Safety and efficacy of a rice-based oral rehydration salt solution in the treatment of diarrhea in infants less than 6 months of age

Polymer-based oral rehydration solution for treating acute watery diarrhoea

BACKGROUND

Acute diarrhoea is one of the main causes of morbidity and mortality among children in low-income countries. Glucose-based oral rehydration solution (ORS) helps replace fluid and prevent further dehydration from acute diarrhoea. Since 2004, the World Health Organization (WHO) has recommended the osmolarity of less than 270 mOsm/L (ORS ≤ 270) versus greater than 310 mOsm/L formulation (ORS ≥ 310). Polymer-based ORS (for example, prepared using rice or wheat) slowly releases glucose and may be superior to glucose-based ORS.

OBJECTIVES

To compare polymer-based oral rehydration solution (polymer-based ORS) with glucose-based oral rehydration solution (glucose-based ORS) for treating acute watery diarrhoea.

SEARCH METHODS

We searched the following sources up to 5 September 2016: the Cochrane Infectious Diseases Group (CIDG) Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 9), MEDLINE (1966 to 5 September 2016), EMBASE (1974 to 5 September 2016), LILACS (1982 to 5 September 2016), and mRCT (2007 to 5 September 2016). We also contacted researchers, organizations, and pharmaceutical companies, and searched reference lists.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of people with acute watery diarrhoea (cholera and non-cholera associated) that compared polymer-based and glucose-based ORS (with identical electrolyte contents).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the search results and risk of bias, and extracted data. In multiple-treatment arms with two or more treatment groups, we combined outcomes as appropriate and compared collectively with the control group.

MAIN RESULTS

Thirty-five trials that included 4284 participants met the inclusion criteria: 28 trials exclusively included children, five included adults, and two included both adults and children. Polymer-based ORS versus glucose-based ORS (osmolarity ≤ 270) Eight trials (752 participants) evaluated this comparison, and seven trials used rice as a polymer source. Polymer-based ORS may decrease mean stool output in the first 24 hours by 24 mL/kg (mean difference (MD) -24.60 mL/kg, 95% CI -40.69 to -8.51; one trial, 99 participants, low quality evidence). The average duration of diarrhoea may be reduced by eight hours (MD -8.24 hours, 95% CI -13.17 to -3.30; I² statistic = 86%, five trials, 364 participants, low quality evidence) with polymer ORS but results are heterogeneous. Limited trials showed no observed difference in the risk of unscheduled use of intravenous fluid (RR 0.66, 95% CI 0.43 to 1.02; I² statistic = 30%; four trials, 376 participants, very low quality evidence), vomiting (very low quality evidence), and hyponatraemia (very low quality evidence). Polymer-based ORS versus glucose-based ORS (osmolarity ≥ 310) Twenty-seven trials (3532 participants) evaluated this comparison using a variety of polymers. On average, polymer ORS may reduce the total stool output in the first 24 hours by around 65 mL/kg (MD -65.47 mL/kg, 95% CI -83.92 to -47.03; 16 trials, 1483 participants, low quality evidence), and may reduce the duration of diarrhoea by around eight hours (MD -8.57 hours; SD -13.17 to -4.03; 16 trials, 1137 participants, low quality evidence) with substantial heterogeneity. The proportion of participants that required intravenous hydration was low in most trials with fewer in the polymer ORS group (RR 0.75, 95% CI 0.57 to 0.98; 19 trials, 1877 participant, low quality evidence) . Subgroup analysis by type of pathogen suggested an effect on unscheduled intravenous fluid in those infected with mixed pathogens (RR 0.63, 95% CI 0.41 to 0.96; 11 trials, 928 participants, low quality evidence), but not in participants positive for Vibrio cholerae (RR 0.94, 95% CI 0.66 to 1.34; 7 trials, 535 participants, low quality evidence). No difference was observed in the number of patients who developed vomiting (RR 0.91, 95% CI 0.72 to 1.14; 10 trials, 584 participants, very low quality evidence), hyponatraemia (RR 1.82, 95% CI 0.52 to 6.44; 4 trials, 385 participants, very low quality evidence), hypokalaemia (RR 1.29, 95% CI 0.74 to 2.25; 2 trials, 260 participants, low quality evidence), or persistent diarrhoea (RR 1.28, 95% CI 0.68 to 2.41; 2 trials, 885 participants, very low quality evidence).

