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ABSTRACT This review examines the historical, physiological, clinical, and epidemiohogical
“Copying from one book, it is said, is plagiarism, while Over the past three decades the study of
copying from two books is research.” (1) acute diarrhea in children (and adults) has
Acute diarrhea affects nearly 500 miffion led to important knowledge ofthe physiology
children annually worldwide (2), is the lead- of body fluids and the intestine, and of ther-
ing cause of death in children under 4 years apy. Table 1 suggests how this knowledge
old (3), and is a substantial cause of under- relates to the falling mortality rate. The es-
nutrition (4). This is the grim situation now sential elements, known sinceDarrow’s work
in the poor under-served parts of the world, (18-20) are adequate replacement of sodium
but it was the same in the West 70 years ago chloride, base, potassium and volume losses,
(5). Since then, sanitation, protected water and maintenance of nutrition. Workers at
supplies, and better medical therapy have clinical centers in Asia, Africa, and Latin
dramatically reduced the incidence of acute America recognized the need to translate
diarrhea, with a nearly hundred fold drop in these elements into a rational treatment that
mortality (6). was simultaneously simple, cheap, and appli-
Nonetheless, in the West, diarrhea still
ranks second to respiratory diseases as the ‘ From The John Snow Public Health Group, Boston,
cause ofnonsurgical pediatric admissions (6); Massachusetts 021 1 1.
2 Supported by Management Sciences for Health, a
approximately one-half the children receive
nonprofit foundation, Boston, Massachusetts.
intravenous therapy (7). Diarrhea causes one-
a Address reprint requests to: Norbert Hirschhorn,
fourth of the avoidable deaths in hospitalized M.D., John Snow Public Health Group, Inc., 141 Tre-
children (8). mont Street, Boston, Massachusetts 02 1 1 1.
The American JournalofClinical Nutrition 33: MARCH 1980, pp. 637-663. Printed in U.S.A. 637
638 HIRSCHHORN
TABLE 1
Changes in hospital mortality of children’s diarrhea
1832 Latta (9) uses intermittent intravenous saline and alkali in Over 75%
cholera. Most relapse when drip ceased.
1926 Powers (12) uses intermittent blood, glucose, saline and bicar- 33%
bonate infusions, and prescribes prolonged fasting.
1928-1938 Hartmann (13) uses sodium lactate to relieve acidosis; recurrent 51%
dehydration, however, causes high mortality.
1931-1933 Kareitz and Schick (14-16) use continuous saline dextrose 12-33%
infusions and recommend a 3-day fast.
1948 Chung (21) urges continued feeding in spite of diarrhea; mor- 10%
tality unaffected, disease not prolonged, nutrition enhanced,
but fluid balance more difficult to achieve.
12-24% for
1947-1958 Rapoport (22), Finberg and Harrison (23) and others (24)
describe hypernatremic dehydration. hypernatremia
1959 Watten et al. (27) measure water and electrolyte loss in cholera.
cable under the adverse conditions and short- use of a single polyelectrolyte intravenous
ages of the developing world. fluid and a single oral glucose electrolyte
The key elements ofthe method developed
are: rapid restoration of salt and water deple- 4 “Volume repletion” and “volume depletion” are
tion with simultaneous correction of acidosis, more precise than “rehydration” and “dehydration.”
Still, the respective words will be used interchangeably
and administration of potassium; use of an
to mean electrolyte and water restoration or loss. The
oral glucose electrolyte solution for repletion4 word “fluid” also indicates solute and water rather than
of those not in shock, and for maintenance; water alone.
