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238 Dutta, Mitra, Manna, Niyogi, Roy, Mondal, Bhattacharya
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Hypo-osmolar ORS in marasmic children 239
Table 3 Mean serum sodium and potassium concentrations (mmol/l) Recovery time of the hypo-osmolar group was
significantly less than that of the standard ORS
Standard ORS (n = 32) Hypo-osmolar ORS (n = 32)
group. Mean serum sodium and potassium
On admission On recovery On admission On recovery concentrations at time of recovery or on day 5
Sodium 129.7 (3.1) 134.4 (3.1) 130.0 (3.3) 134.4 (3.1)
for those who did not recover, were similar in
Potassium 3.1 (0.3) 3.5 (0.3) 3.1 (0.3) 3.5 (0.3) both treatment groups (table 3).
Results expressed as mean (SD).
There was no diVerence on admission and on recovery between the groups. Discussion
Increases in sodium and potassium in the two groups are the same. This study was designed to compare the clini-
cal eYcacy of hypo-osmolar ORS and standard
1.0 ORS in severely malnourished (marasmic)
0.9 children with dehydrating acute diarrhoea. It
Proportion of patients recovered 0.8 WHO ORS confirms the superiority of hypo-osmolar ORS
Hypo ORS over standard ORS. It has shown for the first
0.7 time that hypo-osmolar ORS is safe, and more
0.6 eVective than standard ORS in marasmic chil-
0.5
dren with some dehydration. Hypo-osmolar
ORS significantly decreases the mean duration
0.4
of diarrhoea, stool output, and need for ORS
0.3 and other fluids during the course of treatment
0.2 compared to that of standard ORS. The
beneficial eVect of hypo-osmolar ORS may be
0.1
a result of low osmolality of the solution and
0.0 complete absorption of glucose, thus reducing
0.1 the risk of osmotic diarrhoea.
0 12 24 36 48 60 72 84 96 108 120 The results showed that rehydration could
Hours be achieved and hydration status maintained
Figure 1 Survival curve for recovery. with hypo-osmolar ORS as eVectively as stand-
ard ORS. None of the children in either group
ery) were compared by applying Students t became over-hydrated in the course of treat-
test. The diVerence in proportions of cured ment. Several studies of hypo-osmolar ORS in
patients between the two groups was examined acute diarrhoea have documented reduced
using the 2 test. Recovery time of patients in weight gain in children on hypo-osmolar com-
the two groups was calculated using a survival pared to standard ORS, but this was not statis-
analysis technique in accordance with the tically significant.1013 In contrast, our study
KaplanMeyer method. showed that the mean percentage weight gain
in children in the hypo-osmolar ORS group
Results was significantly lower (p = 0.001) compared
A total of 64 marasmic male children (aged to the standard ORS group on recovery,
648 months) suVering from dehydrating reflecting the lower consumption of hypo-
acute watery diarrhoea were enrolled in the osmolar ORS for correction of dehydration as
study. After decoding the identity of ORS well as for maintenance.
received by the two groups, it was observed that Others have cautioned against the use of
32 children were in the standard ORS and 32 standard ORS because of the potential risk of
in the hypo-osmolar ORS group. Thirty one hypernatraemia.1721 A study conducted in Cal-
children (97%) in the standard and 30 (94%) cutta showed that standard ORS could be used
in the hypo-osmolar ORS group had less than safely and eVectively for the treatment of dehy-
60% Harvard standard weight for age. One drating diarrhoea in marasmic children with
child in the standard and two children in the the provision of an additional source of free
hypo-osmolar group had 6069% Harvard water (plain water, breast milk, or other low
standard weight for age. Table 1 presents clini- solute feeds).6 WHO experts have also recom-
cal features on admission, diarrhoeal pathogens mended the use of standard ORS together with
isolated, serum sodium and potassium concen- additional fluid in the form of breast milk,
trations, and percentage of weight loss; the dilute milk formula, or plain water in the latter
groups were comparable. In table 2, outcome part of rehydration, as well as during the main-
variables of the two groups are compared. tenance phase to reduce the risk of hypernat-
Twenty nine children (91%) in the standard raemia.4 However, if hypo-osmolar ORS is
ORS group and 32 (100%) in the hypo- available, it can be used safely and easily for the
osmolar ORS group recovered within five days; treatment of marasmic children.
