Author: Roger M.

Goodall We are often asked to explain how ORT works - a question that can only be answered successfully by first considering some of the simple physiology of the normal intestine and then the changes that occur in a state of diarrhoeal disease. This is a basic discussion of the question written in reasonable nontechnical terms to provide some of this interesting background information. GLOSSARY OF SOME OF THE TERMS USED METABOLITE Simple components into which food is broken down by digestion and which are subsequently built up into complex materials of body tissues e.g. proteins which are broken down into their component amino-acids by digestion and then metabolized back into further proteins in the body. ION A single electrically charged particle into which the atoms or molecules of some substances dissociate when in solution, e.g. sodium chloride in the solid state consists of molecules containing one atom of sodium Na and one atom of chlorine Cl bound together NaCl - in solution in water the molecule splits into two ions (Na+) and (Cl-) each of which tends to be loosely bound to three or four molecules of water e.g. (H8O4Na) + and (H6O3Cl)although for practical purposes they can be thought of as single ions Na+ and ClPositively charged ions e.g. Na+ are called CATIONS and Negatively charged ions e.g. Cl- are called ANIONS. The substances which show this dissociation into electrically charged ions are called ELECTROLYTES. SOLUTE A dissolved substance e.g. sodium chloride (the solute) dissolved in water (the solvent) to give a solution.

MOLARITY If two different substances are in a solution they are said to be equal in molarity (equimolar) if they have equal numbers of molecules per litre of solution. The mass or weight of each solute is then proportionate to their respective molecular weights. HYPERNATRAEMIA The presence of an excess amount of sodium Na+ in the blood plasma (i.e. over 140 mmol/l.) NORMONATRAEMIC - is the presence of a normal level of sodium and HYPONATRAEMIC - lower than normal sodium level in the plasma. UNICEF/WHO O.R.S

Sodium Chloride 3.5 grams Sodium Bicarbonate 2.5 grams Potassium Chloride 1.5 grams Glucose 20 grams

to be dissolved in one litre of clean drinking water REFERENCE: The management of diarrhoea and use of oral rehydration therapy a Joint WHO/UNICEF statement. THE PHYSIOLOGICAL PROCESS In the normal healthy intestine, there is a continuous exchange of water through the intestinal wall - up to 20 litres of water is secreted and very nearly as much is reabsorbed every 24 hours this mechanism allows the absorption into the bloodstream of soluble metabolites from digested food. Typical values for the daily gains and losses of water in an average man in a temperate climate are: Volume ml per day 1300 850 350 Volume ml per day 1500 400 500

Intake Drink Food Metabolic

Output Urine Expired Air Skin

Water Faeces Total 2500 Total 100 2500

In a state of diarrhoeal disease the balance is upset and much more water is secreted than is reabsorbed causing a net loss to the body which can be as high as several litres a day. In addition to water, sodium is also lost. The body's store of sodium (in the form of sodium ions Na+) is almost entirely in solution in body fluids and blood plasma, i.e., extra cellular. By contrast 98% of the body's total potassium (K+) is held within cells, i.e. intracellular. Approximate concentrations of the principal ions in plasma, interstitial, and intracellular fluids in an average man are: Plasma Cations (mmol per litre Sodium Potassium Calcium Magnesium Anions (mmol per litre) Chloride Bicarbonate Phosphate Sulphate Protein Organic Anions 102 27 1 0.5 2 3 114 30 1 0.5 0.1 6 5 10 50 10 8 2 140 4 2.5 1 144 4 2 1 10 155 1 15 Interstitial Intracellular fluid fluid

The concentration of Na+ in the extracellular fluid has to be held to within close limits (135-150 mmol/l) for the proper functioning of the body. Normally, this sodium concentration is normally precisely controlled by the renal function. However in a state of dehydration water is conserved by anuria and the sodium regulation cannot work effectively. Thus continued diarrhoea causes rapid depletion of water and sodium, which is to say, a state of dehydration. If more than 10% of the body's fluid is lost death occurs. The approximate distribution of body water in an average man is:

