Compiled from:
CDD Information paper - Author: Roger M. Goodall, UNICEF
Brochure: UNICEF, India - Leaflet: AHRTAG - Health Basics Oral Rehydration Therapy (ORT) is the cheap, simple and effective way to treat dehydration caused by diarrhoea. When diarrhoea occurs, essential fluids and salts are lost from the body and must be quickly replaced. Many of the millions of children who die every year in developing countries from diarrhoea could be saved if they were given ORT promptly. This includes giving extra fluids at home such as tea, soups, rice water and fruit juices to prevent dehydration, and the use of oral rehydration salt (ORS) solution to treat dehydration. Made up with clean water the ORS drink contains the main elements that are lost from the body during diarrhea. It is effective in treating dehydration resulting from all types of acute diarrhoeal diseases. Many countries now have diarrhoeal disease control programmes, but ORT is still not nearly as widely used as it should be and more effective information dissemination and promotion of ORT is necessary. Here are answers to some of the more commonly asked questions about Diarrhoea, Dehydration, Oral Rehydration Salts - Home Prepared and Packets, and Oral Rehydration Therapy:

What is diarrhoea?

Diarrhoea is an intestinal disorder characterized by abnormal fluidity and frequency of fecal evacuations, generally the result of increased motility in the colon; may be an important symptom of such underlying disorders as dysenteric diseases, lactose intolerance, GI tumors, and inflammatory bowel disease. Diarrhoea is the passage of watery stools. This means body fluids and salts can be quickly lost from the body. The child becomes dry (dehydrated) and this is very dangerous and may kill the child.
Why is diarrhoea dangerous?

When a person gets diarrhoea, the body begins to lose a lot of water and salts - both of which are necessary for life. If the water and salts are not replaced fast, the body starts to "dry up" or get dehydrated. Severe dehydration can cause death.

What is dehydration?

Dehydration is the loss of water and body salts through diarrhoea. The human body needs water to maintain enough blood and other fluids to function properly. If your body loses substantially more fluids than you are drinking, you become dehydrated. You may lose fluids in a variety of ways:

• when urinating
• when you vomit or have diarrhoea
• when sweating
• from the lungs during normal breathing.

Along with the fluids, your body also loses electrolytes, which are salts normally found in blood, other fluids, and cells.

How does dehydration occur?

The usual causes of dehydration are a lot of diarrhoea and vomiting. Dehydration can also occur if you do not eat or drink much during an illness or if you do not drink enough during or after strenuous exercise. Medications that cause fluid loss to control excess body fluid (diuretics) are a common long-term cause. Although anyone can become dehydrated, those who become dehydrated the most easily are:

• babies under 1 year old
• the elderly
• anyone who has a fever
• people in hot climates.

What are the symptoms of dehydration?

Early features are difficult to detect but include dryness of mouth and thirst

Symptoms of early or mild dehydration include:

• flushed face
• extreme thirst, more than normal or unable to drink
• dry, warm skin
• cannot pass urine or reduced amounts, dark, yellow
• dizziness made worse when you are standing
• weakness
• cramping in the arms and legs
• crying with few or no tears
• sleepy or irritable
• unwell
• headaches
• dry mouth, dry tongue; with thick saliva.

Symptoms of moderate to severe dehydration include:

• low blood pressure
• fainting
• severe muscle contractions in the arms, legs, stomach, and back
• convulsions
• a bloated stomach
• heart failure
• sunken fontanelle - soft spot on a infants head
• sunken dry eyes, with few or no tears
• skin loses its firmness and looks wrinkled
• lack of elasticity of the skin (when a bit of skin lifted up stays folded and takes a long time to go back to its normal position)
• rapid and deep breathing - faster than normal
• fast, weak pulse

  

How is dehydration treated?

If you are mildly dehydrated, you need to drink enough liquid to replace the fluids you have lost. Also, you need to replace the electrolytes (salts) you have lost. Drinking sips of water slowly, along with eating the typical American diet, which is high in salt, will replace fluids and salts you have lost. Nonprescription medicines are available that help replenish fluids and electrolytes. You can also replace both fluids and electrolytes by drinking sports drinks or an oral rehydration solution (ORS).

Drink the solution (or give it to the dehydrated person if he or she is conscious) immediately. Do not wait until dehydration becomes severe.

