Microbiological assessment and evaluation of rehydration instructions on powdered infant formulas, follow-up formulas, and infant foods in Malaysia.

A total of 90 samples comprising powdered infant formulas (n=51), follow-up formulas (n=21), and infant foods (n=18) from 15 domestic and imported brands were purchased from various retailers in Klang Valley, Malaysia and evaluated in terms of microbiological quality and the similarity of rehydration instructions on the product label to guidelines set by the World Health Organization. Microbiological analysis included the determination of aerobic plate count (APC) and the presence of Enterobacteriaceae and Cronobacter spp. Isolates of interest were identified using ID 32E (bioMérieux France, Craponne, France). In this study, 87% of powdered infant formulas, follow-up formulas, and infant foods analyzed had an APC below the permitted level of <10(4) cfu/g. These acceptable APC ranged between <10(2) to 7.2×10(3) cfu/g. The most frequently isolated Enterobacteriaceae was Enterobacter cloacae, which was present in 3 infant formulas and 1 infant food tested. Other Enterobacteriaceae detected from powdered infant and follow-up formulas were Citrobacter spp., Klebsiella spp., and other Enterobacter spp. No Cronobacter species were found in any samples. Rehydration instructions from the product labels were collated and it was observed that none directed the use of water with a temperature >70°C for formula preparation, as specified by the 2008 revised World Health Organization guidelines. Six brands instructed the use of water at 40 to 55°C, a temperature range that would support the survival and even growth of Enterobacteriaceae.

Efficacy and safety of a new apple-flavoured oral rehydration solution in children with acute gastroenteritis: a double-blind randomized controlled trial.

AIM: To assess the efficacy and safety of a new oral rehydration solution (ORS) with improved flavour in the management of children with acute gastroenteritis (AGE). METHODS: Children 4 to 48 months of age with AGE (≥3 loose or watery stools per day for >1 but <5 days) with mild-to-moderate dehydration (3% to 9% loss of body weight) according to the World Health Organization criteria randomly received regular hypotonic ORS (Na 60 mmol/L, glucose 78 mmol/L) or the same hypotonic ORS with an apple taste. RESULTS: Of the 147 children randomized, 130 (88.4%) were available for intention-to-treat analysis. The proportion of children with the resolution of signs of dehydration in the experimental group compared with the control group was similar at 24 h (49/63 vs. 57/67, respectively, p = 0.28). There were also no significant differences in adequate weight gain (p = 0.48) and urine production at 24 h (p = 0.95) between groups. There were no differences between groups in any of the secondary outcome measures, including ORS intake. No adverse events were observed in the study groups. CONCLUSIONS: In an outpatient setting, there was no difference in efficacy between the study products. Both ORSs were equally effective and may be used interchangeably.

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.

Oral rehydration for viral gastroenteritis in adults: a randomized, controlled trial of 3 solutions.

BACKGROUND: Pedialyte and Gatorade are advocated for the treatment of dehydration in viral gastroenteritis, but there is limited evidence to support their use. We examine the efficacy, safety, and palatability of Pedialyte, Gatorade, and a New Oral Rehydration Solution (N-ORS). This was a randomized double-blind trial conducted in an inpatient, community hospital. Seventy-five consecutive adult patients (male, 42; female, 33) admitted with viral gastroenteritis were randomized to receive Gatorade, Pedialyte, or N-ORS for 48 hours. A yogurt/rice diet was allowed ad libitum. Stool and urine output, electrolytes, fluid intake, body weight, hematocrit, and palatability of solutions were measured. RESULTS: Sixty completed the study. Stool frequency, consistency, and body weight improved (p < .001) in all 3 groups, but there was no difference between groups. Likewise, urine output, hematocrit, and correlations between fluid ingested, stool weight, or urine output were similar. At admission and 24 and 48 hours later, hypokalemia was observed in 7, 10, and 8 patients with Gatorade; 3, 2, and 1 with N-ORS; and 2, 2, and 1 with Pedialyte, respectively. Similarly, hyponatremia was observed in 6, 9, and 3 patients with Gatorade; 5, 3, and 4 with N-ORS; and 4, 5, and 4 with Pedialyte. Tastewise, Gatorade and N-ORS were rated higher (p < .05) than Pedialyte. Limitations were a smaller sample size and higher dropout (20%). CONCLUSIONS: Gatorade and N-ORS seem to be as effective as Pedialyte in correcting dehydration and in improving bowel symptoms. All 3 solutions were safe. Unlike other groups, hypokalemia persisted in the Gatorade group. Gatorade and N-ORS may be effective in the treatment of dehydration associated with mild viral gastroenteritis.

