Efficacy of standard glucose-based and reduced-osmolarity maltodextrin-based oral rehydration solutions: effect of sugar malabsorption.

Previously we reported that standard oral rehydration salts (ORS) solution is not as effective as a reduced-osmolarity glucose-based ORS for the treatment of children with acute noncholera diarrhoea: with standard ORS the diarrhoea lasts longer, stool output is greater, serum sodium is higher, and there is more need for supplemental intravenous infusion. We studied a reduced-osmolarity maltodextrin (MD)-based ORS to determine whether it had similar benefits, and also the effect of sugar malabsorption on the efficacy of standard and MD-based ORS. A total of 90 boys aged 3-24 months with acute noncholera diarrhoea and moderate dehydration were randomly assigned to either standard ORS (glucose 20 g/l, osmolarity 311 mmol/l) or MD-ORS (MD 50 g/l, osmolarity 227 mmol/l). There were no differences in treatment results. Some 46% of subjects had a high total stool output (> 300 g/kg), which was unrelated to the type of ORS given. High stool output was significantly associated with a longer duration of diarrhoea (33 vs. 15 hours; P < 0.001), a persistently elevated serum sodium (149 vs. 144 mmol/l at 24 h; P < 0.02), the need for intravenous infusion (11/41 vs. 0/48; P < 0.002), and an increase in faecal reducing substances (10.8 vs. 3.4 g/l at 24 h; P < 0.001). We conclude that some children given standard ORS develop osmotic diarrhoea owing to the combined effect of transient sugar malabsorption and slight hypertonicity of the ORS. Earlier studies show that this adverse outcome can largely be avoided when extra water is given in reduced-osmolarity glucose-based ORS. Reduced osmolarity has no benefit, however, when glucose is replaced by maltodextrin, probably because the sugars released by hydrolysis of MD, when malabsorbed, raise the intraluminal osmolarity to equal or exceed that of standard ORS. Thus, reduced-osmolarity glucose-based ORS is superior to both standard ORS and reduced-osmolarity solutions based on maltodextrin and probably other complex carbohydrates. Studies are in progress to define the optimal formulation of reduced-osmolarity glucose-based ORS.

PIP: At the Diarrhoeal Disease Research and Rehydration Centre of Bab El-Sha'reya Hospital in Cairo, Egypt, clinical researchers randomly assigned 90 fully weaned boys aged 3-24 months with non-cholera diarrhea and signs of moderate dehydration to either the treatment group receiving the standard glucose-based oral rehydration solution (ORS) or the group receiving a reduced-osmolarity ORS with minimally hydrolyzed maltodextrins (MD) (50 g/l) in place of glucose (20 g/l). They wanted to determine whether the reduced-osmolarity, MD-based ORS yielded similar benefits as the glucose-based ORS and to examine the effect of sugar malabsorption on the efficacy of both solutions. The osmolarity of the MD-based ORS was 227 mmol/l compared to 311 mmol/l for the standard ORS. There were no significant differences in the clinical outcomes (duration of diarrhea, stool output, ORS intake, serum sodium level, and weight gain at discharge) for each treatment group. High stool output had a significant positive association with longer duration of diarrhea (33 vs. 15 hours for low stool output; p 0.01), a persistently elevated serum sodium concentration (149 vs. 144 mmol/l for low stool output; p 0.02), the need for intravenous infusion (11/41 vs. 0/48 for low stool output; p 0.002), and an increase in substances that reduce feces (10.8 vs. 3.4 g/l for low stool output; p 0.001). Based on these findings, the researchers hypothesized that, like the standard ORS, the reduced osmolarity ORS, in which glucose is replaced with MD, also caused sugar malabsorption. The sugar malabsorption, in turn, increased the effective intraluminal osmolarity to equal or exceed that of the standard ORS. Both sugar malabsorption and intraluminal hypertonicity were responsible for a net flow of water from extracellular fluid into the gut, an increased serum sodium concentration, increased thirst leading to greater intake of ORS, ORS treatment failure, an increase in stool output, and an increase in duration of diarrhea. In conclusion, reduced-osmolarity, glucose-based ORS is superior to the standard glucose-based ORS and reduced-osmolarity, MD-based ORS.

