Reduced Osmolarity Oral Rehydration Solution Research Articles

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.

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.

Clinical Concerns About Reduced-Osmolarity Oral Rehydration Solution

Demonstration of the benefits of oral therapy for cholera in 1968 soon led to application of the method to all forms of infectious diarrheal diseases. The original oral rehydration solution (ORS) formulation developed by the World Health Organization (WHO) struck a compromise between the ideal solutions for these diverse disorders to meet the programmatic goal of a single formulation and packaging for global use in cholera and noncholera diarrheas in both adults and children. Recently WHO recommended a new oral solution for all acute diarrheas including cholera. This new formula would replace the original ORS which saved millions of lives with a new formulation containing less sodium and glucose. This change was ostensibly to reduce gross stool volume and use of unscheduled intravenous therapy by lowering solution osmolarity. However the reduced-osmolarity formulation is particularly unsuitable for universal use because it contains an amount of sodium insufficient to maintain sodium balance in cholera patients in whom its use induces negative sodium balance and may lead to hyponatremia polyuria and a small but clinically significant risk of neurologic complications. The new reduced-osmolarity formulation stretches the original compromise to the breaking point. It may be time to promote use of different solutions for patients with cholera beginning in controlled settings such as cholera treatment centers and hospitals. (authors)

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

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.

Management of acute diarrhoea with low osmolarity oral rehydration solutions and Lactobacillusstrain GG

Two hypotonic oral rehydration solutions with osmolarities of 224 mosmol/l (Na+ 60 mmol/l, glucose 84 mmol/l) and 204 mosmol/l (Na+ 60 mmol/l, glucose 64 mmol/l), respectively, and oral treatment withLactobacillus...

Evaluation of reduced osmolarity oral rehydration solution in children with severe persistent diarrhea: A randomized double-blind control trial

Evaluation of reduced osmolarity oral rehydration solution in children with severe persistent diarrhea: A randomized double-blind control trial

A double-blind clinical trial comparing World Health Organization oral rehydration solution with a reduced osmolarity solution containing equal amounts of sodium and glucose

OBJECTIVE: To compare the safety and efficacy of an oral rehydration solution (ORS) containing 75 mmol/L of sodium and glucose each with the standard World Health Organization (WHO) ORS among Egyptian children with acute diarrhea. METHODS: One hundred ninety boys, ages 1 to 24 months, who were admitted to the hospital with acute diarrhea and signs of dehydration were randomly assigned to receive either standard ORS (311 mmol/L) or a reduced osmolarity ORS (245 mmol/L). Intake and output were measured every 3 hours. RESULTS: In the group treated with reduced osmolarity ORS, the mean stool output during the rehydration phase was 36% lower (95% confidence interval, 1%, 100%) than in those treated with WHO ORS. The relative risk of vomiting during the rehydration phase was significantly lower in children treated with reduced osmolarity ORS (relative risk, 2.4; 95% confidence interval, 1.2, 4.8). During the maintenance phase, stool output, mean intake of food and ORS, duration of diarrhea, and weight gain were similar in the treatment groups. The relative risk of treatment failure (need for unscheduled administration of intravenous fluids) was significantly increased in children receiving standard WHO ORS (relative risk, 7.9; 95% confidence interval, 1.1, 60.9). The mean serum sodium concentration at 24 hours was significantly lower in children receiving the reduced osmolarity ORS solution (134 ± 6 mEq/L) than in children receiving the standard WHO ORS (138 ± 7 mEq/L) ( p <0.001). The relative risk of the development or worsening of hyponatremia was not increased in children given the reduced osmolarity ORS, and urine output was similar in the treatment groups. CONCLUSION: The reduced osmolarity ORS has beneficial effects on the clinical course of acute diarrhea in children by reducing stool output, and the proportion of children with vomiting during the rehydration phase, and by reducing the need for supplemental intravenous therapy. These results provide support for the use of a reduced osmolarity ORS in children with acute noncholera diarrhea. (J P EDIATR 1996;128:45-51)