Academic journal article Bulletin of the World Health Organization

Efficacy of Standard Glucose-Based and Reduced-Osmolarity Maltodextrin-Based Oral Rehydration Solutions: Effect of Sugar Malabsorption

Academic journal article Bulletin of the World Health Organization

Efficacy of Standard Glucose-Based and Reduced-Osmolarity Maltodextrin-Based Oral Rehydration Solutions: Effect of Sugar Malabsorption

Article excerpt

Introduction

The standard glucose-based oral rehydration salts (ORS) solution (containing glucose, 111 mmol/l and sodium, 90mmol/l; total osmolarity, 311mmol/l), which has been recommended globally by WHO and UNICEF, has proved to be both safe and effective for preventing and treating dehydration in children with diarrhoea (1, 2). Nevertheless, the continuing search for an even more effective composition of ORS (3) and concern about a possible increased risk of hypernatraemia, especially in well-nourished children with noncholera diarrhoea (4), have led to the evaluation of other formulations, most recently those with reduced osmolarity (3, 5-7).

One approach to lowering the osmolarity of ORS solution has been to reduce its content of glucose and sodium. We recently reported improved results when dehydrated children with acute diarrhoea were treated with a solution containing less glucose (75mmol/l) and sodium (60mmol/1), and having a lower osmolarity (210mmol/l) than standard ORS solution. Comparison of this treatment with standard ORS showed that the rate of stool output was 58% greater, duration of diarrhoea 55% longer, intake of ORS solution 20% greater, and the serum sodium concentration was higher in children given standard ORS solution (5). These results were confirmed in a large multicentre study, which also showed a 100% increase in requirement for supplemental intravenous infusion in non-breastfed infants given standard ORS solution (6). Both these studies suggested that the increased stool output with standard ORS solution resulted from its slight hypertonicity combined, in some children, with transient sugar malabsorption. Sugar absorption was not, however, measured directly.

A second approach has been to replace glucose 20g/l) with a greater weight of cooked rice powder (or other cereal powder) or maltodextrins (MD) (30-80g/l; total osmolarity about 230mmol/l) (3, 8). It was proposed that these complex polysaccharides, when hydrolysed, would yield more glucose than provided by standard ORS without increasing intraluminal osmolarity and that the increased glucose would promote greater absorption of sodium and water, thus reducing the stool output (9). Studies with such solutions have, however, shown mixed results. While stool output has been significantly greater in cholera patients given standard ORS solution than in those given rice-based solutions, no significant benefit has been seen in children with noncholera diarrhoea given rice- or MD-based solutions (3, 8). These different results have not been explained.

We report here a randomized, double-blind comparison of standard ORS solution and a reduced-osmolarity, MD-based ORS solution in the treatment of dehydrated infants and children with acute non-cholera diarrhoea. During the study we monitored the incidence of sugar malabsorption and assessed its relationship with ORS efficacy. The results appear to explain the different outcomes of treatment with the two types of reduced-osmolarity ORS solutions described above. They provide strong support for the routine use of reduced-osmolarity glucose-based ORS, but not MD-based or other starch-based ORS. in young children with acute noncholera diarrhoea.

Subjects and methods

The study was carried out at the Diarrhoeal Disease Research and Rehydration Centre of Bab El-Sha'reya Hospital in Cairo, Egypt. The protocol was approved by the ethics committees of the hospital and of WHO. The subjects were fully weaned boys aged 3-24 months with acute non-bloody diarrhoea, which was defined as three or more loose or watery stools per 24 hours with signs of moderate dehydration.(a) Parents or guardians had given consent. Children with diarrhoea for more than three days, or without signs of dehydration or with severe dehydration were excluded, as were those with severe malnutrition (weight-for-length less than 70% of the National Center for Health Statistics (NCHS) median, or showing obvious signs of kwashiorkor) or evidence of a serious systemic infection. …

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