AMBA CUP: Ensuring Accuracy in Measurement of Volume of Water for Salt Sugar Solution or Oral Rehydration Solution Preparation in Diarrhea Management

Diarrhea remains a major cause of under-five mortality globally. In 2016, it accounted for 8% of under-five mortality worldwide. Most of these deaths occur in developing countries. Fluid replacement using Oral Rehydration Solution (ORS) or Salt Sugar Solution (SSS), has been the mainstay of diarrhea management. Gaps in knowledge and practice regarding the preparation of these solutions have been identified by various researchers. One challenge encountered by healthcare providers and caregivers of under-five children has been lack of a standard, easy to clean cup for measurement of accurate volume of water for ORS or SSS preparation. Soft drink bottles, which are currently being used, are difficult to clean because of their narrow necks. More so, the size and volume of these bottles change so often that non-numerate caregivers get easily confused. The aim of this paper is to introduce the AMBA CUP, an easy-to-clean cup that can be used to accurately measure one litre of water for SSS or ORS preparation.

Is oral rehydration therapy associated with early childhood caries in children resident in Ile-Ife, Osun State, Nigeria?

BACKGROUND

Oral rehydration therapy may increase the risk of early childhood caries (ECC) because of reduced pH in the oral environment.

AIM

To investigate associations between the use of oral rehydration therapy and the prevalence and severity of ECC in children resident in the Ife Central Local Government Area of Osun State, Nigeria.

DESIGN

This observational study assessed the prevalence and severity of caries, using the International Caries Detection and Assessment System (ICDAS) II index. The outcome variables were the prevalence and severity of ECC. The explanatory variable was the use of oral rehydration solution for the management of diarrhea in the 12 months preceding the study. A multivariable logistic regression analysis was conducted to determine associations between the explanatory and outcome variables.

RESULTS

Only 217 (14%) of the 1564 children had used oral rehydration solution for the management of diarrhea. Seventy-three (4.7%) children had ECC. The use of oral rehydration solution was not significantly associated with the prevalence and severity of ECC.

CONCLUSION

The study findings suggest that the use of oral rehydration therapy in the management of diarrhea may not be a risk factor for ECC in communities with low prevalence and severity of ECC and high prevalence of gastroenteritis.

A Descriptive Cross-Sectional Assessment of Caregivers' Knowledge and Practices Regarding the Prevention and Management of Diarrhea among Children under the Age of Five in Thulamela B Clinics, South Africa

Diarrhea is a common cause of child-related hospitalization and mortality among children under the age of five in South Africa. This study was conducted to assess the knowledge and practices of caregivers regarding prevention and management of diarrhea among children under the age of five in the Thulamela Municipality of South Africa. A quantitative approach using a descriptive cross-sectional survey was used. A questionnaire was adopted to collect data from caregivers at thirty primary health-care facilities using convenient sampling. Statistical Package for Social Sciences (SPSS) version 24.0 was used to analyze data. Most of the respondents have fair knowledge about diarrhea, oral rehydration therapy/salt sugar solution and its usage during diarrheal episodes. However, most of them (81.7%) do not use the salt sugar solution when their children have diarrhea. Almost all the respondents practice a hand washing hygiene for themselves and their children; 97.2% do not reheat cooked food before feeding their children; 95.5% do not drink untreated water as their source of drinking water is the municipal supply. The practices of these respondents do not reflect their knowledge in terms of the use of oral rehydration solution/salt and sugar solution. Further efforts should be made to educate caregivers on the mode of transmission of diarrheal pathogens.

Low Osmolarity Oral Rehydration Salt Solution (LORS) in Management of Dehydration in Children

JUSTIFICATION

The IAP last published the guidelines "Comprehensive Management of Diarrhea" in 2006 and a review in 2016. The WHO in 2002 and the Government of India in 2004 recommended low osmolarity rehydration solution (LORS) as the universal rehydration solution for all ages and all forms of dehydration. However, the use of LORS in India continues to be unacceptably low at 51%, although awareness about ORS has increased from a mere 14% in 2005 to 69% in 2015. Availability of different compositions of ORS and brands in market added to the confusion.

