oral rehydration solution guidelines for usage.pptx

oral rehydration solution

1. ORS- The magic potion From t he Indian Academy Of Pediatrics, Kerala Prepared by: Dr. Lathika Nayar Reviewed by: Dr. Bindu G. S Associate Professor Prof & HOD of Pediatrics GTDMC, Alappuzha GMC, Thiruvananthapuram “ORS: A SIMPLE SOLUTION FOR A HEALTHIER FUTURE”

2. What is diarrhea? Change in consistency and frequency of stools that occurs >3 times/ day Change in consistency is more important Acute diarrhea subsides within 14 days, mostly by 7 days Presence of visible blood in stools indicates dysentery What is not diarrhea? Pasty stools in exclusively breast fed babies Frequent formed stools

3. Problem statement (Key facts- WHO 2024) Global annual burden : 1.7 billion cases /year Third leading cause of death in children 1-59 months (8%) Kills 4,43832 children /year Two most important consequences are malnutrition and dehydration Leading cause of and malnutrition associated death malnutrition in under5 children

4. Integrated Global Action Plan for the Prevention & Control of Pneumonia & Diarrhea- WHO goal Reduce Under 5 deaths from diarrhea to < 1 / 1000 live births by 2025

5. Indian Data- NFHS - 4 Vs NFHS - 5 Parameter NFHS 4 NFHS 5 Prevalence of diarrhea (No. of U 5 children who had diarrhea in the previous 2 weeks) 9.2 % 7.3 % ORS use No. of children with diarrhea who received ORS 50.6 % 60.6 %

6. Understanding the etiology of diarrhea- Why is it important? Anticipating complications Optimizing management Avoiding unnecessary medications

7. Viral Rota virus Noro Virus Sapo virus Adeno virus (40,41) Astrovirus Corona Virus Bacterial E.Coli - ( ETEC, EIEC,EHEC,EAEC) Shigella - ( sonnei , flexneri, boydii,dysentriae ) Vibrio cholerae Salmonella Campylobacter Parasitic Giardia lamblia Cryptosporidium Entamoeba histolytica Isospora Cyclospora (Uncommon in young immunocompetent children) Rota Virus & Enterotoxigenic E.Coli are the commonest causes in all ages EIEC, Shigella , Campylobacter, Salmonella , Entamoeba cause diarrhea ± dysentery

8. Pathophysiology of diarrhea Diarrhea results when there is loss of the dynamic and finely balanced absorption and secretion of water and electrolytes within the gut.

9. Pathogenic mechanisms and their impact Blunting of villi of enterocytes Decreased surface area for absorption Loss of lactase and other disaccharidases Osmotic diarrhea Viral protein NSP4 Enterotoxin Disrupting calcium homeostasis Release of cytokines Secretory diarrhea Dysfunction of specific transporters in nutrient & fluid absorption Rota viral diarrhea Dehydration & hyponatremia may occur

10. Toxins lead to massive secretion of fluid and electrolytes Profuse watery diarrhea with dehydration and electrolyte abnormalities Predominant mechanism in Cholera, Enterotoxigenic E.Coli Secretory diarrhea

11. Direct invasion of intestinal epithelial cells Inflammatory response of body Invasive diarrhea Dysentery Shigella,EIEC Salmonella Campylobacter Hypovolemia Electrolyte abnormalities Systemic complications and mortality

12. Predominant Sodium absorption mechanisms in gut

13. Impact of diarrhea and Physiological basis of ORT Glucose dependent sodium pump remains intact in diarrhea Transportation of sodium and glucose occur at 1:1 ratio

14. What is ORT? Oral administration of an isotonic solution of various sodium salts , glucose and water to treat acute diarrhea

15. Prerequisites for ORT formulation Intact glucose dependent sodium absorption Glucose and sodium at 1:1 ratio Osmolality below blood for better absorption of fluid and electrolytes along concentration gradient Osmolality below that of blood (290 mOsm /L) Higher glucose increases osmolality Glucose concentration to be kept below 111 mmols /L

16. History of ORT and ORS Dr. Dhiman Barua played a crucial role in WHOs acceptance of ORS as the corner stone in ADD management

17. Standard ORS WHO adopted ORS in 1975 Sodium – 90 mmol/L Potassium -20 mmol/L Chloride - 80 mmol/L Glucose - 111mmol/L Citrate – 10 mmol /L Osmolality – 311 mOsm /L