Is a low-osmolarity ORS solution more efficacious than standard WHO ORS solution?

The clinical efficacy of a diluted oral rehydration salts (ORS) solution was compared in a pilot study with that of intravenous (i.v.) therapy and of standard World Health Organization (WHO)/United Nations Childrens Fund (UNICEF) ORS solution in children with acute diarrhea. Sixty-one boys aged 3 to 24 months, admitted to hospital with acute diarrhea and signs of dehydration, were randomly assigned to groups receiving standard ORS solution, diluted ORS solution, or i.v. therapy. In children treated with standard ORS solution and small amounts of plain water, the total fluid intake was 25-39% greater, the stool output was 58-77% greater (p < 0.01), and the duration of diarrhea was 30-55% greater than in the other treatment groups. Intake of plain water, taken separately or added to the ORS solution, was greater in children given diluted ORS solution (73 +/- 23 ml/kg) than in those given standard ORS solution (21 +/- 32 ml/kg) (p < 0.001). The mean serum sodium concentration increased by 2.2 mEq/L in children given standard ORS solution, whereas it decreased by 2.9 mEq/L in those given diluted ORS solution. This study shows that some children develop worsening diarrhea and increasing serum sodium concentrations when treated with standard ORS solution and given only small amounts of plain water. This is probably caused by the slight hypertonicity of standard ORS solution combined with transient partial glucose malabsorption. This can be avoided if water, breast milk, or another low-solute drink is given liberally during maintenance therapy with ORS solution, as recommended by the WHO.

Caretaker recognition of respiratory signs in children: correlation with physical examination findings, x-ray diagnosis and pulse oximetry.

Caretaker recognition of clinical utility of respiratory signs and symptoms in the prediction of pneumonia was examined in a prospective study of infants and children in four cities in Egypt. In all 688 children aged 2 months-5 years presenting with a history and/or physical examination findings of cough and difficult or fast breathing were recruited from out-patient health facilities. The validity of caretaker terms was determined using paediatrician observation of standard respiratory signs and symptoms, x-ray diagnosis and pulse oximetry as standards. The sensitivity of 'nahagan' (Egyptian Arabic for fast breathing) for identifying elevated respiratory rate was 78% +/- 4, and was slightly higher for < 12 month olds (85% +/- 5) versus children aged 1-5 years (74% +/- 5). 'Sedro tale nazel', which describes the chest as moving up and down, was a sensitive (86% +/- 3) and specific (60% +/- 4) indicator of chest indrawing. 'Tazyeek' (wheeze) had a sensitivity of 75% +/- 3 and specificity of 66% +/- 4 when compared to paediatrician assessment of wheezing during physical examination. Although not specific, the caretaker terms, 'nahagan' or 'nafas seria' (fast breathing) and 'sedro tale nazel' (chest indrawing), either spontaneously or after asking, were sensitive (> 71%) indicators of radiologic pneumonia and oxygen desaturation, and therefore can be used to prompt timely health seeking behaviour in these settings.

An instrument to assess acute respiratory infection case management in Egypt.

UNLABELLED: To develop an instrument to measure the quality of acute respiratory infection (ARI) case management among Egyptian children. METHODS: A baseline survey of all health facilities in a single district, using a multi-data source instrument. Data sources included providers, caretakers, patient records and observation of patient care. MAIN RESULTS: Physicians did not count the respiratory rate and check for subcostal retraction. Eighty-seven per cent of children who did not require antibiotics received them. Of five children who required antibiotics, four (80%) were prescribed an oral regimen. Three of these should have been admitted to a hospital but were not. Antibiotics were available at the facilities an estimated 7.9 months per year. Oxygen for inpatient treatment was available in one of two hospitals. CONCLUSIONS: This instrument was useful for comprehensively evaluating facility capability to provide quality case management. Deficiencies were identified but were not unexpected in a baseline survey. The Egypt ARI program has the potential to have a substantial impact on how children with ARI are diagnosed and treated in health facilities.

