Use Of Oral Rehydration Solution Research Articles

Childhood Diarrhoea in a District in Northeast Thailand: Incidence and Treatment Choices

Diarrhoeal disease is a major public health problem in Thailand. We collected information on childhood diarrhoea from a district in northeast Thailand, using various approaches which focus on both consumers and providers. The overall incidence of diarrhoea in the study area was 2.1 episodes per child per 12 months, with children under two years of age having a higher rate at 3.0 episodes per child per 12 months. Many episodes were not recognized as diarrhoeal episodes by caregivers, and treatment was sought in just over half of all episodes. Although children received an average of 2.4 items of medicine per episode, there was relatively low use of oral rehydration solutions. This study highlights the importance of assessing local beliefs when collecting data on diarrhoeal diseases in children, and the importance of continuing efforts to improve public health education on the management of diarrhoeal diseases.

Reduction in morbidity of rotavirus induced diarrhoea in mice by yeast produced monovalent llama-derived antibody fragments

Apart from the use of oral rehydration solution, there are currently no treatment modalities for rotavirus induced diarrhoea, which is particularly relevant to developing countries. Fragments derived from llama heavy chain antibodies were previously shown to be highly stable, efficiently produced in yeast and exhibiting high epitope specific affinity. We now aim to demonstrate that these antibody fragments are capable of reducing morbidity of rotavirus induced diarrhoea. Here we show the isolation of rotavirus specific antibody fragments and their capability of reducing the morbidity of rotavirus induced diarrhoea in vivo in mice. They could provide a treatment modality for the moderation of human rotavirus infections having a significant impact on the course of an often fatal childhood disease.

The Dawning of the “Zinc Era” in the Treatment of Pediatric Acute Gastroenteritis Worldwide?

Despite the widespread use of oral rehydration solution (ORS) preparations, up to 5 million children each year still die of diarrhea, almost all in developing countries (1). The World Health Organization (WHO) estimates that, in children younger than 5 years, diarrhea accounts for 18% of cause-specific mortality and that there are 6 to 7 episodes per child per year in the developing world versus 1 to 2 in the developed world (2). The effects of diarrhea in developed countries are often measured in financial terms. In the United States, acute diarrhea accounts for a minimum of US$23 billion per year due to loss of productivity and medical costs (3). If we restrict the analysis to rotavirus enteritis (the most frequent infectious diarrhea), there is an estimated cost of approximately US$274 million for medical treatment and more than US$1 billion in costs to the community (4). Oral rehydration solutions are now widely used to treat diarrhea and have greatly reduced mortality from dehydration. However, ORS does not decrease the duration of diarrhea or its severity. Despite the advent of a number of antidiarrheal drugs, none has found a place in the routine management of acute diarrhea. Several hospital and community-based randomized trials, all performed in developing countries, consistently showed that zinc is an effective treatment for acute or persistent diarrhea in children younger than 5 years. Benefits include the reduction of diarrhea duration and its severity as measured by stool output and frequency, and these effects have been obtained in both mild and severe gastroenteritis associated with severe dehydration requiring hospitalization (5). Furthermore, a number of randomized controlled trials carried out in developing countries explored the efficacy of zinc in preventing intestinal infections. The incidence and duration of acute and persistent diarrhea were significantly lower in zincsupplemented children versus placebo-treated counterparts (6,7). Moreover, in children younger than 5 years, zinc treatment during acute diarrhea illness resulted in fewer subsequent diarrhea episodes and in a concomitant reduction in the use of antibiotics (8,9). The preventive and therapeutic effects of zinc in reducing diarrhea morbidity have relevant economic implications in terms of hospitalization and antibiotic use (10). The only negative data come from a recent trial in infants aged 1 to 6 months performed in Bangladesh in which different doses of zinc (5 or 20 mg/d given for the duration of the illness) did not affect the duration or severity of diarrhea (11). Given the benefits of zinc supplementation in a large number of studies, in May 2004, the United Nations Children’s Fund (UNICEF) and the WHO issued a statement recommending that all children with diarrhea in developing countries be treated with zinc (12). Although zinc is recommended for the treatment of childhood acute diarrhea, several important questions remain to be answered. These can be divided into questions that can be addressed by basic research and questions that can be addressed by applied research (Table 1). A major research goal is to investigate the effects of zinc against specific pathogens that cause diarrhea, especially rotavirus. Besides rotavirus, other major causal agents of infectious diarrhea are Vibrio cholerae and the enterotoxigenic Escherichia coli. Using an in vitro model, we recently demonstrated that zinc promotes ion absorption and prevents active secretion induced by V. cholerae heat-labile enterotoxin, thereby exerting a direct effect on intracellular cyclic adenosine monophosphate concentration, but it does not affect E. coli heat-stable, enterotoxin-induced ion secretion (13). This finding suggests that zinc exerts selective effects against intestinal pathogens and highlights the need to investigate whether zinc could be useful against other diarrheal mechanisms elicited by different pathogens (14). Should this prove to be the case, the physician has 2 alternatives: either identify the Received December 14, 2005; accepted December 30, 2005. Address correspondence and reprint requests to Roberto Berni Canani, MD, PhD, Department of Pediatrics, University Federico II of Naples, Via Sergio Pansini, 5, 80131 Naples, Italy. (e-mail: berni@ unina.it).

