Oral Rehydration Therapy for Diarrhea: An Example of Reverse Transfer of Technology

ABSTRACT. On November 13 and 14, 1996, a scientific icant morbidity and mortality in the United States symposium on oral rehydration therapy (ORT) was held and that there are simple therapies available that at the Johns Hopkins University School of Hygiene and could improve the situation. Oral rehydration ther- Public Health in Baltimore, MD. The purpose of the apy (ORT) is a well-established form of therapy for meeting was to review the current treatment practices for the treatment of dehydration attributable to diar- the treatment of this disease in the United States. The rhea. The principles of ORT are early adequate group noted that diarrhea resulted in 300 to 400 deaths -hospitalizations, 1.5 rehydration therapy using an appropriate oral re 000 200ف ,per year among children million outpatient visits, and costs >$1 billion in direct hydration solution (ORS), replacement of ongoing medical costs. stool losses with ORS, and appropriate foods as ORT is well established therapy for the treatment and soon as dehydration is corrected. The effective use prevention of dehydration due to diarrhea. The princi- of ORT has saved millions of lives in developing ples of ORT treatment include early adequate rehydra- countries. However, in the United States, ORT is tion therapy using an appropriate oral rehydration solu- grossly underused. tion (ORS), replacement of ongoing fluid losses from On November 14, 1996, a meeting was held at vomiting and diarrhea with ORS, and frequent feeding Johns Hopkins University School of Hygiene and of appropriate foods as soon as dehydration is corrected. The effective use of ORT has saved millions of lives Public Health in Baltimore, MD, to celebrate the 25th around the world. However, in the United States, ORT is anniversary of ORT use in the United States. grossly underused. Contrary to the recommendations of As part of the celebration, a scientific symposium the American Academy of Pediatrics (AAP) and the Cen- was held among a group of national and interna- ters for Disease Control and Prevention (CDC), health tional experts to discuss the current status of ORT care providers overuse intravenous hydration, prolong use in the United States. The symposium participants rehydration, delay reintroduction of feeding, and inap- noted that there are many unnecessary medical visits propriately withhold ORT, especially with children who and hospitalizations as a result of underuse of ORT. are vomiting. Contrary to the recommendations of the American The expert panel noted that the majority of deaths, Academy of Pediatrics (AAP) and the Centers for hospitalization, and visits to emergency departments could be prevented by the appropriate use of ORT. They Disease Control and Prevention (CDC), health care generated guidelines for the treatment and prevention of providers often unnecessarily use intravenous hy- dehydration secondary to diarrhea. These measures, to- dration, prolong rehydration therapy, delay reintro- gether with training providers, could substantially re- duction of feeding, and inappropriately withhold duce diarrhea mortality and decrease hospitalizations of ORT, especially in children who are vomiting. The children by 100 000 per year in the next 5 years. Pediatrics underuse of ORT, which leads to unnecessary hos- 1997;100(5). URL: http://www.pediatrics.org/cgi/content/ pitalizations, clinic visits, and emergency depart- full/100/5/e10; oral rehydration therapy, oral rehydration ment visits, results in Ͼ$1 billion in direct medical solution, diarrhea. costs each year. The experts at the meeting recommended the fol- ABBREVIATIONS. ORT, oral rehydration therapy; ORS, oral re- lowing measures that could substantially reduce di- hydration solutions; AAP, American Academy of Pediatrics; CDC, arrhea mortality and decrease hospitalizations of Centers for Disease Control and Prevention; WHO, World Health children by 50% in the next 5 years. Organization.

