I.

Clinical Question Among children experiencing diarrhea, is Rice-Based Oral Electrolyte Solutions more effective than standard Oral Rehydration Solutions in management of Diarrhea?

II.

Citations On Rice-Based Oral Electrolyte Solution: Title: Rice-Based Oral Electrolyte Solutions for the Management of Infantile Diarrhea Authors: Daniel Pizarro, M.D., Gloria Posada, M.D., Leyla Sandi, M.B.C. and J. Roberto Moran, M.D. Source: http://www.nejm.org/doi/full/10.1056/NEJM199102213240802#articleBackground. On Oral Rehydration Solutions: Title: Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children (Review) Authors: Seokyung Hahn, Yaejean Kim, Paul Garner Source: http://info.onlinelibrary.wiley.com/userfiles/ccoch/file/CD002847%281%29.pdf

III.

Study Characteristics 1. Patients included On Rice-Based Oral Electrolyte Solution: Population: Infants who were candidates for oral rehydration therapy because they had mild (<5 percent) or moderate (5 to 10 percent) dehydration caused by acute diarrhea of less than seven days' duration. Sample: Ninety-four infant boys, 3 to 18 months of age, were selected from patients entering the Emergency Service of the Hospital Nacional de Nios in San Jos, Costa Rica. On Oral Rehydration Solutions: Population: Cases of children with acute diarrhoea (history of less than 5 days). Sample: Since the study is a descriptive study which requires comparisons of studies or clinical cases/trials, all relevant randomized controlled trials addressing comparative effects of reduced osmolarity ORS with WHO standard ORS were collected and analyzed. 2. Interventions compared Rice-Based Oral Electrolyte Solutions vs. Standard Oral Rehydration Solutions in management of Diarrhea in children 3. Outcomes monitored Both studies used statistical analysis to interpret the data the researchers have gathered. On Rice-Based Oral Electrolyte Solution: The Statistical Analysis System (SAS) software was used for the analyses. Differences between treatments were tested for significance by analysis of variance. Treatment differences over time

were tested by repeated-measures analysis of variance. Nonparametric data were tested by the chi-square test. Differences were considered significant when the P value was less than 0.05. On Oral Rehydration Solutions: Researchers used the Mantel-Haenszel odds ratio (OR) for binary outcomes. The odds ratios were not estimated when neither intervention group found any event, which are indicated in the MetaView figures. They used the Standardized Mean Difference (SMD) for continuous outcomes. They combined studies using a fixed effect method. For all estimates, they calculated 95% confidence intervals. Researchers tested statistical heterogeneity using Chi-square statistic with a P-value less than 0.1 indicating statistical significance. 4. Does the study focus on a significant problem in clinical practice? Yes, both studies focus on a significant problem on a clinical practice among healthcare practitioners especially nurses who deal with cases of diarrhea in infants. It is most especially significant to community nurses since a number of diarrhea cases arent referred to hospitals but to Healthcare Centers instead. For student Nurses it would be part of the health teaching that we can impart to clients who have children suffering from diarrhea.

IV.

Methodology/ design 1. Methods used On Rice-Based Oral Electrolyte Solution: The researchers designed a prospective, randomized, double-blind study to evaluate the efficacy of two rice-based rehydration solutions and a conventional glucose-based solution. Solution A contained only rice-syrup solids, solution B contained rice-syrup solids and casein hydrolysate, and solution C, the glucose-based solution, served as control. The study subjects were 86 mildly to moderately dehydrated infant boys, 3 to 18 months old, who were admitted to a children's hospital with acute diarrhea. Researchers measured fluid intake, fecal and urine output, and absorption and retention of fluid, sodium, and potassium at intervals for 48 hours in all 86 infants. On Oral Rehydration Solutions: The study was purely descriptive and serves as a review of previous studies conducted using orasol solutions in the management of Diarrhea. Search methods for identification of studies: They used the following search terms to search all trial registers and electronic databases: child; diarrhoea; fluid therapy; oral rehydration; osmolar; and rehydration solutions. The following trial register were searched: Cochrane Central Register of Controlled Trials (CENTRAL), published in The Cochrane Library (Issue 3, 2004). They also searched the following electronic databases: MEDLINE (1966 to July 2004); EMBASE (1988 to July 2004); and Current Contents (July 2004). The citations of existing reviews and trial reports were also checked. For unpublished data and ongoing trials, they contacted current researchers and key agencies, including the World Health Organization, the Centers for Disease Control and Prevention, Atlanta (USA), and the International Centre for Diarrhoeal Disease Research, Bangladesh. 2. Design

