Practical tips on the occasion of World ors day - 29^th July, an article published in Family Physicians Association Magazine

Pediatric diarrhea is one such disease where the treatment spectrum may consist of only reassurance to admissions due to dehydration. Included in this spectrum are many beautiful molecules like antidiarrhoeals, pre and probiotics, antisecretory and antimotility agents that are attractively marketed and attractively priced too!!! Sometimes we need to prescribe them even as a placebo, but what we should not forget is the role of oral rehydration therapy to prevent and treat dehydration. We should create awareness for this in the general population at a large scale.

Let us revise some facts regarding pediatric diarrhea and oral rehydration therapy  on this occasion.

HISTORY

Prescriptions from the ancient physician Sushruta date back over 2500 years with treatment of acute diarrhea with rice water, coconut juice, and carrot soup. Dehydration was found to be the major cause of death secondary to the 1829 cholera pandemic in Russia and Western Europe. In 1831, William Brooke O’Shaughnessy noted the loss of water and salt in the stool of cholera patients and prescribed intravenous fluid therapy (IV) to compensate. The results were remarkable, as patients who were on the brink of death from dehydration recovered. ORT then  replaced IV fluids after about 100 years. In the early 1960s, biochemist Robert K. Crane discovered the sodium-glucose co transport as the mechanism for intestinal glucose absorption. These findings were confirmed in human experiments, where it was shown that glucose-containing ORT significantly decreased the necessity for IV fluids by 70-80%. These results helped establish the physiological basis for the use of ORT in clinical medicine

Between 1980 and 2006, ORT decreased the number of worldwide deaths from 5 million a year to 3 million a year. Its remarkable success has led to naming the discovery of its underlying physiological basis as “potentially the most important medical advance in this century.” ORT is part of UNICEF’s GOBI program, a low cost program to increase child survival in developing countries, including Growth monitoring, ORT, Breastfeeding and Immunization.

WHY COMMUNITY BASED AWARENESS IS NEEDED?

Despite the success and effectiveness of ORT, its uptake has recently slowed and even reversed in some developing countries. This raises concerns for increased mortality from diarrhea and highlights the need for effective community-level behavioral change and global funding and policy.

PHYSIOLOGY OF ORT

Without intervention, heavy continuous diarrhea can be a very dangerous and potentially life-threatening condition because liquid secreted into the intestinal lumen during diarrhoea passes through the gut so quickly that very little sodium is reabsorbed, leading to very low sodium levels in the body (severe hyponatremia). This is the motivation for sodium and water replenishment via ORT. The co-transport of sodium into the epithelial cells via the SGLT1 protein requires glucose or galactose. Two sodium ions and one molecule of glucose/galactose are transported together across the cell membrane through the SGLT1 protein. Without glucose or galactose present, intestinal sodium will not be absorbed. This is the reason glucose is included in ORS solutions.

TYPES OF ORS

Since the initial ORS was meant for replacing the choleratic stools which were profuse with large amount of salt loss, newer modifications have been made for the non choleratic diarrhoea.

1) LOW OSMOLAR ORS

In 2003, WHO/UNICEF changed the ORS formula to a reduced osmolarity version   reducing the osmolarity from 311 mmol/L to 245 mmol/L. The ingredients reduced in concentration were glucose and sodium chloride. The benefits of the reduced osmolarity ORS are reducing stool volume by about 25%, reducing vomiting by nearly 30%, and reducing the need for unscheduled intravenous therapy by 33%.

2)IAP HYPO OSMOLAR ORS

Osmolarity is further reduced to 224mmol/L for younger children.

3)SUPER ORS

Super ORS is starch based ORS, starch (rice) instead of glucose. It is helpful in severe and prolonged diarrhea.

4)ReSoMal

It is rehydration solution for the malnourished. Mineral mixture of specific composition is added to ORS.

INSTRUCTIONS TO BE GIVEN TO THE MOTHER

Wash your hands with soap and water before preparing solution.  Prepare a solution, in a clean pot. Ready to prepare ORS sachets are easily available. It can also be prepared at home.

Home made ORS recipe

Preparing a 1 (one) liter oral rehydration solution [ORS] using Salt, Sugar and Water at Home

1) Ingredients:

One level teaspoon of salt

Eight level teaspoons of sugar

One liter of clean drinking or boiled water and then cooled
5 cupfuls (each cup about 200 ml.)

Preparation Method: Stir the mixture till the salt and sugar dissolve.

A rough guide to the amount of salt is that the solution should taste no saltier than tears.

2) Ingredients:

• 1/2 to 1 cup precooked baby rice cereal or 1½ tablespoons of granulated sugar
• 2 cups of water
• 1/2 tsp. salt

Instructions:
Mix well the rice cereal (or sugar), water and salt togather until the mixture thickens but is not too thick to drink.
How much solution to be fed?
Feed after every loose motion.
For a child under the age of two: Between a quarter and a half of a large cup

For older children: Between a half and a whole large cup

Give it slowly, preferably with a teaspoon. If the child vomits, wait for ten minutes and then begin again. Continue to try to feed the drink to the child slowly, small sips at a time. The body will retain some of the fluids and salts needed even though there are vomiting. Extra liquids should be given until the diarrhea has stopped. This will usually take between three and five days.
How to store the solution?

Store the liquid in a cool place. Chilling the ORS may help. If the child still needs ORS after 24 hours, make a fresh solution.

What other food can be given?

Give child alternately other fluids – such as breast milk and juices without added sugar, vegetable or chicken soup with salt, salted buttermilk, yogurt, rice kanji etc..Continue to give solids if child is five months or older. Give easily digestible energy dense food five to six times a day. Unsuitable fluids: only water, only sugar or glucose water, concentrated drinks and juices because they cause osmotic diarrhea.

Explain to mother that ORS does not stop diarrhea. It prevents the body from drying up. The diarrhea will stop by itself.

Danger signs:

Continuous vomiting, large amount and increasing frequency of stools, child appears dull with sunken eyeballs, decreased urine output, high fever and blood in stools.

ROLE OF MEDICATIONS IN PEDIATRIC DIARRHOEA

 1) ROLE OF ZINC:  For children under five, zinc supplementation significantly reduces the severity and duration of diarrhea and is strongly recommended. The dose is 10 mg daily for infants and 20 mg daily for older children to be given for at least a week.

2)USE OF ANTIBIOTICS: They are indicated only in dysentery, suspected cholera, associated infections like pneumonia, urinary infection and in cases of severely malnourished children.

3)ROLE OF OTHER AGENTS: like antisecretory agents, pre-probiotic agents is controversial. Antimotility agents may cause paralytic ileus and are contraindicated in pediatric patients.
 

SUMMARY

ORS is the mainstay in the treatment of diarrhoea. Proper, early and large scale use of ORS   means less hospitalization and therefore less risk of hospital acquired infections, less disruption of breastfeeding, decreased use of needles (which remains a strong advantage especially in high HIV prevalence contexts), less cost, and in areas where IV therapy is not readily available less risk of dying of diarrhoea.

PS: This article was written for FPA times, June 2009

DR NEEMA SITAPARA

MD (Ped), PGDip. (Adolescent Pediatrics)