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

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.

Zinc-fortified oral rehydration solution improved intestinal permeability and small intestinal mucosal recovery

A randomized double-blind placebo-controlled study was conducted in children admitted to hospital with gastroenteritis (≥3 loose stools per day). All were treated for 5 days following admission with either zinc (Zn, 3 mg) or without Zn-fortified rice-based oral rehydration solution (ORS). (13)C-sucrose breath test (SBT) and intestinal permeability (lactulose/rhamnose or L/R ratio) were performed concurrently prior to commencement of ORS with or without Zn and at day 5 post-admission. There was a significant improvement in the SBT results in both the Zn-fortified group, median (5th-95th percentile) 2.1% (0.4% to 8.3%) versus 4.4% (0.4% to 10.4%), P < .05, and control group, 1.4% (0.1% to 5.4%) versus 4.3% (0.4% to 11.4%), P < .05, between the day of admission and day 5 post-admission. In the Zn-fortified group, there was also a significant improvement in L/R ratio between the day of admission and day 5 post-admission, 53.0 (19.5-90.6) versus 17.7 (13.4-83.2), P < .05. Low levels of Zn improved intestinal permeability but did not enhance short-term recovery following diarrheal illness.

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.

Ethnicity and H. pylori as risk factors for gastric cancer in Malaysia: A prospective case control study

OBJECTIVE

To determine the risk factors for gastric cancer (GCA), with particular emphasis on ethnicity in our multiracial population.

METHODS

A prospective case control study with ratio of cancer:controls of 1:2. Diagnosis of H. pylori was made by serology using the ELISA technique. Dietary intake was assessed by dietary recall over the preceding 6 months.

RESULTS

Eighty-seven cases of GCA were enrolled. The cancers were predominantly distal in location and of the intestinal type. Risk factors identified following multiple logistic regression analysis were: Chinese race (OR 10.23 [2.87-36.47]), H. pylori (OR 2.54 [1.16-5.58]), low level of education (OR 9.81 [2.03-47.46]), smoking (OR 2.52 [1.23-5.15]), and high intake of salted fish and vegetables (OR 5.18 [1.35-20.00]) were identified as significant independent risk factors for GCA, while high intake of fresh fruits and vegetables was protective for GCA (OR 0.15 [0.04-0.64]). Chili intake was not a significant protective factor following multivariate analysis.

CONCLUSIONS

Chinese race was a strong independent predictor of GCA. H. pylori was an important predictor of GCA with a 2.5-fold greater risk in our patients. Despite a high prevalence of H. pylori, the prevalence of GCA among Indians was low and this paradox can be appropriately called the "Indian enigma."

Evaluation of a diet containing probiotics and zinc for the treatment of mild diarrheal illness in children younger than one year of age

OBJECTIVES

Supplementation of probiotics and supplementation of zinc during acute gastroenteritis in children have been shown to exert positive effects on diarrhea duration and severity. Our aim was to evaluate a new diet enriched with zinc and probiotic bacteria in the treatment of acute gastroenteritis in young children.

METHODS

In a double blind prospective study, 65 children aged 6-12 months were randomized to receive 6 x 10(9) colony forming units of Streptococcus thermophilus, Bifidobacterium lactis, Lactobacillus acidophilus (2 x 10(9) of each strain), 10 mg of zinc/day, and 0.3 grams of fructo-oligosaccharides in the supplemented group (n = 33) or placebo (n = 32), given in a soy protein based rice cereal. For each child, age, sex, weight, degree of dehydration, the presence of fever or vomiting, stool frequency and consistency were recorded daily until diarrhea resolution.

RESULTS

Diarrhea resolution occurred after 1.43 +/- 0.71 days in the supplemented group vs. 1.96 +/- 1.24 in the control group (p = 0.017). In the subset of children who presented with vomiting, time to vomiting resolution was 0.27 +/- 0.59 vs. 0.81 +/- 0.91 days in the supplemented and control groups, respectively (p = 0.06). On day 3, there was only 1 child with watery stools in the supplemented group versus 10 children in the control group (p = 0.02).

CONCLUSIONS

In our series, the feeding of a cereal containing Streptococcus thermophilus, Bifidobacterium lactis, Lactobacillus acidophilus and zinc, reduced the severity and duration of acute gastroenteritis in young children. However, whether this combination is better than either the addition of probiotics or zinc alone is yet to be determined.

