More lives are saved throughout the world by rehydrating children with acute diarrhea than by any other medical intervention except for immunization. Worldwide, there are approximately 1.7 billion cases of diarrhea annually that kill about 760,000 children, nearly all of whom are <5 years old and living in developing countries.19 Up to 70% of these deaths are due to dehydration.
More than 90% of patients with acute infectious diarrhea can be successfully resuscitated using ORS correctly.20 Yet <25% of those who could benefit from appropriate ORT receive it.21 Oral rehydration therapy generally results in rehydration and the resumption of solid food intake in 4 to 8 hours.22
Administering Oral Rehydration Solutions
For infants, use a clean eyedropper or a syringe without the needle. Drop small amounts into the mouth every 1 to 2 minutes. Also, continue breast-feeding. An alternative is to make a tiny puncture at the tip of a rubber glove finger, fill the finger or glove with ORS (while holding the hole closed), and use that as a nipple. The plastic sheath in which some 3-mL disposable syringes are still packed also works well as a mini-bottle for small-volume liquids or medications.23 Slip a standard baby bottle nipple over the open end; it holds 9 cc.
For children or adults, give the ORS using a clean spoon or cup. Do not use feeding bottles unless they can be properly cleaned. Offer children <2 years old a teaspoonful every 1 to 2 minutes. Alternate other fluids, such as breast milk and juices, with the ORS. Older children and adults should sip from the cup every 1 to 2 minutes. Adults and large children should drink at least 3 L (3 quarts) per day until the diarrhea stops. Chilling the ORS before giving it to the patient may make it more palatable.
Continue to try to feed the drink to the patient slowly, small sips at a time. The body will retain some of the fluids and salts needed, even though there is vomiting. If the patient vomits, wait for 10 minutes and then begin again. Have the patient slowly sip ORS after every loose bowel movement.
In severely dehydrated, but conscious, patients, have them sip ORS every 5 minutes until urination returns to normal (four to five times per day and yellow color) and they no longer feel thirsty.
Oral Rehydration Solutions/Oral Rehydration Therapy
Standard and Reduced-Osmolarity Oral Rehydration Solutions
Oral rehydration solutions come as premade commercial packets, hospital-made solutions, or homemade solutions. In 2002, the World Health Organization (WHO) began recommending a new, low-osmolarity ORS containing less sodium and glucose (Table 11-5). This change has led to some cases of severe hyponatremia, while not significantly changing patients’ disease course.24 The solution does, however, replace bicarbonate with citrate, improving its stability in tropical climates. When stored in temperatures up to 60°C (140°F), no discoloration occurs and the solution has a shelf life of about 3 years.
TABLE 11-5Composition of the WHO Oral Rehydration Solutions (ORS) |Favorite Table|Download (.pdf) TABLE 11-5 Composition of the WHO Oral Rehydration Solutions (ORS)
| ||Standard ORS (1975) ||Reduced-Osmolarity ORS (2002) |
|Na+, mEq/L ||90 ||75 |
|K+, mEq/L ||20 ||20 |
|Cl–, mEq/L ||80 ||65 |
|Citrate–3, mmol/L ||10 ||10 |
|Glucose, mmol/La ||111 ||75 |
|Osmolarity, mOsm/L ||311 ||245 |
Preparing Oral Rehydration Solutions
Commercial Oral Rehydration Solution Packets
To reconstitute a commercial ORS packet, add one packet to 1 L (1 quart; 5 cupfuls) of clean water. (Filter the water using cloth or gauze and boil it, if necessary; let it cool.) Stir the mixture until all the contents dissolve. Even if the powder clumps or hardens, there should be no difficulty in producing a satisfactory solution.26
Homemade Oral Rehydration Solutions
Three methods for making homemade ORS are described in the following paragraphs. Once prepared, store the ORS in a cool place. If you have a refrigerator, store it there. If the patient still needs ORS after 24 hours, make a fresh solution. Do not use too much salt or the patient may refuse to drink it. A rough guide to the amount of salt is that the solution should taste no saltier than tears. Too little salt is less effective in restoring the needed chemicals to the body—and may lead to hyponatremic seizures. If only a 0.5-L (1-pint) container is available, use only half the listed amounts of ingredients to prepare ORS.