PROCESS

The Indian Academy of Pediatrics constituted a panel of experts from the fields of pediatrics, pediatric gastroenterology and nutrition to update on management of dehydration in children with particular reference to LORS and issue a current practice guideline. The committee met twice at CIAP HQ to review all published literature on the aspect. Brief presentations were made, followed by discussions. The draft paper was circulated by email. All relevant inputs and suggestions were incorporated to arrive at a consensus on this practice guideline.

OBJECTIVES

To summarize latest literature on ORT and empower pediatricians, particularly those practicing in rural areas, on management of dehydration by augmenting LORS use.

RECOMMENDATIONS

It was stressed that advantages of LORS far out-weigh its limitations. Increased use of LORS can only be achieved by promoting better awareness among public and health-care providers across all systems of medicine. LORS can also be useful in managing dehydration in non-diarrheal illness. More research is required to modify ORS further to make it safe and effective in neonates, severe acute malnutrition, renal failure, cardiac and other co-morbidities. There is an urgent need to discourage production and marketing all forms of ORS not in conformity with WHO approved LORS, under a slogan "One India, one ORS".

Mass media exposure and childhood diarrhea: a secondary analysis of the 2011 Bangladesh Demographic and Health Survey

In order to reduce child mortality, recommendations for diarrhea management practices have been widely promoted by various methods, including mass media. This study examined whether mother's exposure to mass media was associated with child's diarrhea, and with the diarrhea management practiced by their mothers. Data on 7,068 women, whose youngest child was under five years old, were extracted from the Bangladesh Demographic and Health Survey, 2011, together with information on the child. The outcome variables were an episode of diarrhea in the two weeks prior to the survey and diarrhea management practices; exposure to mass media was used as the major explanatory variable. They were descriptively summarized, and logistic regression analyses were performed. Television was found to be the most common form of media. Among 346 children who had experienced an episode of diarrhea in the previous 2 weeks, less than 42.5% were given zinc and only 26.3% of the mothers provided sufficient fluids. No significant associations between mother's mass media exposure and child's diarrhea were observed. Women who read newspapers/magazines were more likely to provide sufficient fluids and food, and those exposed to the radio were more likely to provide zinc supplementation. Since mother's exposure to newspaper/magazines and radio showed associations with some recommended practices for the treatment of childhood diarrhea, mass media clearly has the potential to improve diarrhea management practices. More effective use of mass media is anticipated; in particular, promotion of zinc supplementation and increasing fluid intake during diarrhea, neither of which were currently well practiced.

Osmolality of Commercially Available Oral Rehydration Solutions: Impact of Brand, Storage Time, and Temperature

Oral rehydration solutions (ORS) are specifically formulated with an osmolality to optimize fluid absorption. However, it is unclear how many ORS products comply with current World Health Organization (WHO) osmolality guidelines and the osmotic shelf-life stability is not known. Therefore, the purpose of this investigation was to examine the within and between ORS product osmolality variation in both pre-mixed and reconstituted powders. Additionally, the osmotic stability was examined over time. The osmolality of five different pre-mixed solutions and six powdered ORS products were measured. Pre-mixed solutions were stored at room temperatures and elevated temperatures (31 °C) for two months to examine osmotic shelf stability. Results demonstrated that only one pre-mixed ORS product was in compliance with the current guidelines both before and after the prolonged storage. Five of the six powdered ORS products were in compliance with minimal inter-packet variation observed within the given formulations. This investigation demonstrates that many commercially available pre-mixed ORS products do not currently adhere to the WHO recommended osmolality guidelines. Additionally, due to the presence of particular sugars and possibly other ingredients, the shelf-life stability of osmolality for certain ORS products may be questioned. These findings should be carefully considered in the design of future ORS products.