A Pilot Test of the Addition of Zinc to the Current Case Management Package of Diarrhea in a Primary Healthcare Setting

Zinc is recommended for the treatment of acute diarrhea in children but the effect of its introduction on drug and oral rehydration solution use is unclear. Government care providers, private practitioners and community workers were trained to distribute zinc and oral rehydration solution to children seeking care for diarrhea. Periodic surveys showed that village-based workers became a common source of diarrhea treatment and private practitioners were used less. Zinc was used in approximately half of the episodes; the prescription and use rates of oral rehydration solution packets increased from 7% at baseline to 44.9% 6 months later. Reduction in use of drugs during diarrhea ranged from 34% for tablets to 64% for injections 6 months later. The cost of treatment to families declined significantly. These findings need confirmation in a randomized controlled trial.

La déshydratation hypernatrémique chez l'enfant : étude rétrospective de 105 cas

The hypernatremic dehydration defined by a serum sodium concentration > to 150 mmol/l, is a particular form of acute dehydration and constitutes a medical emergency requiring a prompt and adequate diagnosis and management. Purpose. – To precise the epidemiological profile, course, causes and therapeutic particularities of hypernatremic dehydration in children. Population and methods. – Retrospective review of 105 children admitted in the general Paediatrics department of the Fattouma Bourguiba university hospital in Monastir (Tunisia), for hypernatremic dehydration between January 1st 1990 and December 31 2002. Results. – Hypernatremic dehydration represented 11,51% of all kinds of dehydration. The mean age was 6.5 months with a small male predominance. The socio-economic level of the parents was good in 62.8% of cases. Half of the children were in shock. Severe dehydration was present in 87.6% of cases and neurological signs were observed in 77.14% of cases. The initial mean serum sodium concentration was 159 mmol/L. Acidosis and acute renal failure were associated respectively in 97.2% and 76.2% of cases. Prominent cause of hypernatremic dehydration was diarrhoea (94.3%). Intravenous rehydration with 5% glucose solution at the average of 147 ml/kg/day and containing a mean sodium level of 42 mmol/L was performed in 74% of cases. In most cases (84.1%) serum sodium was normalized within the first 72 hours. Complications were noted in 5.7% of cases and mortality rate was 11.4%. Conclusion. – Hypernatremic dehydration was common in infant and the prominent cause is still dominated by diarrhoea in our country. The management of hypernatremic dehydration is based on oral or intravenous rehydration and plasma expanding fluids when shock is present or imminent. The serum sodium concentration should be gradually corrected and should not exceed 0,5 mmol/L/h. Prevention is based on the pursuit of breastfeeding and the use of oral rehydration solution in infantile diarrhoeas.

KABP AMONG THOSE WITH ACUTE DIARRHOEAL DISEASE

ISEE-11 Introduction: Acute diarrhoeal disease (ADD) continues to pose a great challenge, even among adult populations. Aim: To assess the Knowledge, Awareness Behaviour & Practice (KABP) among adults with acute diarrhoeal disease, and to design educational modules to educate these populations. Setting: Government Rajaji Hospital (GRH), Madurai (a multispeciality teaching hospital). Methods: The first author interviewed 130 low socio-economic urban adult patients with ADD admitted to GRH, to assess their KABP for acquiring ADD. Results: Total no. of patients – 130 Washing of hands after defecation – NIL Washing of hands before taking food - 51 (39.23%) Boiling water before drinking – NIL Eating roadside preparations - 127 (97.69%) Open-air defecation - 93 (73.07%) Poor sanitation around their houses - 130 (100%) Waste disposal – NIL Unknown cause of diarrhoea - 128 (98.46%) Ignorant to the fact that diarrhoea is a preventable disease - 128 (98.46%) Use of Oral Rehydration Solution - 88 (67.69%) Conclusion: The overall poor sanitary conditions and lack of knowledge may have resulted in acute diarrhoeal disease seen in these patients. The community must be educated & motivated for ways of healthy living & overall clean environments.