ACUTE DIARRHEA IN CHILDREN 639
solution, for all age groups; and early feeding Regimens and patients’ characteristics
with tolerated foods. This approach has been
successful both in well supplied hospitals (31- The death rate in hospitals from acute
33), and, spectacularly, in Bangladesh refugee diarrhea can and should be 2% or less,
camps under the worst of conditions (35). whether in a sophisticated urban hospital or
But the approach deviates considerably in a makeshift tent ward in a rural area. Most
from conventional pediatric teaching. Table ofthe excessive mortality that occurred in the
2 contrasts the differences in methods. Much past (Table I) came soon after admission and
ofcurrent pediatric teaching emphasizes slow was due mostly to uncorrected volume deple-
repletion of fluid losses; great concern over tion or electrolyte imbalance (3 1 , 37-40).
the sodium load, especially for infants; tailor- Given the importance of the first day in
ing of fluid therapy to each individual; and the fluid treatment ofsevere dehydration, the
the need to “rest the bowel” for several days. ranges of a first 24-hr fluid regimen associ-
A classic presentation of this approach was ated with improved survival should be de-
written in 1974 by Blair and Fitzgerald (36). fmed. It is unlikely that such data will ever
Given these differences, this paper has been be generated prospectively, but a retrospec-
1. The physiological model Varying degrees of dehydration Within broad limits a simple and urn-
and tonicity require careful tal- fled therapeutic approach may be
bring of fluid therapy. taken.
3. Choice of initial rehydratmg so- Hypotonic with sodium content Polyclectrolyte solution with sodium
lution 30-60 mEq/liter, especially for content 80-130 mEq/liter for all
infants. ages.
6. Use of oral fluids Small, infrequent sips of H20 in Ad libitum intake of glucosc-elcctro-
first 24 hr. lyte solutions for those able to drink
(in mM/hiter:Na 90, K20,
HC0330, glucose 1 1 1). Need for
intravenous fluid can often be dim-
mated.
7. Feeding Fasting for 24-48 1w, careful rein- Tolerated feeds as soon as appetite
troduction of food. restored (usually within 6-24 hr) in
small frequent amounts.
to specify inclusion of potassium and base at mEq/liter; the effective sodium concentration
levels of at least 1 mEq per kilogram body of regimens associated with 3% mortality or
weight, respectively; and mortality reported less averaged 77 mEq/liter; the difference,
had to be related to the diarrheal illness. however, is statistically insignificant. At a
Fifteen studies reporting 20 regimens met minimum it can be said that, along with
these criteria (20, 25, 3 1, 32, 37, 38, 40, 42- potassium and base, the higher levels of so-
49). All were published after 1945. When dium-containing fluid administered were
ordered in terms of mortality, both higher compatible with improved survival, and may
and lower rates were described from Western have contributed to it.
and tropical countries, in urban and rural Although the successful regimens, higher
settings, among infants and toddlers, and in in volume and sodium than generally advo-
children well or poorly nourished. cated, have been used both in the West and
Five independent variables were analyzed the tropics, it is often said that children from
against mortality: sodium load, total volume, the tropics, or disadvantaged groups such as
“free water” volume, sodium load x total American Indian children, represent a “dif-
volume, and sodium concentration. All vari- ferent type of infant” than the Western child
I”.
32
. D .
28
r’-0.40 r’ +026
24 p< 0.08 p<0.2
20
16
.
12
.
8
1
168 192W 216 240 264 288 60 80 100 140 160
TOTAL VOLUME (rn//kg) “FREE WATER” (rn//kg)
FIG. 1. An analysis was made of 15 studies depicting 20 fluid regimens used in the 1st day treatment of
dehydrating diarrhea in children. Sodium load (A), total volume x sodium load (B), total volume (C), and “free
water” volume (D) are displayed against mortality. Hyperbolic curves were fitted to the data by computer, with the
general equation Y = ho + b,x’ where Y - mortality, bo intercept, b, - regression coefficient and x - the
independent variable. Triangles represent two overlapping points.