Temporal changes of abomasal contents and volumes in calves fed milk diluted with oral rehydration salt solution

Several manufacturers recommend to feed mixture comprising equal amounts of oral rehydration salt (ORS) solution and milk for diarrheic calves after milk withdrawal. Such a feeding method is expected to supply more nutrients and energy compared to feeding only the ORS solution. However, little is known about the effects of feeding milk diluted with ORS solution on calves' digestive process. This study examined the abomasal contents, volumes, and emptying rates in calves fed whole milk, milk diluted by 50% with ORS solution (50% ORS-milk), and ORS solution. Ultrasonography identified curds in the milk-fed calves, but not in the 50% ORS-milk-fed or the ORS-fed calves. The abomasal fluid of the 50% ORS-milk-fed calves contained not only β-lactoglobulin but also α-casein (CN), β-CN, and κ-CN, which were used for curd formation and undetectable in the milk-fed calves. Abomasal pH was relatively higher in the 50% ORS-milk-fed than that in the milk-fed calves. Abomasal emptying rates were significantly faster in the ORS-fed than in the 50% ORS-milk-fed and the milk-fed calves. These data indicate that the formation of abomasal curd is inhibited in the 50% ORS-milk-fed calves due to the resultant high abomasal pH and low κ-CN concentration. The 50% ORS-milk may not provide rehydration as quickly as the ORS solution. In conclusion, we do not recommend feeding 50% ORS-milk to calves.

Prevention and treatment of secretory diarrhea by the lysophosphatidic acid analog Rx100

IMPACT STATEMENT

A critical barrier in treating diarrheal disease is easy-to-use effective treatments. Rx100 is a first in class, novel small molecule that has shown efficacy after both subcutaneous and oral administration in a mouse cholera-toxin- and Citrobacter rodentium infection-induced diarrhea models. Our findings indicate that Rx100 a metabolically stable analog of the lipid mediator lysophosphatidic acid blocks activation of CFTR-mediated secretion responsible for fluid discharge in secretory diarrhea. Rx100 represents a new treatment modality which does not directly block CFTR but attenuates its activation by bacterial toxins. Our results provide proof-of-principle that Rx100 can be developed for use as an effective oral or injectable easy-to-use drug for secretory diarrhea which could significantly improve care by eliminating the need for severely ill patients to regularly consume large quantities of oral rehydration therapies and offering options for pediatric patients.

Comparison of a commercially available oral nutritional supplement and intravenous fluid therapy for dehydration in dairy calves

Calf scours is a primary cause of morbidity and mortality in the dairy industry. Effective treatments are needed to minimize death, maximize welfare, and maintain growth and productivity. The objective of this trial was to compare the efficacy of a commercially available nutritional supplement (Diaque, Boehringer-Ingelheim Vetmedica Inc., St. Joseph, MO) and i.v. lactated Ringer's solution (LRS) in rehydrating, preventing acidemia, and correcting electrolyte imbalances in an experimental model for calf scours. Twenty-four colostrum-fed suckling dairy calves were used in a modified crossover design. An osmotic diarrhea was induced by orally feeding commercial milk replacer modified with high level of sucrose to create a hypertonic milk solution, and administering oral hydrochlorothiazide and spironolactone for 48 h. The intention was to create a challenge sufficient to result in moderately dehydrated, standing calves without producing severe depression or loss of suckle. The efficacy of i.v. fluid therapy and a commercial nutritional supplement were subsequently compared for reversing the effects of the diarrheal disease. Treatment A consisted of administering the nutritional supplement according to label directions (100 g in 1.9 L of warm water, 3 times a day), and treatment B consisted of i.v. LRS (2 L, once a day). Clinical signs and laboratory results were obtained once daily by a blinded observer. The induction method was effective in creating the desired effect, as demonstrated by weight loss and subjective health and hydration scores. Both treatment groups experienced increases in body weight, base excess, and bicarbonate, and decreases in total protein and packed cell volume following treatment. Both i.v. LRS and Diaque are effective methods to correct hypovolemia and control derangements in acid-base status in calves with diarrhea and dehydration.