Chronic diarrhea

Chronic diarrhea can be due to any of several hundred conditions. When investigation fails to uncover a specific cause that can be treated successfully, nonspecific therapy is implemented. This includes dietary alterations if specific aggravating foods can be identified, enteral or parenteral nutrition if nutritional status is compromised, and use of oral rehydration solutions if diarrhea produces volume depletion. Strategic use of dietary fiber can improve stool consistency and can be of special value when fecal incontinence is present concurrently. Medications of value include opiate antidiarrheal drugs, clonidine, octreotide, and bile acid-binding agents. Less potent opiates such as loperamide and diphenoxylate should be tried first, with more potent agents such as codeine, opium, and morphine used in refractory cases. Clonidine has both proabsorptive and motility effects that facilitate its antidiarrheal effect, but its antihypertensive action limits its utility. Octreotide is of great value in treating diarrhea due to endocrine tumors and dumping syndrome; its efficacy in other conditions or in nonspecific diarrhea is less well established. Bile acid binders such as cholestyramine or colestipol have several specific uses but have limited utility in nonspecific chronic diarrhea.

Correct Preparation and Administration of Oral Rehydration Solution: Essential for Safe and Effective Home Treatment of Diarrhea in Indonesia

Diarrhea-related dehydration is a leading cause of childhood death in developing countries such as Indonesia, despite being largely preventable and treatable through use of Oral Rehydration Solution (ORS). While the extent to which ORS is used in Indonesia has been explored in earlier studies, the issue of whether it is being used correctly has not been adequately investigated. The purpose of this study was to assess mothers' ORS preparation and administration practices and to determine their source of instruction for these practices. A structured questionnaire was administered orally to 100 mothers of children under the age of 5 years, in a rural village of West Java, Indonesia. Only 23.7% of mothers were found to have correctly prepared ORS, and none exhibited fully correct administration practices. Primary sources of instruction were health workers (62.9%), package instructions (23.7%), and family members or friends (12.4%). Resulting recommendations include education of health care workers, community health education programs, reallocation of health care resources, and revision of ORS packaging guidelines.

The use of oral rehydration solutions in children and adults

The observation that the intestinal Na(+)-glucose cotransporter remains intact in most diarrheal illnesses led to development of the life-saving, low-cost technology of oral rehydration salt (ORS) solutions. The primary therapeutic role of ORS solutions is in prevention and treatment of dehydration during management of acute gastroenteritis. Successful oral rehydration therapy involves early use of ORS with maintenance or timely resumption of regular feeding. Since the inception of the oral rehydration approach more than three decades ago, the widespread use of ORS solutions has revolutionized the management and outcomes of acute gastroenteritis in children and adults. The efficacy of the World Health Organization ORS solution and of commercial ORS formulations has been enhanced by reducing osmolarity. Newer formulations of ORS are under active investigation, with promise of added benefits, including promotion of intestinal healing. This article reviews fluid and electrolyte transport in the gastrointestinal tract, the pathophysiologic mechanisms of acute diarrhea, and the basis and formulation of current and newer ORS solutions. Guidelines for efficacious use of ORS in the management of acute gastroenteritis and short gut syndrome are also provided.

Travellers' diarrhoea: health advice for travellers

Travellers' diarrhoea is a frequent problem for travellers. Access to a safe water supply when travelling, is undoubtedly a paramount issue. Water and food precautions are important for travellers to be aware of and followed, as is attention to general hygiene. In some situations, chemoprophylaxis and standby treatment with antibiotics may be needed. It is essential that travellers, especially those travelling with young children, be familiar with the use of oral rehydration solutions and the prevention of dehydration.

