The baby is not dehydrated and is in good general condition. Try to avoid dehydration by replenishing what is being lost, avoiding drastic changes in feeding habits as much as possible. The rest of the answers touch on many of the "myths" and customs surrounding gastroenteritis. There is also no evidence of lactose intolerance (perianal irritation, frothy and acid stools, etc.) that would advise lactose-free milk.

The parents of a 5-month-old infant come because their child, who attends day care, has been presenting for 3 days, coinciding with an upper respiratory tract infection, liquid stools numbering 4 per day, occasional alimentary vomiting, and axillary temperature of 38.3°C. He is being fed with mixed breastfeeding. On examination the infant is in good general condition, is well nourished and hydrated and his breathing is eupneic; his weight is 4,730g and has decreased by 70g with respect to the previous week. The abdomen is soft and depressible, without masses or megaliths, and the fontanel is normotensive. Except for the presence of watery rhinorrhea, the rest of the examination by organs and devices is normal. Of the following statements, indicate the answer that you consider CORRECT:

An estimation of losses should be made, recommend a 4-hour fast and rehydrate during this time with oral rehydration solution.

It is advisable to introduce rice cereals for their astringent effect.

A stool culture should be performed as soon as possible to exclude a bacterial origin.

The use of lactose-free formula should be recommended.

It is advisable to replace losses after each bowel movement with oral rehydration solution and continue with the patient's usual diet.

Oral rehydration therapy

An exception is if the severely malnourished child also has severe diarrhea (in which case ReSoMal may not provide enough sodium), in which case standard reduced-osmolarity ORS (75 mmol sodium/L) is recommended. Malnourished children should be rehydrated slowly. The WHO recommends 10 milliliters of ReSoMal per kilogram body weight for each of the first two hours (for example, a 9-kilogram child should be given 90 ml of ReSoMal over the course of the first hour, and another 90 ml for the second hour) and then continuing at this same rate or slower based on the child's thirst and ongoing stool losses, keeping in mind that a severely dehydrated child may be lethargic. If the child drinks poorly, a nasogastric tube should be used. The IV route should not be used for rehydration except in cases of shock and then only with care, infusing slowly to avoid flooding the circulation and overloading the heart.

Randomized, double-blind clinical trial of a lactose-free and a lactose-containing formula in dietary management of acute childhood diarrhea.

Refeeding of artificially fed infants with lactose-containing formula after oral rehydration therapy in the treatment of acute diarrhea was concluded to be indifferent to non-lactose formula by a meta-analysis. In Thai as well as Asian infants and children with low lactase level from genetically determinant and with rotavirus infection, lactose malabsorption is most likely to occur and cause delayed recovery. The aim of this study was to compare the effect of a lactose-free and a lactose-containing formula in dietary management of acute childhood diarrhea. A randomized, double-blind clinical trial of 80 male children, formula-fed, aged 3 to 24 months, admitted with acute watery diarrhea and mild or moderate dehydration, was carried out. All children received oral rehydration therapy for the first 4 hours. After appropriate rehydration, they were fed either a lactose-free formula (Dumex Lactose-Free Formula; treatment group, n = 40) or a lactose-containing formula (Dumex Infant Formula; control group, n = 40) in adjunction with oral rehydration solution. In addition, the infants were fed rice gruel as tolerated. Comparisons of duration of diarrhea, weight gain, vomiting, biochemical changes, stool frequency and weight and unscheduled intravenous fluid were made. Three children (2 treatment, and 1 control) dropped out from the study. The total number of unscheduled intravenous infusions were 6 of 80 children (7.5%), including 2 (5.0%) in the treatment group and 4 (10.0%) in the control group. Three children in the control group did not resolve from diarrhea within 7 days of treatment. Rotavirus was identified in approximately 50% of the children in each group. Using survival analysis, the median duration of diarrhea was significantly shortened by 20.5 hours in the treatment group compared to the control group (77.0 hours in the treatment group vs 97.5 hours in the control group; P = 0.002). Significantly decrease in stool frequency and increase in percent weight gain were seen in the treatment group at 24 hours. Moderate acidosis cleared up to near normal at 24 hours in the treatment group but acidosis persisted in the control group. In the rotavirus diarrhea subgroup, moderate acidosis turned to be mild in treatment group, but acidosis was unchanged with increased plasma chloride level in the control at 24 hours thus suggesting that the children in the control group might have lactose malabsorption and osmotic diarrhea. Duration of rotavirus diarrhea was shortened 23.6 hours in treatment group compared to the control (P = 0.0034). In this study, lactose-free formula was shown to be effective in the dietary management of acute childhood diarrhea. Duration of diarrhea was shortened, weight gain was better, and stool frequency was less when compared to lactose-containing formula. Moderate acidosis cleared up spontaneously at 24 hours. Unscheduled IV could be decreased by 50%. Children receiving lactose-free formula tolerated it well. Data of subgroup analysis of rotavirus diarrhea revealed lactose-free formula scored higher than the control group for all parameters studied.

Acute diarrhoea in infants: oral rehydration is crucial.

