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Oral Rehydration Therapy for Diarrhea-Related Dehydration in India

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A recent article published in Research Review discussed the oral treatment of dehydration associated with acute diarrhea in India and reported on the current World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) recommendations for such therapy. The authors stated that despite this effective and affordable treatment for reducing diarrhea-related dehydration, it remains a leading cause of death in India in children under 5 years of age. Therefore, both healthcare providers and caregivers must understand the importance of timely and appropriate oral rehydration therapy (ORT) in this group of patients.

Diarrhea-induced dehydration is a leading cause or morbidity and mortality in the developing world, especially, in the South-East Asian countries including India. Of the deaths due to diarrhea, occurring in children under 5 years of age in the year 2016, 89.37% were reported in South Asia and sub-Saharan Africa. Furthermore, diarrhea was responsible for 18% of childhood deaths in low-income countries, according to the WHO data published in 2011, diarrhea was.

In children, each episode of diarrhea causes depletion of nutrition, required for growth—resulting in undernutrition and a diarrhea-undernutrition cycle. This promotes further infection and increased morbidity and mortality, particularly among younger children.

The WHO cites following as key measures for the prevention of diarrhea:

  • Access to safe drinking water.
  • Use of improved sanitation; hand washing with soap.
  • Exclusive breastfeeding for the first six months of life.
  • Good personal and food hygiene.
  • Health education about how infections spread.
  • Rotavirus vaccination.
  • Dehydration should be prevented and treated in children with diarrhea by administering an appropriate ORS solution.
  • Most cases of diarrhea-related dehydration can be successfully treated with ORS.
  • Zinc supplementation should be provided for a duration of 14 days in children and infants receiving ORS for diarrhea.
  • Pre-made liquid ORS solutions may be an effective, palatable and convenient option, especially in situations where clean drinking water is unavailable.

In an attempt to improve the uptake of ORS, a number of manufacturers have developed pre-mixed ORS solutions, which meet WHO criteria and have the advantage of convenience, accurate dosing and improved taste.

Diarrhea-induced dehydration is a leading cause or morbidity and mortality in the developing world and is especially problematic in South-East Asian countries, including India. Pre-made liquid ORS solutions are an effective, convenient and safe option, in particular, in regions where clean drinking water is unavailable like in rural areas of developing countries, such as India, and caregivers often prefer such formulations. Management of diarrhea by replenishing the lost body fluid through oral rehydration therapy (ORT) is a simple, affordable and effective intervention that significantly reduces diarrhea-related mortality and morbidity.

In the 1970s, WHO developed a simple, inexpensive iso-osmotic (311 mOsm/L) formulation of glucose-based oral rehydration salts (ORS) designed to correct dehydration and metabolic acidosis in the setting of acute diarrhea. Since the introduction of ORS, the global annual mortality rate for children suffering acute diarrhea and dehydration has dropped from 5 million to 0.5 million, and ORS remains the mainstay therapy for dehydration secondary to acute infectious diarrhea. However, despite the ready availability of ORS, mortality rates in India still remain relatively high—with 102 813 children under 5 years reported to have died from diarrhea in 2016—rendering a mortality rate of 4.1 per 1000 live births.

Despite this effective, simple and affordable treatment for reducing diarrhea-related dehydration, it remains a leading cause of death in India in children under 5 years of age. It is imperative that both healthcare providers and caregivers understand the importance of timely and appropriate oral rehydration therapy (ORT) in this group of patients. Furthermore, children with diarrhea receiving daily zinc supplementation have been shown to experience a significantly faster recovery from diarrhea and an 18-59% reduction in the total stool output. The Indian Academy of Pediatrics, WHO and UNICEF endorse the use of zinc supplementation for 14 days, during treatment with ORS for diarrhea in children.

Issues for rehydration in India in 2004 – an Indian National Expert Group created by the Indian Ministry of Health, recommended that a single universal ORS solution containing sodium 75 mmol/L and glucose 75 mmol/L, with an osmolarity of 245 mOsm/L was acceptable for all ages and all types of diarrhea. In 2012, a survey revealed that the prescription of ORS reported by caregivers in India is low, ranging between 19-47% – although 90% of private providers perceive ORS favorably and 89% acknowledge it as the recommended first-line treatment of diarrhea. The commonly reported caregiver perception that diarrhea is not a life-threatening disease and the frequently employed ‘wait and watch’ approach, where medical attention is only sought when fever, vomiting or severe dehydration develop, is considered a major reason for the poor uptake of ORS in developing countries. Other contributing factors include the poor palatability of some ORS solutions, cost and accessibility.

Source: Research Review. 2019. Available from: www.researchreview.com/India

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