On Rice-Based Oral Electrolyte Solution: The infants were randomly assigned in double-blind fashion to one of three treatment groups. On Oral Rehydration Solutions: Researchers identified 41 studies for inclusion, and 16 studies met the inclusion criteria. The progress through the stages of meta-analysis, using the process suggested in the QUOROM statement (QUOROM Group 1999). These were then analyzed statistically. 3. Setting Emergency Service of the Hospital Nacional de Nios in San Jos, Costa Rica Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea, South. 4. Data sources On Rice-Based Oral Electrolyte Solution: Data gathered are all from primary sources since the data are directly observed and stated by the respondents of the study. On Oral Rehydration Solutions: All data gathered were from existing previous studies regarding the use of orasol as treatment for diarrhea in children 5. Subject selection a. Inclusion criteria On Rice-Based Oral Electrolyte Solution: Infant boys, 3 to 18 months of age, were selected from patients entering the Emergency Service of the Hospital Nacional de Nios in San Jos, Costa Rica. All were candidates for oral rehydration therapy because they had mild (<5 percent) or moderate (5 to 10 percent) dehydration caused by acute diarrhea of less than seven days' duration. On Oral Rehydration Solutions: The following are the criteria used for considering studies in the review Types of studies Randomized controlled trials, defined as a trial in which the subjects followed were assigned prospectively to one of two or more interventions by random allocation. This excludes quasi-randomized designs. Types of participants Children with acute diarrhoea (history of less than 5 days). Types of interventions Experimental: Reduced osmolarity oral rehydration solution (total osmolarity 250 mmol/L or less with reduced sodium). Control: World Health Organization standard oral rehydration solution (90 mmol/L sodium, 111mmol/L glucose, total osmolarity 311 mmol/L). Types of outcome measures Primary outcomes

 Need for unscheduled intravenous fluid infusion during the course of treatment. Secondary outcomes Stool output. Children vomiting during rehydration. Asymptomatic hyponatremia (defined as serum sodium less than 130mmol/L) during follow up. b. Exclusion criteria On Rice-Based Oral Electrolyte Solution: Patients were excluded if any of the following conditions were present: severe malnutrition, obesity, absence of bowel sounds, pneumonia, meningitis, severe congenital or metabolic disease, convulsions, unconsciousness, or shock. No girls were included in the study, since the separate collection of urine and stool from infant girls is difficult unless catheters are used. Researchers had no reason to think that the results of oral rehydration therapy would differ between boys and girls. On Oral Rehydration Solutions: 41 studies comparing oral rehydration solution (ORS) formulation for treating diarrhoea. 6 excluded as not randomized controlled trials (RCTs); 35 remaining RCTs of ORS comparing formulation for treating diarrhoea patients. 9 excluded as intervention was something other than reduced osmolarity ORS; 26 remaining RCTs reporting reduced osmolarity ORS in one treatment arm. 6 excluded if control group did not use World Health Organization (WHO) standard ORS; 20 remaining RCTs reporting comparison of reduced osmolarity ORS with WHO standard ORS. 2 excluded as not in children; 18 remaining RCTs reporting comparison of reduced osmolarity ORS with WHO standard ORS for treating children with diarrhoea. 2 excluded as no relevant outcomes reported; 16 remaining RCTs reporting comparison of reduced osmolarity ORS with WHO standard ORS in children with diarrhoea in relation to need of unscheduled intravenous fluid infusion therapy and some measures of clinical illness. 2 excluded (Mexico 1988, Mexico 1990b) as they appear to be duplicates of a third trial (Mexico 1990a). We have contacted the authors, but while awaiting clarification, we have included only the paper with the largest number of patients (Mexico 1990a). 13 remaining RCTs. As one paper reported on two trials, one in the USA and one in Panama, we present these as separate studies (Panama 1982, USA 1982). This leaves a total of 14 included studies. These were from Egypt (2), Bangladesh (3),Mexico (1), Colombia (1), India (3), Panama (1), and the USA (1). Two other studies were multicentre trials; one was conducted in Brazil, India, Mexico, and Peru, and the other in Bangladesh, Brazil, India, Peru, and Vietnam. 6. Has the original study been replicated? On Rice-Based Oral Electrolyte Solution:

