Oral Rehydration Solution/ORS for Acute Diarrhea

4th Pediatric Infectious Diseases Conference

ISSN 0973 - 0958

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Vomiting and Diarrhea in Children

Upper Gastrointestinal bleed

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Results

ACUTE CHILDHOOD DIARRHEA: A REVIEW OF RECENT ADVANCES IN THE STANDARD MANAGEMENT

Related topics

Diarrhea Introduction

Causes Of Childhood Diarrhea

Acute Childhood Diarrhea Management

Feeding During Diarrhea

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Antimicrobials and Antisecretory drugs

Cholera

SEEMA ALAM RAJEEV KHANNA UZMA FIRDAUS
Pediatric Gastroenterology Section, Department of Pediatrics, JNMC, AMU, Aligarh

Corresponding Author :

Dr Seema Alam, Reader, Department of Pediatrics, JN Medical College, AMU, Aligarh, UP. Email seema_alam@hotmail.com

Oral Rehydration Solution:

A critical factor in the reduction in diarrheal deaths has been the adoption of oral rehydration solution (ORS) programs for the treatment and prevention of dehydration 8 . Despite very low use rates of ORS in large parts of India there has been a decrease in the diarrheal deaths in the past decade. The situation could have been better if the ORS use rates were higher 9. At the same time there is also a very high usage of anti-diarrheal drugs, which could be due to the poor awareness among doctors as well as parental pressure. Improved ORS use rates can avert 14 % of the under five mortality 9 . This is would need training of health personnel and education of the masses.

Since the introduction of WHO ORS in 1978, there have been attempts to improve the existing formulation by reducing the osmolarity. This was done by reducing glucose and salt concentration in the solution 10-17 or by replacing glucose with a complex carbohydrate or amino acids 18-20 . These solutions generally preserve the 1:1 molar ratio of sodium to glucose that is critical for efficient cotransport of sodium. Studies in animal models and human volunteers have shown that osmolarity of ORS may be a critical factor influencing absorption of water and electrolytes from the small intestine 21 . Solutions with osmolarity between 200-250 mmol/L perform better than hypotonic or isotonic solutions. With the exception of rice based ORS 20 , which significantly reduces stool output in cholera patients, these new ORS preparations were not found to be more effective than standard ORS and are more expensive 22 . Concerns about hypernatremia and severe glucose malabsorption as well as better water/sodium absorption seen with lower osmolarity in animal models led to the clinical trials of reduced osmolarity ORS with reduced sodium & glucose. Studies from all over the world revealed beneficial affects of a reduced osmolarity ORS (Total Osmolarity: 245 and 224 mosmls/l) 10,11,13-15 over the standard WHO ORS (Total Osmolarity 311 mosmls/l). A large multicenter clinical trial 23 conducted in 675 children with acute non-cholera diarrhea from 5 developing countries revealed that stool output, vomiting and occurrence of hyponatremia were not statistically different between the 2 groups, however the use of unscheduled intravenous fluid following rehydration was reduced in the group receiving reduced osmolarity ORS (10% vs. 15%, OR 0.6; 95%CI 0.4-1.0). In a meta-analysis 24 , that evaluated the results of 15 randomized trials, encouraging results about the hypo-osmolar ORS was obtained. The use of reduced osmolarity ORS was associated with less frequent use of unscheduled intravenous fluid (combined OR, 0.61; 95% CI 0.47-0.81) and less vomiting (combined OR, 0.71; 95% CI, 0.55-0.92). A statistically significant difference in stool output was also noted (standardized mean difference, -0.21; 95% CI -0.31 to -0.12). No significant difference in the incidence of hyponatremia was noted between the 2 groups (Table 3)

Table 3: Meta-analysis of all RCT's comparing reduced osmolarity ORS with standard WHO ORS in children with acute non-cholera diarrhea:

Outcome	Number of studies	Reduction in odds (95%CI)
Unscheduled IV	9	39% (19%, 53%)
Stool output	12	19% (12%, 26%)*
Vomiting	6	29% (8%, 45%)

*Reduction in geometric means

Based on the above data,WHO and UNICEF concluded in 2001 25

Reduced osmolarity ORS (Table 4) was more effective than standard ORS for acute non-cholera diarrhea in children, as measured by clinically important outcomes such as reduced stool output, reduced vomiting, and reduced need for intravenous therapy.

Among adults with cholera, clinical outcomes were not different although the risk of transient asymptomatic hyponatremia was noted.

Reduced osmolarity ORS was recommended for worldwide use.

Table 4: Composition of Reduced Osmolarity ORS

Reduced osmolarity ORS	grams/litre	Reduced osmolarity ORS	mmol/litre
Sodium chloride	2.6	Sodium	75
Glucose, anhydrous	13.5	Chloride	65
Potassium chloride	1.5	Glucose, anhydrous	75
Trisodium citrate, dihydrate	2.9	Potassium	20
-	-	Citrate	10
-	-	Total Osmolarity	245

Recommendations by IAP National Task Force For The Use Of ORS In Diarrhea, August 18-19, 2003 26 and May 5-6, 2006

All doctors should prescribe ORS for all ages in all types of diarrhea.

The group noted that the new improved universal ORS recommended by the WHO is acceptable for all ages and may be made freely available by the Government. However it was proposed that a pediatric ORS containing sodium 60 mmol/L, glucose 84 mmol/L, osmolarity 224 mosmol/L is the most suitable solution for children and the industry should be encouraged to produce such a formulation.

The powder packet to make 1 liter of solution should be continued. Since mothers tend to use ORS a glass at a time, a measuring device should be included inside to measure the required amount of powder accurately for 200 ml of fluid.

The group was deeply concerned that ORS was not available free of cost at public institutions. It recommended that measures should be taken by the Government to improve its availability and reduce its cost.

There is a concern for the risk of hyponatremia especially among cholera patients with new reduced osmolarity formulation. No significant difference in the incidence of hyponatremia was found in studies comparing hypoosmolar ORS with WHO ORS 15 . It is likely that adults with cholera may have asymptomatic hyponatremia with the hypoosmolar solution. In a recent trial among acute diarrhea patients aged 12-60 years no effect of the type of ORS was seen on mean serum sodium and relative risk of hyponatremia 24 hours after randomization. 27