Compartment

% of Volume total litres body water 42 17 3.2 12.8 1 25 100 40 7.6 30 2.4 60

Total body water Extracellular Plasma Interstitial Transcellular Intracellular

Simply giving a saline solution (water plus Na+) by mouth has no beneficial effect because the normal mechanism by which Na+ is absorbed by the healthy intestinal wall is impaired in the diarrhoeal state and if the Na+ is not absorbed neither can the water be absorbed. In fact, excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens. If glucose (also called dextrose) is added to a saline solution a new mechanism comes into play. The glucose molecules are absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - and in conjunction sodium is carried through by a cotransport coupling mechanism. This occurs in a 1:1 ratio, one molecule of glucose co-transporting one sodium ion (Na+).

It was the discovery of this mechanism of co-transport of sodium and glucose which the Lancet described as "potentially the most important medical advance this century" ( ORT is in fact the practical realization of this potential). It should be noted that glucose does not co-transport water - rather it is the now increased relative concentration of Na+ across the intestinal wall which pulls water through after it. Several other molecules apart from glucose have a similar capacity to co-transport Na+ including: aminoacids (e.g. glycine) dipeptides tripeptides

and the absorption of these molecules may occur independently of each other at different sites - thus their effect can be additive. Research is currently being carried on to utilize these additive effects to develop a multi-component "Super ORS". Starch is metabolized in the intestine to glucose and therefore it has the same properties of enhancing sodium absorption, however it has an added advantage that it has less osmotic effect, which would act to pull water back into the lumen of the intestine. THE COMPOSITION OF ORS. In deciding the optimal composition of an oral rehydration solution the following considerations must apply: 1. Sodium - losses of sodium in the stool range from 50-60 meg/l to well over 100 meg/l in cholera and in fact total body depletion of sodium may be higher than stool losses alone indicate. For this reason a Na+ concentration of 90 meg/l is considered an optimal figure for replenishing Na+ in dehydration from diarrhoea caused by any etiology and in all

age groups from neonates to adults. For some years there was controversy over optimum concentration of sodium in oral rehydration fluids, which stemmed from the fact that in the early days of its use, particularly in USA, causes of hypernatraemia (excess sodium) occurred fairly frequently in infants given oral rehydration therapy. The apparently obvious answer was to assume that the sodium concentration in the oral rehydration fluid used was too high and to reduce it (even to as low as 25 or 30 meg/l). Unfortunately, the apparently obvious was not the correct answer - actually nearly all these children were being given high- solute infant formula which tended to make them hypernatraemic to start with and the oral rehydration solution used then contained excess glucose - up to 8% - which was added to provide extra nutritive calories. Unfortunately, the excess glucose caused osmotic diarrhoea which precipitated acute hypernatraemia in these children. The less obvious but correct answer was to reduce the glucose content - not the sodium. We now recognize that the sodium and glucose should be in a 1:1 ratio in terms of molarity. Experience has now shown that even hypernatraemic neonates with dehydration can be successfully rehydrated and made normonatraemic using the standard WHO / UNICEF ORS formula (with 90 meg/l Na+) when the water intake is sufficient to ensure normal kidney function and hence physiological regulation of the sodium concentration in the plasma. Although ORS with a sodium content of around 50 meq/l is sufficient for maintenance of hydration of a normally willnourished child with diarrhoea it would be inadequate for rehydration of a patient with a secretary diarrhoea (e.g., cholera) losing considerable sodium in the stool. 2. Glucose should be close to equivalent with the Na+ content - it is 111 mmol/l in the WHO / UNICEF formula, which happens to be exactly 2%. It should be noted that if glucose is present in excess of 3% it will cause further losses of water through osmotic effects, this would also upset the electrolyte balance,

