What is the New Oral Rehydration Salt Solution Made Up Of?

Patient Presentation
An 8-month-old male came to clinic with a 24 hour history of diarrhea that was described as loose, watery, and running out the diapers. He had the diarrhea 6 times. He also had 3 episodes of emesis.
There was no blood in the emesis or diarrhea. He was drinking various fluids somewhat, but not his normal amounts. He had had 3 wet diapers, but his father said that it was difficult to tell how wet they were because of the diarrhea.
He was tired, but not otherwise unwell. He had a large, watery stool prior to the physician going into the room, and his father was giving him a sports drink.
The review of systems found him to be in a daycare center that had recent diarrhea in his classroom.
The pertinent physical exam revealed an alert male who appeared tired. His weight was the same as a previous weight 1 month prior. His mucous membranes were moist, with 1-2 seconds of capillary refill.
His abdomen was soft and non-tender but with active bowel sounds.
His buttocks were red with no skin breakdown. The rest of his examination was normal.
The diagnosis of gastroenteritis was made. The patient appeared hydrated and the father was educated about how to give frequent fluids during a gastroenteritis episode.
The father was also counseled about not giving the sports drink or other similar fluid because they don’t contain the correct amount of fluid and electrolytes. He was told to use a commercially prepared, oral rehydration salt (ORS) solution or ORS solution packets which could be mixed.
The father was also given instruction of signs and symptoms to monitor for dehydration or other problems, and when to call or return to the clinic.

Discussion
Gastroenteritis is a common ailment around the world. It is defined as inflammation of the lining of the stomach and the intestine and thus has diarrhea as its major symptom. Vomiting may also occur.
Gastroenteritis is most commonly caused by viruses, usually by rotavirus, or enteric adenovirus. A variety of bacteria can also cause it including Salmonella, Shigella, Campylobacteriacae and Yersinia.
Diarrhea is the second leading cause of childhood death with more than 1.9 million childrens’ deaths worldwide/year. Most symptoms last for 3-5 days. After this time or if symptoms are severe, a patient should seek help from a healthcare provider.

Oral rehydration salt (ORS) solution is the mainstay of treatment world-wide.
ORS solution is easy to make, use and is the most economical treatment. ORS solution is absorbed in the intestines and can quickly replace the water and electrolytes lost through vomiting and diarrhea.
ORS solution should be combined with appropriate education on feeding practices. Continued breastfeeding through acute episodes of diarrhea protects against dehydration and reduces protein and calorie consumption thus decreasing dehydration and malnutrition. Providing zinc supplements (20 mg of zinc per day for 10 to 14 days) is also recommended in some countries, but generally not in the United States.

The United Nations Children’s Fund (UNICEF) recommends that each child drinks as much as possible but “at least a quarter to a half of a large cup of the ORS drink after each watery stool” for a child less than 2 years of age, and “at least a half to a whole large cup of the ORS drink after each watery stool” for a child more than 2 years of age.
UNICEF further recommends that “if the child vomits, the caregiver should wait for 10 minutes and then begin again to give the drink to the child slowly, small sips at a time.”

One study in the US in an urban pediatric continuity clinic found that mixing ORS solution from packets was better tolerated and more well liked by the parents than commercially prepared ORS ready-to-drink solution.

Learning Point
In March 2006, the World Health Organization recommended a new ORS solution formulation.
The newest ORS formula has less glucose and sodium with a total concentration of 245 mOsm/L compared to the previous 311 mOsm/L.
The lower concentration allows quicker fluid absorption in the small intestine which decreases the need for intravenous fluids. Therefore there will be less need for hospitalization in the emergency room or on the wards.

The new formulation contains:

Sodium chloride (NaCl) = 2.6 g
Trisodium citrate dihydrate (C6H5Na3O7,2H2O) = 2.9 g
Potassium chloride (KCl) = 1.5 g
Anhydrous glucose (C6H12O6)= 13.5 g

The contents of each packet should be dissolved in 1 litre of clean water.
The ORS solution should be discarded after 24 hours.

Questions for Further Discussion
1. What is the differential diagnosis of bloody diarrhea?
2. How often should an infant or child urinate normally or if dehydrated?
3. Where can ORS solution packets be purchased?
4. What vaccines are available for rotavirus?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for this topic: Gastroenteritis
and at Pediatric Common Questions, Quick Answers for this topic: Vomiting and Diarrhea

To view current news articles on this topic check Google News.

Landinsky, et al. Archives of Pediatrics and Adolescent Medicine 2000;154:700-705.

World Health Organization. Improved formula for oral rehydration salts to save children’s lives. Available from the Internet at http://www.who.int/mediacentre/news/releases/2006/pr14/en/index (rev. 03/23/2006, cited 11/22/06).

World Health Organization. Oral Rehydration Salts (ORS). Available from the Internet at http://www.who.int/medicines/publications/pharmacopoeia/ors/en/ ( cited 11/22/2006).

