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ORAL REHYDRATON SOLUTIONORAL REHYDRATON SOLUTION�� ORS ORS --special combination of dry salts that, when special combination of dry salts that, when
properly mixed with safe water, can help properly mixed with safe water, can help rehydraterehydrate the body when a lot of fluid has been the body when a lot of fluid has been lost due to diarrhoea.lost due to diarrhoea.
�� Use of ORT prevents deaths of 1 million to 2 Use of ORT prevents deaths of 1 million to 2 million children each yrmillion children each yr
�� Basis of ORS Basis of ORS --During During Diarrhoea,evenDiarrhoea,even thou Na & thou Na & H2O are lost H2O are lost Glucose,AAGlucose,AA, , DipeptidesDipeptides are are absorbed without absorbed without difficulty.Sodifficulty.So……. …….
WHO Recommended ORS typesWHO Recommended ORS typesORS BicarbonateORS Bicarbonate�� NaClNaCl --3.5g3.5g�� NaHCo3 NaHCo3 --2.5g2.5g�� KClKCl --1.5g1.5g�� Glucose Glucose --20g20g�� Water Water --1L1L
ORS CitrateORS Citrate�� NaClNaCl --3.5g3.5g�� Trisod.citrateTrisod.citrate
dehydrate dehydrate --2.9g2.9g�� KClKCl --1.5g1.5g�� Glucose Glucose --20g20g�� Water Water --1L1L
TYPES OF DEHYDRATIONTYPES OF DEHYDRATION�� 50%cases 50%cases -- IsoNatremicIsoNatremic typetype�� 45% 45% -- HyponatremicHyponatremic typetype�� 5% 5% -- HypernatremicHypernatremic typetype�� Why K+ in ORS? Why K+ in ORS? �� Why HCO3 in ORS?Why HCO3 in ORS?
INDICATIONSINDICATIONS
�� MILD to MODERTE dehydrationMILD to MODERTE dehydration
�� As MAINTENANCE therapy in severe As MAINTENANCE therapy in severe dehydrationdehydration
TYPES OF ORS FORMULATIONSTYPES OF ORS FORMULATIONS�� Glucose based ORSGlucose based ORS
�� Rice based ORSRice based ORS
�� Low Low osmolarityosmolarity ORSORS
�� Home available ORSHome available ORS
�� ORS with other nutrientsORS with other nutrients
Oral Oral RehydrationRehydration TherapyTherapy�� Home made Home made -- sugar(40g) +salt (4g) solutionsugar(40g) +salt (4g) solution
�� Food based Food based --rice water(50g)+salt(40g)rice water(50g)+salt(40g)--lassilassi + salt+ salt
�� Others Others --plain H2O, lemon water, coconut plain H2O, lemon water, coconut water, rice kanji, dhal water water, rice kanji, dhal water without salt without salt
WHAT IS NOT ORT?WHAT IS NOT ORT?�� Glucose water without saltGlucose water without salt
�� Fluids without starch / sugar & salt in children Fluids without starch / sugar & salt in children who are starvedwho are starved
�� Fluids consumed in small Fluids consumed in small amounts.egamounts.eg-- tea.tea.