since increased water losses will result in hypernatraemia. 3. We have not yet given more than a passing mention to potassium. Although as we saw that 98% of the body's potassium is held within the cells, repeated diarrhoeal attacks over a period of time will cause a chronic loss of potassium. This results in muscular weakness, lethargy and anorexia. The typical distended abdomen of a chronically malnourished child is caused by loss of muscle tone in the abdominal wall largely due to chronic depletion of potassium. The kidneys are unable to conserve potassium as they do sodium, and there is a continuous obligatory loss of potassium of about 10 mmol daily in the urine, in addition to the larger losses in the stool. Potassium is not involved in any way in the sodium/glucose co-transport mechanism and is absorbed passively. Restoration of potassium levels is therefore achieved more slowly than sodium and water restoration. A potassium concentration of 20 mmol/l is considered optimal for the purpose. Simple mixtures of sugar , salt and water or starch, salt and water contain no potassium and cannot restore potassium depletion - hence these mixtures are an "incomplete" formula and further potassium supplementation is definitely necessary for a child who suffers repeated attacks of diarrhoea. A potassium-rich diet including, for example, bananas or coconut water can be helpful but an ORS solution containing potassium is therapeutically more effective. In order to produce a significant effect it is necessary to provide potassium-rich foods in reasonable large quantities over a period of time. Restoring a potassium deficit promotes a feeling of well-being and stimulates the appetite and activity of the child. If additional food is provided over several weeks an increase in weight gain will occur and the status of the child's health will improve markedly. Dietary intake is needed to achieve this. 4. Electrolyte imbalance and fluid loss also causes metabolic acidosis. These effects are more critical in the case of infants, as their renal function is not fully developed and they have a large surface area in ratio to body weight and a higher

metabolic rate. Acidosis is corrected by the addition of bicarbonate (or another base such as citrate) to the ORS formula. Electrolyte content of stool in acute diarrhoea and the electrolyte and glucose content of ORS solution: Na+ K+ Cl- HCO3 Cholera adults children (less than 5 yrs.) Enteritis children (less than 5 yrs.) 56 25 55 14 140 101 13 104 27 92 44 32

Glucose Na+ K+ cl- HCO3 ORS Solution 111 90 20 80 30

(values expressed as mmol/l) The causative pathogens of diarrhoeal disease (which are very numerous, more than 30) in some cases not only produce the secretion of water and sodium but also damage the intestinal wall. The normal healthy intestine is covered on its inner surface with very numerous tiny hairs, or villi, the surface cells of which are involved in the absorption of metabolites from ingested food. There is a difference between the cells of the tips of the villi and the cells of the base in their absorptive functions. Pathogens, e.g., rotavirus, may strip the tips of the villi from large patches of the intestinal wall thus decreasing the surface area and decreasing by more than 50% the specific absorptive capacities of the intestine. The result is malabsorption which can cause malnutrition - most especially in a child already nutritionally compromised by repeated previous attacks of diarrhoea. Withholding food, even for one or two days, greatly exacerbates the malnutrition; this coupled with anorexia, caused partly by chronic

potassium depletion, causes a vicious circle, i.e. diarrhoea causing malnutrition and malnutrition causing ever more frequent and severe diarrhoea. It is this diarrhoea/malnutrition cycle rather than acute dehydration that causes almost half of the five million deaths a year that are associated with diarrhoeal disease in children under five years old.

