Unsuccessful oral rehydration therapy in an infant with enteropathogenic E. coli diarrhoea. Studies of fluid and electrolyte homeostasis

Nutritional impact and ultrastructural intestinal alterations in severe infections due to enteropathogenic Escherichia coli strains in infants

OBJECTIVE

Enteropathogenic Escherichia coli (EPEC) strains are able to adhere to human intestinal tissue inducing a typical lesion causing dissolution of the brush border membrane and loss of microvillus structure at sites of bacterial attachment. The presence of these lesions can provoke perpetuation of diarrhea associated with malabsorption of the nutrients and nutritional aggravation. In this paper we report the nutritional impact of severe EPEC gastroenteritis in infants in a small bowel ultrastructural study.

METHODS AND RESULTS

Two infants aged 3 months and one 4 month old infant with profuse watery diarrhea lasting less than 6 days were studied. After rehydration therapy, the patients were fed a cow's milk formula and since food intolerance was diagnosed, a protein-hydrolisate, lactose-free formula was introduced. This dietary modification was successful, diarrhea ceased, the patients were discharged and followed up for 30 days. The following EPEC strains were identified in the stools and in the jejunal secretion: O111ab:H2, O119:H6 and O18ab:H14. A small bowel biopsy was performed and the electron microscopic study revealed bacteria tightly adhered to the apical portion of the enterocyte and effacement of the microvilli. These lesions were more prominent in the areas where bacteria were present.

CONCLUSION

The patients underwent an acute nutritional aggravation due to food intolerance, but the introduction of a protein-hydrolisate, lactose-free formula, allowed prompt cessation of diarrhea and nutritional recovery.

Negative findings for use of coconut water as an oral rehydration solution in childhood diarrhea

This study reports the chemical composition of coconut water during its maturation. Composition was measured at 5, 6, 7, 8, 9, 10, 11 and 12 months maturation. Concentrations of sodium and glucose, and the osmolality values showed great variation throughout maturation. The concentration of sodium remained constant between the 5th and 7th months (mean 2.9 mEq/l), but increased after the 8th month (mean 12.5 mEq/l). The concentration of glucose remained constant between the 5th and 8th months (mean 3392.4 mg%), but abruptly decreased after the 9th month (mean 820 mg%). Osmolality followed the variation of the glucose concentration averaging 377.3 mOsm/l up to the 8th month, then decreasing to 310.3 mOsm/l after the 9th month. This study showed great variability in coconut water composition during maturation of the fruit. In no instance did the coconut water contain sodium and glucose concentrations of potential value as an oral rehydration solution.

Acute diarrhea in children. What to do and what not to do

Acute diarrhea is a leading cause of childhood morbidity and mortality. Primary care physicians and pediatricians should be familiar with its clinical features and management. Rehydration and maintenance of proper fluid and electrolyte balance are the most important aspects of treatment. While intravenous rehydration is the best form of treatment for children who are in shock or unable to drink, oral rehydration is the treatment of choice for the majority of children who have mild to moderate dehydration. Oral rehydration therapy is simple, practical, inexpensive, effective, and safe for children in developing as well as developed countries. We recommend the use of commercially available rather than homemade solutions. Antibiotic and antidiarrheal agents are usually not indicated. Early reintroduction of milk, formula, or solid food is important, as is instruction of parents in measures to minimize transmission of infectious agents.

Oral rehydration therapy in neonates and young infants with infectious diarrhoea

The clinical response and changes in water and salt homeostasis during ORT was studied in 15 infants less than 2 months old (range 2-50 days) with acute diarrhoea. Eight patients were neonates and 7 were 1-2 months old. The oral rehydration solution contained 60 mmol sodium per litre. All patients except one were successfully rehydrated. The fluid retention was significantly higher in neonates and young infants than in infants above 3 months of age treated in the same way. One patient in the group of neonates who had a normal sodium level on admission developed hypernatremia with a sodium level of 162 mmol/l 36 hours after the start of ORT. The urinary sodium excretion was lower in the neonates than in the young infants. The results show that neonates and young infants have a lower capacity than older infants to excrete water and salt and therefore run a great risk of developing fluid and salt retention during ORT. The risk is most pronounced in neonates who, due to immaturity of the renal function, are unable to excrete excess fluid and salt.

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.

Oral rehydration therapy in malnourished infants with infectious diarrhoea

The clinical response and changes in water and salt homeostasis was studied for 36 hours during oral rehydration therapy with a rehydration solution containing 60 mmol sodium/l (ORS60) in 14 malnourished 3- to 15-month-old Turkish infants with acute infectious diarrhoea. All patients were successfully rehydrated with this treatment. Sodium was efficiently absorbed from the gut and water balance was rapidly restored. Because of excess fluid retention following the initial rehydration period about 50% of the patients became oedematous. Urine volume and urinary sodium excretion were found to be much lower than in well-nourished patients of the same age with acute diarrhoea who were treated in the same way. In all of the malnourished infants the serum sodium level remained within the normal range during treatment. The results show that malnourished infants retain much more fluid and sodium than infants who are in a normal nutritional state. Excessive retention of water and salt seem to be due to an inability of the kidneys to control sodium and fluid homeostasis while orally administered sodium and fluid are being absorbed from the gut. The results show that ORT is safe and efficient in the treatment of malnourished infants with acute diarrhoea. But since these infants run a high risk of developing a severe retention of fluid and salt, and consequently may develop circulatory failure due to hypervolaemia during oral rehydration therapy, it is important to carefully monitor the volume of fluid that is given.