drawn. Second, hypertonic dehydration does once severe volume depletion occurs, as in-
occur in tropical children, though not as com- dicated by clinical shock, the mean weight
monly as in the West. The incidence of hy- loss in all the groups is approximately 10%;
potonicity is several times greater in tropical and accumulated sodium losses on admission,
children with diarrhea. The differences, how- as measured by net retention studies, were
ever, are unlikely to be explained by differ- approximately the same in the few Western,
ences in evaporative water loss, the incidence tropical, and hypernatremia studies recording
of parenteral infection, carbohydrate intoler- these data. Traditional bacterial pathogens
ance, or sodium loss in the stool. Third, the (shigella, salmonella, enteropathogenic Esch-
severe consequences of diarrhea-marked erichia coli) were more often isolated from
volume depletion, acidosis, and hypokale- children hospitalized in the tropics, but reo-
mia-are seen with nearly equal prevalence virus-like agents seem to be equally distrib-
in the tropical and hypernatremic series, and uted worldwide. The diagnosis of enterotox-
more often than in the Western series. But, igenic E. coil has been confused by a variety
TABLE 3
Clinical and biochemical attributes of children with diarrhea
from different parts of the worldb
No. ofstudies 18 21 16
No. of children 2764 5607 323
(median/series) 79 100 20
Attribute
I . Mean age (mo)
Median ?_ ! 2
1QR ±:JP EL4
2. Malnutrition, % with weight 5, 30, 38 26, 37
< 75% normal
Median
IQR
3. Volume depletion, % with 5-15%
loss body weight
Median ..2 .4
IQR 45-100 72-100 66-100
of assay techniques; they are unlikely to be safety to about 40 mEq/liter each). Yet chil-
common pathogens in Western children (104, dren regularly respond well, perhaps better,
105), but cause 10 to 20% of episodes in to solutions closer in composition to the ECF
tropical and American Indian children (102, (Fig. 1).
106). In two studies ofApache children where A fourth seeming paradox is that children
the newer approach to treatment outlined in from the tropics with diarrhea are predomi-
Table 2 was used exclusively (33, 107), their nantly hyponatremic; yet their attributes
clinical and biochemical attributes resembled closely resemble those of hypernatremic chil-
both Western and tropical children: nutri- dren in severity of volume depletion, acidosis
tional status and severity of illness like the and hypokalemia.
Western children, hypotonicity like the trop- To resolve the paradoxes requires an over-
ical children; evaporative loss, stool sodium view of the pathophysiology of diarrheal de-
concentration and carbohydrate intolerance hydration.
like both.
None of the attributes examined, therefore, The pathophysiology of diarrheal
compel one to believe that tropical (or dehydration
DIARRHEA
A
Rer,o -Vascuor Ion and Water Sugor Intolerance, IntestinoIEvoporotive-
Responses Generolly - Depletion, Imbalance 4 Fosting,Inappropruote - Metabolic Responses
Produce HypOtOniC and Compensation Intake Generally Produce
or ISO?OflC Hypertonic or
Dehydration Isotonic Dehydration
DIARRHEA
B
No’, H on and Water Losses HCO3
‘:= r::::dRr;rIdo.AD;i////as
oseKCeII No’ to ECF
/ r- Decieosed Acdfcohon f [ireosed Respootion
I ECF I
F q c- NtC
No’
H
Inceosed
T -4----
hen Decreased Lose SaltWater
IGtKdney L ng
___________________________
I yper5Iycemio [imonoty ESemo
Increosed _, iii
Blood Volume Liet LosS
LoseK ‘V
ARRHEA
C DI
___
E.ces$ Sugar
Rena -
Concentro’on Jo sad Urea
K’ Increased
Ac,deme: Gijt HO and K’Loss,,,,,,,,,/’ Hsgh Protein Feed ;;creosed Neat Stress
Increosed E’OS’. ‘COSd H Reop P4O Loss i Eacess Salt ;‘[;aseo easai H20 Heidi
5odum etefltj Decreesid H20 intdie Le,ieo iCeil Sodium
(References 18, 19, 78, 107a-l21 contain data With even minimal ECF volume contrac-
providing the basis for the following ideas.) tion (loss of 2% of body weight or less), renin,
With the loss of potassium from the ECF angiotensin, aldosterone and antidiuretic hor-
to the stool, a chemical gradient is created mone (ADH) secretions are increased, and
that facilitates potassium (and water) move- the glomerular filtration rate (GFR) is de-
ment from the ICF to the ECF. Facilitated creased or redistributed. As GFR falls, acid-
by aldosterone, sodium (and water) tend to ification of the urine is also blunted and
move into the ECF. Protons (which accu- accumulating protons tend to be retained,
mulate in the ECF following bicarbonate loss which in turn may further promote tubular
in the stool, during tissue hypoperfusion, and secretion of potassium.