(1) Dehydration is the most immediate complication of acute diarrhoea. Infants still die by dehydration, or suffer severe repercussions. (2) Thirst is an early sign of dehydration in an infant. Other signs are delayed capillary filling, absence of tears, mucosal dryness and a "sickly" appearance. Fever or vomiting in the first 24 hours facilitate dehydration. Weight loss is the main clinical index of the degree of dehydration. (3) Oral rehydration with glucose-electrolyte solution is as effective as intravenous rehydration. It must start immediately dehydration occurs. Infants with signs of severe dehydration must be hospitalised. (4) Oral rehydration of a vomiting infant is feasible, by giving a teaspoonful of solution every one or two minutes. (5) A dehydrated infant rarely refuses oral rehydration solutions. (6) Beverages such as cola drinks are inappropriate for rehydration, as they contain too little sodium and are excessively hyperosmolar, which may worsen the diarrhoea. Rice gruel is better. (7) Antidiarrhoeal drugs do not prevent dehydration. (8) Feeding must be resumed as soon as dehydration has been corrected, as it shortens the course of diarrhoea. Continuing maternal breast-feeding reduces the severity of diarrhoea. Lactose-free "milk" has no demonstrated benefit. (9) Those in charge of an infant with diarrhoea must know how to prevent severe dehydration, which can occur very rapidly. Fluid intake must always be increased in an infant with diarrhoea. Sachets of powder for oral rehydration should be kept at home. Their prescription and dispensing should be accompanied by written instructions.

[Prevention and treatment of acute diarrhea in infants].

The prognosis of acute diarrhoea in infants is most often satisfactory in industrialized countries. However, it has been estimated that 10 to 15 children die every year in France from acute dehydration due to acute diarrhoea. In spite of an increasing use over the least few years, oral rehydration solutions (ORS) are used in only 70% of infants presenting with acute diarrhoea. The use of homemade ORS, plain water or fizzy drink should be strictly avoided. In case of acute diarrhoea there is no indication to stop breastfeeding or the use of infant formula for more than 4 hours. Lactose intolerance is observed in only 5-10% of infants. Lactose free formulae should only be used in infants with severe, persistent or recurrent diarrhoea. Under 3-4 months of age, infants with severe diarrhoea should receive for a period of 2-4 weeks lactose free protein hydrolysate formulae. Racecadotril is the only drug with anti-diarrheal properties, with a reduction of the stool output of 50%. Oral antibiotics should only be used in case of Shigella infection or in case of bacterial infection with severe sepsis or underlying debilitating disease. Oral Rotavirus vaccine, that is not reimbursed yet in France, has been shown to dramatically reduce the number of severe cases of diarrhoea with dehydration, and has been associated with a striking reduction of both morbidity and mortality, as well as of the number of hospitalisations during periods of epidemics.

Controlled clinical trial on the efficacy of rice powder-based oral rehydration solution on the outcome of acute diarrhea in infants.

We report a controlled clinical trial of rice powder-based oral rehydration solution (ORS) versus glucose ORS on the outcome of acute diarrhea in infants. The rice ORS group (n = 30) received ORS containing 50 g rice powder instead of standard WHO solution (20 g glucose, n = 30). Formula-fed male infants were enrolled to enable calculation of milk intake and excretion of urine. Patient allocation to either group depended on the method of random permuted blocks. Both groups were comparable regarding age (4-18 months), duration of diarrhea, number of bowel movements or vomiting per 24 h, rectal temperature, dehydration score, and nutritional status. Results revealed that the rice ORS group had a shorter duration of diarrhea (28.4 +/- 5.1 vs 34.3 +/- 2.3 h) and greater mean weight gain in the first 24 h as percentage of recovery weight (5.7 +/- 0.5% vs 4.1 +/- 0.6%). Furthermore, the mean amount of ORS intake, mean stool output, and mean number of episodes of vomiting were lower in the rice-ORS group as compared with the glucose ORS group. All differences were statistically significant. Due to its observed superiority and low cost, the widespread use of rice ORS should be considered for treatment of acute diarrhea.

Acute infectious diarrhea in children.

Acute infectious enteritis is one of the more common childhood diseases worldwide, especially in the first three years of life. Every year, in Germany, one in six children under age 5 is taken to a physician at least once because of infectious diarrheal disease. 10% of the children presenting with rotavirus infection are admitted to hospital. The existing national and international recommendations for the treatment of acute infectious diarrheal disease are inadequately followed, despite the high level of evidence on which they are based. Selective literature search based on national and international guidelines. The therapeutic goal is to replace the fluid and electrolyte losses resulting from diarrhea and vomiting. The administration of a hypotonic oral rehydration solution (ORS) is indicated to treat impending dehydration (infants aged up to 6 months with diarrhea and/or more than 8 watery stools in the last 24 hours and/or more than 4 episodes of vomiting in the last 24 hours), or when mild or moderate dehydration is already present. Oral rehydration with ORS given in frequent, small amounts over 3-4 hours is successful in more than 90% of cases. Regular feeding can be begun immediately afterward. Laboratory testing of blood or stool is usually unnecessary. Children who can be rehydrated orally or through a nasogastric tube should not be given intravenous fluids.

[A multicentric study of a lactose free formula supplemented with Saccharomyces boulardii in children with acute diarrhea].