Unicef. Facts for Life. Available from the Internet at http://www.unicef.org/ffl/07/1.htm ( cited 11/22/06).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    December 18, 2006

  • How Do You Measure All Those Angles?

    Patient Presentation
    A 14-year-old female came to clinic for her sports physical in August. She said that her friends had noticed her left shoulder being more prominent when she bent over at the pool this summer.
    She had no pain, or difficulty moving and no one else had noticed it. She had been screened for scoliosis at school about 18 months earlier.
    The past medical history revealed a healthy female with menarche at age 12 and regular periods since age 13.
    The family history was negative for musculoskeletal or neurological disorders.
    The pertinent physical exam showed a healthy female with growth parameters in the 50-75%. She had full range of motion in her back, shoulders and hips. Her left scapula was slightly more prominent when bending forward and the scoliometer measured 10 degrees.
    She was Tanner stage 5 for breast and pubic hair development.
    The radiologic evaluation of radiographs of her spine showed a thoracic curve to the right with a Cobb angle of 15 degrees and Risser index of 4. She was referred to orthopaedics because of parental and patient anxiety.
    The diagnosis of adolescent idiopathic scoliosis was confirmed and the family was educated that it was less likely that her curve would progress because of the pattern, magnitude, age, menarche status and Risser index.
    The patient was to return in 6 months for monitoring.

    Discussion
    Alignment of the spine is measured from a plumbline dropped from C7 vertebrae as the line of reference. Lordosis is anterior curving, kyphosis is posterior curving and scoliosis is lateral curving relative to this line.

    In 1954 J. James classified idiopathic scoliosis according to the age of the patient at the time of diagnosis: infantile idiopathic scoliosis for patients < 3 years, juvenile idiopathic scoliosis for patients 3-10 years and adolescent idiopathic scoliosis for patients > 10 years.
    This system has prognostic significance with juvenile idiopathic scoliosis having a high rate of progression and need for intervention.
    The precise etiology of idiopathic scoliosis remains unknown.

    Adolescent idiopathic scoliosis is the most common type of idiopathic scoliosis and the most common type of scoliosis overall. By mid- to late- adolescence, 2-3% will have a 10-degree angle or more.
    Most patients present because of a perceived deformity usually by the patient or family members. Patients also may be identified through screening by health care providers using the Adams forward bending test. This test has been found to be an effective screening tool when used with a scoliometer. Screening is usually begun in the pre-adolescent age group.

    The most common lateral curves are located in the thoracic spine with the curve’s apex to the right. The second most common is a lumbar curve with apex to the left. The third most common is a thoracolumbar curve with the apex to the right. Double curves also happen and the most common is a thoracic curve with apex to the right and lumbar curve with apex to the left.

    Risks of progression

    • Curve pattern – double curves progress more than single curves, lumbar curves progress the least
    • Curve magnitude – larger curves are more likely to progress, this is measured by the Cobb angle (see Learning Point below)
    • Age – the younger the patient, the more likely the curve will progress
    • Menarche – curves detected before menarche are more likely to progress
    • Gender – females are more likely to progress
    • Risser sign or index – lower Risser indexes are at greater risk for progression

    In general, < 10% of children who screen positively will need intervention. Treatment includes observation, orthosis or bracing and surgical intervention.
    Current treatment for adolescent idiopathic scoliosis is based mainly on the curve magnitude. Curves less than 30 degrees are observed, bracing occurs for those 30-40 degrees and surgery for curves that are > 40 degrees.
    There are many caveats to these numbers and treatment is individualized particularly if the curve is rapidly progressing or the patient is skeletally immature.

    Learning Point
    Cobb angle -
    On the radiograph beginning at the head and moving toward the feet, identify the first vertebral body that is maximally angled or tilted. Draw a line on the top of this vertebral body extending toward the apex of the curve. Again going from the head to the feet, identify the last vertebral body that is maximally angled or tilted and draw a line on the bottom of this vertebral body extending toward the apex of the curve. On each of these two lines, draw a perpendicular line (90 degree line) such that the perpendicular line intersect. The angle between the intersecting perpendicular lines is the Cobb angle.


    Figure 42 – Diagram showing the calculation of a Cobb angle in a patient with a thoracic curve with the apex to the right. The Cobb angle measures 43 degrees.

    Risser sign or index is the ossification of the epiphysis of the iliac crest. It usually begins on the anterior superior iliac spine and progresses posteriorly. The iliac spine is divided into 4 quarters and the Risser index is designated 1-4 as to where the ossification is occurring and 5 if it is completely fused.

    Questions for Further Discussion
    1. How is the natural history of congenital scoliosis different than idiopathic scoliosis?
    2. How effective are back exercises or electric stimulation for treating idiopathic scoliosis?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Scoliosis
    and at Pediatric Common Questions, Quick Answers for this topic: Scoliosis

    To view current news articles on this topic check Google News.

    James JI: Idiopathic Scoliosis: The Prognosis, Diagnosis, and Operative Indications Related to Curve Patterns and the Age of Onset. J Bone Joint Surg 1954; 36B: 36-49.

