Osmolarity Oral Rehydration Solution Research Articles

Comparative, randomized-controlled trial on efficacy and safety of Lactobacillus rhamnosus GG and Saccharomyces boulardii in treatment of acute diarrhea in Indian children (COMPARE-GG trial)

Background: Probiotics are routinely prescribed to boost gut health and reduce severity of diarrhea. This study aimed to compare the efficacy and safety of Lactobacillus rhamnosus GG (LrGG) and Saccharomyces boulardii as an adjunct treatment for acute diarrhea in Indian children aged 6–36 months. Methods: In this single-center, open label, comparative, randomized controlled study, children were randomized into three groups (n=35, each) and provided either low osmolarity oral rehydration solution (ORS) and zinc (20 mg/day) alone or ORS+Zinc supplemented with one of the two probiotic preparations, LrGG ATCC 53103 or S. boulardii CNCM 1-745. Children were monitored every 8 hours after admission and the duration of diarrhea and hospital stay, and stool frequency were evaluated. Results: Of the total 105 children enrolled in the study, majority were aged between 13–24 months (40%). LrGG significantly reduced the mean duration of diarrhea by nearly 19 hours, when compared to the control group (p=0.003), while reduction by S. boulardii was not significant. The mean hospital stay duration for control group was about 6 days, which was significantly reduced (p=0.0001) by nearly 23 hours by LrGG, and non-significantly by S. boulardii. On day 2, LrGG significantly reduced stool frequency by 32.31%, as compared to 27.44% reduction in control group. S. boulardii reduced stool frequency by 31.76%, which was not statistically significant compared to that in control group. Conclusions: LrGG showed statistically significant reduction in duration of diarrhea and hospital stay, when compared against the group receiving ORS+zinc either alone or with S. boulardii.

Cholera -"Rice water stools.

An adult female presented with acute watery diarrhoea and severe dehydration during a cholera outbreak in Mae La refugee camp, Thailand in 2007. Her stools had the classic appearance of cholera “rice water stools”, which is similar to water where rice was boiled. Stool are watery, greyish in colour, cloudy, with flecks of mucus, with a non offensive fish-like odour (Panels A, B, C and D from this patient). The patient was isolated, treated initially with Ringers’s lactate intravenously and then with oral rehydration solution. Tetracycline per os was given for three days according to local protocol and the patient recovered completely. A culture of stools obtained by rectal swab upon admission subsequently tested positive for Vibrio Cholerae, 01 Inaba serotype, which was also the cause of the outbreak. Cholera is transmitted through contaminated food or water, can cause epidemics and may also infect travellers. Clinical spectrum ranges from asymptomatic to severe disease with massive watery diarrhoea often fatal if untreated. Treatment includes rapid fluid replacement with the WHO’s reduced osmolarity oral rehydration solution or intravenous rehydration (Ringer’s lactate) for severe cases. Antibiotics (azithromycin, erythromycin,tetracycline or ciprofloxacine) decrease disease duration.

Translating Molecular Physiology of Intestinal Transport Into Pharmacologic Treatment of Diarrhea: Stimulation of Na+ Absorption

Diarrheal diseases remain a leading cause of morbidity and mortality for children in developing countries, while representing an important cause of morbidity worldwide. The World Health Organization recommended that low osmolarity oral rehydration solutions plus zinc save lives in patients with acute diarrhea, but there are no approved, safe drugs that have been shown to be effective against most causes of acute diarrhea. Identification of abnormalities in electrolyte handling by the intestine in diarrhea, including increased intestinal anion secretion and reduced Na(+) absorption, suggest a number of potential drug targets. This is based on the view that successful drug therapy for diarrhea will result from correcting the abnormalities in electrolyte transport that are pathophysiologic for diarrhea. We review the molecular mechanisms of physiologic regulation of intestinal ion transport and changes that occur in diarrhea and the status of drugs being developed to correct the transport abnormalities in Na(+) absorption that occur in diarrhea. Mechanisms of Cl(-) secretion and approaches to anti-Cl(-) secretory therapies of diarrhea are discussed in a companion review.