with ketosis of catabolism) also tend to dis- These actions lead to a compensatory re-
place ICF potassium. Since an effect of al- tention of salt and water, but proportionately
dosterone is to promote sodium retention and more ofthe latter. The first palpable response
potassium excretion via the kidney, a sub- to ECF contraction is thirst. If water is taken,
stantial proportion of the potassium deficit in it will be mostly retained as ADH increases
diarrheal disease may be accounted for in this distal tubule and collecting duct permeability
way. The effect of aldosterone may account to free water, facilitating its reabsorption.
for the observations of Darrow (19), and Even without much intake, water may be
Mann et al. (78), that potassium retention is generated internally, and retained, in the re-
inversely related to the volume of stool loss, sponse to stress by steroids and catechol
even though potassium loss in the stool can- amines which promote catabolism of body
not account for the total deficit. tissue; the latter aggravated by fasting.
ACUTE DIARRHEA IN CHILDREN 645
We may now suggest resolutions for three sition have been used in rehydration therapy
of the four apparent paradoxes. First, the for years. Their apparent success, however,
tendency to hypernatremia, due to loss of derives in part from the avid retention of
more water than sodium, is counteracted by “maintenance” fluids over several days, and
avid retention of water (ingested or internally from the unproved view that severely dehy-
generated). drated children have lost, and therefore
The second paradox is also explained: fluid should be given, 15% or more of their weight
deficits in acute diarrhea, as measured by net in fluid (compare Reference 30, Table 3). The
retention studies, combine both ECF and use of hypotonic solutions more nearly ap-
ICF losses in roughly equal proportions; but proximating the ICF, however, explains the
the predominant contraction measured by necessity of the traditional practice to allow
chloride and inulin space takes place in the rehydration to proceed slowly over 24 to 48
ECF because sodium and hydrogen ions (and hr; a rehydrating fluid more nearly approxi-
water) replace ICF potassium (and water). In mating the ECF can be given more rapidly.
other words, ECF space contracts in two di- A hypothetical profile of a child most sus-
rections: out in the stool, and into the cell; so ceptible to hyponatremia may now be drawn.
mia, augmenting mechanisms, and abnormal 142); but ifGFR per unit oftotal body water,
water loss. or per unit extracellular fluid volume, or per
Epidemiology. Hypernatremia complicat- unit kidney weight are calculated, values
ing diarrhea is a condition of infants and equivalent to those in adults are reached by
toddlers of either sex. The median age in 16 one to two months of age (143, 144). Mc-
reported series is 7 months. But the median Cance et al. (143), who first called attention
age of the general group of children hospital- to the maturation question in 1941, decided
ized with diarrhea in the West is also 7 by 1957 that the latter method of comparison
months (Table 3). Hypernatremia has been was more rational. Finally, maximal concen-
reported both to have winter (28, 103, 129, trating ability reaches at least 85% of adult
130) as well as summer peaks ( 13 1 , 132), levels by the second month of life (143, 145-
suggesting that it reflects only the dominant 147) in the majority ofchildren, and certainly
diarrheal seasonal pattern in a particular lo- by 10 to 12 months in all. Any remaining
cale. Hypernatremia occurs both in the trop- difference between adults and children would
ics and in temperate zones, but is more com- permit conservation of only trivial amounts
mon in the latter (50, 66, 71, 73, 83, 84, 133, of water. So it would not seem that immature
compensation on the lungs is then increased; tration (10%) (169, 129).6 interesting con-
but with increased respiration, unfortunately, comitant clue to the pathogenesis of hyper-
water loss also increases. Moreover, as aci- natremia is the tendency of hypernatremic
dosis becomes severe, (pH less than 7.1), children to produce voluminous, watery stool
blood is shunted from the peripheral vessels low in sodium (28, 169). Normally, as stool
to the lungs causing puLmonary congestion rate rises, so does the stool sodium concentra-
(157). If carbohydrates are poorly absorbed, tion, approaching plasma levels; this occurs
additional protons are generated during bac- in adults with cholera (170) as well as in
terial fermentation of the sugars in the gut infants with noncholera enteritis (calculation
and are either transferred to the body fluids of data presented by Darrow et al. (18, 19).