The Oral Rehydration Therapy

The Canadian Journal of Paediatrics 1994; 1(5): 160-164 Oral rehydration therapy with an inexpensive glucose and electrolyte solution as promoted by the World Health Organization has reduced substantially the number of deaths from dehydration due to diarrhea. In addition, recent research suggests that these solutions have advantages over conventional therapy. Yet, oral rehydration therapy has not been used extensively in developed countries. Acute gastroenteritis is one of the most common illnesses affecting infants and children in Canada and the world. The average child under age 5 experiences 2.2 diarrheal episodes per year.1 Treatment from resulting dehydration accounts for an estimated 200,000 hospitalizations per year in the U.S.2 with comparable rates occurring in Canada. Worldwide as many as 4,000,000 children per year die as a result of gastroenteritis and resulting malnutrition. Prolonged diarrhea and malnutrition are a primary cause of morbidity and mortality in Canadian native populations. Oral rehydration therapy (ORT), using a simple, inexpensive, glucose and electrolyte solution promoted by the World Health Organization (WHO) has reduced the number of deaths from dehydration due to diarrhea by about a million per year.1,3 In spite of its efficacy, ORT has not been used extensively in developed countries. Recent research, summarized in this report, suggests that the use of oral rehydration solutions have advantages over conventional therapy. In an effort to encourage the use of ORT, a simple approach to rehydration is outlined.

Oral rehydration takes advantage of glucose-coupled sodium transport,4 a process for sodium absorption which remains relatively intact in infective diarrheas due to viruses or to enteropathogenic bacteria, whether invasive or enterotoxigenic. Glucose enhances sodium, and secondarily, water transport across the mucosa of the upper intestine.5 For optimal absorption, the composition of the rehydration solution is critical. The amount of fluid absorbed depends on three factors: the concentration of sodium, the concentration of glucose and the osmolarity of the luminal fluid. Maximal water uptake occurs with a sodium concentration from 40 to 90 mmol/L, a glucose concentration from 110 to 140 mmol/L (2.0 to 2.5 g/100 mL) and an osmolarity of about 290 mOsm/L, the osmolarity of body fluids.6 Increasing the sodium beyond 90 mmol/L may result in hypernatremia; increasing the glucose concentration beyond 200 mOsm/L, by increasing the osmolarity of the solution, may result in a net loss of water. CHO to Na ratio should not exceed 2:1 in these solutions. For practical purposes in Canada, rehydration can be accomplished using solutions with higher sodium, i.e., 75-90 mmol/L. These are termed rehydration solutions (ORS). Prophylaxis of dehydration and maintenance involve solutions with 45-60 mmol/L of sodium. These are termed maintenance solutions. High sodium rehydrating solutions used to treat acute dehydration may be used for maintenance by giving the solution alternately on a 1-to-1 basis with a no-sodium or low-sodium fluid such as water, low CHO fluids, or breast milk. The high sodium ORS should not be used as the sole fluid intake for maintenance of hydration. Fruit juices and pop are not efficacious because of their high carbohydrate concentration, osmolarity and the inadequate sodium concentration.7 Individualized dietary management of the patient during acute diarrhea is the key and should be emphasized. Oral rehydration and maintenance solutions presently in use, although effective in rehydration, do not decrease stool volume because of the relatively high osmolarity of the glucose which they contain. The challenge, therefore, is to provide adequate glucose to the sodium pump without increasing the osmolarity of the rehydration solution. This has been done successfully by substituting short chain glucose polymers (starch) from rice and other cereals for glucose in the oral rehydration mixture.8 In field trials in developing countries,8,9 ORS

containing glucose polymers, primarily from rice and corn, were found not only to be as effective in correcting dehydration as glucose-based ORS, but also to offer the additional advantage of reducing the amount and duration of diarrhea by 30%, thereby reducing morbidity and costs of treatment and increasing acceptability. The effectiveness in diarrhea typical of North America may be less marked, i.e., reducing stool output by 18%. Defined short-chained glucose polymers from rice may also be safe and effective in the treatment of acute diarrhea.10 Wapnir et al11 found that a solution containing 30 g/L of rice syrup solids (180 mOsm/L) resulted in 40% more water absorption than a similar solution which contained 20 g/L of glucose (230 mOsm/L). A clinical study with solutions containing rice-syrup solids confirmed their efficacy in the rehydration of infants with acute diarrhea. Further, such solutions decreased stool output, and promoted greater absorption and retention of fluid and electrolytes than did a glucosebased solution.12 Amino acids have also been suggested as additives to ORS. The addition of alanine alone to the WHO oral rehydration solution (ORS) was not found to give additional benefits.13 However, Khin-MaungU and Greenough8 found that alanine, added to a glucose polymerbased ORS, decreased the amounts of stool by a further 10% to 40%. Nevertheless, these are not currently recommended by WHO. Rice-based corn and lentil-based oral rehydration solutions have been extensively tested and may eventually be made available. Along with improved oral rehydration solutions have come advances in the field of early refeeding. Fasting has been shown to prolong diarrhea. This may be due to undernutrition of the bowel mucosa which delays the replacement of mucosal cells destroyed by the infection. Although there is general agreement that breast-feeding should continue in spite of diarrhea,14 early refeeding with a lactose-containing formula is usually well tolerated.15 Early refeeding should commence 6-12 hours into therapy. On the basis of these findings and recent recommendations, 16 the following principles should be followed in treating diarrheal disease: Fluid therapy should include the following three elements: rehydration, replacement of ongoing losses, and maintenance. Fluid therapy is based on an assessment of the degree of