Economic costs to caregivers of diarrhoea treatment among children below 5 in rural Gujarat India: findings from an external evaluation of the DAZT programme

INTRODUCTION

Diarrhoea is a leading cause of mortality among young children in India although few receive the recommended treatment. The diarrhoea alleviation through zinc and oral rehydration salts (ORS) therapy (DAZT) team initiated a programme in Gujarat from 2011 to 2013 to increase coverage of these interventions through public and private providers at scale. This study evaluates the economic impact of diarrhoea to caregivers before and after the introduction of zinc and ORS at scale through the DAZT programme.

METHODS

The DAZT programme evaluation took a before-and-after study design using a two-stage clustered cross-sectional survey. Factors associated with the odds of caregivers incurring economic costs and their amounts were evaluated in a two-part modelling approach.

RESULTS

The DAZT programme lowered unadjusted economic costs to caregivers of treating a diarrhoeal episode from $4.04 to $2.49 in 2 years. Controlling for covariates, analysis showed no association between the programme and a change in odds of incurring an economic cost but did show an association with a reduction in economic cost of $2.15 (95% confidence interval (CI) $1.20-$3.11) per diarrhoea episode. A more than 4-fold increase in care-seeking from public community health workers, reduction in care-seeking from higher levels of the health system and reduced spending on drugs besides ORS and zinc may explain these results.

DISCUSSION

This study found an association between zinc introduction and a reduction in economic burden of diarrhoea treatment to caregivers in underserved rural areas of Gujarat through more efficient patterns of care-seeking and content of care.

Oral Rehydration Therapy and Feeding Replaces Total Parenteral Nutrition: A Clinical Vignette

A 27-year-old patient with spina bifida and a high output loss of water and electrolytes from her ileostomy was successfully liberated from dependency on total parenteral nutrition and intravenous fluid and electrolyte replacement by the use of a rice-based oral rehydration therapy (ORT). This allowed her to return home to the care of her mother. We suggest that ORT can be effective in the context of modern high-technology settings, as well as in resource-poor situations.

Robert K. Crane-Na(+)-glucose cotransporter to cure?

Dr. Robert K. Crane made major contributions to our understanding of carbohydrate metabolism and transport of the intestine over a very long and productive career. This Perspective examines, briefly, his early life and academic positions, but more importantly, this Perspective highlights his contributions to the understanding of coupled Na(+)-glucose absorption by the small intestine. I discuss how his early hypothesis of a "cotransport" of sodium and glucose ushered in and provided the physiological explanation for the clinical treatment of acute diarrhea and cholera when using oral rehydration therapy (ORT). ORT saves millions of lives each year. Certainly, humankind is better off because of Crane's hypothesis of the Na(+)-glucose cotransporter that he put forth over 50 years ago?

From cholera to burns: a role for oral rehydration therapy

According to the practice guidelines of the American Bum Association on burn shock resuscitation, intravenous (i.v.) fluid therapy is the standard of care for the replacement of fluid and electrolyte losses in burn injury of > or = 20% of the total body surface area. However, in mass burn casualties, i.v. fluid resuscitation may be delayed or unavailable. Oral rehydration therapy (ORT), which has been shown to be highly effective in the treatment of dehydration in epidemics of cholera, could be an alternate way to replace fluid losses in burns. A prospective case series of three patients was carried out as an initial step to establish whether oral Ceralyte 90 could replace fluid losses requiring i.v. fluid therapy in thermal injury. The requirement of the continuing i.v. fluid therapy was reduced by an average of 58% in the first 24 hours after the injury (range 37-78%). ORT may be a feasible alternative to i.v. fluid therapy in the resuscitation of burns. It could also potentially save many lives in mass casualty situations or in resource-poor settings where i.v. fluid therapy is not immediately available. Further studies are needed to assess the efficacy of this treatment and to determine whether the present formulations of ORT for cholera need modification.