PIP: An instrument consisting of 10 questionnaires was developed to assess the ability of facilities to implement acute respiratory infection (ARI) case management guidelines. Data sources included interviews with physicians, nurses and area pharmacists; observation of patient care; review of patient records and an inventory of supplies. All 21 outpatient and two inpatient health facilities as well as 20 of 28 pharmacies in the district were included in the study. Of 93 child assessments observed, physicians asked the age for only 38 (41%). No child was questioned on ability to drink or experience of seizures. In addition, no physician checked for stridor, wheeze or chest indrawing, or counted the respiratory rate. 81 of 93 (87%) children with ARI were prescribed antibiotics. Among the 88 children assessed as not requiring antibiotics, 77 (88%) received them. Five children (2 pneumonia, 2 severe pneumonia, and 1 very severe disease) were determined to require antibiotics; four were prescribed an oral regimen. Of the four children that both required antibiotics and received them, three should have been admitted to the hospital for parenteral antibiotics, but were not. A variety of prescribed antibiotics were used among the 77 children. 27 (35%) children received two or three antibiotics without specifying the dose, frequency or duration on the prescription. Only two physicians mentioned the antibiotic dosage schedule for home care to the mother. Physicians at each of the outpatient facilities estimated the mean availability of antibiotics at 7.9 +or- 3.9 months. Three facilities (14%) had ampicillin suspension, none had amoxicillin and two (9%) had cotrimoxazole for the treatment of outpatient pneumonia. 19 (90%) had aspirin. Oxygen was available for inpatient care for children with pneumonia in one of the two hospitals, no nebulizers were available for treatment of wheezing, and disposable syringes were available in only one hospital. Parenteral bronchodilators were available in both, oral in neither. This instrument was useful for comprehensively evaluating facility capability to provide quality case management in the Egyptian ARI program.

Comparison of latex agglutination test with an ELISA to diagnose rotavirus-associated diarrhoea in infants and young children.

An agglutination (LA) test, using latex beads sensitised with anti-rotavirus immunoglobulin G, was evaluated to detect human rotavirus in 200 stool specimens by comparing its results with those of an ELISA (Rotazyme, Abbott Laboratory, Diagnostic Div., North Chicago, IL). The specimens were collected from a systematic sample of 200 infants and pre-school children attending the Diarrhoeal Disease Research and Rehydration Centre at the Bab-El-Sha'reya University Hospital, Egypt. Of the 200 stool specimens tested, 79 were positive by the ELISA and 68 were positive by the LA test. Taking the ELISA as the standard, the LA test showed 11 false-negative and six false-positives giving a sensitivity and specificity of 86% and 95% respectively. Using 48 stool specimens positive for rotavirus by both the tests, the degree of positivity of the LA test roughly showed a linear relationship with the degree of rotazyme optical density. Thus, the simple and inexpensive LA test may be useful as a screening procedure to detect rotaviruses in the stools of children with diarrhoea.

Epidemiological and clinical features of rotavirus associated acute infantile diarrhoea in Cairo, Egypt.

Rotavirus was looked for in stool specimens from 200 randomly chosen infants and children aged 1-24 months presenting with acute diarrhoea of not more than 5 days duration at the Bab El-Sha'reya University Hospital during a 12-month period (January-December 1986). Forty per cent of cases were positive for rotavirus by the ELISA technique. Considering the seasonal pattern, during the hot months May to August, the monthly percentage of rotavirus positive cases ranged from 24 to 32 per cent while during the rest of the year, the range was from 37 to 60 per cent. There was no statistically significant difference between the rotavirus positive and negative cases as regards mean age in months (9.5 +/- 5.1 and 9.2 +/- 5.5, respectively), type of feeding or nutritional status. However, rotavirus positive cases were significantly more likely to present earlier, to have watery stools, to vomit or even to have vomiting before the onset of diarrhoea and to have respiratory symptoms. On the other hand, the means of dehydration score, rectal temperature and serum Na+ were not significantly different between the two groups.

Controlled clinical trial on the efficacy of rice powder-based oral rehydration solution on the outcome of acute diarrhea in infants.