or remove bicarbonate already secreted into Since stool fluid is rarely hypoosmotic to
the lumen (158, 159). Both acidosis and hy- plasma, voluminous stool low in sodium must
perosmolarity cause hyperglycemia (86, 160- contain other solutes such as organic metabo-
163) which, by an osmotic diuresis, can fur- lites. Such metabolites are generated in the
ther force renal water loss. gut during malabsorption of carbohydrates
We come back to our fourth, as yet unre- (17 1). Intestinal bacteria degrade undigested
(172). Voluminous, low sodium stools are the the contrary, with early prevention or correc-
result, in which potassium is also lost. Intes- tion of volume depletion, acidosis and potas-
tinal fermentation produces acidemia, while sium loss, both hyponatremia and hyperna-
distension and ileus increase fluid loss and tremia should be avoidable or easily cor-
the accompanying nausea reduces total in- rected. Perhaps we are relearning Darrow’s
take. If the incidence of hypernatremia has wisdom: “These patients with hypernatremia
followed an epidemic curve between the received.the usual fluid therapy used in other
1950’s and 1970’s, perhaps it may be related cases of diarrhea” (45).
to the common medical practice in that time It is now necessary to examine more closely
which promoted boiled skim milk plus sugar, some of the origins ofcurrent pediatric teach-
or dextrose polymer-salt solutions, as suitable ing which emphasize that an absolute ceiling
therapy for diarrhea. The hypothesis that for safe sodium intake exists, one regularly
carbohydrate intolerance is a principal initi- exceeded by the regimen recommended in
ating cause of hypernatremia awaits formal this review.
testing.
An hypothetical profile of a child most Sodium: striking the balance
ml/kg volume (sodium concentration 43 to So far this review has dealt principally with
64 mEq/liter). Such a child, if severely vol- only the first 24 hr of therapy. It is possible
ume depleted, will have lost approximately that adverse effects of excess sodium loading
640 to 960 ml (80 to 120 mi/kg) of fluid and might be avoided if it occurs for only 1 day.
approximately 90 mEq of sodium, or 11 In fact, the mainstay of the regimen this
mEq/kg (see Table 3). The volume of fluid review recommends is the use of a single
and sodium thus recommended for rehydra- intravenous or oral polyelectrolyte solution,
tion is likely to be insufficient and only the both for initial deficit and continuing losses,
ceiling approaches adequacy (see Fig. 1). On with the addition of food and low-solute liq-
the basis of his balance studies, Darrow had uids. In practice, and on the average, this has
arrived at a much higher value, supplying an meant providing sodium to (for example):
average of 17 mEq/kg sodium in the first day Apache infants 14 mEq/kg per day for 2 to
of rehydration (20) at an overall concentra- 3 days (33, 107); Bengali children (average
tion of 86 mEq sodium per liter fluid volume. weight 8 to 9 kg) with cholera, and given
How, then, did Talbot and Butler derive their tetracycline, 1 1 mEq/kg per day for 2 days
ceiling for sodium administration for infants? (32); Bengali children (average weight 1 1 kg)
clinically well is commonplace, is not related lent. Data obtained from six independent
to electrolyte imbalance ( 13, 33, 54), and is lines of physiological and clinical research,
not a problem. Its presence indicates an cx- however, have given oral therapy a broader
cess fluid volume isotonic to ECF amounting significance with regard to both medical sci-
to I to 3% of body weight (33). Transient ence and health care delivery.