The 2008 cholera epidemic in Zimbabwe: experience of the icddr,b team in the field

During August 2008-June 2009, an estimated 95,531 suspected cases of cholera and 4,282 deaths due to cholera were reported during the 2008 cholera outbreak in Zimbabwe. Despite the efforts by local and international organizations supported by the Zimbabwean Ministry of Health and Child Welfare in the establishment of cholera treatment centres throughout the country, the case-fatality rate (CFR) was much higher than expected. Over two-thirds of the deaths occurred in areas without access to treatment facilities, with the highest CFRs (>5%) reported from Masvingo, Manicaland, Mashonaland West, Mashonaland East, Midland, and Matabeleland North provinces. Some factors attributing to this high CFR included inappropriate cholera case management with inadequate use of oral rehydration therapy, inappropriate use of antibiotics, and a shortage of experienced healthcare professionals. The breakdown of both potable water and sanitation systems and the widespread contamination of available drinking-water sources were also considered responsible for the rapid and widespread distribution of the epidemic throughout the country. Training of healthcare professionals on appropriate cholera case management and implementation of recommended strategies to reduce the environmental contamination of drinking-water sources could have contributed to the progressive reduction in number of cases and deaths as observed at the end of February 2009.

National scale-up of zinc promotion in Nepal: results from a post-project population-based survey

The World Health Organization and the United Nations Children's Fund recommend using a new oral rehydration solution (ORS) plus zinc supplementation for 10-14 days for the treatment of diarrhoea in children aged less than five years. The Social Marketing Plus for Diarrhoeal Disease Control: Point of Use Water Disinfection and Zinc Treatment (POUZN) project in Nepal was one of the first zinc-promotion projects to move beyond pilot efforts into a scaled-up programme with national-level reach. This study used data from a survey conducted in 26 districts in Nepal in 2008 to examine zinc-use behaviour, knowledge, and beliefs of caregivers of children aged less than six years, other diarrhoea-treatment practices, and recollection of project communication messages. The results of the survey indicated that, by six months following the onset of a zinc-promotion campaign, the majority (67.5%) of children (n=289), aged less than six years, with diarrhoea were treated with ORS, and 15.4% were treated with zinc. Over half (53.1%) of all caregivers (n=3,550) interviewed had heard about zinc products; most (97.1%) of those who had heard of zinc knew that zinc should be used for the treatment of diarrhoea. Zinc-related knowledge and behaviours were positively associated with recall of communication messages. Children whose caregivers recalled the mass-media message that zinc should be used for 10 days [odds ratio (OR)=2.02, 95% confidence interval (CI) 1.85-2.19] and whose caregivers perceived that zinc is easy to obtain (OR=1.76, 95% CI 1.49-2.09) were more likely to be treated with zinc for 10 days, along with ORS. The findings demonstrated that mass media play an important role in increasing caregivers' knowledge about zinc and encouraging trial and correct use. Future efforts should also focus on understanding the factors that motivate providers to continue recommending antibiotics and antidiarrhoeals instead of zinc. These findings are being used for informing the design and implementation of zinc programmes in other developing countries with a high prevalence of diarrhoea.

Acute gastroenteritis: from guidelines to real life

Acute gastroenteritis is a very common disease. It causes significant mortality in developing countries and significant economic burden to developed countries. Viruses are responsible for approximately 70% of episodes of acute gastroenteritis in children and rotavirus is one of the best studied of these viruses. Oral rehydration therapy is as effective as intravenous therapy in treating mild to moderate dehydration in acute gastroenteritis and is strongly recommended as the first line therapy. However, the oral rehydration solution is described as an underused simple solution. Vomiting is one of the main reasons to explain the underuse of oral rehydration therapy. Antiemetics are not routinely recommended in treating acute gastroenteritis, though they are still commonly prescribed. Ondansetron is one of the best studied antiemetics and its role in enhancing the compliance of oral rehydration therapy and decreasing the rate of hospitalization has been proved recently. The guidelines regarding the recommendation on antiemetics have been changed according to the evidence of these recent studies.

