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ORAL REHYDRATION SALT (ORS)

What are the constituents?
The composition of the new, reduced osmolarity ORS, as recommended by WHO, is as follows:
• Sodium chloride—2.6 g
• Glucose (anhydrous)—13.5 g
• Potassium chloride—1.5 g
• Trisodium citrate dehydrate—2.9 g
(Total weight of a packet = 20.5 g)
The new ORS was launched by WHO in January 2004 and in India in June 2004.

What benefit does trisodium citrate offer over the use of sodium bicarbonate in ORS?
Trisodium citrate has the following advantages over sodium bicarbonate:
• It improves the shelf life of ORS.
• It helps in reducing the stool output probably through a direct action on the intestinal mucosa, enhancing the absorption of sodium and water.

How is the ORS reconstituted?
The contents of the packet are dissolved in 1 L of drinking water.

What is the role of each of the constituents?
• Glucose facilitates absorption of sodium and hence water.
• Sodium and potassium replace the loss of these essential elements in diarrhea and vomiting.
• Citrate corrects the acidosis that occurs due to diarrhea and dehydration.selection of fluids

How is the new ORS different from the older formulation?
The new ORS contains lesser amount of sodium and glucose thereby resulting in a lower osmolarity solution after reconstitution.
The reduced osmolarity of the solution has been shown to have the following benefits in addition to correction of dehydration:
• It reduces the stool output by 25% in comparison to the original formula.
• It reduces vomiting by 30%.
• It has been demonstrated to reduce the need for IV therapy by more than 30%.

What is the indication?
Mild and moderate dehydration

What are the instructions given regarding reconstitution?
• Dissolve the entire content of the packet in 1 L of clean drinking water.
• The prepared solution should be used within 24 hours. Discard the solution left after 24 hours.
• The solution should be made fresh daily.
• It should not be boiled or sterilized otherwise.

How is the mother instructed to give the ORS solution?
• Regarding the amount and frequency of giving ORS:
- A child under the age of 2 year is to be given one to two spoonful every 1-2 minutes.
- The older child can be given frequent sips from a cup.
- Adults can drink as much solution as they feel like.
- If the child wants to drink more ORS than the recommended amount, allow her if it is not vomited.
- If ORS is vomited out, wait for 10 minutes and then try again at a slow rate of one spoon every 2–3 minutes.
• Plain and clean drinking water should also be given in addition. This can be given as per the demand of the patient.
• Continue to breastfeed if the child is breastfed. A child under 6 months who is not breastfed should be given 100–200 mL of plain water also, in the first 4 hours. Continue normal feeding in older children and adults.

How will you manage when these packets are not available?
If this mixture is not available, a simple sugar and salt solution can be prepared as follows:
• Table salt—5 g
• Sugar—20 g
• Water—1 L
Dissolve the salt and sugar in 1 L of water.

What are the alternatives if ORS is not available?
The alternatives to ORS solution are home available fluids. Some examples are as follows:
• Green coconut water
• Rice water
• Dal water
• Buttermilk
• Vegetable soup
• Unsweetened fresh fruit juice

Write some examples of drinks NOT suitable for treating dehydration.
• Soft drinks
• Sweetened fruit drinks
• Sweetened tea
The sugar in these drinks may lead to more dehydration due to high osmolarity.

How do classify dehydration?
The hydration status is classified as:
1. Severe dehydration
2. Some dehydration
3. No dehydration
assessment of dehydration
Mention the principles of management of dehydration.
• Plan A, B or C for giving fluids based upon the assessed level of hydration
• Giving ORS
• Zinc supplementation
• Antibiotic only if indicated

What are the 4 rules of home treatment in diarrhoea?
The four rules of home treatment are:
1. Give extra fluid – as much as the child will take
2. Give zinc
3. Continue feeding
4. When to return (for a follow-up visit, or immediately if danger signs develop)WHO dia module

What are the benefits of giving zinc to a child suffering from diarrhoea?
1. The use of zinc tablets along with oral rehydration therapy (ORT) decreases both, the
• Severity and
o Less watery stools
o Less frequency of stools
• Duration of diarrhoea.
2. Zinc administration during diarrhoea decreases hospital admission rates by 15-20% and child mortality by 3-5%.
3. It can decrease the incidence of subsequent episodes of diarrhoea and possibly also pneumonia over next 3 months.

What is the recommended dose of zinc for a child with diarrhoea?
Government of India has recommended the following dose of zinc:
For children between 2- 6 months:
• 10 mg of elemental zinc per day for a total period of 14 days from the day of onset of diarrhoea.
One tablet of zinc contains 20 mg of elemental zinc. Therefore half tablet should be given to the children in this age group.
For children above 6 months:
• One full tablet (20 mg of elemental zinc)
It should be started when diarrhoea starts and continued for a total period of 14 days.

How should the zinc tablets be administrated to a young child?
Zinc comes in the form of dispersible tablets which easily gets converted into syrup on addition of breast milk or water.
• For infants below 6 months of age the tablet can be given by dissolving the tablet in breast milk and
• For infants above 6 months of age it can be given by dissolving the tablet in breast milk or water.

Mention some food items which contain zinc?
Zinc is present in good amount in meat, egg, grains, nuts and oilseeds. As the plant foods do not contain good amount of zinc, therefore vegetarians are more prone to zinc deficiency.

References:
1. Park K. Epidemiology of communicable diseases. In: Park's Textbook of Preventive and Social Medicine, 24th ed. Jabalpur, India: M/S Banarasidas Bhanot Publishers; 2017.
2. WHO, 2014: Diarrhoea; IMCI INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS: Module 4, Distance Learning Course; available at http://apps.who.int/iris/bitstream/10665/104772/6/9789241506823_Module-4... accessed on 23rd July 2016
3. NIHFW. Zinc Supplementation during Diarrhoea; Health workers information series no. 3. National Child Health Resource Centre (NCHRC)
4. Chapter 2-Maternal and Child Health; In: Mastering Practicals – Community Medicine. 2nd ed. Eds. Tiwari P, Tiwari S. Lippincott Williams & Wilkins; Wolters Kluwer, New Delhi