iarrhea is well known to be a leading cause of GUIDELINES mortality and morbidity in developing coun- 1. Treatment of dehydration Dtries. Even in the United States, each year The guidelines published by the AAP in March diarrhea results in 300 to 400 deaths, 180 000 to 1996 that recommend ORT as the first line of therapy 200 000 hospitalizations, 1.5 million outpatient visits, for all children with mild to moderate dehydration and a total of 20 million episodes among children.1 In secondary to diarrhea should be implemented as the addition, there are ϳ2600 deaths among the elderly. standard of care and adopted as a performance stan- However, many health professionals and health care dard. managers do not realize that diarrhea causes signif- All medical care facilities, including emergency departments and physician offices, should have ORS readily available and implement its use according to Received for publication May 22, 1997; accepted Aug 1, 1997. the AAP guidelines. Reprint requests to (M.S.) Johns Hopkins University, 615 North Wolfe St, Parents of infants seeking medical care for diar- Room 5505, Baltimore, MD 21205. PEDIATRICS (ISSN 0031 4005). Copyright © 1997 by the American Acad- rhea should be trained in the use of ORS and early emy of Pediatrics. feeding. http://www.pediatrics.org/cgi/content/full/100/5/Downloaded from www.aappublications.org/newse10 PEDIATRICS by guest on October Vol. 2, 100 2021 No. 5 November 1997 1of3 2. Prevention of dehydration human physiologic studies were conducted to eval- uate the absorption of different ORS formulations Educational material about the prevention and 4–7 treatment of diarrhea, emphasizing the importance from the gut. Subsequently, in the 1970s many clinical studies were conducted in developing coun- of early hydration with appropriate fluids available 8 in the home and ORS, should be developed and tries to document the safety and efficacy of ORT. As widely distributed. a result, ORT was adopted by the World Health All providers should be encouraged to educate Organization (WHO) in 1978 as its principal strategy and provide materials to parents during preventive for preventing diarrheal deaths. This strategy was health care visits about the management of diarrhea quickly adopted by several international agencies including UNICEF and USAID and national pro- and the appropriate use of ORS. Families should be 8 encouraged to have ORS available at home. grams throughout the developing world. As a re- sult, millions of children were saved.9 Despite the 3. Training of providers remarkable success of ORT in developing countries, Continuing educational opportunities regarding US pediatricians were reluctant to use ORT among the management of diarrhea should be provided to children primarily because of their concern about all health care providers. hypernatremia. Regional ORT centers should be established for the The WHO-recommended ORS was first evaluated training of health care providers charged with im- in the United States among the White Mountain plementing ORT programs. Apache Indians in Arizona in 1971.10 There were also The American Academies of Pediatrics, family concerns raised about lack of comparable data physicians, emergency medicine, and professional among US children. Studies conducted among organizations in the field of nursing should be en- Apache Indian children were thought to be irrele- couraged to develop health professional training cur- vant by many pediatricians because Apaches were ricula designed to implement the guidelines pub- not considered to be a representative US population. lished by the AAP in March 1996 for the ORT was dismissed as third world medicine. In the management of diarrhea. 