In a double-blind, randomized, controlled, multicentric study, the study compared the efficacy of a specific adapted formula (lactose-free, high-mineral, low-osmolarity formula, containing rice and pectin fortified with Saccharomyces boulardii) in the management of infants with acute diarrhea with a standard formula used to feed healthy infants from birth. Seventy infants with an average age of 163 days+/-11.7 suffering from acute diarrhea with an average of 6.6+/-0.4 stools per day received, after randomization, either a standard (control) formula (n=36) or an adapted lactose-free formula fortified with S. boulardii (26mg/100ml; n=34). The duration of the diarrhea was defined as the time needed until the occurrence of the first normal stool after the last liquid stool. At inclusion, the age, weight, and number of stools per day were the same in the two groups. There were 15 infants with rotavirus in the treated group and 13 in the control group. The duration of the diarrhea from time of inclusion was significantly reduced in the treated group (35.4+/-3.7h) versus the control group (67.1+/-5h; p<0.001), In both groups, with or without rotavirus, the duration of diarrhea did not depend on the presence or absence of rotavirus but only on the treatment. The average daily weight gain was significantly higher in the treated group compared with the control group (74.2+/-26.4g versus 23.7+/-6.7g; p<0.05). The oral rehydration solution consumption was, however, higher in the control group than in the treated group; the consumption of formula was higher in the treated group, but these differences were not significant. The number of stools as of Day 4 remained significantly higher in the control group than in the treated group. After 6.5 days, almost no S. boulardii was found in the stools. In moderately dehydrated infants (<10 %), the use of a specially designed formula, containing S. boulardii (Novalac AD+/Diarinova+), significantly shortens the duration of diarrhea and allows quicker weight regain than a standard formula.

[Treatment of infants with acute diarrhea in Hungary].

In the treatment of infants with acute diarrhoea complicated by mild to moderate dehydration, there is a great importance of rapid rehydration over 3-4 hours with oral rehydration solution containing 60 mmol/l sodium and then the rapid reintroduction of normal diet or breast feeding which should be continued all the time if possible. The pharmacological treatment of diarrhoea is not justified. In the present study which was part of a European multicentre survey using questionnaires the authors analysed how the recommendation of European Society of Pediatric Gastroenterology, Hepatology and Nutrition are followed in Hungary. It was evaluated 131 returned questionnaires, 80 of primary care and 51 of hospital-based pediatricians. The overwhelming majority of pediatricians (92%) recommended the oral rehydration at the beginning of treatment. The four fifth of them use the ORS with recommended composition. Only 31% of them use rapid oral rehydration over 3-4 hours. Merely 10% of them suggest the early reintroduction of normal feeding after the oral rehydration, while more than half of the respondent pediatricians (52%) think that temporarily the use of lactose free formula is justified. It is a very favourable fact that 84% of doctors recommend the continuation of breast feeding. Some kind of drugs for the treatment of diarrhoea is suggested by 15% of repliers. On the base of results it is obvious that the guidelines for the treatment of acute diarrhoea in infancy is complied only partially in Hungary and the reintroduction of normal feeding is delayed.

A comparison of rice-based oral rehydration solution and "early feeding" for the treatment of acute diarrhea in infants.

To compare the use of rice-based oral rehydration solution (R-ORS), with the introduction of food immediately after rehydration ("early feeding"), using standard glucose-based oral rehydration solution (G-ORS) in the management of acute diarrhea, we conducted a four-cell randomized, controlled trial among 200 hospitalized Egyptian infants between 3 and 18 months of age. During the rehydration phase (first 4 hours), three groups were given G-ORS and a fourth group was given R-ORS. During the subsequent maintenance phase, the control group was given a soy-based, lactose-free formula (G-ORS + SF), a second group (G-ORS + RF) was given a rice-based formula, and a third group (G-ORS + rice) was given boiled rice. The fourth group (R-ORS + SF) continued to receive R-ORS for the first 24 hours of the maintenance period, followed by a soy-based lactose-free formula. During the first and second 24 hours of the maintenance period, infants in the three treatment groups had a lower mean stool output in comparison with the control group (p = 0.006 and 0.03, respectively). The mean total stool output in the R-ORS + SF group was significantly lower than in the control group (p = 0.02). There were no statistically significant differences among the four groups in the mean duration of diarrhea. We conclude that (1) infants who were given R-ORS had reduced total stool output (by 35%) compared with the control group and (2) feeding of boiled rice or a rice-based formula immediately after rehydration therapy was as efficacious as treatment with R-ORS alone for 24 hours, followed by feeding with a soy-based, lactose-free formula.

Oral rehydration therapy

Feeding should usually resume within 2–3 hours after starting rehydration and should continue every 2–3 hours, day and night. For an initial cereal diet before a child regains his or her full appetite, the WHO recommends combining 25 grams skimmed milk powder, 20 grams vegetable oil, 60 grams sugar, and 60 grams rice powder or other cereal into 1,000 milliliters water and boiling gently for five minutes. Give 130 ml per kilogram of body weight during per 24 hours. A child who cannot or will not eat this minimum amount should be given the diet by nasogastric tube divided into six equal feedings. Later on, the child should be given cereal made with a greater amount of skimmed milk product and vegetable oil and slightly less sugar. As appetite fully returns, the child should be eating 200 ml per kilogram of body weight per day. Zinc, potassium, vitamin A, and other vitamins and minerals should be added to both recommended cereal products, or to the oral rehydration solution itself.

Use of a single solution for oral rehydration and maintenance therapy of infants with diarrhea and mild to moderate dehydration.