18. Impact of standard ORS 50% reduction in mortality associated with diarrhea The Lancet  once called ORS “ potentially the most important medical advance of the 20th century. ”

19. Need for modification of Standard ORS Standard ORS

20. Cholera stool Vs Non cholera stool Cholera ETEC Rota viral Purge volume 60.1 ml 39.2 ml 31.4 ml Stool sodium conc. 88.9 mmol /L 53.7 mmol / L 37.2 mmol / L Stool Potassium conc. 17 – 20 mmol/L 17 – 20 mmol/L 17 – 20 mmol/L Molla AM, Rahman, M Sarkar SA, Sack DA,,Molla A.Stool electrolyte content and purging rates in diarrhea caused by rotavirus, enterotoxigenic E.coli and V.cholerae in children. J Pediatr.1981

21. Low osmolar ORS solution (LORS) Osmolarity of 245mmol/L Sodium - 75 mmol/L Glucose – 75 mmol/L Chloride-65 mmol/L Potassium -20mmol/L Citrate – 10 mmol/L Significant reduction in : Stool output Duration of illness Need for IVF Effective in cholera and non cholera diarrhea No significant hyponatremia WHO accepted ORS with osmolality 245 as the new standard ORS in 2004

22. Sugar- salt solution

23. Acceptable home available fluids Salted drinks : e.g. salted rice water or salted yoghurt drink Vegetable or chicken soup with salt Plain water Unsalted rice water Unsalted soup Yoghurt drinks without salt Green coconut water Weak tea ( unsweetened ) Unsweetened fresh fruit juice Fluids that contain salt Fluids that do not contain salt (Considered as ORT along with regular food ) Unsuitable fluids Drinks sweetened with sugars , can cause osmotic diarrhoea and hypernatremia. Commercial carbonated beverages Commercial fruit juices Sweetened tea

24. Other modifications in ORS Rice based ORS Amino acid based ORS ORS with Zinc ReSoMal : Recommended ORS solution in malnourished children Not Recommended by WHO

25. How to give ORS/ORT Clean spoon or cup Do not use feeding bottle <2 years of age : a teaspoonful every 1-2 mins Older children : frequent sips directly from the cup

26. How much ORS ? Give as much as the child wants until diarrhoea stops Amount of fluid to be given after each loose stool <2 years of age 50-100 ml ( a quarter to half of 200ml glass) 2-10 years of age 100-200 ml ( a half to one 200ml glass ) Older children and adults As much as fluid they want Assess hydration and follow Plan A,B, C as per the WHO guidelines

27. Vomiting often occurs only initially and subsides with rehydration More when the child drinks the ORS solution too quickly . If the child vomits , wait 5-10 mins : give ORS again – more slowly ( spoonful every 2-3 mins) Single dose of Ondansetron may be given in frequent vomiting Very rarely only warrants IVF What if the child vomits ?

28. Can ORT fail? Rare in < 3% cases with low osmolar ORS. Frequent severe vomiting Continuing rapid stool loss ( > 15-20 ml/kg/hr ) , as occurs in some children with cholera. Insufficient intake of ORS solution owing to fatigue or lethargy. Paralytic ileus

29. What if ORT fails? ORS solution by NG tube or IVF as a temporary measure Resume ORT later

30. Role of Zinc Decreases the frequency and volume of stools- 7% higher recovery with Zinc 24% reduction in diarrhea-related hospitalization rate and overall decrease in mortality Restores integrity of the intestinal barrier, reducing fluid and electrolyte leakage Reduces the risk of persistent diarrhea and subsequent diarrheal episodes WHO recommends oral zinc (sulfate/acetate/gluconate) for 10-14 days at 20 mg per day in children older than 6 months and 10 mg per day in children younger than 6 months for acute diarrheal illness. Zinc gluconate formulation has a better vomiting profile than other forms of zinc.