What if symptoms of dehydration begin to appear? The child should be taken quickly to the nearest health post, or station where prepacked ORS is available. The trained health worker will then show the parents how to mix ORS and supervise giving it. The health worker should also be able to assess a child who is severely dehydrated who needs hospital treatment (including IV if necessary). During the time before the complete ORS can be started the home-prepared solution should continue to be given. In the unfortunate event that complete formula ORS is unavailable the home-prepared solution will have to be used instead BUT it is not as effective for the TREATMENT of dehydration. Only in a minority of countries, such as some of the more affluent ones and some other mostly fairly small countries with easy communications, is prepacked ORS recommended as the exclusive treatment both for preventive, first-line treatment in the hoe and for treatment of dehydration. In most countries, home-prepared solutions are the recommendation for prevention and complete formula ORS for treatment, as described here.

How long will the effects of dehydration last?

If dehydration is not treated, it can cause death. If it is treated in time,
recovery is usually complete.

What is ORT?

ORT is the giving of fluid by mouth to prevent and/or correct the dehydration that is a result of diarrhoea. As soon as diarrhoea begins, treatment using home remedies to prevent dehydration must be started. If adults or children have not been given extra drinks, or if in spite of this dehydration does occur, they must be treated with a special drink made with oral rehydration salts (ORS) . The formula for ORS recommended by WHO and UNICEF contains:

• 3.5 gms sodium chloride
• 2.9 gms trisodium citrate dihydrate (or 2.5 gms sodium bicarbonate)
• 1.5 gms potassium chloride
• 20 gms glucose (anhydrous)

The above ingredients are dissolved in one litre of clean water. WHO has recently recommended a change in the complete formula, replacing 2.5 gms of sodium bicarbonate with 2.9 gms of trisodium citrate dihydrate. The new formula gives the packets a longer shelf life and is at least as effective in correcting acidosis and reducing stool volume. Packets containing sodium bicarbonate are still safe and effective.

How does ORT work?

Acute diarrhea normally only lasts a few days. ORT does not stop the diarrhoea, but it replaces the lost fluids and essential salts thus preventing or treating dehydration and reducing the danger. The glucose contained in ORS solution enables the intestine to absorb the fluid and the salts more efficiently. ORT alone is an effective treatment for 90-95% of patients suffering from acute watery diarrhoea, regardless of cause, This makes intravenous drip therapy unnecessary in all but the most severe cases.

How do I use an ORS package?

Packets of oral rehydration salts are widely available. To use one of these packets, mix the contents with 1 quart or liter of drinking water. If drinking water is not available, or if you are not sure the water is drinkable, boil the water for at least 10 minutes.

How do I prepare an ORS solution at home?

If ORS packets are not available, mix an oral rehydration solution using one of the following recipes; depending on ingredients and container availability:

Recipe for Making a 1 litre ORS solution using Sugar, Salt and Water

1. Clean Water - 1 litre - 5 cupfuls (each cup about 200 ml.)
   
2. Sugar - Six level teaspoons
   
3. Salt - Half level teaspoon
   
4. Stir the mixture till the sugar dissolves.

The home-made solution is adequate in most causes. If the diarrhoea is severe, ask your chemist for a special packet of Oral Rehydration Salts. Follow the instructions on the packet carefully. Drink sips of the ORS (or give the ORS solution to the conscious dehydrated person) every 5 minutes until urination becomes normal. (It's normal to urinate four or five times a day.) Adults and large children should drink at least 3 quarts or liters of ORS a day until they are well. If you are vomiting, continue to try to drink the ORS. Your body will retain some of the fluids and salts you need even though you are vomiting. Remember to take sips of liquids slowly. Chilling the ORS may help. If you have diarrhea, continue to drink the ORS. The fluids will not increase the diarrhea. Someone with symptoms of severe dehydration needs to go to an emergency room or other health care facility to get intravenous fluids (fluids given directly into the veins through a needle) if possible. If able to drink, he or she should also drink the ORS. During or after treatment of dehydration, whatever is causing the diarrhea, vomiting, or other symptoms should also be treated.

Can the solution be made with dirty water?

The benefits of fluid replacement in diarrhoea far outweigh the risks of using contaminated water to make oral rehydration solution. In situations where it is difficult to boil water, mothers are advised to use the cleanest water possible.

Can the ORS solution be stored?

Generally a made-up solution should be covered and not kept for more than 24 hours, due to the risk of bacteriological contamination. Packets of ORS should be stored carefully and not kept in temperatures of over 30 degree C or in conditions of high humidity. Where the ingredients to make up ORS are being stored in bulk the glucose/sucrose should be kept apart from the rest of the dry ingredients. The new citrate formula ORS has a longer shelf life.