We report a controlled clinical trial of rice powder-based oral rehydration solution (ORS) versus glucose ORS on the outcome of acute diarrhea in infants. The rice ORS group (n = 30) received ORS containing 50 g rice powder instead of standard WHO solution (20 g glucose, n = 30). Formula-fed male infants were enrolled to enable calculation of milk intake and excretion of urine. Patient allocation to either group depended on the method of random permuted blocks. Both groups were comparable regarding age (4-18 months), duration of diarrhea, number of bowel movements or vomiting per 24 h, rectal temperature, dehydration score, and nutritional status. Results revealed that the rice ORS group had a shorter duration of diarrhea (28.4 +/- 5.1 vs 34.3 +/- 2.3 h) and greater mean weight gain in the first 24 h as percentage of recovery weight (5.7 +/- 0.5% vs 4.1 +/- 0.6%). Furthermore, the mean amount of ORS intake, mean stool output, and mean number of episodes of vomiting were lower in the rice-ORS group as compared with the glucose ORS group. All differences were statistically significant. Due to its observed superiority and low cost, the widespread use of rice ORS should be considered for treatment of acute diarrhea.

Accuracy of mixing oral rehydration solution at home by Egyptian mothers.

PIP: The study was conducted by the Rehydration Unit of Bab El-Sha'reya Hospital, Cairo to determine the impact on the mixing accuracy of oral rehydration solution (ORS) of a group of mothers of infants suffering from acute diarrhea. 1 group received a special 200 ml cup and brief verbal instructions; a control group received neither the cup nor instructions. The mothers were illiterate and of a low socioeconomic class. Results show that the median capacity of home containers used was 160ml/L. The mean ORS sodium concentration (98mmol/L) for the group supplied with the specified container was significantly lower than the ORS sodium concentration (123 mmol/L) of the group that used home containers (p 0.02). All mothers who received the 200 ml cup from the medical unit used it. 96% of mothers in both groups were ready to use ORS in the future. The present study showed that mothers mixing premarked ORS containers along with brief instructions and the 200 ml cups dispensed with the ORS container were more accurate because the standard container was provided. There is no financial obstacle to providing such containers since the cost in Egypt is US$0.1. Such containers could be provided free if Egyptian companies producing pediatric medicines would agree to such containers away as promotional tools.^ieng

An epidemiological study of energy protein malnutrition in a rural community in Egypt.

PIP: A field study was carried out in Sendion Village in Qualyubeya Governorate, Egypt, to assess the nutritional status of infants and preschool children. 1527 children from 0-6 years were studied. Of the 840 males and 687 females studied, 404 children (26.45%) were suffering from various degrees of energy protein malnutrition (EPM). The total prevalence rate was lower among male than among female children but the difference was not statistically significant. 97 of the 404 EPM cases were considered severe while 307 were classified as underweight or mildly undernourished. Age was an important factor in the incidence of malnutrition. The prevalence rate of EPM was 13.6% in the 1st 6 months of life, 23.2% in the 2nd 6 months, and highest (32.6-35.2%) in the 12-47 month age group. The rate dropped off after 48 months. The prevalence rate was higher among those fed with all artificial milk or a combination of artificial and breast milk (29.8%) than among those infants who were totally breast fed (22.49%); the difference was statistically significant at the p.01 level. Birth order had no effect on the incidence of EPM. There was a greater but not significantly different incidence of EPM among children in larger families. Prevalence rates in this study were lower than have been found by other investigators.^ieng

The nutritionally at risk child. Part 2 : study of factors pertinent to the child, siblings or mother.

Several high risk factors were evaluated in an attempt to determine the Egyptian children who are more prone to become malnourished. The study included 110 children with energy protein malnutrition and 98 normal children. Their ages were between 4 months and 3 years. Among the factors investigated, the 2nd 6 months of life was found to be the most critical for nutritional deficiency. Presence of previous siblings with malnutrition, presence of more than 2 sibling deaths and presence of history of severe diarrhoea with dehydration were significantly related to the nutritional status of children. Twinning, birth order and birth interval showed some relation to malnutrition but were not statistically significant. The sex of the child and maternal weight did not influence the nutritional state of children. However, these low-socialclass children were found to be mostly (92.8%) breast fed.