FREQUENCY OF HYPONATREMIA

Introduction: Acute diarrhea is defined as passage of three or more stools in a day, of consistency softer than usual for thechild, or one watery stool. Acute diarrhea is the major cause of morbidity and mortality in developing countries. It accounts for approximately25% of total admissions in children ward and causes mortality of 5-10% in community. As dehydration is the main complication of diarrhea,treatment focuses upon rehydration through fluid replacement. Oral Rehydration solution (ORS) is the recommended treatment in children withacute diarrhea and some dehydration. Now WHO has recommended Low Osmolarity ORS which contains less sodium and glucose thanstandard ORS. One of the side effect of use of ORS solution with reduced sodium level is the development of hyponatremia ( i.e. serum sodiumlevel less than 130 meq/L) in some of children with acute diarrhea and results in adverse clinical events. Objective: To determine thefrequency of hyponatremia in children taking low osmolarity ORS for management of acute diarrhea with some dehydration. Study design:Descriptive case series. Place and Duration of Study: Study was conducted in Department of Pediatrics, Children ward-2 Bahawal VictoriaHospital Bahawal Pur and Department of Pathology Quaid-e-Azam medical college Bahawal Pur from 7th August 2010 to 22nd September2010. Subjects and methods: Total 32 children with age between 3 months to 60 months with acute diarrhoea and some dehydration withnormal initial serum sodium were included. An informed consent was taken from the parents to include their children in the study. Proforma wasfilled at the time of admission and after 4 hours. Blood sample was taken to measure serum sodium level. Criteria of hyponatreima was serumsodium level below 130 meq/l after giving low osmolarity ORS at a dose of 75 ml/kg to drink. Results: A total of 32 children with acute diarrheawere included in study with age ranging from 3 months to 60 months. Male to female ratio was 1.1:1. Hyponatremia was seen in 2 (6.3%) ofpatients. Conclusions: The risk of hyponatremia in patients treated with the low osmolarity ORS was minimal.

Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in Ujjain, India - a cross-sectional prescription analysis

BackgroundDiarrhoea accounts for 20% of all paediatric deaths in India. Despite WHO recommendations and IAP (Indian Academy of Paediatrics) and Government of India treatment guidelines, few children suffering from acute diarrhoea in India receive low osmolarity oral rehydration solution (ORS) and zinc from health care providers. The aim of this study was to analyse practitioners' prescriptions for acute diarrhoea for adherence to treatment guidelines and further to determine the factors affecting prescribing for diarrhoea in Ujjain, India.MethodsThis cross-sectional study was conducted in pharmacies and major hospitals of Ujjain, India. We included prescriptions from all practitioners, including those from modern medicine, Ayurveda, Homeopathy as well as informal health-care providers (IHPs). The data collection instrument was designed to include all the possible medications that are given for an episode of acute diarrhoea to children up to 12 years of age. Pharmacy assistants and resident medical officers transferred the information regarding the current diarrhoeal episode and the treatment given from the prescriptions and inpatient case sheets, respectively, to the data collection instrument.ResultsInformation was collected from 843 diarrhoea prescriptions. We found only 6 prescriptions having the recommended treatment that is ORS along with Zinc, with no additional probiotics, antibiotics, racecadotril or antiemetics (except Domperidone for vomiting). ORS alone was prescribed in 58% of the prescriptions; while ORS with zinc was prescribed in 22% of prescriptions, however these also contained other drugs not included in the guidelines. Antibiotics were prescribed in 71% of prescriptions. Broad-spectrum antibiotics were prescribed and often in illogical fixed-dose combinations. One such illogical combination, ofloxacin with ornidazole, was the most frequent oral antibiotic prescribed (22% of antibiotics prescribed). Practitioners from alternate system of medicine and IHPs are significantly less likely (OR 0.13, 95% CI 0.04-0.46, P = 0.003) to prescribe ORS and zinc than pediatricians. Practitioners from 'free' hospitals are more likely to prescribe ORS and zinc (OR 4.94, 95% CI 2.45-9.96, P < 0.001) and less likely to prescribe antibiotics (OR 0.01, 95% CI 0.01-0-04, P < 0.001) compared to practitioners from 'charitable' hospitals. Accompanying symptoms like the presence of fever, pain, blood in the stool and vomiting significantly increased antibiotic prescribing.ConclusionThis study demonstrated low adherence to standard treatment guidelines for management of acute diarrhoea in children under 12 years in Ujjain, India. Key public health concerns were the low use of zinc and the high use of antibiotics, found in prescriptions from both specialist paediatricians as well as practitioners from alternate systems of medicine and informal health-care providers. To improve case management of acute diarrhoea, continuing professional development programme targeting the practitioners of all systems of medicine is necessary.