IMPROVED ORSIMPROVED ORS�� APPROACH 1:APPROACH 1:
Glucose Glucose -- replaced by starch based cereal replaced by starch based cereal powder(50g/L) powder(50g/L)
eg:cookedeg:cooked rice powderrice powder�� APPROACH 2:APPROACH 2:
Glucose Glucose polymers(Maltodextrin)ORpolymers(Maltodextrin)OR AA areAA arecombined with or used instead of glucosecombined with or used instead of glucose( AA & ( AA & DipeptidesDipeptides cause increase in cause increase in
absorption of absorption of H2O &Na by diff H2O &Na by diff mechanism. So double benefit) mechanism. So double benefit)
LOW OSMOLARITY ORSLOW OSMOLARITY ORS
�� Why low Why low osmolarityosmolarity??In stool outputIn stool outputDehydrationDehydrationneed for IV fluidsneed for IV fluids
�� In both Na & Glucose results in in In both Na & Glucose results in in osmolarityosmolarity
�� Overall Overall –– 224mOsm/L(Glu224mOsm/L(Glu--84 & Na84 & Na--60)60)
LOW OSMOLARITY ORSLOW OSMOLARITY ORS
20.520.5Total WeightTotal Weight
2.92.9TrisodiumTrisodium citrate, citrate, dihydratedihydrate
1.51.5Potassium chloridePotassium chloride
113.53.5Glucose, anhydrous Glucose, anhydrous
2.62.6Sodium chloride Sodium chloride
gramsgrams//litrelitre
Reduced Reduced osmolarityosmolarity ORSORS
245245Total Total OsmolarityOsmolarity
1010CitrateCitrate
2020PotassiumPotassium
7575GlucoseGlucose
6565Chloride Chloride
7575Sodium Sodium
MmolMmol//litrelitre
Reduced Reduced osmolarityosmolarity ORSORS
245245
1010
2020
6565
7575
7575
((mEqmEq or or mmol/lmmol/l))
210210--260260251251311311OsmolarityOsmolarity
101030301010CitrateCitrate
202020202020PotassiumPotassium
6060--707040408080ChlorideChloride
6060--707050509090SodiumSodium
7575--9090111111111111Glucose Glucose
((mEqmEq or or mmol/lmmol/l))
((mEqmEq or or mmol/lmmol/l))
((mEqmEq or or mmol/lmmol/l))
Reduced Reduced OsmolarityOsmolarity ORS solutions ORS solutions Standard ORS Standard ORS solution solution
RICE BASED ORSRICE BASED ORS�� Tastes better and provides more calories than the glucoseTastes better and provides more calories than the glucose--based based �� culturally acceptable, culturally acceptable, �� reduces stool volume (by about 40 percent) reduces stool volume (by about 40 percent) �� shortens the duration of diarrhea in both cholera and other seveshortens the duration of diarrhea in both cholera and other severe re
diarrhealdiarrheal diseases.diseases.
�� Starches other than rice,Starches other than rice, including wheat flour and maize, have including wheat flour and maize, have also been shown to reducealso been shown to reduce stool volume in patients with cholera.stool volume in patients with cholera.
�� reduce diarrhea by adding more substrate to thereduce diarrhea by adding more substrate to the gut lumen gut lumen without increasing osmolality, thus providing additionalwithout increasing osmolality, thus providing additional glucose glucose molecules for glucosemolecules for glucose--mediated absorption.mediated absorption.
HOME AVAILABLE ORSHOME AVAILABLE ORS
�� SUGAR SUGAR -- 3 Finger scoop &3 Finger scoop &Salt Salt -- 3 Finger pinch &3 Finger pinch &1L 1L -- boiled & cooled waterboiled & cooled water
�� Rice kanji , tea Rice kanji , tea dicoctiondicoction , lemon water, etc.,, lemon water, etc.,
Home based ORSHome based ORS�� HomeHome--prepared solutions prepared solutions -- recommended for use recommended for use
by parents to give to their child immediately after by parents to give to their child immediately after an attack of diarrhoea starts and BEFORE any an attack of diarrhoea starts and BEFORE any signs of dehydration occursigns of dehydration occur
�� Basically, the idea is to PREVENT dehydration Basically, the idea is to PREVENT dehydration and PRESERVE good nutritional status by and PRESERVE good nutritional status by maintaining fluid and food intake.maintaining fluid and food intake.
HOME MADE ORSHOME MADE ORS�� Home made ORS recipeHome made ORS recipe
Preparing a 1 (one) Preparing a 1 (one) litrelitre oral oral rehydrationrehydration solution [ORS] using Salt, solution [ORS] using Salt, Sugar and Water at HomeSugar and Water at Home
Mix an oral Mix an oral rehydrationrehydration solution usingsolution using one of the following recipes; one of the following recipes; depending on depending on ingredients and container availabilityingredients and container availability::
Ingredients:Ingredients:�� one level teaspoon of salt one level teaspoon of salt �� eight level teaspoons of sugar eight level teaspoons of sugar �� one one litrelitre of clean drinking or boiled water and then cooledof clean drinking or boiled water and then cooled
5 cupfuls (each cup about 200 ml.) 5 cupfuls (each cup about 200 ml.)
ORS WITH NUTRIENTSORS WITH NUTRIENTS
�� Why nutrients?Why nutrients?