Experience in managing severe malnutrition in a government tertiary treatment facility in Bangladesh

Children with severe acute malnutrition, defined as weight-for-height <70% of the reference median or bilateral pedal oedema or mid-arm circumference <110 mm having complications, were managed in the Nutrition Unit of the Chittagong Medical College Hospital (CMCH) following the guidelines of the World Health Organization, with support from Concern Worldwide Bangladesh and ICDDR,B. In total, 171 children aged less than five years (mean +/- SD age 23.5 +/- 15.3 months) were admitted during June 2005-May 2006. Of them, 66% were aged less than two years, and 84.2% belonged to households with a monthly income of less than US$ 40. The main reason for bringing children by their families to the hospital was associated major illnesses: bronchopneumonia (33%), oedema (24%), diarrhoea (11%), pulmonary tuberculosis (9%), or other conditions, such as meningitis, septicaemia, and infections of the skin, eye, or ear. The exit criteria from the Nutrition Unit were: (a) for children admitted without oedema, an absolute weight gain of > or = 500 and > or = 700 g for children aged less than two years and 2-5 years respectively; and for children admitted with oedema, complete loss of oedema and weight-for-height >70% of the reference median, and (b) the mother or caretaker has received specific training on appropriate feeding and was motivated to follow the advice given. Of all the admitted children, 7.6% of parents insisted for discharging their children early due to other urgent commitments while 11.7% simply left with their children against medical advice. Of the 138 remaining children, 88% successfully graduated from the Nutrition Unit with a mean weight gain of 10.6 g/kg per day (non-oedematous children) and loss of -1.9 g/kg per day (oedematous children), 86% graduated in less than three weeks, and the case-fatality rate was 10.8%. The Nutrition Unit of CMCH also functions as a training centre, and 197 health functionaries (82 medical students, 103 medical interns, and 12 nurses) received hands-on training on management of severe malnutrition. The average cost of overall treatment was US$ 14.6 per child or approximately US$ 1 per child-day (excluding staff-cost). Food and medicines accounted for 42% and 58% of the total cost respectively. This study demonstrated the potential of addressing severe acute malnutrition (with complications) effectively with minimum incremental expenditure in Bangladesh. This public-private approach should be used for treating severe acute malnutrition in all healthcare facilities and the treatment protocol included in the medical and nursing curricula.

Operational issues and trends associated with the pilot introduction of zinc for childhood diarrhoea in Bougouni district, Mali

Zinc for the treatment of childhood diarrhoea was introduced in a pilot area in southern Mali to prepare for a cluster-randomized effectiveness study and to inform policies on how to best introduce and promote zinc at the community level. Dispersible zinc tablets in 14-tablet blister packs were provided through community health centres and drug kits managed by community health workers (CHWs) in two health zones in Bougouni district, Mali. Village meetings and individual counselling provided by CHWs and head nurses at health centres were the principal channels of communication. A combination of methods were employed to (a) detect problems in communication about the benefits of zinc and its mode of administration; (b) identify and resolve obstacles to implementation of zinc through existing health services; and (c) describe household-level constraints to the adoption of appropriate home-management practices for diarrhoea, including administration of both zinc and oral rehydration solution (ORS). Population-based household surveys with caretakers of children sick in the previous two weeks were carried out before and four months after the introduction of zinc supplementation. Household follow-up visits with children receiving zinc from the health centres and CHWs were conducted on day 3 and 14 after treatment for a subsample of children. A qualitative process evaluation also was conducted to investigate operational issues. Preliminary evidence from this study suggests that the introduction of zinc does not reduce the use of ORS and may reduce inappropriate antibiotic use for childhood diarrhoea. Financial access to treatments, management of concurrent diarrhoea and fever, and high use of unauthorized drug vendors were identified as factors affecting the effectiveness of the intervention in this setting. The introduction of zinc, if not appropriately integrated with other disease-control strategies, has the potential to decrease the appropriate presumptive treatment of childhood malaria in children with diarrhoea and fever in malaria-endemic areas.