1980s, a number of controlled trials in the United 4. Third-party payment for services States demonstrated the safety and efficacy of ORT among US children.11–14 Based on these studies, the All third-party payers, including public assistance AAP first endorsed the use of ORT for diarrhea in programs, should reimburse physicians and hospi- 1985. In 1993, the AAP also published guidelines for tals when ORS is used for the treatment and/or the management of diarrhea, which were revised in prevention of dehydration attributable to diarrhea. 1996.15 Despite the endorsement of the AAP and the Appropriate provider codes for ORT should be es- CDC, ORT is appropriately used in Ͻ30% of cases of tablished. diarrhea in the United States.16 ORS should be included in all formularies. What are the reasons for this gap between the Epidemiologic and economic research leading to scientific knowledge about ORT and its practical im- cost–benefit analyses should be conducted to further plementation? Experts at the 25th anniversary meet- strengthen the case for reimbursement. ing noted a lack of training of all categories of health Ironically, the successful use of oral rehydration care providers about the proper use of ORT. In ad- solutions for treatment of diarrhea was first docu- dition, appropriate information is not provided to mented by Harold E. Harrison in Baltimore in 1945. parents and guardians about the use of ORT for The ORS formulation used by Harrison contained (in treatment and prevention of dehydration. The suc- mmol/L) sodium 62, potassium 20, chloride 52, lac- cessful implementation of the guidelines outlined in tate 30, and glucose 180 (3.3%).2 This formulation this manuscript is dependent on the cooperation be- was remarkably similar to some commercial solu- tween the health care providers, parents, health care tions currently available in the United States. The administrators, and major professional organizations glucose in the ORS was used for its protein-sparing like the AAP, family physicians, emergency medi- effect. The dangers of inappropriately increasing the cine, and professional organizations in the field of carbohydrate concentration in ORS, which increases nursing. These organizations should provide appro- the osmotic load and results in increased secretion of priate training opportunities and develop appropri- water into the gut (thus aggravating the diarrhea), ate educational material that can be distributed to were also not known. As a result, in the 1950s solu- parents and practitioners at all levels. The educa- tions containing inappropriately high concentrations tional objectives should ensure that health care pro- of carbohydrates were dispensed commercially in viders know the following facts about ORT: 1) It is a powder form throughout the United States. In addi- simple cost-effective method of treating acute diar- tion, parents were not given proper education about rhea, regardless of etiology, in patients with mild to appropriate mixing of the ORS. As a result of the moderate dehydration. 2) Vomiting is not a contra- inappropriate composition and improper mixing of indication for using ORT. 3) Rehydration therapy ORS, many cases of hypernatremia occurred in the should be instituted as soon as diarrhea begins. 4) United States3. Therefore, in the 1960s physicians Appropriate feeding should be instituted as soon as generally returned to the use of intravenous therapy initial rehydration therapy has been completed. for the treatment of diarrhea. Physicians should provide training to their staff In the mid- to late 1960s, a number of animal and about the appropriate use of ORT. In addition, parents

