ACUTE CHILDHOOD DIARRHEA: A REVIEW OF RECENT ADVANCES IN THE STANDARD MANAGEMENT
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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: firstname.lastname@example.org
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). C oncerns 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:
*Reduction in geometric means
Based on the above data, WHO and UNICEF concluded in 2001 (25)
Table 4: Composition of Reduced Osmolarity ORS
Recommendations by IAP National Task Force For The Use Of ORS In Diarrhea, August 18-19, 2003 26 and May 5-6, 2006
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).
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