    Weinstein SL. Adolescent Idiopathic Scoliosis, Prevalence, Natural History and Treatment Indications. Pamphlet from the Scoliosis Research Society and the American Academy of Orthopaedic Surgeons.

    Mehlman CT. Idiopathic Scoliosis. eMedicine.
    Available from the Internet at http://www.emedicine.com/orthoped/topic504.htm (rev. 6/30/2004, cited 11/22/2006).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    December 11, 2006

  • What Causes Neonatal Bilious Emesis?

    Patient Presentation
    A 4 day old, 37 1/2 week gestation male infant was having some difficulty breastfeeding at home. During a lactation consultant’s visit, he had a large yellow-green emesis that the lactation consultant felt had feculent material in it.
    She recommended that a physician see him. In the emergency room, the patient had another emesis that was clearly bilious.
    The past medical history and family history were negative.
    The review of systems showed poor suck and swallowing with few wet diapers. The last stool was 2 days ago.
    The pertinent physical exam revealed an ill-appearing infant with a decrease of 10% of body weight (Birth weight was 3123 grams). He had poor skin turgor with a slightly sunken anterior fontanelle.
    The cardiac, pulmonary and rest of the HEENT examinations were normal. His abdomen was distended, slightly tender and some rushed abdominal sounds. He had no palpable organomegaly.
    He was slightly hypotonic and sleepy. He would arouse to stimulation.
    A nasogastric tube was placed with 50 cc of yellow-green gastric contents returned.
    The local work-up included a complete blood count showing a hematocrit of 41% and a white blood cell count of 7500 with no left shift.
    His electrolytes showed sodium = 130 mEq/L, potassium = 3.9mEq/L, chloride = 110mEq/L, and CO2 = 18 mEq/L. Liver enzymes and bilirubin were normal. Lactic acid was 4.0 mEq/L.
    He was begun on Ampicillin and Gentamicin for presumed sepsis and had a work-up including blood cultures, urine cultures, cerebrospinal fluid cultures which eventually were negative.
    An abdominal x-ray was unremarkable.
    He was transferred to a larger institution for further radiology studies and surgical consultation.
    The radiologic evaluation of an upper GI exam initially demonstrated markedly delayed emptying of contrast out of the proximal duodenum. A spot image demonstrates dilation of the proximal duodenum along with malrotation of the small bowel with the Ligament of Treitz (black arrow) noted to be projecting over the midline of the spine and lower than the level of the duodenal bulb. The Ligament of Treitz should normally be located over the left upper quadrant of the abdomen and at the same level as the duodenal bulb. Subsequent spot images demonstrated the proximal jejuneum to be in the right upper quadrant of the abdomen.
    The diagnosis of of malrotation with midgut volvulus was made.
    The patient’s clinical course included being taken to the operating room where a midgut malrotation with 270 degrees of volvulus was confirmed. The volvulus was devolved and viable bowel was found.
    A Ladd’s procedure and appendectomy were performed. The patient tolerated the procedure and had an uneventful post-operative course.


    Figure 41

    Discussion
    As there is almost continuous production of gastrointestinal fluids and swallowing in utero, obstruction or injury causing abnormal peristalsis can by itself cause abdominal distension with vomiting. Abominal distension and vomiting is always abnormal.
    Bilious emesis is also always abnormal and indicates ileus or obstruction distal to the common bile duct insertion into the duodenum.
    Other associated symptoms may include sepsis, bleeding, pain and respiratory distress.
    Treatment includes stopping feedings, decompression of the stomach, and prompt radiologic and surgical evaluation and treatment.

    Normally during embryonic life, the primary gastrointestinal loop undergoes a 270 degree rotation counterclockwise around the superior mesenteric artery. If this normal rotation does not occur, the duodenum and cecum end up lying together near the epigastrium with the superior mesenteric artery and vein located centrally, forming a poorly fixated stalk.
    Volvulus around this stalk causes obstruction of the duodenum and the superior mesenteric artery and vein. The volvulus causes abdominal obstruction, distension and emesis. Additionally, there is vascular compromise of the upper intestinal tract.
    Intestinal malrotation and volvulus are surgical emergencies and need immediate attention.

    Learning Point
    The differential diagnosis for bilious emesis includes:

    • Hirschsprung disease
    • Intestinal atresia – distal duodenum, jejunal and ileal
    • Intestinal duplication
    • Intestinal malrotation and midgut volvulus
    • Meconium plug and ileus
    • Organomegaly causing obstruction
    • Pancreas, annular
    • Peritonitis
    • Viscous perforation

    Questions for Further Discussion
    1. What is the differential diagnosis of non-bilious emesis in a newborn?
    2. What is the differential diagnosis of other neonatal surgical emergencies?
    3. Describe the Ladd’s procedure.

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Birth Defects and Digestive Diseases

    To view current news articles on this topic check Google News.

    Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1998:69-82.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2003-2007.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.

    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    December 4, 2006