child identified by the mothers was respiratory ailments. This suggests a new area of concentration for future research and training of CHWs. A host of new questions related to respiratory problems such as health beliefs, causative factors, course of disease, traditional treatments, mortality rate, etc. need to be investigated. When transcultural nurses plan health care programs for women and children in other cultures, it is important to recognize the concerns mothers have for their children, and their intense desire to nature and care for them. In this study, mothers willingly participated and demonstrated active interest in learning to use methods to improve the health and well being of their children. It is well documented (Lieban, 1977) that established health beliefs are not automatically discarded when new knowledge is made available, but that exploration and incorporation of new information when presented in a culturally relevant framework does occur. An understanding of local beliefs surrounding health is fundamental to the development of appropriate transcultural nursing interventions.

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.

Experimental models for the investigation of water and solute transport in man. Implications for oral rehydration solutions

For patients suffering from mild to moderate dehydration, oral rehydration therapy has proved a simple and efficacious treatment. There remains, however, a need to develop improved oral rehydration solutions (ORS), and suitable experimental models are required to develop and assess new formulations. The ideal model for such investigations would take into account rates of gastric emptying, influx and efflux of water and solutes in the intestine, and the consequent changes in body composition. As no such definitive model is currently available, a variety of techniques are used to examine parts of the process of intestinal absorption. Clinical studies which assess the recovery of dehydrated patients during therapy using different ORS will ultimately evaluate the efficacy of treatment. However, ethical considerations, the relative insensitivity of this technique and the exacting nature of such studies make this approach unsuitable for the development of specific ORS. Gastric emptying of solutions can be determined by a variety of techniques, among which the radioactive tracer method offers the advantage of having no direct effect on the emptying rate, giving almost continuous measurement and allowing the use of relatively small volumes of fluids. Perfusion techniques allow measurement of the net flux of water and solute in predetermined sections of the intact human intestine. Measurement of the rate of accumulation in the circulation of orally ingested tracer molecules for water and solutes can estimate unidirectional flux. This method allows for the rates of gastric emptying and intestinal absorption of the test substance, but the rate of efflux of the tracer from the vascular space must be known to calculate net uptake. Each of these models has limitations, and care must be taken in interpreting the results in a clinical context. However, their use in the development of improved formulations is well established.

Two-year survey of etiologic agents of diarrheal disease at San Lazaro Hospital, Manila, Republic of the Philippines

The prevalence of bacterial pathogens and rotavirus in 2,908 patients with diarrhea who were admitted to San Lazaro Hospital in Manila in 1983 and 1984 was determined. One or more enteric pathogens were isolated or detected in samples from 1,698 (58.4%) patients. Isolation rates for the various enteropathogens were as follows: rotavirus, 30.6%; Shigella spp., 11.6%; Salmonella spp., 9.2%; enterotoxigenic Escherichia coli (1983 only), 7.8%; Vibrio cholerae biotype eltor, 3.8%; non-O1 V. cholerae, 2.8%; Vibrio parahaemolyticus, 1.7%; other Vibrio spp., 1.1%; Campylobacter jejuni, 3.0%; Aeromonas hydrophila, 1.3%; and Plesiomonas shigelloides 1.1%. Giardia lamblia and Entamoeba histolytica were detected in 0.6 and 0.1%, respectively, of stool samples examined. Determination of the etiologic role of isolates was complicated by one or more of the following factors: isolation of multiple enteric pathogens (302 cases); isolation of Salmonella spp., enterotoxigenic E. coli, and C. jejuni from a similar proportion of asymptomatic control patients and patients with diarrhea; and isolation of a high proportion of certain pathogens (especially Salmonella spp.) only from enrichment broth, suggesting infection with a small number of organisms. Isolation of V. cholerae eltor was seasonal, with the majority of cases occurring in the rainy months. In addition, the number of patients with diarrhea increased with the onset of the monsoon rains and peaked during the months of maximum rainfall. Rotavirus infection occurred in both children and adults throughout the year and was the most frequently identified cause of diarrhea in children under 5 years of age. Shigella spp. were the most common agents of diarrhea in adults.