2. Acute infectious diarrhoea and dehydration in children

Gastroenteritis in children is still a common reason for consulting a general practitioner and for hospital admission. Rotavirus is the most common cause of gastroenteritis in children and accounts for half of all hospital admissions for severe acute infectious diarrhoea. Most children with gastroenteritis do not develop dehydration and can be treated at home. Children with mild to moderate dehydration should be treated with low osmolarity oral rehydration solutions, and those with severe dehydration or shock need to be admitted for administration of intravenous fluids. Lactose-free feeds should not be routinely used after acute gastroenteritis, but there is some evidence that a lactose-free diet may reduce the duration of diarrhoea. Antimotility drugs are rarely indicated in children with gastroenteritis, as the potential risks outweigh the benefits. The development of a rotavirus vaccine would provide huge public health benefits and cost savings. Other preventive strategies include educating people about personal and food hygiene and encouraging breastfeeding.

Nutritional effects and management of diarrhoea in infancy

The interactions between diarrhoeal disease and nutritional status are complex and synergistic. These are serious issues globally because they affect hundreds of millions of young children and annually cause > 3 million deaths in children aged under 5 y. Despite intensive field-based and laboratory studies over three decades, many questions remain unanswered about the causes, pathophysiology and best approaches to management and prevention of this "diarrhoea-malnutrition" syndrome. Oral rehydration therapy (ORT) has been a major advance and has saved many lives from acute diarrhoea. However, persistent diarrhoea is now a major problem and is very significant because of its strong negative impacts on nutritional status and because persistent diarrhoea and dysentery are now major causes of infant and young child deaths. ORT provides clear and practical methods for replacement of fluid and electrolyte losses during diarrhoea. Rehydration salts can be made available as (i) a simple, easy-to-use package, complete with user instructions; (ii) cereal-based formulae based on widely available ingredients that can be prepared domestically or commercially; and (iii) home-made mixtures of sugar and salt which should be simple to prepare but are risky because of inadequate understanding about their preparation at home and the chance of mixing the ingredients inaccurately and giving them wrongly. Continuation and encouragement of breastfeeding is an important strategy to prevent and control diarrhoea and as part of its management. Early refeeding during diarrhoea is another important principle to help to reduce its duration, severity and its nutritional impacts. Supplementation with specific dietary ingredients, such as vitamin A, zinc and folate, is rather contentious and drug therapy is of little value unless specifically indicated. Some patients may require enteral nutrition or parenteral nutrition but these require specialized equipment and skills that are usually beyond the reach of developing countries and infants and children who live in remote areas.

Studies of water and electrolyte movement for oral rehydration solutions (rice- and glucose-based) across a normal and secreting gut using a dual isotope tracer technique in a rat perfusion model

AIMS

To establish a model to measure bidirectional flow of water from a glucose oral rehydration to solution (G-ORS) and a newly developed rice-based oral rehydration solution (R-ORS) using a dual isotope tracer technique in a rat perfusion model. To measure net water, sodium and potassium absorption from the ORS.

METHOD

In vivo steady-state perfusion studies were carried out in normal and secreting (induced by cholera toxin) rat small intestine (n = 11 in each group). To determine bidirectional flow of water from the ORS the animals were initially with tritium, and deuterium was added to the perfusion solution. Sequential perfusate and blood samples were collected after attainment of steady-state conditions and analysed for water and electrolyte content.

RESULTS

There was significant increase in net water absorption from the R-ORS compared to the G-ORS in both the normal (P < 0.02) and secreting intestine (P < 0.05). Water efflux was significantly reduced in the R-ORS group compared to the G-ORS group in both the normal (P < 0.01) and the secreting intestine (P < 0.01). There was an increase in sodium absorption in the R-ORS group compared to the G-ORS. The G-ORS produced a significantly greater blood glucose level at 75 min compared to the R-ORS (P < 0.03) in the secreting intestine.

CONCLUSIONS

This study demonstrates the improved water absorption from a rice-based ORS in both the normal and secreting intestine. Evidence that the absorption of water may be influenced by the osmolality of the ORS was also demonstrated.