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Rapid Responses: Rapid Responses published:
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Why not tell us the actual sodium and glucose concentrations of the reduced osmolarity solutions?
- Somnath Banerjee (16 July 2001)
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What are the best outcomes...?
- Vaishali Mona Verma (16 July 2001)
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‘Oral Rehydration Salts (ORS) Solution Use in India: Why Are Doctors Not Still Convinced?
- Vipin M Vashishtha (17 July 2001)
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Superiority of reduced osmolarity oral rehydration solution for treating diarrhoea in children
- Ting Fei Ho (24 July 2001)
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Re: Superiority of reduced osmolarity oral rehydration solution for treating diarrhoea in children
- Christopher Duggan (26 July 2001)
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Somnath Banerjee, Community Paediatrician East Kent Community NHS Trust, Ramsgate, Kent
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Dear Sir/Madam Re: Reduced Osmolarity Oral Rehydration Solution for Treating Dehydration due to Diarrhoea in Children: Systematic Review. I read with great interest the article by S Han, Y Kim and P Garner1. The medical profession has had concerns for many years regarding the use of WHO recommended oral rehydration solution to manage children with diarrhoea. In the past cholera was an important cause of diarrhoea in children of developing countries, which is still seen in Asian, African and eastern European countries. Even in these countries not every diarrhoea case is cholera.There are many other enteric infections causing diarrhoea which are more common than cholera. Therefore doctors have been sceptical about the routine use of WHO oral rehydration solution in managing all diarrhoea cases. This systematic review strongly supports that reduced osmolarity rehydration solution may be better than the WHO rehydration solution in managing these children. The article remained unclear however, about the concentration of sodium in low osmolarity rehydration solution. If the concentration of sodium and sugar was mentioned, the message would have been more clear to the medical professionals. References 1. Hahn S, Kim Y, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration due to diarrhoea in children : systematic review. BMJ 2001;7304:81-5. (14th July) |
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Vaishali Mona Verma, Medical Practitioner Delhi, India
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Dear Ed, The outcome measure, of starting an unscheduled intravenous drip, could be inappropriate, as in practical situations, a drip maynot be started as a consequence of severe dehydration itself, but as a consequence of an episode of severe vomiting to prevent dehydration. Sometimes, an acute episode of rotavirus may present itself only as acute vomiting for the first couple of days, and in the natural course of events, severe diarrhoea takes over, and the vomiting stops..how are then we to ensure, that it was the hyposmolar solution, and not the natural course of the infection, that led to changes in the number of episodes of diarrhoea and vomiting ? kind regards, Dr.V.M.Verma vermadr@hotmail.com |
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Vipin M Vashishtha, Consulting Pediatrician Mangla Hospital, Bijnor-246701,Uttar Pradesh, India
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‘Oral Rehydration Salts (ORS) Solution Use in India: Why Are Doctors Not Still Convinced? I am in total agreement with the conclusion made by George J. Fuchs that reduced osmolarity ORS is “an important step, but not a leap forward”(1). Now, there are enough studies to suggest superiority of low osmolarity ORS over standard WHO solution (2,3). In a recent study conducted by the ‘John Hopkins School of Public Health’ and five other institutions around the world and funded by WHO and UNICEF, the researchers concluded that the children who received reduced osmolarity solution were 33 percent less likely to need IV treatment when compared to children treated with the current WHO formula (3). Hence, there is no dearth of recent literature documenting superiority of low osmolarity ORS over standard WHO solution. However, the issue in India and in other developing countries is not which one is a better product, but how to make existing ORS salts more popular or even rather acceptable to their vast medical fraternity! As a matter of fact, the number one OTC brand of ORS in India does not confirm to the recommendations of standard WHO formula! Still, the majority of medical practitioners consider ORS, at best a supportive measure, not the only treatment available for acute diarrhea cases. According to a recent survey, conducted amongst the doctors all over the country (ORG-MARG, June 1999- Prescription audit) it was found that only 18 percent of doctors were prescribing ORS for children below 3 years of age with acute diarrhea whereas anti-diarrheals were written in 49 percent cases. In certain part of the country, for example Rajasthan, the prescription for ORS was foud to be as low as mere 8.3 percent! These were the few startling finding of the survey in a country where 6 lacs children are dying annually because of acute diarrhea. The greatest irony of the times is the fact that ORS use is not picking up in a country whose one of the greatest ancient medical scholars - Sushurta, considered by many father of Ayurveda, had recommended Oral Rehydration Therapy for cholera patient as early as in 1500 BC( Sushruta Smhita III, verse II)! Now, the question comes, “Why are the doctors, especially in this part of the world, still prescribing drugs, not ORS in acute diarrhea cases in children? To find an answer, I resorted to a sort of mini-survey amongst the practicing colleagues, and following are the few reasons: -Lack of proper understanding of patho- physiology of diarrhea
amongst most doctors;