To prepare 1 L (1 quart) of homemade ORS, start with 1 L (1 quart; 5 cupfuls) clean water. (Filter the water using cloth or gauze and boil it, if necessary; let it cool.) Add one level teaspoon of salt and eight level teaspoons of sugar. Mix the solution. Add 0.5 cup orange juice or half a mashed banana to provide potassium and improve the taste.26
To prepare 1 L (1 quart) of homemade ORS, start with 1 L (1 quart; 5 cupfuls) clean water. (Filter the water using cloth or gauze and boil it, if necessary; let it cool.) Add one-fourth teaspoon baking soda (bicarbonate of soda) and one-fourth teaspoon salt. Double the amount of salt (to one-half teaspoon) if baking soda is not available. Mix the solution. Add two tablespoons sugar or honey and mix until everything dissolves. Add 0.5 cup orange juice or half a mashed banana to provide potassium and improve the taste.26
Plantain-based ORS. Plantain flour-based ORS uses green Hartón plantain (Musa paradisiaca), which is common in Columbia and elsewhere. (There are many plantain/banana varieties; several can be used for ORS.) Remove the plantain’s peel and cut it into very thin slices. Dry these slices in the sun and grind them into powder. Add 50 g plantain flour to 1100 mL water and 3.5 g sodium chloride. Mix these and boil the mixture for 12 minutes. This results in an ORS with a mean osmolarity of 134 mOsm/L.
This ORS formulation was shown to decrease diarrhea frequency by one-third and the volume by one-half over that in children taking the WHO formula. However, some children taking this formula had nonclinically significant hyponatremia and hypokalemia.27
Alternatives to Oral Rehydration Solution
If ORS is not available or cannot be made, reasonable alternatives are breast milk, vegetable or chicken soup with salt, other salted drinks (e.g., salted rice water, salted yogurt drink), or other normally unsalted drinks to which 3 g/L salt has been added.
Two pinches of salt using three fingers (thumb, index, and long fingers coming together) are often said to equal about 3.5 g, and this measure is used as an improvised salt measure for homemade ORT solutions.12 However, this commonly used measure is highly inaccurate and can vary by a factor of 30 between individuals, meaning that it can deliver a negligible amount of salt or nearly 4 g with each pinch.28 A more accurate measure is to use one-fourth teaspoon iodized salt, which equals 1.5 g and which, in 1 L of water, produces a concentration of 90 mmol/L; using slightly less will yield the currently recommended ORS concentration of 75 mmol/L.
As can be seen in Table 11-6, some alternative rehydration solutions commonly used at home (e.g., apple juice, Coca Cola Classic) are not suitable due to their osmolarity, electrolyte composition, or both.