AUTHORS' CONCLUSIONS

Polymer-based ORS shows advantages compared to glucose-based ORS (at ≥ 310 mOsm/L). Comparisons favoured polymer-based ORS over ORS ≤ 270 but analysis was underpowered.

The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality

Background Most diarrhoeal deaths can be prevented through the prevention and treatment of dehydration. Oral rehydration solution (ORS) and recommended home fluids (RHFs) have been recommended since 1970s and 1980s to prevent and treat diarrhoeal dehydration. We sought to estimate the effects of these interventions on diarrhoea mortality in children aged <5 years.

Methods We conducted a systematic review to identify studies evaluating the efficacy and effectiveness of ORS and RHFs and abstracted study characteristics and outcome measures into standardized tables. We categorized the evidence by intervention and outcome, conducted meta-analyses for all outcomes with two or more data points and graded the quality of the evidence supporting each outcome. The CHERG Rules for Evidence Review were used to estimate the effectiveness of ORS and RHFs against diarrhoea mortality.

Results We identified 205 papers for abstraction, of which 157 were included in the meta-analyses of ORS outcomes and 12 were included in the meta-analyses of RHF outcomes. We estimated that ORS may prevent 93% of diarrhoea deaths.

Conclusions ORS is effective against diarrhoea mortality in home, community and facility settings; however, there is insufficient evidence to estimate the effectiveness of RHFs against diarrhoea mortality.

Polymer-based oral rehydration solution for treating acute watery diarrhoea

BACKGROUND

Acute diarrhoea is one of the principal causes of morbidity and mortality among children in low-income countries. Glucose-based ORS helps replace fluid and prevent further dehydration from acute diarrhoea. Since 2004, the World Health Organization has recommended the osmolarity < 270 mOsm/L (ORS </= 270 ) over the > 310 mOsm/L formulation (ORS >/= 310). Glucose polymer-based ORS (eg prepared using rice or wheat) slowly releases glucose and may be superior.

OBJECTIVES

To compare polymer-based ORS with glucose-based ORS for treating acute watery diarrhoea.

SEARCH STRATEGY

In September 2008, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, LILACS, and mRCT. We also contacted researchers, organizations, and pharmaceutical companies, and searched reference lists.

SELECTION CRITERIA

Randomized controlled trials of people with acute watery diarrhoea (cholera and non-cholera associated) comparing polymer-based and glucose-based ORS (with identical electrolyte contents).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the search results and risk of bias, and extracted data. In multiple treatment arms with two or more treatment groups, we combined outcomes as appropriate and compared collectively with the control group.

MAIN RESULTS

Thirty-four trials involving 4214 participants met the inclusion criteria: 27 in children, five in adults and two in both. Twelve trials used adequate methods to conceal allocation. Most compared polymer-based ORS with ORS >/= 310. There were fewer unscheduled intravenous infusions in the polymer-based ORS group compared with glucose-based ORS (ORS >/= 310 and </= 270 groups combined) (RR 0.75, 95% CI 0.59 to 0.95; 2235 participants, 19 trials). Adults positive for Vibrio cholerae had a shorter duration of diarrhoea with polymer-based ORS than with ORS </= 270 (MD -7.11 hours, SD -11.91 to -2.32; 228 participants, 4 trials). Wheat-based ORS resulted in lower total stool output in the first 24 hours compared with ORS </= 270 (MD -119.85 g/kg, SD -114.73 to -124.97; 129 participants, 2 trials). Adverse effects were similar for polymer-based ORS and glucose-based ORS.

AUTHORS' CONCLUSIONS

Polymer-based ORS shows some advantages compared to ORS >/= 310 for treating all-cause diarrhoea, and in diarrhoea caused by cholera. Comparisons favoured the polymer-based ORS over ORS </= 270, but the analysis was underpowered. If specialists consider a potential role for polymer-based ORS, further trials against the current standard (ORS </= 270) will be required.

WITHDRAWN: Rice-based oral rehydration solution for treating diarrhoea

BACKGROUND

Oral rehydration therapy is used to treat dehydration caused by diarrhoea. However the rehydration solution does not reduce stool loss or length of illness. A solution able to do this may lessen the use of ineffective diarrhoea treatments as well as improve morbidity and mortality related to diarrhoea.