Nutrients help in absorption of Na & H2ONutrients help in absorption of Na & H2O
Hastens recovery of intestinal epitheliumHastens recovery of intestinal epithelium
ADVANTAGES OF ORSADVANTAGES OF ORS�� More physiologicalMore physiological�� Easy to administerEasy to administer�� Cost effectiveCost effective�� Home equivalents availableHome equivalents available�� Free of cost at PHC ,Free of cost at PHC ,SubcentersSubcenters�� Readily available & needs no Readily available & needs no sterilisationsterilisation
DISADVANTAGES OF ORSDISADVANTAGES OF ORS�� INEFFECTIVE when, INEFFECTIVE when,
Stool purge is high (>5ml/kg/hr)Stool purge is high (>5ml/kg/hr)Persistent Persistent vomittingvomittingIncorrect preparation /administrationIncorrect preparation /administrationAbdAbd. Distension & . Distension & IleusIleusGlusoseGlusose malabsorptionmalabsorption casescases
�� Most importantly , ORS doesn’t reduce severity / Most importantly , ORS doesn’t reduce severity / duration of duration of diarrhoeadiarrhoea
OTHERSOTHERS�� Another possible way to produce a better oral Another possible way to produce a better oral
rehydrationrehydration solutionsolution would be to combine the would be to combine the standard solution with nutrients andstandard solution with nutrients and vitamins vitamins that have been shown to modify the courses of that have been shown to modify the courses of diarrhealdiarrheal illnesses, probably by their illnesses, probably by their antioxidativeantioxidative actions. These includeactions. These include vitamin vitamin A, zinc, magnesium, selenium, and A, zinc, magnesium, selenium, and other micronutrientsother micronutrients
ZINC TREATMENTZINC TREATMENT�� zinc deficiency caused by limitations in the diet is a zinc deficiency caused by limitations in the diet is a
common problem and a contributing factor to the common problem and a contributing factor to the high prevalence of some infectious diseases in high prevalence of some infectious diseases in children, including pneumonia and diarrhea.children, including pneumonia and diarrhea.
�� Recent studies suggest that a 10Recent studies suggest that a 10-- to 14to 14--day therapy day therapy of zinc treatment can considerably reduce the of zinc treatment can considerably reduce the duration and severity of duration and severity of diarrhealdiarrheal episodes, decrease episodes, decrease stool output, and lessen the need for hospitalization.stool output, and lessen the need for hospitalization.
�� Zinc may also prevent future diarrhea episodes for Zinc may also prevent future diarrhea episodes for up to three months.up to three months.
ADVICEADVICE�� REST THE GUT Theory REST THE GUT Theory �� Give as much as ORS Give as much as ORS ––NO Harm in feeding excessNO Harm in feeding excess�� DO NOT stop breast feeding during ORTDO NOT stop breast feeding during ORT�� Non breast fed infants(<6m)Non breast fed infants(<6m)-- additional 100additional 100--200ml of 200ml of
clean water during first 4 hrsclean water during first 4 hrs�� <2yrs <2yrs --1 teaspoon q11 teaspoon q1--2M2M�� Older children Older children –– freq. sips in a cupfreq. sips in a cup�� If child vomits If child vomits –– wait for 10 wait for 10 minsmins & start again slowly& start again slowly�� Avoid high Avoid high fibrefibre diet during ORTdiet during ORT�� Staple foods Staple foods –– to be enriched with fats& oils/sugarsto be enriched with fats& oils/sugars
eg:riceeg:rice +milk/curd &sugar +milk/curd &sugar
REFERENCESREFERENCES�� The New England Journal Of MedicineThe New England Journal Of Medicine�� http://http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmdwww.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd==Retrieve&dRetrieve&d
bb�� http://www.pjonline.com/Editorial/20040508/articles/p580oralrehhttp://www.pjonline.com/Editorial/20040508/articles/p580oralreh
ydration.htmlydration.html�� http://www.rehydrate.org/ors/rice_based_ors.htmhttp://www.rehydrate.org/ors/rice_based_ors.htm�� http://www.rehydrate.org/ors/solution_for_survival.htmhttp://www.rehydrate.org/ors/solution_for_survival.htm�� http://www.unu.edu/unupress/food/8F172e/8F172E04.htmhttp://www.unu.edu/unupress/food/8F172e/8F172E04.htm�� http://www.supply.unicef.dk/Catalogue/bulletin9.htmhttp://www.supply.unicef.dk/Catalogue/bulletin9.htm�� http://www.eddcontrol.org/index.htm#ORShttp://www.eddcontrol.org/index.htm#ORS�� PARK Textbook of medicine PARK Textbook of medicine �� Text book on PAEDIATRICS by Text book on PAEDIATRICS by O.P.GhaiO.P.Ghai�� Control of Control of diarrhoealdiarrhoeal diseases by WHOdiseases by WHO�� ORSORS