Can ORS be used for everyone?

ORS is safe and can be used to treat anyone suffering from diarrhoea, without having to make a detailed diagnosis before the solution is given. Adult need rehydration treatment as much as children, although children must always be treated immediately because they become dehydrated more quickly.

What should be done if the child vomits?

Vomiting does not usually prevent the therapy from being successful. Mothers must be taught to persist in giving ORS solution, even though this requires time and patience. They should give regular, small sips of fluid. Giving ORT reduces nausea and vomiting and restores the appetite through correction of acidosis and potassium losses.

Should feeding continue at the same time as ORT?

Feeding, especially breastfeeding, should be continued once dehydration has been corrected. Even if the diarrhoea continues or the child is vomiting, some of the nutrients are being absorbed. Suitable food should not be withheld, as the child may become malnourished. Once the diarrhoea episode has passed, the child should be given more food than usual to make up for losses during diarrhoea. Breastfeeding is particularly beneficial because breastmilk is easily digestible. It also contains protective substances which help to overcome the infection causing the diarrhoea.

What sort of foods are good during diarrhoea?

High energy foods such as fats, yogurt and cereals are quite well absorbed during diarrhoea. Small, frequent feeds of energy-rich local foods familiar to the child should be given. A little vegetable oil can be added to foods such as millet or rice to increase the energy content.

• Foods high in potassium are important to restore the body's essential stores depleted during diarrhoea. Such foods include lentils, bananas, mangoes, pineapples, pawpaw, coconut milk and citrus fruits.
• Certain foods should be avoided during diarrhoea, for example those containing a lot of fibre such as coarse fruits and vegetables, whole grain cereals and spicy foods.

It is very important to continue feeding a person with diarrhoea. Give soft, easy-to-digest foods, like khichri, watery dal, idlis, curd, bananas etc. You should also give plenty of other fluids, like nimbu pani, rice kanji, lassi, coconut water, weak tea etc. If the baby is being breast-fed, continue to give her mother's milk. Give an extra meal a day, after the diarrhoea stops, to help the body get strong again.

Is it necessary to use drugs as well as ORT?

In most cases, no. The diarrhoea will get all right by itself in a day or two. If there is any blood or mucous in the stools, any fever or vomiting, you must see the doctor immediately. Don't take any medicines yourself, It is important to follow the doctor's advice. You should also see the doctor if the child's condition gets worse or if there are any signs of dehydration. Drugs should not be used except in the most severe cases. Even then they should be administered with care, preferably after the organism causing the diarrhoea has been identified. Small children with dysentery and fever require an antibiotic. Refer such patients to a health service for advice. ORT on its own is usually enough to rehydrate the child. Unnecessary antibiotic therapy upsets the normal bacteriological balance of the intestine. Many anti-diarrhoeal preparations have proved to be either ineffective or too powerful for very small infants.

What can be done to prevent dehydration?

The important thing is to keep replacing the fluid and body salts. At the first sign of diarrhoea, you must give ORS to the patient. You must give this drink after every loose motion. If you have diarrhoea or vomiting, or if you are not drinking very much, force yourself to begin drinking liquids before you become dehydrated. If you are with someone you think is becoming dehydrated, follow these
guidelines when possible:

• Give more liquids than usual.
• Remember that a dehydrated person will have less of an appetite.
  Encourage him or her to eat and drink small amounts of food and
  liquids five to seven times a day.
• Watch for signs of more severe dehydration and get medical help as soon as possible.

How can I protect myself from getting dehydrated?

1. Know the symptoms of dehydration.
   Try to drink extra fluids if you know your body is losing them rapidly.
2. Know the recipe for ORS.
3. If you are traveling in a country that does not have water that is safe for drinking, carry with you a quart (or liter) of boiled water and packets of ORS or the ingredients to make it.

Questions about 'Home-prepared' and packets of ORS

Questions are often asked about "Home - prepared" ORS solutions and the relationship between them and pre-packed complete formula ORS. This is a discussion of our present knowledge and understanding:

When is it appropriate to recommend the use of "home-prepared oral rehydration therapy" and when is prepacked ORS better?

Home-prepared solutions are recommended for use by parents to give to their child immediately an attack of diarrhoea starts - BEFORE any signs of dehydration occur. Basically, the idea is to PREVENT dehydration and also by maintaining fluid and food intake to preserve a good nutritional status.