The original study has been replicated and subjected to different studies but with the same goal to further analyze the use of Rice-based Oral Electrolyte Solution in the manage of diarrhea in children. Other studies used Rice-Based Oral Electrolyte Solution but with the difference in the concentrations of electrolytes added. Some studies also expounded on the use of Rice-Base Oral Electrolyte Soultion for the management of cholera in children and infants. On Oral Rehydration Solutions: The descriptive study is an evaluation of all previous existing studies regarding orasol solutions used in children having diarrhea. It serves as a comparison between the effectiveness of Orasol solutions when it comes to its osmolality for the management of Diarrhea. The study which is a review has been cited for many other studies following it. The study although conducted first in 2001, review content has been assessed up to November of 2009. 7. What were the risks and benefits of the nursing action or intervention tested in the study? On Rice-Based Oral Electrolyte Solution: On Oral Rehydration Solutions:

V.

Results of the study On Rice-Based Oral Electrolyte Solution: The mean (SE) fecal output was significantly lower in the infants given solution A (group A infants) than in the infants given solution C (group C) (294 vs. 467 ml per kilogram of body weight, P<0.05) during the first six hours of therapy. The infants in group A also had greater fluid absorption (22116 vs. 1679 ml per kilogram, P<0.05) over the entire 48 hours of therapy and greater potassium absorption (1.60.2 vs. 0.60.1 mmol per kilogram, P<0.05) during the first six hours than the infants in group C. Solution B offered no advantages over solution A. On Oral Rehydration Solutions: The primary outcome, unscheduled intravenous fluid infusion, was reported in 11 trials. In a metaanalysis of 8 trials, reduced osmolarity ORS was associated with fewer unscheduled intravenous fluid infusions compared with WHO standard ORS (Mantel Haenzel odds ratio 0.59, 95% confidence interval 0.45 to 0.79) with no evidence for heterogeneity between trials. No unscheduled intravenous fluid infusion therapy was required in any participant in three trials. Eleven trials reported stool output, and data suggested less stool output in the reduced osmolarity ORS group. Vomiting was less frequent in the reduced osmolarity group in the six trials reporting this. Six trials sought hyponatremia, with events in three studies, but no obvious difference between the two arms.

VI.

Authors conclusion or recommendation On Rice-Based Oral Electrolyte Solution: Solutions containing rice-syrup solids were effective in the rehydration of infants with acute diarrhea. They decreased stool output and promoted greater absorption and retention of fluid and electrolytes than did a glucose-based solution.

On Oral Rehydration Solutions: In children admitted to hospital with diarrhea, reduced osmolarity ORS when compared to WHO standard ORS is associated with fewer unscheduled intravenous fluid infusions, lower stool volume post randomization, and less vomiting. No additional risk of developing hyponatremia when compared with WHO standard ORS was detected.

VII.