To compare the efficacy of two commonly used solutions in the rehydration of infants with mild to moderate dehydration caused by acute diarrhea in the United States. Double-blind, parallel-group, randomized study performed at Children's Hospital Medical Center. Sixty infant boys (< or = 2 years old), with mild (< or = 5%) or moderate (6 to 9%) dehydration caused by acute diarrhea of less than 1 week's duration were included in the study. Infants were randomly assigned to receive treatment with either a glucose-based oral rehydration solution (ORS) (Pedialyte, Ross Laboratories, Columbus, OH) or a rice syrup solids-based ORS (Infalyte, Mead Johnson Nutritional Group, Evansville, IN). After rehydration was achieved, patients entered a maintenance phase during which, in addition to a maintenance ORS, breast milk or a soy-based formula was offered; infants older than 1 year were also given a lactose-free diet. Rehydration was judged clinically. Infants remained on a metabolic bed during the study in to separate and quantitate urine and stool output. Therefore, in addition to clinical outcome, we compared intake, output and apparent absorption and retention of fluid, sodium, and potassium between groups. All patients were successfully rehydrated using an ORS without the use of intravenous fluids. No differences were detected between treatment groups in time to rehydration, percentage of weight gain after rehydration, consumption of ORS to achieve rehydration, or stool output. However, the apparent sodium absorption (net intake less fecal output) was greater in the Infalyte group than the Pedialyte group during the first 24 hours. The two maintenance oral electrolyte solutions (Pedialyte and Infalyte) most commonly used in the United States are effective as rehydration solutions for infants with mild to moderate dehydration. We speculate that a strategy for oral rehydration therapy in the United States, based on the use of a single solution during the rehydration and maintenance phase, might gain additional acceptance by practicing pediatricians and family physicians.

[Feeding infants and young children with acute diarrhea].

Acute gastroenteritis remains a common and often severe illness among infants and children throughout the world. The management of a child with acute diarrhea includes rehydration and maintenance fluids with oral rehydration solutions (ORS), combined with continued age-appropriate nutrition. However, although substantial data support the role of continued nutrition in improving gastrointestinal function and anthropometric, biochemical, and clinical outcomes, the practice of continued feeding during diarrheal episodes has been difficult to establish as accepted standard of care. Recommendations for maintenance dietary therapy depend on the age and diet history of the patient. It has been clear for many years that, when affected by gastroenteritis, breastfed infants should be continued on breast milk without any need for interruption and, by that way, will get faster recovery and improved nutrition. Moreover, many well-conducted studies have provided evidence that in formula-fed children not severely dehydrated, a rapid return to full feeding is well tolerated. Lactose intolerance and/or secondary cow's milk allergy are not a clinical concern for the vast majority of patients. In fact early refeeding i.e resumption of normal diet, in amounts sufficient to satisfy energy and nutrient requirements, should be the rule. However, in children younger than 6 months of age, the lack of suitable studies must lead to caution and use of specific lactose-free or extensively hydrolysate formulae, especially in case of severe and/or prolonged diarrhea. Several studies support the use of zinc supplementation or probiotics for acute diarrhea but some doubts persist in infant in developed countries.

After rehydration: what happens to the child?

Three-hundred infants and toddlers with diarrhoea were followed up for 5 days after initial rehydration with oral rehydration solution (ORS). When an average of 300-340 ml per day was given at home (520 ml if the diarrhoea was watery), only two children required re-hospitalization; one other child died whose voluminous losses should not have been treated at home. Fifteen per cent of the children still had watery diarrhoea and vomiting by the fifth day, perhaps as a result of multiple drug therapy. Continued feeding, especially breast milk and cereal grains, should reduce the duration of diarrhoea and vomiting (and perhaps the number of drugs). The amount of time a mother can spend giving ORS ultimately limits the amount a child receives.

WITHDRAWN: Rice-based oral rehydration solution for treating diarrhoea.

Oral rehydration therapy is used to treat dehydration caused by diarrhoea. However the rehydration solution does not reduce stool loss or length of illness. A solution able to do this may lessen the use of ineffective diarrhoea treatments as well as improve morbidity and mortality related to diarrhoea. The objective of this review was to assess the effects of rice-based oral rehydration salts solution compared with glucose-based oral rehydration salts solution on reduction of stool output and duration of diarrhoea in patients with acute watery diarrhoea. We searched the Cochrane Infectious Diseases Group trials register, the Cochrane Controlled Trials Register, Medline, Embase, Lilacs and the reference lists of relevant articles. We also contacted researchers in the field. Randomized trials comparing standard World Health Organization oral rehydration solution with an experimental oral rehydration salts solution in which glucose (20 grams per litre) was replaced by 50-80 grams per litre of rice powder, with the electrolytes remaining unchanged. Data were extracted independently by a statistician and a clinician. Twenty-two trials were included. Concealment of allocation was adequate in 15 of these trials. Irrespective of age, people with cholera who were given rice oral rehydration salts solution had substantially lower rates of stool loss than those given oral rehydration salts solution in the first 24 hours. Mean stool outputs in the first 24 hours were lower by 67 millilitres/kg of body weight (weighted mean difference -67.40, 95% confidence interval -94.26 to -41.53) in children, and by 51 millilitres/kg of body weight (weighted mean difference -51.07, 95% confidence interval -65.87 to -36.27) in adults. The rate of stool loss in infants and children with acute non-cholera diarrhoea was reduced by only four millilitres/kg of body weight (weighted mean difference -4.29, 95% confidence interval -9.36 to 0.78). Rice-based oral rehydration appears to be effective in reducing stool output in people with cholera. This effect was not apparent in infants and children with non-cholera diarrhoea.

[Recommendations for the diagnosis and management of pediatric acute gastroenteritis in Israel].