dehydration present. Principles are as follows: No dehydration - If diarrhea is present, but urinary output is normal, the normal diet and breast-feeding may continue at home with fluid intake dictated by thirst. High osmolarity fluids such as undiluted juices should be avoided, and maintenance oral electrolyte solution (Na 45-60 mmol/L) offered "ad libitum." Mild - If symptoms and signs are limited to decreased urinary output and increased thirst, mild dehydration is suspected. Assessment and treatment under close supervision are indicated. Rehydration consists of ORS or maintenance solution 10 mL/kg/hr with reassessment at 4-hour intervals. Breast-feeding continues. Early refeeding with the child's customary formula at the usual concentration is recommended. Extra ORS or maintenance solution (e.g., 5-10 mL/kg) may be given after each stool if diarrhea persists. Moderate - If at least two of the following signs, sunken eyes, loss of skin turgor ("tenting" of abdominal skin lasting less than 2 seconds), or dry buccal mucous membranes are present, moderate dehydration is diagnosed and rehydration consisting of ORS 15-20 mL/kg/hr with direct observation and reassessment at 4-hour intervals. If dehydration is corrected, therapy for ongoing losses and maintenance are continued as outlined above. If not, treatment is repeated as indicated by clinical signs or symptoms. Severe - If, in addition to signs of moderate dehydration, there is rapid breathing, lethargy, coma, a rapid thready pulse or "tenting" of the skin lasting more than 2 seconds, severe dehydration and shock are present. Blood pressure should be measured. Prompt intravenous therapy is indicated with rapid infusion of saline plasma or colloid sufficient to replete blood volume (10-20 mL/kg over 30 minutes may be necessary). Intraosseous infusion should be used if an intravenous line cannot quickly be inserted. General comments. Vomiting is not a contraindication to ORT. ORS should be given slowly but steadily to minimize vomiting. Fluids may be administered by nasogastric tube if required. The child's clinical condition should be frequently assessed. A child should never be kept on ORS fluid alone for more than 24 hours. Early refeeding should begin within 6 hours. A full diet should be reinstituted within 24 to 48 hours, if possible. There are certain contraindications to the use of ORT:

Protracted vomiting despite small, frequent feedings Worsening diarrhea and an inability to keep up with losses Stupor or coma Intestinal ileus. As ORS can be administered easily by a properly instructed parent, and because dehydration can be corrected quickly, it lends itself well for use in an outpatient department or nursing station. At the end of 4 hours, the child can either be sent home on maintenance therapy or, if dehydration persists, be observed for further therapy. Intelligent use of ORT can decrease hospital admissions, an important consideration in a time of decreasing hospital budgets. Although in our society intravenous therapy is often considered more convenient than ORT, clinicians should feel more comfortable as they become more accustomed to the use of ORT.

