ORS - WHICH ONE TO USE?
Professor of Gastroenterology
Department of Gastrointestinal Sciences, Christian Medical College & Hospital, Vellore 632004, India.
Children presenting with acute diarrhea should be assessed as to whether they have a watery diarrhea syndrome or bloody diarrhea syndrome, and whether there is evidence of clinical dehydration. Dehydration is assessed as none, some or severe according to the WHO Management of Diarrhoea guidelines (Figure 1). Children who have severe dehydration require intravenous hydration (with Ringer lactate solution preferentially) of which 100 ml/kg is given over four hours, 30% in the first hour and the remaining 70% over three hours. Children with some dehydration are presumed to have dehydration of between 5-10% of body weight and should be treated with reduced osmolarity ORS. ORS can be administered via nasogastric tube in the initial stages of rehydration in sick children who are unable to take adequate amounts of ORS. It is estimated that approximately one in every 25 children that are given ORS will go on to require intravenous hydration. Children are assessed frequently and oral intake, urine output and stool output measured. It is expected that rehydration (replacement of lost fluid) would have completed in the first four hours and the subsequent phase is maintenance of hydration, where ORS intake is matched to stool losses. The usual diet of the child is allowed after the first four hours in children with significant dehydration, and is continued without interruption in normal in children with no dehydration. The use of zinc has become commonplace and 20 mg of elemental zinc is given as suspension or tablet once daily for 14 days. The use of starchy foods is encouraged. Commercially available fruit juices have a high osmolarity and are best avoided in the initial phase of hydration of the child. Antibiotics are generally not necessary in the treatment of diarrhea in children, except in older children with severely dehydrating diarrhea where cholera is suspected or proved by dark field microscopy of the feces, or in children with blood and mucus diarrhea due to an invasive organism such as Shigella. Early return to normal nutritional intake is highly desirable both in terms of recovery from the current episode of diarrheal illness and in prevention of persistent diarrhea and malnutrition.
Figure 1. Flow chart for ORS administration and management of diarrhea in children. The WHO classification of dehydration is shown and equivalent percentage dehydration is shown. Use the reduced osmolarity ORS for children. Zinc is given in 20 mg dose daily for a period not exceeding 14 days.
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