Update on ORS Usage in Pakistan: Results of a National Study

1 Abstract: Diarrhea disease continues to rank as one of the leading causes of child mortality throughout the world. It is estimated that 1 billion episodes of diarrhea occur in young children each year, The World Health Organization has recommended the use of oral rehydration solution (ORS) for the treatment of dehydration associated with diarrhea. Numerous studies have documented the effectiveness of ORS in treating diarrhea and reducing mortality. Diarrheal disease in Pakistan has been identified as the major cause of child mortality in Pakistan, accounting for an estimated 200,000 - 300,000 deaths each year. This paper reports the results of a nationwide survey conducted in Pakistan to obtain information regarding the practices of mothers concerning child health care and factors that influence these practices. The purpose of the survey was to collect baseline data on a variety of issues, in order to develop effective health education programs and evaluate ongoing ones. Within the context of two theoretical models (diffusion of innovation and stages of change), adoption practices of the population with respect to use of ORT treatment are described and assessed. These results pose new challenges to health care professionals in their ability to influence and persuade adoption of effective public health practices. Recommendations are provided as how to modify the misconceptions of mothers with young children in the treatment of diarrhea.

Zinc Supplementation in Oral Rehydration Solutions: Experimental Assessment and Mechanisms of Action

Background: Zinc deficiency is associated with chronic diarrhea. This condition is generally linked to an overproduction of nitric oxide (NO), which induces secretion and cellular damage as a free radical. Use of oral rehydration solutions (ORS) is an important part of diarrhea treatment, especially early in infancy and for patients with cholera. The presence of zinc in an ORS could be a positive factor in recovery from diarrheal disease.Objective: This study was undertaken to determine whether zinc added to an ORS could regulate the synthesis of NO metabolites in the lumen of zinc deficient rat intestine, acting as a gastrointestinal protector and thus accelerating normalization of intestinal function and zinc status.Methods: The effects of zinc on NO metabolism were studied in young male rats fed a zinc deficient diet for three weeks to mimic the condition of patients with recurrent diarrheal episodes. During the fourth week of the zinc deficient feedings, experimental diarrhea was induced using cathartics (magnesium citrate plus phenolphthalein) that exacerbate NO production. A standard ORS with or without 1 mM zinc was given to the rats for the last two days. A control group received a zinc sufficient diet. Rats were killed at each stage. Intestinal nitric oxide synthase (NOS) was assayed, cecal fluid contents were analyzed for nitrates and nitrites, intestinal histology was examined, and activation of nuclear factor NF-κB DNA binding activity was determined.Results: Rats fed the zinc-deficient diet for three weeks gained less weight than rats fed a normal zinc content diet and had a lower plasma zinc than controls (51.6 ± 5.4 [n = 10] vs. 143.6 ± 7.2 μg/dL [n = 11], p < 0.05). Recovery with ORS+Zn resulted in a higher plasma zinc than with the ORS-Zn (ORS+Zn: 186.5 ± 12.2; ORS−Zn: 57.5 ± 6.6 μg/dL, p < 0.05). The zinc-deficient diet did not alter mucosal NOS, as compared to the values of rats fed a normal diet. However, those animals which received five days of cathartic fluids had a small intestinal NOS higher than that of all other groups. Either ORS+Zn or ORS−Zn normalized NOS activity, regardless of cathartic treatment. The rats fed the zinc deficient diet had generally a higher content of NO metabolites in the cecum than rats fed a normal diet. After recovery with either type of ORS, rats given the cathartic remained with higher cecal NO metabolite concentrations than rats that had no induced diarrhea. After recovery with ORS+Zn, intestinal villi showed significant expansion of the lamina propria, an indication of greater absorption of fluid, while with ORS−Zn this was not present. Small intestinal homogenates of rats recovering with ORS+Zn had a decreased NF-κB DNA binding activity than tissues from rats consuming ORS−Zn.Conclusions: The results are consistent with the hypothesis that addition of Zn to an ORS may contribute to improving the physiologic status of the small intestine and potentially reduce the risks of recurrent diarrhea episodes.

Etiology of chronic diarrhea.