Nearly all children will experience at least one episode of acute gastroenteritis (AGE) by the age of three years. Acute gastroenteritis is a common cause of admissions to the pediatric wards in Israel, but usually the disease is mild. This paper aims to present guidelines for diagnosis and management of pediatric AGE in Israel, based on the recently published European recommendations after adjustment to the Israeli setup. The recommendations arising from the systematic review of the literature were graded by level of evidence. The guidelines were endorsed by the Israeli associations of Pediatric Gastroenterology, Pediatric Infectious Diseases and Pediatrics. The clinical signs with the predictive value for dehydration are weight loss, prolonged capillary refill, poor turgor, reduced urinary output and abnormal respiration. Routine stool or blood cultures are not recommended. Reduced or low osmolarity oral rehydration solutions (ORS) are the first line therapy for rehydration. Full diet, including lactose, should be resumed following the four hours required for rehydration. In most cases no medications are required for this self-limited disease but certain types of probiotics may shorten the diarrheal episode and reduce its severity. Antimicrobial therapy is not recommended in most cases but should be considered in shigellosis, during the first three days of campylobacter infectious and in other selected cases. Vaccination against rotavirus is recommended as per the recent European, American and Israeli guidelines. Implementation of the scientific evidence in clinical practice, may improve the standard of care of pediatric AGE in Israel.

Comparison of two regimens of feeding and oral electrolyte solutions in infants with diarrhea.

Glucose-based oral rehydration solutions (ORS) available in the United States do not appear to reduce the severity or duration of diarrhea. The use of cereal-derived ORS and cereal-based feedings appears to diminish the severity of illness in studies conducted in the developing world. To our knowledge, no controlled trials of cereal-derived ORS or cereal-based feedings have been performed in the United States. We performed a randomized, double-blind trial of two ORS feeding regimens in outpatients with diarrhea. Patients aged 2-13 months with acute watery diarrhea were enrolled. Subjects received standard glucose-based ORS in alternation with soy-based, lactose-free infant formula (Group 1) or rice syrup solid containing ORS in alternation with rice-based, lactose-free infant formula (Group 2). Subjects were visited at home daily to determine the severity of illness and characteristics of the stool. After the first 2 days, significantly more Group 1 subjects continued to have diarrhea than did Group 2 subjects (median duration of diarrhea 3 vs. 2 days) as demonstrated by Kaplan-Meier survival curves (p = 0.04). We conclude that infants fed a regimen consisting of rice syrup solid containing ORS and rice formula resolved their diarrhea sooner than did infants fed a regimen of standard glucose-based ORS and formula. The relative contributions of ORS and formula to this more rapid recovery can be elucidated by further studies.

Breath hydrogen responses in infants using lactose-rice formula and regular lactose formula.

Starch thickened infant formulas have been shown to relieve regurgitation and increase caloric retention. We compared the completeness of digestion of the carbohydrates in lactose-rice formula (study formula) with routine infant formula in infants with GER. A prospective open study of 30 normal, well-nourished infants with simple regurgitation was conducted. The clinical history on regurgitation, stool pattern and baseline breath hydrogen (bH2) test were obtained at entry, with the infants still using their original routine infant formula, and after a wash out period of 7 days, during which they were fed only with study formula. Analysis of bH2 results showed lower levels of bH2 at 1, 2 and 3 hours with study formula compared with the original formula at the 2nd and 3rd hour (p<0.05). The effectiveness of the study formula in managing GER was demonstrated by the fact that 26 out of 30 had either "some improvement" or a "good response." Hardening of the stool pattern was reported in 13 of the 30 infants after 1 week of study formula. The mean of peak bH2 in study formula fed subjects with formed and firm/hard stool was significantly lower than in those with soft and pasty stool. In conclusion, this study has shown the effectiveness of rice thickened infant formulas in managing infants with GER. Rice-starch has an additional advantage of ease of digestion. The hardening of stool pattern was also frequently observed.

Comparative efficacy of rice-based and glucose-based oral rehydration salts plus early reintroduction of food.

The use of oral rehydration salts (ORS) to restore fluid balance in children with diarrhoea is universally accepted. However, there is uncertainty about whether glucose-based ORS or ORS based on precooked rice powder is more effective. In a randomised trial we compared the two types of ORS in children who were given food immediately after completion of rehydration. 460 boys aged 3-18 months, admitted to hospital with acute diarrhoea and signs of dehydration, were randomly assigned to groups receiving rice-based and glucose-based ORS solution (230 to each group). After full rehydration (4-12 h), a weaning food consisting of rice and mixed vegetables was given until the diarrhoea stopped. Continuing losses of liquid stool and vomitus were replaced with the assigned ORS solution. There were no differences between the groups during the rehydration phase in stool volume, volume of ORS solution taken, duration of rehydration phase, or weight gain. However, after initiation of feeding, the glucose-based ORS group had significantly lower stool volumes than the rice-based ORS group (142 [95% CI 117-173] vs 96 [77-120] g/kg); they also took a smaller amount of ORS solution (153 [127-185] vs 111 [90-136] mL/kg) and had a shorter duration of diarrhoea (55 [SD 35] vs 44 [35] h). Glucose-based ORS solution was more effective than rice-based ORS solution for the treatment of diarrhoea in children when feeding with a rice-based diet was started soon after correction of dehydration. These results support the continued recommendation of glucose-based ORS solution as standard therapy for treatment of children with acute diarrhoea and emphasize the importance of resuming feeding as soon as dehydration has been corrected.

Management of acute gastroenteritis in Europe and the impact of the new recommendations: a multicenter study. The Working Group on acute Diarrhoea of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition.