Palatability assessment of an oral recuperation fluid in healthy dogs during the perioperative period.

The objective of this study was to determine whether healthy dogs undergoing elective surgery will accept and prefer an oral recuperation fluid (ORF) to water during the perioperative time period and if the consumption of an ORF would lead to increased caloric intake during the final preoperative and first postoperative periods. This prospective, observational study was performed in the setting of a University Veterinary Teaching Hospital. A total of 67 healthy dogs were presented for routine ovariectomy (n = 30) or castration (n = 37). Before surgical intervention, dogs were offered an ORF to assess their voluntary acceptance of the fluid. After 2 hours, the ORF was offered alongside water to assess fluid preference. Routine castration or ovariectomy was then performed. During the immediate postoperative period, dogs were reassessed as to their acceptance and preference of the ORF. A high percentage of dogs accepted the ORF in both the preoperative (55/67, 82%) and postoperative (42/67, 63%) periods (P < .01 and P = .04, respectively). Of dogs that demonstrated a preference between the ORF and water, 87% (95% CI: 77%-93%) chose the ORF preoperatively, whereas 98% (95% CI: 87%-99.5%) chose the ORF postoperatively (P < .01 and P < .01, respectively). Dogs that consumed the ORF in each measurement period ingested a higher amount of food (measured as percentage of kilocalories offered) when compared with those that did not consume the ORF (preoperatively 83% vs. 49%, P < .01; postoperatively 51% vs. 27%, P = .01). A commercially manufactured veterinary ORF was found to be palatable, as determined by acceptance and preference testing, in healthy dogs during the preoperative and postoperative phases of routine sterilization. Further studies in dogs undergoing more intensive surgical procedures or recovering from nonsurgical illness or both are warranted.

First do no harm: making oral rehydration solution safer in a cholera epidemic.

Oral rehydration solution (ORS) is lifesaving therapy for cholera and pediatric diarrhea. During a cholera epidemic in Guinea-Bissau, we evaluated the microbiologic quality of ORS prepared at a hospital and tested a simple intervention using special vessels for disinfecting tap water with bleach and for preparing, storing, and dispensing ORS. Few coliform bacteria and Escherichia coli were recovered from tap water; however, pre-intervention ORS contained numerous bacteria including E. coli and toxigenic Vibrio cholerae O1. In contrast, ORS samples from intervention vessels had few or no coliform bacteria, no E. coli, and no V. cholerae. Mean pre-intervention counts of coliform bacteria (3.4 x 10(7) colony-forming units [cfu]/100 ml) and E. coli (6.2 x 10(3) cfu) decreased significantly during the intervention period to 3.6 x 10(2) cfu and 0 cfu, respectively (P < 0.001). This simple system using bleach disinfectant and special storage vessels prevents bacterial contamination of ORS and reduces the risk of nosocomial transmission of cholera and other enteric pathogens.

PIP: This paper evaluates the microbiologic quality of oral rehydration solution (ORS) prepared at a hospital during a cholera epidemic in Guinea-Bissau. The study tested a simple intervention using special vessels for disinfecting tap water with bleach and for preparing, storing, and dispensing ORS. Subjects included approximately 80% of the cholera patients seeking treatment, who were referred to the cholera ward of Simao-Mendes National Hospital. Results suggest that only few coliform bacteria and Escherichia coli were recovered from tap water; however, pre-intervention ORS contained numerous bacteria including E. coli and toxigenic Vibrio cholerae O1. In contrast, ORS samples from intervention vessels had few or no coliform bacteria, no E. coli, and no V. cholerae. This simple system using bleach disinfectant and special storage vessels prevents bacterial contamination of ORS and reduces the risk of nosocomial transmission of cholera and other enteric pathogens.

Epidemic cholera in the Amazon: the challenge of preventing death.