Applicability 1. Does the study provide a direct enough answer to your clinical question in terms of type of patients intervention and outcome? On Rice-Based Oral Electrolyte Solution: On Oral Rehydration Solutions: Yes, the study provides a direct answer on the clinical question in which independent nursing management can somewhat alleviate fatigue during pregnancy mostly due to pain and other contributing factors such as anxiety and loss of energy. The study further implies that this independent nursing management has its own strengths and weaknesses in addressing to the needs of the client during the progress of labor. Yes, the study provides a direct answer on the clinical question in analgesics has its own strength and weakness. Analgesics can optimize pain and fatigue along with other contributing factors such as anxiety but it has also side effects on the mother yet it isnt harmful but may delay activities of the mother after the immediate delivery of the baby and before the baby has been delivered. 2. Is it feasible to carry out the nursing action in the real world? On independent nursing action Yes, it is feasible to carry out the nursing action in reality, since this independent nursing management is usually done in addressing the needs of pregnant mothers especially on the process of labor. This immediate nursing action is found out to alleviate fatigue due to pain and other contributory factors during the progress of labor and promotes wellness on the side of the client and with the baby. The study is applicable in our setting here in the country in which student nurses along with immediate health care providers attends to the immediate needs of the client is assuring their safety and well-being during the labor process until the baby is delivered and continuous care will follow afterwards. On drugs analgesia Yes, because at present it is being practiced and observed among hospitals and lying in clinic here in the country thus administration of analgesics is beneficial in optimizing pain and fatigue on the mother yet it has side effect which is not harmful but delays immediate activity of the mother after the administration of the drug, it dulls the senses.

VIII.

Reviewers Conclusion (both studies)

The study conducted both on Independent Nursing Interventions and Drug Analgesia needs more revision and updated facts and information in order to strengthen the initial findings and support the initial output of the study. The study also should be done on a larger group of respondents to obtain and yield more information regarding the studies, and verify datas gathered if its useful and factual in strengthening the foundation of the initial findings, output and assessment of the initial study. Outputs gathered must be collaborated on nursing process, nursing practice, nursing administration and nursing research in which will be more helpful on nursing students and health care practitioners. a. Safety In regards to safety, independent nursing action is more appropriate to use and utilize in responding to the immediate needs of the client during the onset and progress of labor. Studies shows that this immediate nursing action can alleviate and optimize pain and fatigue during the progress of labor as compared to the use of analgesics which in fact can also alleviate and optimize pain and fatigue which has its side effect yet not eventually harmful but delays immediate action on the part during the progress of labor. We must always put in our mind that as health care providers the safety and wellness of the patient is our responsibility. b. Competence Prior to knowing the competency, we should ask ourselves first, What is the role of the primary health care provider (HCP) with regards to independent nursing action and administration of analgesics in alleviating pain and fatigue during the progress of labor. The role of the HCP is to make sure to give the right dose of the said medicine and to perform the immediate nursing action properly. Competency is measured by how appropriate, how effective and how efficient the primary health care to be delivered or rendered. With these we can conclude that a health care provider is competent enough so long as he/she is equipped with the right knowledge and skill needed to perform nursing action. c. Acceptability Based on the studies shown, Immediate Nursing Action and Administrations of analgesics during the first stage of labor and towards the progress of labor is effective in alleviating and optimizing pain and fatigue on the respondents. Yet, this two nursing interventions has its own strength and weaknesses. The said interventions are well accepted in the country since it is being practice on hospitals and lying in clinic with the proper ways and right knowledge on doing it. d. Effectiveness

Studies prove that the immediate nursing action can alleviate fatigue and pain during the progress of labor thus making it appropriate to nursing practiced. Administration of analgesics also is effective in alleviating and optimizing pain yet it has side effects but not harmful thus, usage of this until knows is still possible. In regards to clients safety, independent nursing action is a lot safer to initiate that the administration of analgesics. e. Appropriateness & Efficiency Both interventions are appropriate in alleviating and optimizing pain and fatigue during the progress of labor, yet it is much safer using the independent nursing action. f. Accessibility These interventions can yield immediate responses which are not harmful and readily accessible. Independent nursing action is usually done and performed by the health provider along side with the client while upon the administration of analgesics drowsiness and un able to participate on the health care action is easily noticed on the client.