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 hydration solutions: experimental optimization of water and sodium absorption

Eight solutions of potential efficacy for hydration orally, which differed in composition, osmolality, and pH, were tested in an in vivo perfusion system on rat jejunum to assess the rate of water and sodium absorption or secretion. Optimal results were obtained with a preparation of the type recommended by the World Health Organization, containing 60 mEq/L sodium and 111 mM glucose; there was a maximum influx of both water and sodium, which may be ideal for rehydration. It appeared that the critical factor was the molar relationship between glucose and sodium at a 2:1 ratio. Sodium absorption was inversely correlated with glucose concentration in the perfusates. Osmolality and pH may also have a role in the regulation of fluxes across the mucosa. Citrate at concentrations up to 30 mEq/L did not interfere with water absorption. The data presented may thus contribute to a better rationale for the use of orally administered hydration solutions and guidelines for the preparation of more effective ready-to-use solutions.

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.

Race-associated differences in drinking behaviour

An evaluation of the oral intake and the need for alternative therapy in aboriginal and white (European ancestry) children hospitalized for dehydration due to diarrhoea revealed significant differences in drinking behaviour. In a retrospective study of 120 children (36 aboriginal), the white children were far more likely to require an alternative mode of fluid administration (39 of 86 white versus 3 of 34 aboriginal). In a prospective study, although treated in the same manner by the same staff, during the first eight hours after admission white children had a mean oral intake of 2.9 ml/kg/hr (range 0.4-6.6, S.D. 1.6) whereas the aboriginal children had a mean oral intake of 6.1 ml/kg/hr (range 2.2-9.2, S.D. 2.1). The drinking behaviour of children varies with racial and/or cultural background. This should be considered in designing and administering rehydration solutions.

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.

Home-administered oral therapy for diarrhoea: a laboratory study of safety and efficacy

Serum electrolytes were measured for persons treated for diarrhoea at home with prepackaged or locally available sugar and salt oral rehydration therapy (ORT) solutions and for persons with diarrhoea who received no ORT but were treated according to local customs. No detrimental effect was found for persons treated with ORT at home; no significant difference was found in the frequency at which members of the groups had hypernatraemia. The rates of hyponatraemia and hypokalaemia were significantly lower for persons who took estimated appropriate volumes of ORT than for those who took less than appropriate volumes or for persons treated according to local customs without ORT. These laboratory results indicate that ORT administered in rural homes in Bangladesh was safe and effective under the conditions of our study.

Oral rehydration for diarrhoeal diseases in children

Electrolyte disturbances and response to oral electrolyte therapy were studied in 88 children with mild to moderate dehydration due to acute gastroenteritis. A solution with a sodium concentration of 50 mmol/litre was tested in a group of 60 children and results obtained with those in a group of 28 children taking a standard oral solution with a concentration of 90 mmol/litre. Adequate hydration was accomplished in both groups and none of them received intravenous fluids. Neither group received additional water or other fluid in the first 24 hours. There was a significant rise in sodium concentration with both solutions and none of the children developed hypernatraemia. A significant rise in potassium is observed in children with clinical kwashiorkor when hydrated with the low sodium solution.

Oral solutions for infantile gastroenteritis--variations in composition

Four different carbohydrate electrolyte solutions were provided for children under 18 months with acute gastroenteritis treated as outpatients. Osmolality and sodium content were measured in samples of solutions as given by the parents. All types of feed were made up with marked inaccuracy. Osmolality was sometimes unacceptably high in solutions containing glucose, while the highest osmolality for sucrose solutions hardly exceeded the correct value for glucose solutions. Most parents could use a sachet with reasonable accuracy although there were still wide extremes of errors. The ideal preparation for use in developed countries may be a sachet containing sucrose and electrolyte, particularly if such sachets could be made generally available and not just for use in hospitals and clinics.

Oral rehydration therapy for treatment of rotavirus diarrhoea in a rural treatment centre in Bangladesh

In November 1977, an enzyme-linked immunosorbent assay for detecting rotavirus antigen was introduced in the laboratory of a rural treatment centre in Bangladesh. During the next 40 days rotavirus without other pathogens was found in the stools of 216 (45%) of 480 children under age 5 years who visited the centre with a gastrointestinal illness. 188 (87%) of these children were treated with oral rehydration alone, using the solution currently recommended by the World Health Organisation, while 28 (13%) also required some intravenous rehydration; there were no deaths. Oral rehydration treatment was judged successful in 205 (95%) of the rotavirus patients and was not associated with any serious side effects. Oral rehydration treatment, with this solution, has been used extensively and successfully in the treatment of enterotoxin-mediated diarrhoea and can also safely be used for treating rotavirus diarrhoea in infants and young children.