Epidemic cholera struck Peru in January 1991, and spread rapidly. The national cholera case-fatality rate (CFR) was less than 1% in the first six months of the epidemic, but in some rural areas, the CFR exceeded 10%. We investigated cholera mortality in the rural Amazon region, an area with a CFR of 6.3%. We conducted a case-control study, comparing 29 decedents with 61 survivors of recent cholera-like diarrheal illness in 12 villages with a combined CFR of 13.5%. Of 29 decedents, 28 (96%) died in the village or en route to a health facility. Death occurred within 36 hours of illness onset for 83% of the decedents. In 11 (92%) villages, the first or second recognized case was fatal. Death was associated with receiving treatment only at home (odds ratio indeterminate; 95% confidence interval 3.5, indeterminate). Treatment with oral rehydration salts (ORS) was not protective against death for patients who received treatment only at home. Treatment with homemade sugar-salt solution (SSS) was also not protective; fewer than one-third of respondents knew the correct SSS recipe. Most decedents experienced multiple barriers to health care. Cholera victims died rapidly and early in village outbreaks, and few patients had access to health care. Provision of threatened villages with ORS supplies and education in their use before cholera strikes is essential to reducing cholera mortality in this region.

Sports drinks: research asks for reevaluation of current recommendations.

Results of two clinical studies support the use of a carbohydrate-electrolyte beverage to improve performance of intermittent moderate- to high-intensity exercise, such as soccer and ice hockey. Two other studies documented that such beverages improved performance during steady-state moderate- to high-intensity exercise, although the mechanism by which carbohydrate improved performance in these protocols is yet to be determined.

Guidelines for optimal replacement beverages for different athletic events.

During exercise, especially endurance exercise in the heat, vital body fluids and essential ions are lost in sweat, and the body may deplete its glycogen stores. Unless essential body fluids are restored, these conditions can produce hypovolemia, hypoglycemia, hyponatremia, hyperthermia, and dehydration. Performance may also be reduced. This paper briefly reviews pertinent aspects of gastric emptying and intestinal absorption and proposes the formulation of beverages for ingestion both pre-event and during exercise. For events lasting less than 1 h, 300-500 ml of a 6-10% CHO beverage is recommended pre-event (0-15 min), and cool (5-15 degrees C) water in a volume approximately half the subjects sweat rate is recommended during exercise. For events between 1-3 h long, 300-500 ml of water is recommended pre-event, and 800-1600 ml.h-1 of a 6-8% CHO solution with 10-20 mEq Na+ is recommended during exercise. For events longer than 3 h, 300-500 ml of water is recommended pre-event, and 500-1000 ml.h-1 of a 6-8% CHO beverage with 20-30 mEq Na+ is recommended during exercise. In recovery, a beverage containing 5-10% CHO with 30-40 mEq Na+ should be ingested to achieve euhydration. A minimum of 50 g.h-1 of CHO should be ingested in the first 2 h to maximize glycogen repletion. Guidelines to follow in formulating these beverages are reviewed and the rationale for each formulation is provided.

Fluid and electrolytes: parenteral fluid therapy.

Parenteral fluid therapy is a basic component of the care of hospitalized infants and children. Clinicians who care for inpatients must be able to assess the need for parenteral fluid therapy and to specify the composition of fluid and rate of administration. Fluid and electrolyte problems can be challenging but generally can be "tamed" by an organized approach, application of a few principles of physiology, and careful monitoring of the patient. It can be useful to consider separately the amount of fluid needed and the electrolyte composition for maintenance needs, deficit, and ongoing losses. Because maintenance is not as directly related to weight as deficit or as directly measureable as ongoing losses, it tends to cause the most confusion. It will, therefore, be discussed first and in more detail than deficit or ongoing losses.

Controlled trial of hypo-osmalar versus World Health Organization oral rehydration solution.