Why is prepacked ORS referred to as "complete formula" and why is a home-prepared solution not as effective for treatment? Are they not both basically sugar, salt and water anyway?

No. They are not the same thing at all. The "complete formula" ORS contains potassium and a base - either bicarbonate or citrate - which corrects acidosis which small infants in particular suffer when they are dehydrated. Potassium is important in the treatment of dehydration - most especially for the child who suffers repeated bouts of diarrhoea. Potassium is a vital essential element that occurs in the body cells (but very little exists in the body fluids, almost all of the body's potassium is locked inside the cells). It is not involved in the so-called "glucose-sodium co-transport mechanism" which is the basis of the way in which ORS achieves rehydration. Therefore potassium is only absorbed passively and more slowly. If a child is rehydrated with a solution containing no potassium each successive attack of diarrhoea leaves the child more and more depleted of potassium - this results in fatigue, apathy and muscular weakness, the typical bloated belly of a malnourished child is largely caused by potassium depletion causing the muscles of the abdomen to slack. Finally such a child will die.

Can potassium be made good by feeding potassium rich foods like bananas?

Fortunately to some extent yes. However, mothers need to be taught and motivated how to modify a child's normal diet to include these foods for several weeks after an attack of diarrhoea - or more or less permanently in fact in order to have much of an effect.

Does a home-prepared ORS have to be made of sugar, salt and water?

Sugar is in many places very expensive, or even unobtainable. The "red booklet" "THE MANAGEMENT OF DIARRHOEA AND USE OF ORAL REHYDRATION THERAPY - A Joint WHO/UNICEF Statement" makes clear on page 11 that there are two basic types of Home- prepared solutions: (a) Those containing starch rather sugar - throughout the world all people have a basic starchy foodstuff that is a staple part of their diet - it may be rice, root tubers, e.g. yams, potatoes, etc, or grains e.g. wheat, etc. Those starchy foods are nearly always boiled in water to cool them and in the process the cooling water, especially near the end of cooking, becomes a rich starchy solution, already boiled and cooled. With the addition of a little salt (so that it tastes no more salty than tears) such liquids are an excellent home-prepared solution to give to children for the prevention of dehydration. Unfortunately, they may be less effective for children less then 3 months old. Only in areas of famine would such solutions not be readily available in the home at no significant extra cost. With starches you cannot really give an excess - whereas with sugar as excess in solution (over 3%) will cause a worsening of diarrhoea due to osmotic effects. More operational research needs to be done in specific regions and countries to identify and popularize the use of these starch based home- prepared solutions and uncover and unforeseen problems e.g. fermenting of the solution after a few hours storage - or that the liquid is normally fed to animals and may be culturally unacceptable to give to children. In such cases some simple modification to the procedure may be devised to overcome these problems. (b) Sugar and salt solutions have been widely promulgated for years simply because they are analogous to ORS. They have certain disadvantages, for instance: It involves measuring quite accurately two different weights (or measures) of solids - hence a very real possibility of muddling the two up, with disastrous consequences = and measuring the volume of water accurately. It is thus more difficult to mix properly than ORS, where you only need to measure the water. It requires more tuition time and a more competent parent to do it correctly. It is more expensive - often much more expensive and so may be used too sparingly and therefore be of no use. In spite of this, there are examples where it has been widely used with great success, e.g. lobon-gur in Bangladesh. The applicability of either method depends very much on local or national circumstances and policies and should be decided accordingly - there is never a universal "right" method.

Apart from ORT, are there any other important aspects to the management of diarrhoea?

First of all, prevention including the following measures:

• breastfeeding
• environmental sanitation
• personal hygiene
• clean drinking water
• clean preparation and storage of food
• insect and fly control

Secondly, maintaining or increasing food and fluid intake during and after an attack of diarrhoea. Starving children with diarrhoea to "dry it up" probably causes millions of deaths a year.

If these two strategies - preventive and nutritional could be taught, most of the present catastrophic problem of diarrhoeal diseases could be overcome.

Footnote:

People often refer to home-prepared oral rehydration solutions as "home-brew." This should be discouraged because the word brew implies either fermenting - which in fact is an obstacle to some home-prepared solutions especially those made with rice-powder, or it implies boiling (as in tea) which especially with sugar and salt or packet ORS should not be done because it decomposes the sugar, or caramelises.