Role of zinc in pediatric diarrhea

Zinc supplementation is a critical new intervention for treating diarrheal episodes in children. Recent studies suggest that administration of zinc along with new low osmolarity oral rehydration solutions / salts (ORS), can reduce the duration and severity of diarrheal episodes for up to three months. The World Health Organization (WHO) and UNICEF recommend daily 20 mg zinc supplements for 10 – 14 days for children with acute diarrhea, and 10 mg per day for infants under six months old, to curtail the severity of the episode and prevent further occurrences in the ensuing -two to three months, thereby decreasing the morbidity considerably. This article reviews the available evidence on the efficacy and safety of zinc supplementation in pediatric diarrhea and convincingly concludes that zinc supplementation has a beneficial impact on the disease outcome.

Causes and management of diarrhoea in children in a clinical setting

Diarrhoeal disease and its complications remain a major cause of morbidity and mortality in children, especially in developing countries. Diarrhoea is characterised by an increased frequency and volume, and decreased consistency of stool from the norm. Pathogens vary between developed and developing world settings. Rotavirus diarrhoea is the most important aetiological agent implicated in severe dehydrating diarrhoea. Although it is important to recognise the specific microbiological causation of diarrhoea in order to target appropriate treatment, the broader preventive aspects put forward by the World Health Organization (WHO) indicate the fundamental contributors to the massive burden of disease in developing countries. The management of a child presenting with acute diarrhoea must include a thorough history and examination with evaluation of hydration status, nutritional status and comprehensive clinical evaluation for any complications or associated illnesses. The most recent advances in the area of acute diarrhoeal disease include zinc supplementation, reduced osmolarity oral rehydration solution (ORS) and rotavirus vaccination.

Efficacy of reduced osmolarity oral rehydration solution, rice ... based oral rehydration solution, and standard WHO oral rehydration solution in children with acute diarrhea - a randomized open trial

Background The composition of the WHO's standard oral rehydration solution (ORS) is similar to that of choleric stool. Currently, there are questions about whether the composition is acceptable for treating dehydration caused by diarrhea. Efforts are being made to try and improve the WHO ORS, e.g., to decrease the solution osmolarity to avoid hypertonic side effects.lt is acknowledged that if glucose is used in ORS, the sodium will go through enterocytes and glucose will tum into an absolute substance for the formula. Glucose is less affordable and not widely produced in developing countries, hence researchers are currently exploring substitutes such as rice flour.Objective To compare the efficacy of reduced osmolarity ORS,rice-based ORS and the WHO standard ORS among childrenwith acute diarrhea.Methods A randomized open trial was conducted in children aged6-59 months old admitted for acute diarrhea. One-way AN OVAwas used to compare the three different types of ORS given.Results The mean duration of diarrhea was significantly lower inthe group treated with reduced osmolarity ORS (52.66 h, 95%CI 4 7.13 to 58.18) and rice-based ORS (54.66 h, 95% CI 4 7.97to 61.34) compared to the group treated with the WHO standardORS (67.34 h, 95% CI 61.50 to 73.18). Multivariate analysisshows that intervention had a significant effect on reducing theduration of diarrhea.Conclusions Reduced osmolarity ORS and rice-based ORSsignificantly lower the mean duration of children with acutediarrhea compared with the group treated with the WHO standardORS.