The European Society for Paediatric Gasteroenterology, Hepatology and Nutrition (ESPGHAN) issued two sets of recommendations for the treatment of infants with acute gastroenteritis (1992, 1997). The purpose of this multicentre study performed in 29 European countries was to determine how closely current treatment compares with the ESPGHAN recommendations. The outline of the study was based on a questionnaire that addressed the management of a 6-month-old infant with acute gastroenteritis complicated by mild to moderate dehydration. National coordinators circulated the questionnaire to randomly selected primary care physicians and to hospital-based paediatricians. A total of 2997 questionnaires were returned, of which 1768 were from Western Europe (WE) and 1229 from Central and Eastern Europe (CEE). Eighty-four percent of responding physicians said they would follow the ESPGHAN recommendation to use oral rehydration solution (ORS) for rehydration, with 66% using an ORS containing 60 mmol/l sodium ORS. Only 16% (WE 15%, CEE 19%) would follow the guidelines and use rapid oral rehydration over 3 to 4 hours. Forty-five percent would rehydrate infants in a 3- to 6-hour period (WE 35%, CEE 60%), and 17% (WE 23%, CEE 9%) would extend the rehydration period to 12 to 24 hours. ESPGHAN recommendation of rapid reintroduction of normal feeding after 3 to 4 hours of oral rehydration would be followed by only 21% of responding physicians, and only 43% (WE 46%, CEE 38%) would start feeding with full-strength formula. However, the guideline about continuation of breast-feeding is widely followed (total 77%; WE 78%, CEE 75%). Thirty-six percent (WE 45%, CEE 23%) use a lactose-containing formula after successful oral rehydration. Contrary to the ESPGHAN guideline 35% (WE 30%, CEE 42%) would use a lactose-free formula and 19% (WE 12%, CEE 28%) a lactose and cow's milk protein-free formula. Only 37% (WE 30%, CEE 46%) of responding physicians would follow the recommendation to use ORS to replace ongoing losses from watery diarrhoea. The results of the survey suggest that with the exception of recommending ORS for rehydration and continuation of breast-feeding during diarrhoea, a minority of responding European physicians follow the ESPGHAN guidelines for optimal management of children with acute gastroenteritis.

[Acute gastroenteritis and dehydration in infants].

Gastroenteritis continue to be a major cause of mortality and morbidity worldwide. The main objectives in the approach to a child with acute gastroenteritis are to assess the degree of dehydration and provide fluid and electrolyte replacement. The general agreement among paediatric gastroenterologists is to consider that the optimal management of acute gastroenteritis in mild to moderately dehydrated children in Europe should consist of the following practical guidelines: use of oral fast rehydration solution (ORS) to correct estimated dehydration over 3-4 hours using an hypo-osmolar solution; continuation of breast feeding throughout; early refeeding i.e. resumption of normal diet (without restriction of lactose intake) after 4 hours rehydration in most children, while maintaining supplementing fluids with ORS in order to prevent further dehydration; no unnecessary medication.

Gastroenteritis

Dietary It is recommended that breast-fed infants continue to be nursed in the usual fashion, and that formula-fed infants continue their formula immediately after rehydration with ORT. Lactose-free or lactose-reduced formulas usually are not necessary. Children should continue their usual diet during episodes of diarrhea with the exception that foods high in simple sugars should be avoided. The BRAT diet (bananas, rice, applesauce, toast and tea) is no longer recommended, as it contains insufficient nutrients and has no benefit over normal feeding.

[Comparison of an oral rehydration solution (ORS 90) and a "supersolution" during acute infantile diarrhea].

As acute diarrhoea gives rise to a loss of water and electrolytes, the most effective therapy results the oral rehydration. Harrison and Darrow tried this way first. Only in the years '60 we began to use oral rehydration commonly. Usually, solutions contain glucose, Na, K, Cl, Bicarbonate in various concentration. When glucose is replaced by rice starch or when amino acid are added, then we have a "supersolution". Nutrients intake provides more calories and increases absorption Na-depending. We used one of these new "supersolutions". Two groups of children, hospitalised for acute diarrhoea, were treated with different rehydration solutions. The first one (Dicodral Forte), prepared according to the WHO, contains glucose and electrolytes as we know. The second one (Amidral) has rice starch instead of glucose and presents a lower concentration of Na and Cl. The present study looked over: A) Weight increase from the first to the third day of hospitalisation in our department. B) Duration of diarrhea. C) Number of stools. D) Haematological values before and after rehydration. All the patients ingested the same amount of solution. Children which received WHO's solution presented diarrhea longer than others (2.55 +/- 2.06 vs 2.2 +/- 1.1 days). Number of stools was below average too (3.05 +/- 2.64 vs 2.8 +/- 1.5). Refeeding was done employing the same milk used in former times. AMIDRAL was used to dilute the milk when it was possible. Most important result is the increase of weight we had using this "supersolution". 15/20 children which received AMIDRAL showed an increase of their weight as shown in Tab. 1.

Effectiveness of packed rice-oral rehydration solution among children with acute watery diarrhea.

This study aims to compare the effectiveness between the packed rice-oral rehydration solution (R-ORS) and the glucose-based oral rehydration solution (G-ORS) in children with acute watery diarrhea. Randomized control trial was conducted to compare duration of diarrhea, stool frequency, incremental weight gain, intravenous fluid requirement, and duration of admission. Subjects were 70 pediatric patients (9-60 months-old) and were equally divided into two groups (n=35 for each): treatment group (with R-ORS treatment) and control group (with G-ORS treatment). The data were collected during January 1, 2007 to January 2008. All patients were treated with oral rehydration therapy within first 4 hours of admission. Intravenous rehydration was also scheduled. Both groups were fed with rice gruel or lactose-free formula as tolerated. Using survival analysis, both duration of diarrhea and admission was significantly shortened in the treatment group compared to the control group. (27.5 hrs. vs. 40.5 hrs: p = 0.01 and 40.1 hrs. vs. 56.0 hrs: p = 0.02 respectively). However, stool frequency, incremental weight gain and intravenous fluid requirement between the two groups remained insignificantly different. R-ORS was more effective in the management of acute watery diarrhea in children. Duration of diarrhea and treatment was shortened when compared to G-ORS.