With worldwide use of oral rehydration solutions, the treatment of acute diarrhea does not pose much of a problem. However, chronic diarrhea is still harmful, especially for the growth and development status of the children. Between January 1993 to December 1996, patients who suffered from chronic diarrhea for more than one month duration and admitted to Dr. Sami Ulus Children's Hospital were evaluated for epidemiological and etiologic factors. Seventy consecutive patients were evaluated. The mean age was 40.8 months and 52% were males. Malnutrition was detected in 80% of cases. Etiologic factors included celiac disease 30%, cow milk allergy 17%, bacterial and parasitic factors 26%, cystic fibrosis 10% and postinfectious gastroenteritis 10%. Eosinophilic gastroenteritis, chronic nonspecific diarrhea, pseudo-obstruction, neurofibromatosis and inflammatory bowel disease were rarely detected. Celiac disease and cow milk allergy were implicated as the most common causes of chronic diarrhea. The vicious cycle of faulty nutrition, malnutrition and infection and postinfectious enteropathy were also significant factors in the etiology of chronic diarrhea. It may be considered that cow milk protein prick test, sweat test, immunologic tests and mucosal biopsies should be performed for the definite diagnosis of chronic diarrhea.

CROSS SECTIONAL ANALYTIC STUDY OF AWARENESS REGARDING FACTORS RELATED TO CHILD SURVIVAL AMONG MARRIED WOMEN IN A SEMI-URBAN COMMUNITY

A cross sectional analytic study was undertaken on 480 married women living in a semi-urban locality in Pune, with the objective of assessing their awareness regarding factors related to child survival. It was observed that 62.1 per cent of the ladies had adequate knowledge about immunisation. A highly significant trend was evident as regards knowledge about immunisation and formal education and socio-economic status (p<0.01). 93 per cent ladies initiated breast feeding within 24 hours of birth of the new born. Significantly larger proportion of ladies from lower education favoured prolonged breast feeding (p<0.001) and favoured late introduction of top milk (p<0.001). In general, the awareness about growth chart was very poor with only 3.5 per cent ladies having adequate knowledge. Larger family size was significantly associated with declining probability of use of oral rehydration solution (ORS). Certain recommendations for improving the awareness regarding child survival have been submitted accordingly.

Oral rehydration solution in the year 2000: pathophysiology, efficacy and effectiveness

The use of oral rehydration solution (ORS) with early refeeding forms the basis of therapy for dehydration secondary to diarrhoea. ORS has produced such positive results in dehydrated patients that no further scientific demonstration is needed to confirm its efficacy. This review presents several issues that remain unsettled or controversial. They include the following. 1. 1. The mechanism of water handling by the intestine is discussed; this is more complex than initially thought, at the epithelial, cellular and molecular level. 2. 2. The composition of ORS which has been successfully adapted for the most frequent conditions, except for severely malnourished children, is described. 3. 3. In contrast to the strong scientific basis and obvious efficacy in rehydration of ORS, its consequences for growth, nutrition and mortality are difficult to demonstrate, unless adequate long-term nutritional support is also provided in addition to ORS. 4. 4. Finally, discrepancies between the recommendations and the practice of oral rehydration therapy are now well documented. Analysis of the causes of these discrepancies may participate in improving public health campaigns.

Self-reported concepts about oral rehydration solution, drug prescribing and reasons for prescribing antidiarrhoeals for acute watery diarrhea in children.

Sixty-seven general practitioners (GPs) and 27 paediatricians practising in Karachi were interviewed to evaluate their knowledge and attitude towards use of oral rehydration solution (ORS) and management of acute watery diarrhoea (AWD) in children and to define factors for their self-reported prescribing of antidiarrhoeals. Whilst nearly 50% of them reported ORS to be palatable and acceptable by children, 80% reported that ORS was not accepted by parents as sole treatment. Eighty per cent of GPs and 37% of paediatricians reported prescribing antidiarrhoeals for AWD in children, and 'parental pressure' and 'use as placebo' were the commonest reasons. In addition 45% of GPs believed in the efficacy of antidiarrhoeals and thought these drugs necessary for the control of diarrhoea.

Medical practitioners' knowledge of dysentery treatment in Bangladesh.