Oral Rehydration Solutions in Non-Cholera Diarrhea: A Review

The use of oral rehydration solution (ORS) has revolutionized the management of acute diarrhea. The implementation of the standard World Health Organization ORS (WHO-ORS) has resulted in decreased mortality associated with acute diarrheal illnesses in children, although in general stool volume and diarrhea durations are not reduced. Decreased morbidity and mortality have occurred because of improved hydration status. Decreased morbidity has also been described in adults who used this therapy. Various modifications to the standard ORS have been derived. These modifications have included hypo-osmolar or hyperosmolar solutions, use of rice-based ORS, zinc supplementation, and the use of amino acids, including glycine, alanine, and glutamine. Some of these variations have been successful, some have not, and others are still under investigation. ORS has been used for travelers' diarrhea and to decrease intravenous (IV) fluid requirements in patients with short bowel syndrome (SBS) who require parenteral nutrition (PN). This paper reviews the standard WHO-ORS and its mechanism of action, followed by more contemporary reduced osmolarity ORS and rice-based ORS in non-cholera diarrhea. Various modifications to improve ORS are also discussed.

Evaluation of Oral Rehydration Solution by Whole‐Gut Perfusion in Rats: Effect of Osmolarity, Sodium Concentration and Resistant Starch

Reduced osmolarity oral rehydration solution (ORS) improved small bowel absorption of fluid and electrolytes in segmental perfusion in experimental animals; this was borne out in clinical practice. Adding amylase-resistant starch (RS) to ORS is expected to increase colonic fluid absorption. This study used combined small and large bowel perfusion to evaluate combinations of reduced osmolarity and starch in ORS. Single-pass steady-state perfusions of the whole gut at 30 mL/h, using the nonabsorbable marker C-polyethylene glycol 4000, were performed in Wistar rats after exposure to cholera toxin or Escherichia coli heat-stable enterotoxin (STa). Steady state was established within 90 minutes after commencing perfusion. Net secretion of water, sodium and chloride induced by cholera toxin was partially reversed by standard glucose-ORS (G-ORS). Substituting glucose in G-ORS with RS (RS-ORS) substantially increased net water absorption (P < 0.001) as did reduced osmolarity ORS (RO-ORS) (P < 0.001); addition of RS to RO-ORS further increased water absorption (P < 0.001). In STa-treated intestine, RO-ORS and RS-ORS significantly improved water absorption compared to G-ORS (P < 0.005). RO- and RS-RO-ORS did not significantly augment net electrolyte absorption compared with G-ORS. RS-ORS was associated with highest net absorption of sodium and chloride compared with all other groups. RS increased net water (and sodium) absorption from isosmolar and reduced osmolar ORS consistent with increased absorption by the colon. RS in reduced osmolar ORS may have advantages to reduce severity of diarrhea and prevent hyponatremia in severe diarrhea and may be applicable to diarrhea of different etiologies.

Symptomatic Hyponatremia During Treatment of Dehydrating Diarrheal Disease With Reduced Osmolarity Oral Rehydration Solution

In May 2002, the World Health Organization and the United Nations Children's Fund recommended that the formulation of oral rehydration solution (ORS) for treatment of patients with diarrhea be changed to one with a reduced osmolarity and that safety of the new formulation, particularly development of symptomatic hyponatremia, be monitored. To measure the rates of symptomatic hyponatremia during treatment of patients with diarrhea with reduced osmolarity ORS. A phase 4 trial conducted at the Dhaka hospital (December 1, 2002-November 30, 2003) and Matlab hospital (February 2, 2003-January 31, 2004) of the International Centre for Diarrhoeal Disease Research Bangladesh: Centre for Health and Population Research, Dhaka, Bangladesh. All patients admitted with uncomplicated watery diarrhea were treated with the newly recommended ORS and monitored. Patients developing neurological symptoms (seizure or altered consciousness) were transferred to the special care ward for treatment and investigated to identify the cause of the symptoms. Patient records of the Dhaka hospital were reviewed during the previous year when the old ORS formulation was used. Reduced osmolarity ORS. Incidence rate of symptomatic hyponatremia in a 1-year period. A total of 53,280 patients, including 22,536 children younger than 60 months, were monitored at the Dhaka and Matlab hospitals. Twenty-four patients, none older than 36 months, developed seizures or altered consciousness associated with hyponatremia, with an overall incidence rate of 0.05% (95% confidence interval [CI], 0.03%-0.07%) at the Dhaka hospital and 0.03% (95% CI, 0.01%-0.09%) at the Matlab hospital. During the previous year, 47 patients at the Dhaka hospital had symptoms associated with hyponatremia, for an estimated incidence rate of 0.10% (95% CI, 0.07%-0.13%). The reduction in the rates was statistically significant (odds ratio, 0.50; 95% CI, 0.29-0.85; P = .009). The risk of symptoms associated with hyponatremia in patients treated with the reduced osmolarity ORS is minimal and did not increase with the change in formulation.