Is rice based oral rehydration therapy effective in young infants?

Rice based oral rehydration therapy (ORT) solutions have been shown to be superior to glucose oral rehydration salts (World Health Organisation (WHO) ORS) in reducing stool volume and duration of diarrhoea in children and adults. Rice based ORT has been used only sparingly in young infants, however, because of theoretical concerns about digestibility. A randomised controlled trial of rice based ORT (50 g rice and electrolytes identical to WHO ORS) and WHO ORS was carried out in 52 male infants less than 6 months old with moderately severe acute diarrhoea to evaluate efficacy and digestibility. Nineteen (70%) of 27 children who received rice based ORT and 18 (72%) of 25 children who received WHO ORS were treated successfully. The mean (SD) diarrhoeal stool output for the first 24 hours of treatment was significantly lower in the infants receiving the rice based ORT than in those receiving WHO ORS (101.0 (60.5) v 137.1 (74.6) g/kg). The stool output was also significantly less in the rice based ORT group in the second 24 hours. Infants in the rice based ORT group drank significantly less rehydration solution than infants in the WHO ORS group (mean (SD) 165.4 (77.4) v 217.9 (86.1) during the first 24 hours of treatment. There was no difference in the duration of diarrhoea between the groups. The volume of breast and formula feeding was similar in the two groups. No difference was seen in the frequency of finding reducing substances or acid pH in the stools of either group of children. The results suggest that rice based ORT is as effective as WHO ORS in infants with moderately severe diarrhoea and that rice based ORT is as well tolerated as WHO ORS in infants.

Management of acute diarrhea in infants.

In 1999, children seen in the emergency room of a developed country for watery diarrhea and dehydration will most likely receive an intravenous infusion of fluid, followed by instructions to give oral rehydration solution (ORS) and clear liquids for a day, followed by half-strength lactose-free formula. In fact, the majority of these children could best be managed with supervised ORS followed by early (within 4-6 h) refeeding of their normal diet, based on large numbers of clinical trials and a meta-analysis. In the next decade, effective therapy in addition to glucose-containing oral rehydration solutions should be available which should reduce diarrheal volume and duration of purging. These include amino acid-supplemented "Super ORSs," ORS with soluble fibers, liquid zinc, and probiotic milks containing bacteria which boost the immune response and reduce stool number. In addition, children wealthy enough to be able to afford the new tetravalent vaccine will be largely protected from dehydrating rotavirus diarrhea, the most common cause of dehydration in infants.

InternalMed_Harrison

Moderatec,d <4 months (<5 kg) 200–400 mL of ORS 4–11 months (5–<8 kg) 400–600 mL of ORS 12–23 months (8–<11 kg) 600–800 mL of ORS 2–4 years (11–<16 kg) 800–1200 mL of ORS 5–14 years (16–<30 kg) 1200–2200 mL of ORS ≥15 years (≥30 kg) 2200–4000 mL of ORS All ages and weights Undertake IV fluid replacement with Ringer’s lactate (or, if not available, normal saline). Give 100 mL/kg in the first 3-h period (or the first 6-h period for children <12 months old); start rapidly, then slow down. Give a total of 200 mL/ kg in the first 24 h. Continue until the patient is awake, can ingest ORS, and no longer has a weak pulse. aAdapted from World Health Organization: First steps for managing an outbreak of acute diarrhoea. Global Task Force on Cholera Control, 2009 (www.who.int/topics/cholera). bContinue normal feeding during treatment. cReassess regularly; monitor stool and vomit output. dVolumes of ORS listed should be given within the first 4 h. Abbreviation: ORS, oral rehydration solution.

Oral rehydration therapy

WHO/UNICEF guidelines suggest ORT should begin at the first sign of diarrhea in order to prevent dehydration. Babies may be given ORS with a dropper or a syringe. Infants under two may be given a teaspoon of ORS fluid every one to two minutes. Older children and adults should take frequent sips from a cup, with a recommended intake of 200–400 ml of solution after every loose movement. The WHO recommends giving children under two a quarter- to a half-cup of fluid following each loose bowel movement and older children a half- to a full cup. If the person vomits, the caregiver should wait 5–10 minutes and then resume giving ORS. ORS may be given by aid workers or health care workers in refugee camps, health clinics and hospital settings. Mothers should remain with their children and be taught how to give ORS. This will help to prepare them to give ORT at home in the future. Breastfeeding should be continued throughout ORT. Associated therapies Zinc