OBJECTIVE: To compare the safety and efficacy of a hyposmolar oral rehydration solution (H-ORS) (245 mmol/liter) with the World Health Organization oral rehydration solution (WHO ORS) in cholera and acute non-cholera diarrhea. DESIGN: Controlled clinical trial. SETTING: Diarrhea training and treatment unit. METHODS: Thirty-five culture proven cholera and 135 acute non-cholera diarrheal patients randomly received H-ORS or WHO-ORS. Intake and output were measured every 4 hours. RESULTS: Analysis of the total cases revealed rehydration phase (p=0.048, 95% CI 0.64-0.99) and overall (p=0.046, 95% CI 0.70-0.99) frequency of stools to be significantly less in the H-ORS group. In the severely malnourished, the rehydration phase (p=0.032, 95% CI 0.55-97), maintenance phase (p=0.035, 95% CI 0.51-0.97) and overall (p=0.011; 0.95% CI 0.55-0.93) stool frequency were significantly decreased in the H-ORS group. The amount of ORS consumed in the maintenance phase of the cholera cases was significantly (p=0.04, 95% CI 0.44-0.98) less in the H-ORS group. All other parameters, despite showing a decreasing trend, were statistically comparable in the cholera, non-cholera and total cases. The amount of intravenous fluid needed was significantly more in the noncholera and total cases on H-ORS. In the non-breastfed cases, under two years of age, the total duration of diarrhea was significantly decreased (p=0.03; 95% CI 11.07-11.45) but the need for intravenous fluids significantly increased (p=0.02; 95% CI 109.8-112.1) in the H-ORS group. The proportion of children vomiting, the weight gain, urine passed in 24 hours, serum sodium, caloric intake and failure rate were comparable. CONCLUSIONS: H-ORS is as safe and effective as the WHO-ORS and may have some additional benefits in malnourished children.

Effect of dilution of sports drink on water balance and beverage preference of heat-exposed steel workers.

Eight skilled workers engaged in heat-exposed work in front of a blast furnace in a steel factory were asked to drink a sports drink or one of its dilutions of x 2, x 3, or x 5 during a regular daytime shift in the summer of 1999. A regular lunch was taken and the examined beverage was iced and was allowed to be consumed ad libitum. The beverage was changed each day during four days of the experiment without informing the dilution ratio. The non-diluted beverage contained 21 mEq/l of Na+, 5 mEq/l of K+, 6.7 g/dl of carbohydrate. In average, the body temperature measured in the ear canal was elevated by 0.34 degree C, the loss of body weight was 1.77 kg, total beverage intake was 1,875 g, total amount of urine was 291 g, and the total water loss was 3,732 g (1,350-5,810 g) during a single shift. Twenty out of 24 cases experienced more than 1.5% of weight reduction during morning work without noticing any subjective symptoms of dehydration. The amount of weight loss during morning work was significantly smaller when x 2 or x 3 dilution was taken compared to a non-diluted beverage. The mean value of urinary Na+ concentration was decreased after 8 hours of work; however, the difference was not significant. The urinary K+ concentration was significantly increased. When the total amount of urinary sodium excretion in stored urine was calculated, the x 3 dilution recorded the largest amount. Regarding palatability, the x 2 dilution received the best evaluation, whereas all subjects felt the original beverage as too condensed. We did not observe any adverse effect from diluting the sports drink for x 2 or x 3, when supplying them as water and electrolyte replacements for dehydrated steel workers.

Survey of total mercury in infant formulae and oral electrolytes sold in Canada.

Total mercury (Hg) was measured in 150 infant formula products (as sold) and oral electrolyte solutions purchased in Canada in 2003. Results less than the limit of detection (LOD) were reported as the numeric value of the LOD. Electrolytes contained the lowest concentrations, averaging 0.026 ng/g. Average levels in milk-based ready-to-use, concentrated liquid and powdered concentrate were 0.028, 0.069 and 0.212 ng/g, respectively. In soy-based formulae, the respective mean concentrations were 0.049, 0.101 and 0.237 ng/g. These concentrations cannot be considered on an absolute basis because 76% of sample concentrations fell below the limit of detection. Despite the inability to measure many of the actual background concentrations, the method was sufficiently sensitive to identify clear cases of low-level Hg contamination (up to 1.5 ng/g) of individual lots of powdered formula. Also, all the different lots of one brand of concentrated liquid infant formulae had significantly higher concentrations of Hg than those of all other concentrated liquid products. After dilution with preparation water, the Hg concentrations in all products would be lower than the Canadian Drinking Water Guideline for Hg of 1 ng/mL and too low to impact on health.