31. Indications for antibiotics Suspected cholera (Voluminous watery diarrhea with vomiting with severe dehydration, electrolyte abnormalities, often in epidemics) Dysentery Severe malnutrition Lab proven giardiasis/ amoebiasis With coexisting infections like pneumonia, UTI ORT is the corner stone of management of ADD Antimicrobials should be initiated only in children with above indications

32. Antimicrobials in dysentery WHO recommendation Ciprofloxacin is the first line antibiotic recommended by WHO Cefixime is an alternative Ceftriaxone and azithromycin are second line antibiotics in resistant cases Regional Sensitivity Mostly Ciprofloxacin resistant Cefixime can be used as empiric first line drug Ceftriaxone in sick children Azithromycin sensitivity better than quinolones Health workers should refer to local sensitivity patterns of antibiotics

33. Antibiotic dosage & duration in dysentery- WHO Ciprofloxacin: 15 mg/kg per dose twice daily for three days Ceftriaxone: 50–80 mg/kg daily for three days

34. Other drugs – current recommendations Anti motility drugs - contraindicated Anti secretory agents- Not recommended due to limited evidence Probiotics –not recommended due to limited evidence Antiemetics : a single dose of Ondansetron may be used in severe vomiting

35. Diet during diarrhea

36. Principles of feeding during diarrhea More frequent breastfeeding to be continued Usual diet should be continued during diarrhoea and increased afterwards Food should never be withheld and shouldn’t be diluted Small frequent high energy foods (add oil to make food calorie dense) 20% extra calories needed- Give one extra meal till 2 weeks after diarrhoea subsides

37. What to give ? In general , food suitable for a child with diarrhoea are the same as those required by healthy children What not to give ? Carbonated drinks Sweetened beverages Fruit juices with high sugar content Bulky food

38. Diarrhoea in a child with severe malnutrition is associated with higher risk of complications and mortality and should be managed as per the specific guidelines given by WHO ORT to be used is ReSoMal (Rehydration Solution For Malnutrition) Diarrhea and SAM

39. Prevention Access to safe drinking water Improved sanitation Hand washing with soap and water before feeding and after toilet use Optimum IYCF practices Food hygiene Health education Rotavirus vaccination

40. Rota Viral Vaccination 3 doses at 6, 10, 14 weeks orally Maximum age of rota viral vaccine administration: 1 year

41. Take home messages Dehydration is the most important cause of diarrhea associated morbidity and mortality Oral rehydration therapy is the only method to reduce morbidity & mortality associated with diarrhea Optimum feeding practices during diarrhea reduce the risk of malnutrition associated with diarrhea Public awareness creation on preventive strategies is to be highlighted “ SIP SMART, STAY STRONG - SAY YES TO ORS”

42. References World Health Organisation (WHO), United Nations Children Fund (UNICEF) Joint Statement: Clinical management of acute diarrhea . WHO 2004. Available from: https://www.who.int / maternal_child_adolescent /documents/who_fch_cah_04_7/ en /. Accessed June 20, 2020. Koustav Ghosh, Atreyee Sinha Chakraborty, Mithun Mog,Prevalence of diarrhoea among under five children in India and its contextual determinants: A geo-spatial analysis.Clinical Epidemiology and Global Health,Volume 12,2021,100813,ISSN 2213-3984, https://doi.org/10.1016/j.cegh.2021.100813.(https://www.sciencedirect.com/science/article/pii/S2213398421001214) Bhattacharya SK. History of development of oral rehydration therapy. Indian J Public Health. 1994 Apr-Jun;38(2):39-43. PMID: 7530695. Zubairi MBA, Naqvi SK, Ali AA, Sharif A, Salam RA, Hasnain Z, Soofi S, Ariff S, Nisar YB, Das JK. Low-osmolarity oral rehydration solution for childhood diarrhoea: A systematic review and meta-analysis. J Glob Health. 2024 Dec 6;14:04166. doi : 10.7189/jogh.14.04166. PMID: 39641334; PMCID: PMC11622343. 7. Alam NH, Yunus M, Abu S, et al. Symptomatic hyponatremia during treatment of dehydrating diarrheal disease with reduced osmolarity oral rehydration solution. JAMA. 2006;296:567-73. Suh JS, Hahn WH, Cho BS. Recent Advances of Oral Rehydration Therapy (ORT). Electrolyte Blood Press. 2010 Dec;8(2):82-6. doi : 10.5049/EBP.2010.8.2.82. Epub 2010 Dec 31. PMID: 21468201; PMCID: PMC3043760.   Molla AM, Rahman, M Sarkar SA, Sack DA,,Molla A.Stool electrolyte content and purging rates in diarrhea caused by rotavirus, enterotoxigenic E.coli and V.cholerae in children. J Pediatr. 1981 May;98 (5):835-8.doi:10.1016/s0022- 3476(81)80863-3.PMID:6262471