Oral
Rehydrating Solution and Children
By Karl
Neumann, MD
When
tramping in the wilderness or traveling overseas with infants
and small children in tow, carry oral rehydrating solution
(ORS) in your medical kit. ORS is now available in small,
sealed packets that weigh next to nothing and take up almost
no space. All you do is add safe water. Such solutions are
indispensable in case the tots come down with gastroenteritis.
To prevent problems, the time to start ORS is with the first
episode of vomiting or diarrhea, before you know whether
or not this will be a limited or severe case. This way you
can prevent virtually all cases of dehydration.
Studies
of diarrhea among travelers to developing countries show
that children, especially children under the age of three
have a higher incidence of diarrhea than adults, have more
severe symptoms, and have symptoms that last longer. While
there are no good data about diarrhea in the wilderness,
anecdotal evidence suggests gastroenteritis is not uncommon.
Moreover, such illnesses are sufficiently common in young
children that by chance illness may occur while away from
home. Children place their fingers and other objects in
their mouths, swallow water while bathing and swimming,
rarely wash their hands, make improper food and beverage
selections, and, overseas, may be cared for by local caretakers.
Better parental supervision can reduce the incidence. But
lack of immunity to diarrhea-causing organisms may also
be a factor. Moreover, treatment of diarrhea in children
can be problematic: small children often refuse fluids when
they need them the most; some effective medications given
to adults are not appropriate; and reliable medical facilities
may not be at hand. Also, infants in diapers can spread
the disease to their parents.
Optimum
treatment of gastroenteritis consists of giving children
ORS and to continue feedings. Young children dehydrate rapidly,
sometimes in a matter of hours. Commonly used treatments
ó giving clear fluids and withholding food óworsens diarrhea.
Clear fluids do not replace electrolytes lost in the vomitus
or stool, further worsening electrolyte imbalance and hastening
dehydration. In virtually all cases of infectious diarrhea,
regardless of severity or causative organism, the impaired
intestinal wall will continue to absorb needed electrolytes
(and calories) IF the electrolytes, especially sodium and
glucose, are present in the correct ratios. Food (calories)
stimulates intestinal cell renewal, increases absorption
of other nutrients, decreases the volume and frequency of
stools, and speeds recovery. In addition, commercial ORS
contains glucose, sodium, potassium, and base (citrate or
bicarbonate) in amounts that approximate fluids being lost.
Glucose and sodium also promote the absorption of water.
Many
traditional treatments of diarrhea are counterproductive.
Sugar-sweetened sodas contain too much sugar and little
or no sodium and potassium. The osmolality of such drinks
is much greater than the desired 270-300 mOsm/Liter and
can actually worsen diarrhea by pulling fluids from the
blood stream into the intestines (see table). Most juices
and juice-like drinks are merely flavored sugar-water. Gatorade
and other sport drinks are intended to replace fluids lost
by perspiration. Chicken broth contains much sodium but
no glucose.
Two main types of ORS are available.
WHO/UNICEF ORS contains 90 mEq/L of sodium. American commercial
ORSs (Pedialyte and Lytrin, for example,) contain 45-50m
Eq/L of sodium. The WHO/UNICEF product is meant for children
in developing country who tend to have more severe diarrhea
and often lose large amounts of sodium. However, in most
situations, either can be used. ORS is available premixed
in liquid form or in packets to which measured amounts of
water (purified) must be added.
Ideally, small children should
take about 100 cc (about 3 ounces) of ORS with every loose
stool or bout of vomiting. Food should be avoided as long
as vomiting continues, which is rarely more than 12 hours.
If small children refuse to drink, they can be given smaller
amounts every few minutes, by teaspoon or dropper. Amounts
larger than 100 cc should be avoided when children are vomiting;
large amount may induce vomiting. Unless vomiting occurs
more frequently than every 45 minutes some fluid reaches
the intestine and is absorbed. Infants can continue to breast
feed or drink formula and regular milk.
ORS does not stop diarrhea.
Children who take fluids and are reasonably active and content
are not dehydrated, even if the diarrhea continues for a
week. Symptoms of impending dehydration include continuing
vomiting and diarrhea, refusal to take or inability to retain
fluids, listlessness, blood or much mucus in the stool,
and high fever. In such cases intravenous fluids or large
amounts of oral replacement fluids may become necessary.
Such treatment is best done in a hospital setting. Parents
traveling with small children should keep such eventualities
in mind when choosing destinations.
Newer cereal-based (CB) ORS
may be even more effective than plain ORS in stopping diarrhea.
CB-ORS contains cooked starches (usually rice) in place
of glucose. Starches results in more calories and fluid
being absorbed from the intestine. CB-ORS is available in
the U.S. in liquid form (Ricalyte, for example), and in
packet form from Cera Products, Inc. 8265 Patuxent Range
Road, Jessup, MD 20794. Tel: (816) 421-2880. Fax: (816)
421-2883.
When ORS is not available,
children can be given plain water with one or more of the
following: pretzels, salted crackers, mashed potatoes, or
banana flakes. Drinks made with pre-cooked infant rice cereal,
unsweetened yogurt or vegetable juices can also be used.
Older children can be offered carbohydrates (starches),
including rice, wheat and potatoes, cereal, pasta, and bread.
Medications for Diarrhea
in Infants and Children
Nonspecific antidiarrheal medications
and antibiotics should almost never be used in the treatment
of diarrhea in infants and children. The rare child who
becomes very ill in spite of prompt and optimal fluid treatment
generally requires intravenous fluids.
Nonspecific antidiarrheal drugs
are problematic in children. Kaolin-pectate (Kaopectate)
may reduce the number of stools, but may do so by retaining
fluids in the intestine, worsening electrolyte imbalance.
Bismuth subsalicylate (Pepto-Bismol) contains 130 mgs salicylate
per tablespoon, and many tablespoons per day are usually
required to have an effect on diarrhea. Salicylate (aspirin)
is contraindicated in children. Diphenoxylate (Lomotil)
gives unpredictable results in children, especially in dehydrated
ones, and may result in serious, delayed opiate-related
toxicity. Loperamide (Imodium) can cause drowsiness, abdominal
distention, and ileus.
Antibiotics that have been
used include trimethoprim/
sulfamethoxazole (TS), furazolidone,
TS/erythromycin, and, less commonly, nalidixic acid. These
drugs have a wide spectrum of effectiveness, are available
in liquid form, do not require refrigeration, and have a
long shelf life. However, organisms in many areas of the
world are becoming resistant. Prescribers should be familiar
with these medications, availability, dosages, side effects,
geographic resistance patterns, and younger age limitations,
for example. Quinolone antibiotics are effective in treating
diarrhea in adults but are contraindicated in children under
the age of 18 years; in experiments, these drugs damage
weight-bearing cartilage in large joints of young animals.
However, these drugs have been given successfully to infants
with a variety of life-threatening infections, with no known
permanent adverse effects. While quinolones can not be recommended
for treating diarrhea in children, in fact, they are very
effective for this purpose, many parents have them on hand
for their own use, and are readily available from and freely
prescribed by physicians and pharmacists in many developing
countries.
Karl is a pediatrician in Forest
Hills, NY and the Editor-in-Chief of the Wilderness Medicine.
Letter.
Volume 17, Number 3, Summer
2000