2of3 ORAL REHYDRATIONDownloaded THERAPY from www.aappublications.org/news FOR DIARRHEA by guest on October 2, 2021 should be given information at well-child visits about Edward Maurice Keenan, MD, Past President the management of diarrhea and the importance of American Academy of Pediatrics replacing fluid loss as soon as diarrhea begins. Physi- West Newton, MA 02165 cians should also encourage parents to keep a supply of Jim Tulloch, MD, Director, Child Health and ORS at home at all times. In many developing coun- Development tries, ORT training centers have been created that have World Health Organization been very successful in training providers. There is no 1211 Geneva 27, Switzerland reason why similar regional training centers could not Denis Broun, MD, Chief of Health be created in the United States. UNICEF The experts at the symposium identified third- New York, NY 10017 party payment services as a significant barrier to the Roger Glass, MD use of ORT. Unfortunately, many insurance carriers Centers for Disease Control and Prevention do not reimburse physicians and hospitals for ORT Atlanta, GA 30333 use. Studies designed to demonstrate the relative costs and benefits of ORT are urgently needed. REFERENCES If our goal is to promote the use of ORS for most episodes of diarrhea, it has to be easily accessible to 1. Glass RL, Lew JF, Gangarosa RE, LeBaron CW, HO M-S. Estimates of morbidity and mortality rates for diarrheal diseases in American chil- all families. Unfortunately, it is not currently avail- dren. J Pediatr. 1991;118(suppl):S27–S33 able in many formularies. In the commercial phar- 2. Harrison HE. The treatment of diarrhea in infancy. Pediatr Clin North macies, the cost of1LofORScanrange from $2 to Am. 1954;1:335–348 $9. This can be a significant barrier to ORT use in 3. Paneth N. Hypernatremic dehydration of infancy: an epidemiologic some sectors of the population. review. Am J Dis Child. 1980;134:785–792 4. Curran PF. Na Cl and water transport by rat ileum in vitro. J Gen Finally, if we are to have success in delivering health Physiol. 1960;43:1137–1148 care to children, we must empower the parents to 5. Schultz SG, Zalusky R. Ion transport in isolated rabbit ileum II. The handle the illness appropriately. ORT involves simple interaction between active sodium and active sugar transport. J Gen technology that enables parents to treat one of the most Physiol. 1964;47:1043–1059 common illnesses among children. 6. Riklis E, Quastel JH. Effects of cations on sugar absorption by isolated by For decades, technology has been transferred from isolated surviving guinea pig intestine. Can J Biochem. 1958;36:346–362 7. Schultz SG. Sodium-couples solute transport by small intestine: a status the United States to developing countries. However, report. Am J Physiol. 1977;233:249–254 ORT has been primarily developed in emerging 8. Hirschhorn N. The treatment of acute diarrhea in children: an historical countries and has the potential to benefit enormously and physiological perspective. Am J Clin Nutr. 1980;33:637–663 the developed world. If this reverse transfer of tech- 9. Claeson M, Merson MH. Global progress in the control of diarrheal nology is properly implemented, it will both save diseases. Pediatr Infect Dis J. 1990;9:345–355 10. Hirschhorn N, Cash R, Woodward W, Spivery G. Oral therapy of lives and prevent unnecessary clinic visits and hos- Apache children with acute infectious diarrhea. Lancet. 1972;1:15–18 pitalizations. In addition, it would save millions of 11. Santosham M, Daum RS, Dillman L, et al. Oral rehydration therapy of health care dollars each year. This type of program infantile diarrhea: a controlled study of well-nourished children hospital- can be successful only if there is a commitment from ized in the United States and Panama. N Engl J Med. 1982;306:1070–1076 all sectors of the medical system, including provid- 12. Santosham M, Burns B, Nadkarni V, et al. Oral rehydration therapy for acute diarrhea in ambulatory children in the United States: a double ers, health administrators, managed care officials, blind comparison of four different solutions. Pediatrics. 1985;76:159–166 insurance carriers, and health care providers. The 13. Listernick R, Zieseri E, Davis AT. Outpatient oral rehydration of infants United States must be a leader not only in high- in a large urban U.S. medical center. Am J Dis Child. 1986;140:211–215 technology medicine, but also in implementing the 14. Tamer AM, Friedman LB, Maxwell SRW, et al. Oral rehydration of most effective technology, even if it is considered a infants in a large urban U.S. medical center. J Pediatr. 1985;107:11–19 15. American Academy of Pediatrics, Provisional Committee on Quality low-technology, low-cost strategy. Improvement, Subcommittee on Acute Gastroenteritis. Practice Param- eter. The management of acute gastroenteritis in young children. Pedi- Mathuram Santosham, MD, MPH atrics. 1996;97:424–435 Johns Hopkins University Center for American Indian 16. Duggan C, Santosham M, Glass R. The management of acute diarrhea in and Alaskan Native Health children: oral rehydration, maintenance and nutritional therapy. Baltimore, MD 21205 MMWR. 1992;41:(RR-16):1–20

Downloaded from www.aappublications.org/newshttp://www.pediatrics.org/cgi/content/full/100/5/ by guest on October 2, 2021 e10 3of3 Oral Rehydration Therapy for Diarrhea: An Example of Reverse Transfer of Technology Mathuram Santosham, Edward Maurice Keenan, Jim Tulloch, Denis Broun and Roger Glass Pediatrics 1997;100;e10 DOI: 10.1542/peds.100.5.e10

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/100/5/e10 References This article cites 14 articles, 5 of which you can access for free at: http://pediatrics.aappublications.org/content/100/5/e10#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Nutrition http://www.aappublications.org/cgi/collection/nutrition_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on October 2, 2021 Oral Rehydration Therapy for Diarrhea: An Example of Reverse Transfer of Technology Mathuram Santosham, Edward Maurice Keenan, Jim Tulloch, Denis Broun and Roger Glass Pediatrics 1997;100;e10 DOI: 10.1542/peds.100.5.e10

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/100/5/e10

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1997 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on October 2, 2021