ORAL REHYDRATION SOLUTION,DIARRHEA,SAM

1. Dr. Rajesh Kulkarni
Pune

2. India- the Pioneer
Over 2,500 years ago, Indian physician Sushruta
described the treatment of acute diarrhea with rice
water, coconut juice and carrot soup.

3. IV fluids in Cholera
 In 1831, William Brooke treated
cholera patients with IV Fluids
reducing mortality from 70 % to 40 %.
IV fluid replacement became the standard of care for
moderate/severe dehydration for over a hundred
years.

4. INDIA AGAIN!!
Late 1950’s: Dr Hemendranath Chatterjee
1971: Dr. Dilip Mahalanabis
350,000 treated with mortality of 0.36%

5. Na-Glucose co-transport
In the early 1960s, Robert K. Crane discovered the
sodium-glucose co-transport as the mechanism for
intestinal glucose absorption.
Around the same time, other scientists showed that
the intestinal mucosa was not disrupted in cholera, as
previously thought.

6. Importance Realized!!!
1978 – In recognition of the lives saved with ORT,
The Lancet proclaims that “THE discovery that
sodium transport and glucose transport are coupled
in the small intestine, so that glucose accelerates
absorption of solute and water, was potentially the
most important medical advance this century.”

7. PRINICIPLE OF ORS
The sodium-coupled co-transport with glucose and
other carrier organic solutes remains intact, even with
viral enteritis associated with epithelial damage .

8. Ingredient
Standard WHO
ORS mmol/l
Reduced
osmolarity ORS
mmol/l (2002)
Glucose
111
75
Na
90
75
K
20
20
Cl
80
65
Citrate
10
10
Osmolarity
mOsm/kg
311
245

9. Limitation of high osmolarity ORS
Does not lower volume, frequency and duration of
diarrhoea.
Induces vomiting due to taste, so acceptability poor.
More chances of dehydration, more chances of
requiring iv fluid.
Hypernatremia.
Good to correct fluid deficit, not good for
maintenance fluid.

10. LOW OSMOLARITY ORS
Compared to WHO standard ORS , hypo-osmolar
ORS is associated with
a) fewer unscheduled intravenous fluid
infusions(33%)
b)lower stool volumes (20%), and
c) less vomiting(30%)

11. Clinical relevance - low osmolarity ORS
Reduction in need of IV therapy results in reduced
hospitalization and in turn results:
Reduced risk of hospital acquired infections.
 Reduced disruption of breastfeeding.
 Reduced use of needles and interventions
 Reduced therapy cost.
 Reduced risk of diarrheal deaths in areas where
IV therapy is not readily available.

12. Rice-based ORS, Maltodextrin-containing and
Amino acid-containing ORS—SUPER ORS
They are not superior to glucose-based ORS for
acute non-cholera diarrhea, provided that feeding
was promptly resumed after initial rehydration of the
child.

13. Flavored/Colored ORS
Studies showed neither an advantage nor
disadvantage for the flavoured and coloured ORS
when compared to the standard ORS with regard to
safety, acceptability and correct use.
Concerns about the type of sweetners ,coloring and
flavouring agents used.
More expensive

14. CASE STUDY
Pinky 18 month old girl was brought by her mother to
the OPD complaining of 4 episodes of loose stools
without blood or mucus.
On examination,Pinky is alert and playful.She weighs
12 kg.
She does not have sunken eyes and her skin pinch
goes back instantly.
DIAGNOSIS AND MANAGEMENT

15. PLAN A
After each loose stool and in between them give ORS
Age <2 years
50 to 100 ml
Age >2 years
100 to 200 ml
Continue breastfeeding
If not exclusively breastfed, give food based
fluids(Soup, Rice water, Yoghurt drinks)

16. CASE STUDY
Munna a 10 month old boy is brought by his mother
to OPD with complaints of loose motions since 2
days,12-14 episodes in the last 24 hours.
On examination his weight is 8 kg.When offered
ORS,Munna drinks it eagerly.He is irritable and has
sunken eyes.
His skin pinch goes back slowly.
DIAGNOSIS & TREATMENT

17. Some Dehydration
If the child has two or more of the following signs, the
child has some dehydration:
restlessness/irritability
thirsty and drinks eagerly
sunken eyes
skin pinch goes back slowly.

18. PLAN B
In Clinic, give 75 ml/kg ORS over 4 hours
If < 6 months and exclusively breastfed, also give
extra 100 to 200 ml clear water over this period.