2. Acute infectious diarrhoea and dehydration in children

Gastroenteritis in children is still a common reason for consulting a general practitioner and for hospital admission. Rotavirus is the most common cause of gastroenteritis in children and accounts for half of all hospital admissions for severe acute infectious diarrhoea. Most children with gastroenteritis do not develop dehydration and can be treated at home. Children with mild to moderate dehydration should be treated with low osmolarity oral rehydration solutions, and those with severe dehydration or shock need to be admitted for administration of intravenous fluids. Lactose-free feeds should not be routinely used after acute gastroenteritis, but there is some evidence that a lactose-free diet may reduce the duration of diarrhoea. Antimotility drugs are rarely indicated in children with gastroenteritis, as the potential risks outweigh the benefits. The development of a rotavirus vaccine would provide huge public health benefits and cost savings. Other preventive strategies include educating people about personal and food hygiene and encouraging breastfeeding.

Reduced Osmolarity Oral Rehydration Solutions: New and Improved ORS?

Reduced Osmolarity Oral Rehydration Solutions: New and Improved ORS?

Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children.

Oral rehydration solution (ORS) has reduced childhood deaths from diarrhoea in many countries. Recent studies suggest that the currently recommended formulation of ORS recommended by the World Health Organization (WHO) may not be optimal, and solutions that contain lower concentrations of sodium and glucose may be more effective. In children with acute diarrhoea, to compare reduced osmolarity glucose-based oral rehydration salt solution with international WHO formulation. The Cochrane Collaboration Trials Register, MEDLINE, and EMBASE were searched. Additional trials were identified by hand searching. Content experts were contacted. Randomised controlled trials comparing reduced osmolarity ORS solution with the WHO formulation. Outcomes sought were unscheduled intravenous fluid infusion therapy and measures of clinical illness. Data were extracted by two reviewers. We tested for heterogeneity using the chi-square statistic, conducted sensitivity analysis by allocation concealment, and the regression approach to assess funnel plot asymmetry from selective trial publication. The primary outcome was reported in 12 trials. In a meta-analysis of nine trials, reduced osmolarity ORS was associated with fewer unscheduled infusions compared with standard WHO ORS (Mantel Haenzel odds ratio 0.61, 95% confidence interval 0.47 to 0.81) with no evidence for heterogeneity between trials. No unscheduled intravenous fluid infusion therapy was required in any participant in three trials. Thirteen trials reported stool output, and data suggested less stool output in the reduced osmolarity ORS group. Vomiting was less frequent in the reduced osmolarity group in the six trials reporting this. Six trials sought hyponatraemia, with events in three studies, but no obvious difference between the two arms. In children admitted to hospital with diarrhoea, reduced osmolarity ORS when compared to WHO ORS is associated with fewer unscheduled intravenous infusions, smaller stool volume post randomisation, and less vomiting. No additional risk of developing hyponatraemia when compared with WHO ORS was detected.

Reduced osmolarity oral rehydration solution for treating dehydration due to diarrhoea in children: systematic review.