TABLE 3: Simplified ORT protocol in mild to moderate rehydration mild 1st hour next 6-8 hours Reassessment at 4-hour intervals moderate

20 mL/kg/hr 20 mL/kg/hr 10 mL/kg/hr 15-20 mL/kg/hr

There are many different equations for calculating administration rates in oral rehydration. ORT may be given in amounts equal to fluids calculated for intravenous administration. Alternately, fluids may be delivered by nasogastric tube Recommendations Dehydration accompanying infantile gastroenteritis should be treated with early oral rehydration and early refeeding strategies.

Infants with gastroenteritis should be offered maintenance solution to prevent dehydration. Parents and daycare centres should keep maintenance solution on hand in anticipation of episodes of infectious diarrhea.

ORS and maintenance solutions and instructions in their use should be made available at reasonable costs. Medical facilities should have ORT protocols available for staff and patients. Antidiarrheal drugs, antibiotics and antiemetic therapy are rarely indicated in gastroenteritis in childhood and should be discouraged. Home-made oral rehydration solutions are discouraged since serious errors in formulation have occurred. Infants with mild to moderate dehydration should be treated under medical supervision with ORT in preference to intravenous rehydration. Infants with severe dehydration should initially be treated with intravenous or intraosseous rehydration. Breast-fed infants with dehydration should be given ORT in conjunction with continued breastfeeding. Early refeeding should commence as soon as vomiting has resolved, approximately 6-12 hours. Non-lactose containing formulae or milks may be used if diarrhea and abdominal cramps persist beyond expected 5- to 7-day course suggesting clinical lactose intolerance. Further initiatives to encourage ORT use by patients and professionals should be developed.

Oral Rehydration Therapy (ORT)

From Wikipedia, the free encyclopedia Oral rehydration therapy, (also called ORT, oral rehydration salts or solutions (ORS), or oral electrolyte), is a simple, cheap, and effective treatment for diarrhea-related dehydration, caused by e.g. cholera. It consists of a solution of salts and other substances

such as glucose, sucrose, citrates or molasses, which is administered orally. It is used around the world, but is most important in the Third World, where it saves millions of children from diarrheastill their leading cause of death. History ORT was developed in the late 1960s by researchers in India and International Centre for Diarrhoeal Disease Research in Bangladesh(then East Pakistan), for the treatment of cholera. The Indo-Pakistani War of 1971 provoked a public health emergency in the refugee camps set up to house those fleeing the violence. With cholera spreading rapidly and death rates rising, the head of a medical centre in one of the camps instructed his staff to distribute Oral Rehydration Salts (ORS). In the refugee camps where ORS was being used the death rate was only 3%, compared to 2030% in those camps using only intravenous fluid therapy.[citation needed] In 2002, Drs. Norbert Hirschhorn, Dilip Mahalanabis, David R. Nalin, and Nathaniel F. Pierce were awarded the first Pollin Prize for Pediatric Research, in recognition of their work in developing ORT. Between 1980 and 2000, ORT decreased the number of children under five dying of diarrhea from 4.6 million worldwide to 1.8 milliona 60% reduction. According to The Lancet (1978), ORT is "potentially the most important medical discovery of the 20th century". Today, the total production is around 500 million ORS sachets per year, with the children's rights agency UNICEF distributing them to children in around 60 developing countries. ORS represents a cheap and effective way of reducing the millions of deaths caused each year by diarrhea. Physiology Oral rehydration therapy is widely considered to be the best method for combating the dehydration caused by diarrhea and/orvomiting. Various diseases cause damage to the intestine, allowing water to flow from the blood into the intestine, depleting the body of both fluid and electrolytes. This may be

a direct destruction of the cells lining the intestine (the enterocytes), a toxic effect causing them to loose their microvilli (the brush border), a toxic effect (by an enterotoxin) causing them to secrete water.