Oral rehydration therapy is used to treat dehydration caused by diarrhoea. However the rehydration solution does not reduce stool loss or length of illness. A solution able to do this may lessen the use of ineffective diarrhoea treatments as well as improve morbidity and mortality related to diarrhoea. The objective of this review was to assess the effects of rice-based oral rehydration salts solution compared with glucose-based oral rehydration salts solution on reduction of stool output and duration of diarrhoea in patients with acute watery diarrhoea. We searched the Cochrane Infectious Diseases Group trials register, the Cochrane Controlled Trials Register, Medline, Embase, Lilacs and the reference lists of relevant articles. We also contacted researchers in the field. Randomized trials comparing standard World Health Organization oral rehydration solution with an experimental oral rehydration salts solution in which glucose (20 grams per litre) was replaced by 50-80 grams per litre of rice powder, with the electrolytes remaining unchanged. Data were extracted independently by a statistician and a clinician. Twenty-two trials were included. Concealment of allocation was adequate in 15 of these trials. Irrespective of age, people with cholera who were given rice oral rehydration salts solution had substantially lower rates of stool loss than those given oral rehydration salts solution in the first 24 hours. Mean stool outputs in the first 24 hours were lower by 67 millilitres/kg of body weight (weighted mean difference -67.4, 95% confidence interval -94.3 to -41.0) in children, and by 51 millilitres/kg of body weight (weighted mean difference -51.1, 95% confidence interval -65.9 to -36.3) in adults. The rate of stool loss in infants and children with acute non-cholera diarrhoea was reduced by only four millilitres/kg of body weight (weighted mean difference -4.3, 95% confidence interval -9.3 to 0.8). Rice-based oral rehydration appears to be effective in reducing stool output in people with cholera. This effect was not apparent in infants and children with non-cholera diarrhoea.

A traditional diet as part of oral rehydration therapy in severe acute diarrhoea in young children.

Recently, the role of feeding as treatment of acute diarrhoea has received increasing attention. To assess the efficacy of early feeding in acute diarrhoea, we conducted a randomised, clinical trial of a traditional legume-based weaning diet khitchri in boys 9 to 48 months old with moderate to severe dehydration. Khitchri is composed of rice and lentils cooked with cottonseed oil. Children were randomly allocated to 2 groups: group A received only WHO ORS but no food for the first 24 hours and then khitchri and half-strength cow's milk formula freely; group B received khitchri and the half-strength formula in addition to ORS after the initial rehydration period of 4 to 6 hours. The mean period of evaluation was 3 days. 69 patients were admitted into the study, 33 in group A and 36 in group B. The initial mean purging rate for the children was greater than 200 g/kg/day. Six children did not complete the study because they developed intercurrent infections or were removed by their parents for non-medical reasons. Of the 63 patients who were evaluated, 44 (70%) were successfully treated, 21 in group A and 23 in group B. There were no significant differences in the 2 groups in mean stool output, number of stools, or weight gain, although a trend toward earlier improvement was seen in group B. These data indicate that early feeding of khitchri and WHO/ORS may be as well tolerated as WHO/ORS alone in the first 24 hours treatment of severe acute diarrhoea in young children.

[Oral rice-based rehydration solution (SRO), alternative of SRO of WHO in acute diarrhea in malnourished patients].

Although malnutrition is frequently associated with diarrhea, most oral rehydration solutions have been tested in well-nourished children. The study tests efficacy of rice, a traditional treatment for diarrhea in Madagascar. 150 severely malnourished children, aged 6 months to 3 years, took part in this randomized trial. All the children were given oral rehydration solution, (100 ml/kg) in the first 6 hours. The first group (68 children) was given a solution containing glucose, (20 g/l). The second group (82 children) was given a solution containing rice powder (50 g/l). Treatment was then continued according to WHO recommendations, including feeding after rehydration (mixture of milk, oil and sugar). The age, weight, height, duration of diarrhea before admission, degree of dehydration and pathogens in stools of the two groups were comparable on admission. Only 2 patients were withdrawn from the trial. The percentage of death was the same in both groups: 16% of those given glucose and 15% of those given rice-based rehydration solution. The weight gains were similar in both groups; the duration of diarrhea was 89 +/- 6 hours in the glucose-fed groups and 68 +/- 4 hours for those given the rice-based rehydration solution (p < 0.02). Both glucose and rice-based rehydration solutions are equally effective for rehydrating severely malnourished children with acute diarrhea. The rice-based rehydration solution also reduces the duration of diarrhea.

Low milk supply

To evaluate whether milk supply is actually insufficient, qualitative parameters should be used such as the following: By 3–5 days, of age, the infant should be stooling 3–4 times per day and urinating 3—5 times per day. By 5–7 days of age, there should be 3—6 stools per day and 4—6 urines. The infant should be alert, have good muscle tone, and show no signs of dehydration. The infant should be consistently gaining weight and growing. In newborns, a loss of more than 5 to 7 percent of birth weight warrants investigation. The use of IV fluids in labour tends to artificially increase the birth weight of the baby, and subsequently inflate the baby's weight loss. Newborns should regain their birth weight by two weeks of age, and gain at least 150 g per week. If an infant is not showing these signs of growing well, other possible causes include: Poor milk transfer due to tongue-tie, or cleft palate. Medical conditions in the infant, such as malabsorption of nutrients.

Oral rehydration therapy

Feeding After severe dehydration is corrected and appetite returns, feeding the person speeds the recovery of normal intestinal function, minimizes weight loss and supports continued growth in children. Small frequent meals are best tolerated (offering the child food every three to four hours). Mothers should continue to breastfeed. A child with watery diarrhea typically regains his or her appetite as soon as dehydration is corrected, whereas a child with bloody diarrhea often eats poorly until the illness resolves. Such children should be encouraged to resume normal feeding as soon as possible. Once diarrhea is corrected, the WHO recommends giving the child an extra meal each day for two weeks, and longer if the child is malnourished. Children with malnutrition