Oral Rehydrating Solution and ChildrenBy 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