19. CASE STUDY
Payal is a 14 months old girl weighing 10 kg. She is
brought to the emergency department with
complaints of 20-25 episodes of loose stools within
the last 12 hours.
On examination ,she is lethargic ,has sunken eyes
and her skin pinch goes back very slowly.
DIAGNOSIS AND MANAGEMENT

20. Severe Dehydrtion
If any two of the following signs are
present, severe dehydration is present
lethargy or unconsciousness
sunken eyes
skin pinch goes back very slowly (2 seconds or
more)
not able to drink or drinks poorly.

21. PLAN C
I.V. THERAPY POSSIBLE..GIVE RINGER
LACTATE.
AGE
< 12
MONTHS
12 MONTHS
TO 5 YEARS
FIRST GIVE
30 ML/KG
IN
THEN GIVE
70 ML/KG IN
ONE HOUR
FIVE
HOURS
HALF HOUR TWO AND
HALF
HOURS

22. PLAN C
IV THERAPY NOT POSSIBLE:
ORAL OR NG TUBE ORS 20 ml/kg/hour for 6 hours
(i.e. total 120 ml/kg over 6 hrs)
Reassess Hourly
If not better in 3 hours,IV therapy MUST be
given(Refer)

23. Limitations
Altered mental status with concern for aspiration
Abdominal ileus
Underlying disorder that limits intestinal
absorption of ORT (e.g, short gut, carbohydrate
malabsorption)

24. PRACTICAL PROBLEMS
Vomiting: Give less amount more frequently,wait for
10 minutes and try again.Give food in the form of
Kanji,Amylase rich food.
Taste: It is a MEDICINE and the most important
medicine in diarrhea. Convince the parents. First drug
in your prescription.
If affording, flavoured ORS may help.

25. ORS
IV fluids
Once ORT has been initiated, intervention with
intravenous hydration is indicated:
If stool output continues to be excessive, and ORT is
unable to adequately rehydrate the child
If there is severe and persistent vomiting, and
inadequate intake of ORS

26. WHO Statement
2006: The World Health Organization states that,
“there is no evidence to support the ongoing use
of IV therapy for the first-line management of
most cases of childhood gastroenteritis.”

27. CASE STUDY-special scenario
Roshan is a 14 month old boy.He was brought to the
hospital with a history of loose stools since one day 67 episodes.
His weight is 6 kg , mother gives h/o faulty feeding
since 5 months of age.(SAM)
He has sunken eyes and his skin pinch goes back
slowly.
Peripheral pulses are palpable and sensorium is
normal
DIAGNOSIS AND MANAGEMENT

28. DIAGNOSIS AND MANAGEMENT
SAM with AGE with dehydration without shock.
(History very important)
NO IV Rehydration, manage with ReSoMal or low
osmolarity ORS(in 1 litres) with added potassium
20mmol/L .(IAP 2006)
How often to give ORS
Amount to give
Every 30 minutes for first 2 hours
5ml/kg
Alternate hours for up to 10 hours
5-10 ml/kg

29. CASE STUDY
Anita is a 14 month old girl. She was brought to the
hospital with a history of loose stools since one day 67 episodes.
Her weight is 6 kg, mother gives h/o faulty feeding
since 5 months of age.(SAM)
She has sunken eyes and her skin pinch goes back
very slowly.
She is lethargic and her peripheral pulses are very
feeble .
DIAGNOSIS AND MANAGEMENT

31. Preventing and Treating Diarrhea

33. RESOMAL COMPOSITION
Water 2 litres
WHO-ORS One 1-litre packet*
 Sucrose 50 g
 Electrolyte/mineral solution** 40 ml
(* 3.5 g sodium chloride, 2.9 g trisodium citrate
dihydrate, 1.5 g potassium chloride, 20 g glucose).
** If this cannot be made up, use 45 ml of KCl
solution (100 g KCl in 1 litre of water) instead.

34. Electrolyte/mineral solution-COMPOSITION
 Potassium chloride: KCl 224 gm 24 mmol/20 ml
Tripotassium citrate 81gm, 2 mmol/20 ml
Magnesium chloride: MgCl2.6H2O 76gm, 3 mmol/20
ml
Zinc acetate: Zn acetate.2H20 8.2gm, 300 µmol/20 ml
Copper sulfate: CuSO4.5H2O 1.4gm, 45 µmol/20 ml
Water: make up to 2500 ml
If available, also add selenium (0.028 g of sodium
selenate, NaSeO4.10H20) and iodine (0.012 g of
potassium iodide, KI) per 2500 ml.

35. WHO ALTERNATIVE TO
RESOMAL
2 LITRES WATER
1 PACK LOW OSMOLARITY ORS
45 ml Potassium Chloride solution(from stock
solution containing 100 gm KCL/Litre)
50 gm Sucrose