TABLE 11-6Composition of Commonly Used Rehydration Solutions |Favorite Table|Download (.pdf) TABLE 11-6 Composition of Commonly Used Rehydration Solutions
|Solution ||Carbohydratea (g/L) ||Sodium (mmol/L) ||Potassium (mmol/L) ||Chlorideb (mmol/L) ||Basec (mmol/L) ||Osmolarity (mOsm/L) |
|WHO ORS (2002) ||13.5 ||75 ||20 ||65 ||30 ||245 |
|WHO ORS (1975) ||20 ||90 ||20 ||80 ||30 ||311 |
|Commercial Sugar-Electrolyte Solutions |
|Pedialyte ||25 ||45 ||20 ||35 ||30 ||250 |
|Pedialyte Freezer Pop ||25 ||45 ||20 ||35 ||30 ||250 |
|Enfalyte ||30 ||50 ||25 ||45 ||34 ||200 |
|Rehydralyte ||25 ||75 ||20 ||65 ||30 ||305 |
|Cerealyte ||40 ||50-90 ||20 ||— ||30 ||220 |
|Gatorade (premixed) ||46 ||20 ||3 ||3 ||20 ||330 |
|The following solutions are generally not appropriate for rehydration due to their osmolarity, electrolyte content, or both. |
|Commercial Clear Liquids |
|Jell-O ||20 ||22-27 ||1.3-2.0 ||26 ||— ||570-640 |
|Coca Cola (Classic) ||112 ||1.6 ||— ||— ||13.4 ||650 |
|Ginger ale ||53 ||2.7 ||0.1-1.5 ||0.2 ||4 ||520-540 |
|7-Up ||74 ||5.0-5.5 ||1-2 ||6.5 ||— ||520-560 |
|Kool-Aid (sugarless) ||— ||0.5-1.2 ||0.1-1.3 ||— ||— ||250-590 |
|Popsicles ||180 ||4.7-5.6 ||0.5-2.0 ||6 ||— ||670-720 |
|Fruit Juices |
|Apple (liquid) ||120 ||0.4 ||44 ||45 ||— ||730 |
|Grape (concentrate) ||151 ||0.8-2.8 ||31-44 ||4 ||32 ||1170-1190 |
|Orange (concentrate) ||86 ||0.1-2.5 ||46-65 ||20 ||50 ||540-710 |
|Other Liquids |
|Beef bouillon (cubes) ||— ||110-170 ||5.5-11 ||130 ||— ||300-390 |
|Chicken broth (canned) ||— ||170-250 ||2.2-8.2 ||210 ||— ||380-500 |
|Tea (unsweetened) ||— ||0 ||5 ||5 ||— ||~0 |
|Milk ||4.9 ||22 ||36 ||58 ||30 ||260 |
Self-Administered Oral Rehydration
ORS can be self-administered with a straw. For adults and cooperative older children, a simple and inexpensive method exists for them to administer their own ORS—if they can resist the temptation to drink too much or too often. Self-administration markedly reduces staff time associated with managing nasogastric (NG) feedings or parenteral infusions, especially for children without an adult family member who can administer ORS. Simply fill a disinfected or sterile IV container, another bottle, or a commercial ORS bottle with the desired liquid and hang it (inverted) from an IV pole or hook.
Hang a loop of the tubing higher than the fluid level in the bottle and give the other end to the patient. Depending on the size of the bottle and the tubing, adjust the bottle’s height until there is no spontaneous flow. (No flow controller is needed.) When the patient sucks on the tube, a mouthful of fluid comes out; when suction stops, the fluid flow stops. Do not use this for patients who cannot suck the fluid or who have difficulty swallowing.30
Use a piece of orthopedic stockinet, stretch bandage, or even the sleeve from a shirt to hang bottles or bags without hooks or handles. Insert the bottle into the material, and tie the end at the bottom of the container (the end away from the IV tubing) to a pole or hook. Cut a slit in the other end so it can be tied—and retied—tightly around the end with the IV tubing. Many Pedialyte bottles now come so a straw can be inserted. An IV tubing connection fits this hole perfectly.
Under normal circumstances, adult surgical patients are kept NPO (nothing by mouth) and are not allowed to ingest oral food or liquid for hours prior to surgery. But, in rudimentary environments, some latitude is needed so as not to exacerbate the situation.
Boulton and Cole, writing about care in austere circumstances, noted that stomach “emptying time for fluids is often overestimated—2 hours for water or clear fluids is normally adequate. Nonmedical auxiliaries and first aid workers should be encouraged to give moderate amounts of water to injured patients who are conscious and not vomiting; this is especially necessary in isolated circumstances where evacuation is likely to be prolonged and medical aid delayed.”31