Child: Care, Health and DevelopmentVolume 28, Issue 1 p. 118-118 Reduced osmolarity oral rehydration solution for treating dehydration due to diarrhoea in children: systematic review. Richard Reading, Richard ReadingSearch for more papers by this author Richard Reading, Richard ReadingSearch for more papers by this author First published: 20 April 2002 https://doi.org/10.1046/j.1365-2214.2002.0255c.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume28, Issue1January 2002Pages 118-118 RelatedInformation

Lower osmolarity oral rehydration solution is better than WHO solution

Lower osmolarity oral rehydration solution is better than WHO solution

Reduced osmolarity oral rehydration solution for treating dehydration due to diarrhoea in children: systematic review

Objectives: To compare reduced osmolarity oral rehydration solution with standard World Health Organization oral rehydration solution in children with acute diarrhoea.Design: Systematic review of randomised controlled trials.Studies: 15 randomised controlled...

Reduced osmolarity oral rehydration solution superior?

Reduced osmolarity oral rehydration solution superior?

Reduced osmolarity oral rehydration solution for persistent diarrhea in infants: A randomized controlled clinical trial

Objective: We evaluated and compared the efficacy of the World Health Organization (WHO) oral rehydration solution (ORS) and 2 different formulations of reduced osmolarity ORSs in infants with persistent diarrhea. Study design: Infants with persistent diarrhea (n = 95) were randomized to 1 of the 3 ORSs: WHO-ORS (control, n = 32), a glucose-based reduced osmolarity ORS (RORS-G, n = 30), or a rice-based reduced osmolarity ORS (RORS-R, n = 31) for replacement of ongoing stool losses for up to 7 days. Major outcome measures were stool volume and frequency, ORS intake, and resolution of diarrhea. Results: Although there were variations from one study day to another, the stool volume was approximately 40% less in the reduced osmolarity ORS groups; consequently, these children required less ORS (22% for RORS-G and 27% for RORS-R groups). A higher proportion of children in the RORS-R groups also had resolution of diarrhea during the study period. No children in any of the treatment groups had hyponatremia. Conclusion: Reduced osmolarity ORS is clinically more effective than WHO-ORS and may thus be advantageous for use in the treatment of children with persistent diarrhea. (J Pediatr 2001;138:532-8)

Efficacy and safety of oral rehydration solution with reduced osmolarity in adults with cholera: a randomised double-blind clinical trial

The effects of oral rehydration solution (ORS) with reduced osmolarity on children with acute watery diarrhoea are known, but little is known about the effects of such ORS on adults with cholera. We aimed to compare the efficacy and safety of an ORS with reduced osmolarity with that of standard WHO ORS in adults with cholera. We undertook a double-blind, controlled clinical trial in adults with severe cholera at the International Centre for Diarrhoeal Disease Research, Bangladesh. Our primary outcomes were mean stool output in the 24 h after randomisation, proportion of patients who needed unscheduled intravenous therapy, and proportion of patients with biochemical hyponatraemia 24 h after randomisation. 147 patients received ORS with reduced osmolarity and 153 received standard WHO ORS. There was no significant difference between the two groups in terms of main outcome variables: mean initial 24 h and total stool output (reduced osmolarity vs standard WHO ORS 212 [SE 8] vs 207 [8] and 284 [13] vs 273 [13] g/kg respectively), duration of diarrhoea (46 [1.5] vs 43 [1.5]). The proportion of patients vomiting during the first 24 h and the proportion who received unscheduled intravenous infusion during the first 24 h was similar between groups. More patients on reduced osmolarity ORS than on standard WHO ORS developed hyponatraemia during the first 24 h, defined as serum sodium concentration below 130 mmol/L (29 of 142 vs 16 of 150; odds ratio 2.1 [95% CI 1.1-4.1]). However, all hyponatraemic patients in both groups were symptom-free and the proportion of patients with serum sodium concentration below 125 mmol/L was similar between groups. There was no difference in clinical outcome between cholera patients treated with reduced osmolarity ORS solution and those treated with standard WHO ORS. The risk of increased incidence of symptom-free hyponatraemia in patients with cholera treated with an ORS with reduced osmolarity should be further assessed by meta-analysis. The risk should be taken into account when choice of ORS is made in areas in which cholera is endemic.