isotonic overexpansion after large doses of
NaC1 is seen both in adults (189-191) and A ctive cotransport of sodium and organic
children (183). The cause of delayed sodium substrates in the intestine
excretion is complex but several explanations The details of this line of research have
may fit: “Postloading antinatriuresis” de- been well summarized (194-196). Briefly,
scribes a brief period of renal tubular reab- several actively transported substances like
sorption of sodium in response to a sodium glucose, galactose, certain amino acids, some
load (192); after chronic salt depletion, salt disaccharides, and some dipeptides show an
and water are retained even when a hypo- absolute or partial dependence on sodium for
tonic salt solution is given (1 1 1); and fmally, their absorption, and the rate of sodium ab-
the very handling of children during sam- sorption is considerably increased in the pres-
ence of chloride is necessary for the full so- two studies indicate that oral therapy may be
dium-glucose effect ( 199). Fifth, glucose is safer than intravenous with respect to sodium
much better absorbed in the jejunum than in loading in children, and that any oral fluid
the ileum in man (213). Sixth, rapid flow without glucose (or some other appropriate
rates of lumenal contents (over 10 mi/mm) substrate) will considerably worsen diarrhea
reduce absorption substantially (209). 5ev- if even a slight depletion of blood volume
enth, the loss of sodium on admission in exists. Diarrhea itself affects intestinal ab-
acute, severe diarrheal disease averages from sorption, as the next section discusses.
76 to 109 mEq/liter of fluid loss in infantile
The effect of diarrhea on intestinal absorption
diarrhea (19, 70); and up to 120 mEq/liter of
stool (17, 70). Potassium losses may be simi- Morphological abnormalities in the intes-
larly extensive. tine accompany acute bacterial and viral diar-
Taking these eight points together, a ra- rheas, the severity of which correlate with
tional solution for oral therapy should, there- indices of malabsorption (217). Reversible
fore, be sufficiently concentrated in sodium changes in concentrations of enzymes asso-
to replace losses on a volume for volume basis ciated with absorption (Na-K ATPase, di-
hypertonic (casein hydrolysates or commi- monia and other infections following bouts
nuted protein, amino acids, glucose or glucose of diarrhea and reduction of intake.
polymers, etc.) even to the point of not re- It may still be argued that, although pro-
quiring total parenteral nutrition (223, 228- longed fasting or reduced intake can be harm-
233). It is possible that these organic sub- ful, one should prove the positive effects of
strates facilitate salt and water absorption by feeding during diarrhea. The fourth line of
the intestine. Since each class of substrate research points the way.
(sugar, dipeptide, amino acid, etc.) appears to
interact with separate sodium-carriers in the The induction effect offeeding
intestinal membrane, there may be an addi- It is clear from numerous animal and hu-
tive effect when two or more substrate types man studies that intraluminal foodstuffs, car-
are used together. Such has been shown in bohydrate, and protein, increase intestinal
cholera when glucose and glycine are used digestive enzymes and cell proliferation in a
(234). It also seems possible that one sub- dose-related way, even without prior fasting
strate, glucose for example, could reverse the (237, 245-249). The inductions are somewhat
net secretion and attendant clinical symptoms specific: sucrose is a better inducer of sucrase
the weight deficits fmally incurred by chil- practice. In fact, it simply extended years of
dren in the tropics, which are only partially experience with a single intravenous solution
reversed by generous supplementation with that yielded the remarkably low mortality
a high protein and calorie diet (4). Third, rate of under 2% in children under 4 years of
faltering of growth is acutely related to each age (31).
episode of diarrheal illness (252), in part due Oral therapy had a solid impact on mor-
to catabolism and malabsorption, but also to tality in situations where standard intrave-
anorexia and decreased food intake as well nous therapy was scarce. In Bangladesh ref-
(253). Finally, nutritional deterioration alone ugee camps in 197 1, the death rate from
increases the likelihood of a subsequent epi- diarrheal diseases soared to 30%. Oral ther-
sode of diarrhea (254). Can appropriate ther- apy, vigorously administered by family mem-
apy reverse these events? The sixth line of bers (“give them as much as they will drink”)
research has begun to defme the range of helped reduce the mortality rate to about 1%
effectiveness of oral therapy, including its (35). Due to the severe shortage of materials
effect on nutrition. and staff, intravenous fluids were reserved to
resuscitate those in shock.
volumes over 80 g/kg. Of99 Apache children weights on discharge of Apache children on
(mean age 1 1 months; 28 were under 3 oral therapy and fed early, compared to those
months of age), one-half were moderately to of the previous year treated with intravenous
severely dehydrated, with stool losses aver- fluids, fasting, and slow return to diet (265).