And, in the last, lack of initiative by the government and other professional bodies, engaged in the field of child health promotional activities is most appalling. Even “Indian Academy of Pediatrics”, of whom I am a national executive board-member and the sole representative body of pediatricians of India, woke-up quite late to address this critical issue. It needed an aid from a ‘western agency’ to spur the academy to pursue the matter further. And what to talk of the government initiative in this direction! It is a well-known fact that health lists quite low in the priorities of the establishment. To expect from a government who is wasting billions of rupees in patrolling ‘deserted and empty’ hills in and around Kashmir to demonstrate certain resolve to address the problem and to dole out substantial funds for the purpose is definitely asking for too much! -Dr. Vipin M. Vashishtha, MD,
REFERENCES: 1-Fuchs GJ. A better oral rehydration solution? BMJ 2991 323: 59-60. 2-Sarker SA, Mahalanabis D, Alam HN, Sharmin S, Khan AM and Fuchs GJ. Reduced osmolarity oral rehydration solution for persistent diarrhea in infants: A randomized controlled clinical trial. J Pediatr 2001; 138:532- 538. 3- CHOICE study group. Multicentre,randomized, double-blind clinical trial to evaluate the efficacy and safety of a reduced osmolarity oral rehydration salts solution in children with acute watery diarrhea. Pediatrics 2001; 107: 613-618. |
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Ting Fei Ho, Associate Professor National University of Singapore
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Dear Sir Superiority of reduced osmolarity oral rehydration solution for treating diarrhoea in children It is a commendable effort by Hahn, Kim and Garner in their meta- analysis of randomized trials on the use of reduced osmolarity rehydration solution versus standard WHO oral rehydration solution in children with acute diarrhoea (1). It is encouraging to know that reduced osmolarity rehydration solution is associated with better outcome with regard to use of intravenous infusion, stool output and vomiting. As Fuchs has aptly pointed out in the Editorial (2), stool output or duration of diarrhoea is an important clinical outcome in the consideration of the efficacy of an oral rehydration fluid. In the context of reduced osmolarity rehydration fluid and the relevance of stool output as an important clinical outcome, we wish to bring attention to the cheap and easily available rice water in the treatment of mild to moderate gastroenteritis. Rice water is a common home or folk remedy for mild gastroenteritis in infants and children in many South East Asian families. It has also been used in hospital paediatric practice with good results (3). Almost 20 years ago Wong (3) highlighted the superior efficacy of rice water over WHO oral electrolyte solution for the treatment of gastroenteritis in children. In this report rice water was found to significantly decrease the number of stools per day when compared to oral electrolyte solution. Moreover, there was no need for intravenous intervention. One notable property of rice water that may be responsible for its efficacy is its low osmolality (8.9±3.4 mosmol/kg) in comparison to oral electrolyte solution (317.5±77.2 mosmol/kg, p<0.0001) (4). In a study of two infants with ileostomies and fed either oral humanized milk or rice water, it was found that rice water led to significantly lower ileal fluid osmolality (362±63 mosmol/kg) and volume (36±24 ml/day) compared to milk (601±125 mosmol/kg, p<0.02; 130±95 ml/day) (5). This observation supports the experimental evidence of osmoregulation of luminal contents in rat duodenum and ileum (6). It is believed that hyposmotic solutions result in increased luminal absorption of water and thus may lead to lower ileal fluid volume. Furthermore, in gastroenteritis, absorption of monosaccharide (glucose) may be affected more than that of polysaccharide (starch) (3). Many of the infants and children who are at increased risk of gastroenteritis and susceptible to complications of dehydration live in under-developed or developing countries. Therefore rice water, as an option for a rehydration fluid that is cheap, easily available and efficacious, should be considered since it combines the theoretical advantage of low osmolality and the proven efficacy of reduction of stool output. Ting Fei Ho William CL Yip References: 1. Hahn S, Kim Y, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration due to diarrhoea in children: systemic review. BMJ 2001; 323: 81-85. 2. Fuchs GJ. A better oral rehydration solution. BMJ 2001; 323:59-60. 3. Wong HB. Rice water in treatment of infantile gastroenteritis. Lancet 1981; ii:102-103. 4. Ho TF, Yip WCL, Tay JSH, Wong HB. Rice water & dextrose-saline solution: A comparative study of osmolality. J Singapore Paediatr Soc 1982; 24:87-91. 5. Ho TF, Yip WCL, Tay JSH, Vellayappan K. Rice water and milk: Effect on ileal fluid osmolality and volume. Lancet 1982; I; 169. 6. Miller DL, Hamburger SA, Schedl HP. Effects of osmotic gradients on water and solute transport: in vivo studies in rat duodenum and ileum. Am J Physiol 1979; 237:E389-E396. |
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Christopher Duggan, Assistant Professor of Pediatrics Harvard Medical School and Childrens Hospital Boston
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Dear Sir/Madam, Rice water has insufficient electrolytes for replacement of sodium and potassium losses during acute diarrhea, in contrast to rice-based oral rehydration solutions (to which these and other electrolytes are added). Moreover, the superiority of cereal-based solutions has only been proven in patients with cholera infections; children with non-cholera diarrhea given cereal-based ORS do not have a reduction in stool output when compared with children treated with standard glucose-based ORS (Fontaine O, Gore SM, Pierce NF: 1999 Rice-based oral rehydration solution for treating diarrhoea. Cochrane Database of Systematic Reviews). The low level of use and acceptance of ORS by clinicians in all countries of the world is a tragedy in light of the widespread evidence of its efficacy. Hopefully, the data presented by Hahn et al will help to reinvigorate efforts by policy-making bodies to establish ORS as the standard of care for all patients with diarrhea. Sincerely, Christopher Duggan, MD, MPH |
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