this diVerence was not statistically significant In developing countries, it has been thought
(p > 0.05). The interval to recovery, stool out- that use of hypo-osmolar ORS in marasmic
put, and daily ORS and fluid intake per kg were diarrhoeal children might cause hyponatrae-
significantly less in the hypo-osmolar ORS mia, because these children are already sodium
group than in the standard ORS group. Mean depleted, and furthermore acute diarrhoea
percentage weight gain in children in the hypo- may be caused by various bacterial pathogens
osmolar ORS group was significantly lower which may induce high stool sodium losses.
than in the standard ORS group at discharge or However, the present study shows that hy-
on day 5 if they did not recover during this ponatraemia was present at the time of admis-
period (p = 0.001). Figure 1 shows the survival sion in 15 (47%) children in the hypo-osmolar
curve for recovery time in the two groups. group, but it was corrected using the low
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240 Dutta, Mitra, Manna, Niyogi, Roy, Mondal, Bhattacharya
sodium solution. This can be explained by the 6 Dutta P, Bhattacharya SK, Dutta D, et al. Oral rehydration
solution containing 90 millimol sodium is safe and useful in
fact that although serum sodium may be low in treating diarrhoea in severely malnourished children. J
marasmic children, total body sodium may be Diarrhoeal Dis Res 1991;9:11822.
normal. 7 Klahr S, Alleyne AOG. EVects of chronic protein calorie
malnutrition on the kidney. Kidney Int 1973;3:12941.
We conclude that hypo-osmolar ORS is 8 Nichols BL, Alvarado MJ, Radrigua SJ, et al. Therapeutic
superior to standard ORS for the treatment of implications of electrolyte, water and nitrogen losses during
recovery from protein-calorie malnutrition. J Pediatr 1974;
dehydrating acute watery diarrhoea in severely 84:75968.
malnourished (marasmic) children. Hypo- 9 Alley GAO. The eVect of severe protein calorie malnutrition
osmolar ORS resulted in a shorter duration of on renal function of Jamaican children. Pediatrics 1967;39:
40011.
diarrhoea, a reduced stool output, less need for 10 Rautanen T, El-Radhi S, Vesikari T. Clinical experience with
maintenance therapy, and a reduced chance of a hypotonic oral rehydration solution in acute diarrhoea.
Acta Paediatr 1993;82:524.
hypernatraemia. On the basis of this study on 11 International study group on reduced-osmolarity ORS solu-
malnourished children and previous studies in tions. Multicentre evaluation of reduced-osmolarity oral
well-nourished children, a general recommen- rehydration salts solution. Lancet 1995;345:2825.
12 Mahalanabis D, Faruque ASG, Hoque SS, Faruque SM.
dation is made that hypo-osmolar ORS (so- Hypotonic solution in acute diarrhoea: a controlled clinical
dium content 60 mmol/l) should be used for trial. Acta Pediatr 1995;84:28993.
rapid rehydration, and maintenance of hydra- 13 Rautanen T, Salo E, Verkasalo M, Vesikari T. Randomised
double blind trial of hypotonic oral rehydration solutions
tion in children with non-cholera diarrhoea. with or without citrate. Arch Dis Child 1994;70:446.
14 El-Mougi M, El Akkad W, Hendawi A, et al. Is a low osmo-
larity ORS solution more eYcacious than standard WHO
We acknowledge Drs Bipul Chandra Roy, Soumyadip Das Gupta, ORS Solution? J Pediatr Gastroenterol Nutr 1994;19:836.
and Shanta Dutta for their help in clinical and microbiological
work; Mr Mahendra Mullick and Milan Dey for technical assist- 15 Nutrition sub-committee of Indian Academy of Pediatrics.
ance; and Mr Shyamal Kumar Das for secretarial help. Report of the Convener. Indian J Pediatr 1972;9:360.
16 World Health Organization. Manual for laboratory investiga-
tion of acute enteric infection. Programme for control of
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Int J Epidemiol 1980;9:2533. dration for diarrhoea. J Pediatr 1982;101:4979.
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and disease in a group of South Indian families. II. General dration due to diarrhoeal syndrome. Am J Clin Nutr 1977;
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3 James JW. Longitudinal study of the morbidity of diarrhoeal
and respiratory infections in malnourished children. Am J children: a historical and physiological perspective. Am J
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4 World Health Organization. Programme for the control of diar- 20 Samadi AR, Wahed MA, Islam MR, Ahmed SM. Conse-
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CDD/SER/80.2 Rev 2. Geneva: WHO, 1990. with acute diarrhoea in Bangladesh. BMJ 1983;286:6713.
5 Chatterjee A, Mahalanabis D, Jalan KN, et al. Oral rehydra- 21 Cleary TG, Cleary KR, DuPont HL, et al. Relationship of
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