aging 6 ml/kg per hour for the first 6 hr (33, The former group went home at 90 to 99% of
107). Only 10 required partial or total intra- the Harvard median (the average for Apache
venous rehydration; only one needed a na- infants and children generally), the latter at
sogastric drip because of failure to keep up 70 to 79%. Associated with this was the din-
orally with stool loss. The oral solutions used ical perception that children rapidly rehy-
contained 80 to 90 mEq of sodium per liter drated with oral therapy were vigorous and
(plus potassium, bicarbonate, and glucose) hungry soon after. It was hypothesized that
and corrected instances of both hypo and oral therapy would help improve or maintain
hypernatremia. In Bangladesh 57 children (5 nutrition by restoring appetite quickly and
to 30 months old, mean age 12 months) with helping mothers (and doctors) see the value
rotavirus diarrhea were treated completely of not fasting their children. Given the rela-
with oral therapy (World Health Organiza- tionship between diarrhea and malnutrition,
1% in a clinic setting have glucose intolerance children more comfortable (33). It would be
(27, 33); they are made worse by oral therapy. useful to know how staff time is affected.
The condition is easily suspected on clinical It has recently been demonstrated by this
grounds (voluminous, watery stools; failure author and colleagues that lightly trained and
to rehydrate) and confirmed by simple bed- supervised Philippine village women can
side measurements of stool-reducing sub- teach mothers how to prepare and use oral
stances (33). Stool spillage of carbohydrate fluids, and to feed their children at home
can be quite high, even with an adequate during diarrhea. The clinical outcomes com-
clinical response, however. In reovirus diar- pared well to those in doctor-based clinics. A
rhea up to 30% of the administered glucose gratifying and significant increase in the
load appears in the stool (261). Oral therapy number of mothers who kept on feeding their
also fails in patients with very high rates of children during the illness was seen in the
stool loss, over 10 mi/kg per hour, perhaps course of a year (272).
due to fatigue in drinking so much (269). A The studies on oral therapy continue the
final possible limitation is the use of oral development of knowledge of diarrheal dis-
therapy in neonates with diarrhea. There is ease; their authors are conscious inheritors of
access, safety, cost, and effectiveness in pre- mortality in childhood. Report of the Inter-Ameri-
can Investigation of Mortality in Childhood. Pan
venting volume depletion and electrolyte im-
American Health Organization Scientific Publica-
balance are all important here. Even fmding tion no. 262,
1973.
a suitable container for mixing will be a 4. MARTORELL, F., i-P. HABICHT, C. YARBROUGH, A.
problem in much of the world. More direct LECHTIG, R. E. KLEIN AND K. A. WESTERN. Acute
comparisons of oral fluids higher or lower in morbidity and physical growth in rural Guatemalan
children. Am. J. Diseases Children 129: 1296, 1975.
sodium content (e.g., 90 versus 50 mEq/liter) 5. AYKROYD, W. R. Nutrition and mortality in infancy
are needed. One study (260) attempted this, and early childhood: past and present relationships.
but gave virtually the same amount of total Am. J. Clin Nutr. 24: 480, 1971.
sodium to both groups. More recently, Nalin 6. VAUGHAN, V. C., AND R. J. MCKAY. The field of
pediatrics. In: Textbook of Pediatrics (10th ed),
has shown in Jamaican children that the so-
edited by W. E. Nelson. Philadelphia: W. B. Saun-
lution lower in sodium resulted in persistent ders 1975, p. 4.
(days) hyponatremia in five of 24 children, 7. MOFFET, H. L., H. K. SHULENBERGER AND E. R.
while the one higher in sodium resulted in
transient (6 hr), asymptomatic elevations of
serum sodium in three of 84 (D. Nalin, per-
9 Pizarro of Costa Rica has just completed a study of
sonal communication). 40 neonates, mean dehydration 6.6% of body weight.
In Western hospitals, the use of oral ther- treated with oral therapy and extra water; 39 required
apy instead of intravenous fluids can make no intravenous fluids (270).
656 HIRSCHHORN
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