Reduced osmolarity oral rehydration solution for treating dehydration due to diarrhoea in children: systematic review
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7304.81 (Published 14 July 2001) Cite this as: BMJ 2001;323:81All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
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.="_4." in="in" a="a" study="study" of="of" two="two" infants="infants" with="with" ileostomies="ileostomies" and="and" fed="fed" either="either" oral="oral" humanized="humanized" milk="milk" or="or" rice="rice" water="water" it="it" was="was" found="found" that="that" led="led" to="to" significantly="significantly" lower="lower" ileal="ileal" fluid="fluid" osmolality="osmolality" _36263="_36263" mosmol="mosmol" kg="kg" volume="volume" _3624="_3624" ml="ml" day="day" compared="compared" _601125="_601125" p0.02="p0.02" _13095="_13095" _5.="_5." this="this" observation="observation" supports="supports" the="the" experimental="experimental" evidence="evidence" osmoregulation="osmoregulation" luminal="luminal" contents="contents" rat="rat" duodenum="duodenum" ileum="ileum" _6.="_6." is="is" believed="believed" hyposmotic="hyposmotic" solutions="solutions" result="result" increased="increased" absorption="absorption" thus="thus" may="may" lead="lead" volume.="volume." furthermore="furthermore" gastroenteritis="gastroenteritis" monosaccharide="monosaccharide" glucose="glucose" be="be" affected="affected" more="more" than="than" polysaccharide="polysaccharide" starch="starch" _3.="_3." p="p"/> 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
Associate Professor
Department of Physiology, Faculty of Medicine, National University of
Singapore
William CL Yip
Adjunct Associate Professor
Department of Paediatrics, Faculty of Medicine, National University of
Singapore
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.
Competing interests: No competing interests
‘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;
-Lack of faith in the ‘product’ (Doctors not convinced!);
-Parents demand drugs- syrups, injections, and tablets. They thought this
to be the ‘modern way’ to cure illness.( Parents are not properly educated
about the management);
-Fear of loosing patient to some other doctor, if drugs are not
prescribed. (Lack of confidence amongst doctors in their abilities.);
-Acceptance of ORS by the child is poor (because of its taste and color);
-Lack of enough time to explain and educate mother about ORS and diarrhea.
( Proper case management seems to interfere with the established norms-
‘spend less time, earn more money’!);
-‘Peer pressure’ (when my colleague is writing drugs for diarrhea why
can’t I?);
- Pressure from pharmaceutical industry;
- Lack of flexible approach and generation gap amongst the practitioners
(will a seasoned doctor, established in practice for more than 30 years
behave in the same manner as a fresh graduate from a medical college?).
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,
Consulting Pediatrician,
Mangla Hospital, Shakti Chowk,
Bijnor-246701, Uttar Pradesh, India.
Pin-246701
E-mail: vmv9@vsnl.com
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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)
Competing interests: No competing interests
Re: Superiority of reduced osmolarity oral rehydration solution for treating diarrhoea in children
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
Competing interests: No competing interests