OBJECTIVES

The objective of this review was to assess the effects of rice-based oral rehydration salts solution compared with glucose-based oral rehydration salts solution on reduction of stool output and duration of diarrhoea in patients with acute watery diarrhoea.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group trials register, the Cochrane Controlled Trials Register, Medline, Embase, Lilacs and the reference lists of relevant articles. We also contacted researchers in the field.

SELECTION CRITERIA

Randomized trials comparing standard World Health Organization oral rehydration solution with an experimental oral rehydration salts solution in which glucose (20 grams per litre) was replaced by 50-80 grams per litre of rice powder, with the electrolytes remaining unchanged.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by a statistician and a clinician.

MAIN RESULTS

Twenty-two trials were included. Concealment of allocation was adequate in 15 of these trials. Irrespective of age, people with cholera who were given rice oral rehydration salts solution had substantially lower rates of stool loss than those given oral rehydration salts solution in the first 24 hours. Mean stool outputs in the first 24 hours were lower by 67 millilitres/kg of body weight (weighted mean difference -67.40, 95% confidence interval -94.26 to -41.53) in children, and by 51 millilitres/kg of body weight (weighted mean difference -51.07, 95% confidence interval -65.87 to -36.27) in adults. The rate of stool loss in infants and children with acute non-cholera diarrhoea was reduced by only four millilitres/kg of body weight (weighted mean difference -4.29, 95% confidence interval -9.36 to 0.78).

AUTHORS' CONCLUSIONS

Rice-based oral rehydration appears to be effective in reducing stool output in people with cholera. This effect was not apparent in infants and children with non-cholera diarrhoea.

Effect of mucosal amino acids on SCC and Na and Cl fluxes in the porcine small intestine

Most amino acids are, like glucose, co-transported with sodium and are thereby potential additives to oral rehydration solutions for the treatment of diarrhea. In this study the effects of mucosal amino acids on short-circuit current and Na and Cl fluxes in three segments of the porcine small intestine were studied. L-alanine, L-leucine, L-lysine, L-proline, L-phenylalanine and L-glutamine were added (chamber concentration of each amino acid was 20 mmol x l-1) to the mucosal side of stripped proximal, mid, and distal small intestine sheets mounted in Ussing chambers in glucose containing (16 mmol x l-1) bathing medium; electrical parameters and unidirectional fluxes were measured. The amino acids induced a significant elevation in mucosa to serosa flux and unaltered serosa to mucosa flux of Na in all three segments, resulting in significant elevation in net Na absorption in proximal (2.4 +/- 0.3 microEq x cm-2 x hr-1 to 3.5 +/- 0.3 microEq x cm-2 x hr-1, P < 0.05), mid (5.9 +/- 0.5 microEq x cm-2 x hr-1 to 8.1 +/- 0.7 microEq x cm-2 x hr-1, P < 0.05) and distal (5.9 +/- 0.6 microEq x cm-2 x hr-1 to 8.3 +/- 0.7 microEq x cm-2 x hr-1, P < 0.05) small intestine. The mucosa to serosa Cl flux was significantly elevated in all three segments (P < 0.01) by amino acids abolishing the net Cl secretion in proximal (2.5 +/- 0.4 microEq x cm-2 x hr-1 to 0.8 +/- 0.6 microEq x cm-2 x hr-1, P < 0.01) and mid (2.2 +/- 0.4 microEq x cm-2 x hr-1 to 0.1 +/- 0.9 microEq x cm-2 x hr-1, P < 0.01) small intestine. The changes in SCC were carried by the electrogen Na absorption. In conclusion, the amino acids, in addition to glucose, stimulate Na absorption by about 1.0 microEq x cm-2 x hr-1 in the proximal part, and 2.5 microEq x cm-2 x hr-1 in the mid and distal part of the small intestine.

The emergency department approach to diarrhea

Enteric disease represents a significant medical problem on a worldwide basis. The evaluation of patients with diarrhea in the emergency department should follow a stepwise methodology to identify potentially serious disorders. The evaluation of the stool for fecal leukocytes is an important differentiation point in the evaluation of the moderately to seriously ill diarrhea patient. Oral rehydration alone can treat the vast majority of diarrhea patients. Oral rehydration solution takes advantage of the sodium glucose coupled active absorption mechanism, which is largely unaffected by enteric toxins. Antimicrobial or antidiarrheal agents are rarely indicated in the treatment of diarrhea.