Effect of HIV/AIDS and malaria on the context for introduction of zinc treatment and low-osmolarity ORS for childhood diarrhoea

Diarrhoea was estimated to account for 18% of the estimated 10.6 million deaths of children aged less than five years annually in 2003. Two--Africa and South-East Asia--of the six regions of the World Health Organization accounted for approximately 40% and 31% of these deaths respectively, or almost three-quarters of the global annual deaths of children aged less than five years attributable to diarrhoea. Much of the effort to roll out low-osmolarity oral rehydration solution (ORS) and supplementation of zinc for the management of diarrhoea accordingly is being devoted to sub-Saharan Africa and to South and South-East Asia. A number of significant differences exist in diarrhoea-treatment behaviours and challenges of the public-health systems between Africa and Asia. The differences in rates of ORS use are the most common indicator of treatment of diarrhoea and vary dramatically by and within region and may significantly influence the roll-out strategy for zinc and low-osmolarity ORS. The prevalence of HIV/AIDS and the endemicity of malaria also differ greatly between regions; both the diseases consume the attention and financial commitment of public-health programmes in regions where rates are high. This paper examined how these differences could affect the context for the introduction of zinc and low-osmolarity ORS at various levels, including the process of policy dialogue with local decision-makers, questions to be addressed in formative research, implementation approaches, and strategies for behaviour-change communication and training of health workers.

Does an L-glutamine-containing, glucose-free, oral rehydration solution reduce stool output and time to rehydrate in children with acute diarrhoea? A double-blind randomized clinical trial

This study assessed whether an oral rehydration solution (ORS) in which glucose is replaced by L-glutamine (L-glutamine ORS) is more effective than the standard glucose-based rehydration solution recommended by the World Health Organization (WHO-ORS) in reducing the stool volume and time to rehydrate in acute diarrhoea. In a double-blind, randomized controlled trial in a Mexican hospital, 147 dehydrated children, aged 1-60 month(s), were assigned either to the WHO-ORS (74 children), or to the L-glutamine ORS (73 children) and followed until successful rehydration. There were no significant differences between the groups in stool output during the first four hours, time to successful rehydration, volume of ORS required for rehydration, urinary output, and vomiting. This was independent of rotavirus-associated infection. An L-glutamine-containing glucose-free ORS seems not to offer greater clinical benefit than the standard WHO-ORS in mildly-to-moderately-dehydrated children with acute non-cholera diarrhoea.

Management of acute diarrhoea in primary care in Bahrain: self-reported practices of doctors

This nationwide study was conducted to assess the extent of adherence of primary-care physicians to the World Health Organization (WHO)-recommended guidelines on the use of oral rehydration therapy (ORT), antimicrobials, and prescribing of other drugs used in treating symptoms of acute diarrhoea in Bahrain. A questionnaire-based, cross-sectional survey was carried out in primary-care health centres. During a six-week survey period (15 August-30 September 2003), 328 (25.2%) completed questionnaires were returned from 17 of 20 health centres. In a sample of 300 patients, oral rehydration salts (ORS) solution was prescribed to 89.3% (n=268) patients; 12.3% received ORS alone, whereas 77% received ORS in combination with symptomatic drugs. Antimicrobials were prescribed to 2% of the patients. In 11.4% of the cases, rehydration fluids and other drugs were given parenterally The mean number of drugs was 2.2+0.87 per prescription. In approximately one-third of the patients, three or more drugs were used. Primary-care physicians almost always adhered to the WHO guidelines with respect to ORT and antimicrobials. However, in several instances, ORT was prescribed along with polypharmacy, including irrational use of drugs for symptomatic relief. Effective health policies are needed to reduce the unnecessary burden on the healthcare system.