| • |
Prevent dehydration through early administration of increased amounts of appropriate fluids in the home including reduced ORS.
|
| • |
Continue feeding/breast feeding during the episode and increase feeding afterward. |
| • |
Recognize signs of dehydration and treat as per Plan A, B or C. |
| • |
Provide 20 mg/day Zinc supplementation (10 mg/day for infants less than 6 months) for 10-14 days. |
| • |
Use antibiotics only when appropriate i.e. in presence of bloody diarrhea or shigellosis. |
| • |
Abstain from administering anti-diarrheal drugs. |
Improved ORS formulations
Efficacy of ORS solution for treating children with acute non-cholera diarrhea is improved by reducing its sodium concentration to 75 mEq/L, its glucose concentration to 75 mmol/L and its total osmolarity to 245 mosm/L. The need for unscheduled supplemental IV therapy in children given this solution was reduced by 33%. The 245 mosm/L solution also appeared to be as safe and at least as effective as standard ORS for use in children with diarrhea.
Thus WHO and UNICEF now recommend that countries use the following formulation in place of previously recommended ORS solution with total osmolarity of 311 mosm/L.
| Reduced osmolarity ORS |
gm/L |
Reduced osmolarity ORS |
mmol/L |
| Sodium chloride |
2.6 |
Sodium
chloride |
75
65 |
| Glucose, anhydrous |
13.5 |
Glucose anhydrous |
75 |
| Potassium chloride |
1.5 |
Potassium |
20 |
| Trisodium citrate, dehydrate |
2.9 |
Citrate |
10 |
WHO and UNICEF acceptable ORS formulations
| • |
The total osmolarity should be within range of 200-310 mosm/L |
| • |
Glucose should be at least equal to that of sodium but should not exceed 111 mmol/L
|
| • |
Sodium should be within range of 60-90 mEq/L. |
| • |
Potassium should be within range of 15-25 mEq/L. |
| • |
Citrate should be within range of 8-12 mmol/L. |
| • |
Chloride should be within range of 50-80 mEq/L. |
Implementation of low osmolarity ORS
| • |
The new ORS is packaged in sachet to be dissolved in 1 litre of clean water. |
| • |
Should be implemented in national IMNCI guidelines and training of health care workers should be revised. |
Zinc supplement in treatment of acute diarrhea
The use of zinc is thought to hasten epithelial recovery during diarrhea and restore intestinal structure or function. WHO convened a meeting of experts in 2001 and concluded that zinc supplementation given at a dose of 10-20 mg per day for 10-14 days is efficacious in significantly reducing severity of diarrhea and duration of the episode.
Implementation of zinc
| • |
Zinc syrup should be in concentration of 10 mg /5 ml or 20 mg / 5 ml. |
| • |
Any soluble zinc salt eg. sulphate, gluconate or acetate may be used for the formulation of the syrup / tablet. |
| • |
Syrup should contain only zinc. However in some cases copper (1 mg/dose) could be added. |
| • |
Iron should never be added to a zinc formulation as iron may interfere with zinc absorption. |
| • |
The shelf life of zinc syrup should be at least 2 years when stored in appropriate conditions, away from light and in dry cool place (< 30oC) |
| • |
Zinc tablets should be dispersible and formulated as 10 mg or 20 mg tablets. |
| • |
Should be implemented in national IMNCI guidelines and training of health care workers should be revised. |
Antidiarrheal drugs that should never be used for treatment of acute diarrhea
Adsorbents - kaolin, attapulgite, smectite, activated charcoal, cholestyramine.
Antimotility drugs - loperamide, diphenoxylate with atropine, opium, paregoric, codeine, Bismuth subsalicylate.
Further Reading
Implementing the New Recommendations on the Clinical Management of Diarrhoea. Guidelines for Policy Makers and Programme Managers. World Health Organization. Geneva, 2006.