In the human body, water is absorbed and secreted passively; it follows the movement of salts, based on a principle called osmosis. So, in many cases, diarrhea is caused by intestine cells secreting salts (primarily sodium) and water following passively along. Simply drinking water is ineffective for 2 reasons: (1) the large intestine is usually secreting instead of absorbing water, and (2)electrolyte losses also need compensating. As such, the standard treatment is to restore fluids intravenously with water and salts. This requires trained personnel and materials which are not sufficiently available in the Third World. However, it was discovered that the body can absorb a simple solution containing both sugar and salt. The dry ingredients can be mixed and packaged, and then the solution can be prepared and delivered by people with minimal training. One diarrhea mechanism (like in cholera, which is a very dangerous form of profuse diarrhea), is an enterotoxin interfering with enterocyte cAMP and G-proteins. However, water can still be absorbed by cAMP-indepentent mechanisms, like the SGLTtransporter (sodium and glucose transporter, of which 2 types exist). This is achieved by combining salts and glucose. Oral rehydration can be accomplished by drinking frequent small amounts of an oral rehydration salt solution. It is important to rehydrate with solutions that contain electrolytes, especially sodium and potassium, so that electrolyte disturbancesmay be avoided. Sugar is important to improve absorption of electrolytes and water, but if too much is present in ORS solutions,diarrhea can be worsened. Oral rehydration does not stop diarrhea, but keeps the body hydrated and healthy until the diarrhea passes. Recipe

There are several commercially available products but an inexpensive home-made solution consists of 8 level teaspoons of sugar and 1 level teaspoon of table salt mixed in 1 liter of water. A half cup of orange juice or half of a mashed banana can be added to each liter both to add potassium and to improve taste. If commercial solutions are used, true rehydration solutions should be used andsports drinks should be avoided (especially in younger children) as these solutions contain too much sugar and not enough electrolytes. One standard remedy is the WHO/UNICEF glucose-based Oral Rehydration Salts (ORS) solution. WHO/UNICEF ORS solution contains Reduced osmolarity ORS Sodium chloride Anhydrous Glucose Potassium chloride Trisodium citrate, dihydrate Reduced osmolarity ORS Sodium Anhydrous Glucose Chloride Potassium Citrate Total Osmolarity

grams/litre 2.6 13.5 1.5 2.9

mmol/litre 75 75 65 20 10 245

In the human body, the plasma osmolality is about 285 mOsm/l. An inexpensive home-made solution consists of

1 litre of water, mixed with 8 teaspoons of sugar, 1 teaspoon of table salt.

A half cup of orange juice or half of a mashed banana can be added to each liter to add potassium and improve taste. If commercial solutions are used, true rehydration solutions should be used and sports drinks should be avoided (especially in younger children) as these solutions contain too much sugar and not enough electrolytes.

The amount of rehydration that is needed depends on the size of the individual and the degree of dehydration. Rehydration is generally adequate when the person no longer feels thirsty and has a normal urine output. A rough guide to the amount of ORS solution needed in the first 4-6 hours of treatment for a mildly dehydrated person is:

Up to 5 kg (11 lb): 200 400 ml 5-10 kg (11-22 lb): 400 600 ml 10-15 kg (22-33 lb): 600 800 ml 15-20 kg (3344 lb): 800 1000 ml 20-30 kg (44-66 lb: 1000 1500 ml 30-40 kg (66-88 lb): 1500 2000 ml 40 plus kg (88 lb): 2000-4000 ml

Technique Adults and children with dehydration who are not vomiting can be allowed to drink these solutions in addition to their normal diet. People who are vomiting should be fed small frequent amounts of ORS solution until dehydration is resolved. Once they are rehydrated, they may resume eating normal foods when nausea passes. Vomiting itself does not mean that oral rehydration cannot be given. As long as more fluid enters than exits, rehydration will be accomplished. It is only when the volume of fluid and electrolyte loss in vomit and stool exceeds what is taken in that dehydration will continue. When vomiting occurs, rest the stomach for ten minutes and then offer small amounts of ORS solution. Start with a teaspoonful every five minutes in children and a tablespoonful every five minutes in older children and adults. If output exceeds intake or signs of moderate to severe dehydration occur, medical assistance should be sought.