Interviews conducted with four groups of medical practitioners in Bangladesh revealed widespread deviation from the treatment protocol for dysentery established by the World Health Organization (WHO). Questioned were 136 doctors (46 of whom had postgraduate training), 87 drug dispensers, and 50 medical students from Dhaka; also included were 150 drug dispensers from Matlab. Each respondent was presented with a hypothetical case of a 2-year-old with bloody diarrhea of 3 days' duration and asked to identify the treatment they would offer. Less than half of the medical practitioners in each group identified the WHO-approved regimen of use of oral rehydration solution and a single antibacterial drug appropriate for shigellosis (e.g., ampicillin and co-trimoxazole). Provision of the correct answer ranged from a low of 8% among urban and 11% among rural drug dispensers to a high of 46% among medical students and doctors without postgraduate training. 398 of the 423 respondents recommended use of at least one antibiotic; 155 advised use of two or more such drugs. The drug dispensers were most likely to recommend use of the antibacterial agents metronidazole or furazolidone, neither of which are appropriate choices for children with dysentery. Of particular concern is the low level of correct knowledge of dysentery management among drug dispensers given the fact that private pharmacies are the main source of acute medical care in Bangladesh.

ELECTROLYTE FLUXES IN THE GUT AND ORAL REHYDRATION SOLUTIONS

This article provides a brief overview of the normal physiology of water and electrolyte fluxes across the gut as a prerequisite for understanding the pathologic disturbances occurring with diarrheal illnesses. In turn, the rationale for the use of oral rehydration solutions in diarrheal disorders is explored.

Childhood diarrhea and malnutrition in pakistan, part III: Social policy issues

D IARRHEA AND MALNUTRITION remain the leading cause of death in children younger than 5 years old in developing countries. In Pakistan, there are 138 child deaths/I,000 births compared with the United States, which has 11 child deaths/I,000 births (The Progress of Nations, 1993). As mentioned in the first part (David & Lobo, 1995a) of this series, most of these deaths are attributable to the presence of a low economy, a low literacy rate, the unavailability of clean water, poor child care practices, a trend to bottle feed instead of breast feed, and poor sanitation (Black & Schroeder, 1989; Edwards & Tomkins, 1988; Khalil, Lindblom, Mazhar, Khan, & Kajiser, 1993; Motarjemi, Kaferstein, Moy, & Quevedo, 1993; Torun & Chew, 1991; Woods, 1991; Zaman, Jalil, & Karlberg, 1993). All of these factors lead to diarrhea and subsequent malnutrition. Furthermore, the greatest nutritional problem is found in South Asia where the regional average of malnourished children is 60% compared with the developing world average of 36%. In Pakistan, 40% of children younger than 5 years old are malnourished (The Progress of Nations, 1993, p. 16). Thus, politicians and health care providers need to develop a national social policy to address the treatment and management of diarrhea and malnutrition in developing countries. The social policies are inclined to have a direct impact on the wellbeing of children younger than 5 years of old. The government of Pakistan has taken major steps in reducing the morbidity and mortality in children resulting from diarrhea and malnutrition. Some of these strategies include the initiation of the Child Survival Projects, an immunization campaign, diarrhea control programs, and nutrition rehabilitation. The use of oral rehydration therapy (ORT) in developing countries is estimated to save more than 1,000,000 lives/ year. However, there is a great need for educating parents on the proper use of oral rehydration solution (ORS) and informing them about the different ways to prevent diarrheal diseases and reduce the morbidity associated with malnutrition. Reduction of diarrheal diseases and improved nutrition will improve the well-being of the child. This article examines the strategies adopted by the World Health Organization (WHO) references for the control of diarrheal diseases and malnutrition in developing countries. This article, third in a series on diarrhea and malnutrition (David & Lobo, 1995a, 1995b), includes a discussion of Pakistan's social policy issues related to control of diarrhea and malnutrition. Finally, recommendations are provided for practice, education, and further research in this area.

The impact of systematic use of oral rehydration therapy on outcome in acute diarrheal disease in children

A review of our experience with diarrheal disease (DD) at the University of Istanbul Children's Hospital in Capa, covering the years 1987 to 1989, is presented in this paper. DD is one of the most common conditions encountered among patients presenting to the outpatient clinic (5.9% of all cases). The majority of DD cases were in the four- to 12-month age group. During the surveillance period, summertime peaks in DD were observed, suggesting an increase in bacterial infection. Out of 8749 cases of DD, 5.2% showed severe dehydration. Rates of hospitalization for DD did not show any differences over the three years. However, mortality from DD significantly decreased from 1.15 to 0.57% during this three-year period. This was attributed to more rational use of oral rehydration solutions, as a result of the close monitoring and recording of findings introduced by the protocol of this study. Malnutrition, sepsis, pneumonia, and other severe systemic diseases were found to be the most important risk factors affecting hospitalization and mortality rates. Infants, especially those under three months, had the highest risk for hospitalization and mortality.