R E C O M M E N D A T I O N S Low Osmolarity Oral Rehydration Salt Solution (LORS) in Management of Dehydration in Children NIMAIN MOHANTY1, BABU RAM THAPA2, JOHN MATHAI3, UDAY PAI4, NIRANJAN MOHANTY5, VISHNU BIRADAR6, PRAMOD JOG7 AND PURNIMA PRABHU8 1Department of Pediatrics, MGM Institute of Health Sciences, Navi Mumbai, Maharashtra, India; 2Department of Gastroenterology, Liver and Nutrition, PGIMER, Chandigarh, India; 3Consultant in Pediatric GE, Masonic Children’s Hospital, Coimbatore, India; 4Consultant Pediatrician, Chembur, Mumbai, India; 5Department of Pediatrics, KIMS, Bhubaneswar, Odisha, India; 6Department of Pediatrics, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India; 7Department of Pediatrics, DY Patil Medical College, Pune, Maharashtra, India; 8Pediatric Nutritionist, P.D. Hinduja Hospital, Mumbai, Maharashtra, India. Correspondence to: Prof. Nimain Mohanty, Department of Paediatrics, MGM Medical College, Kamothe, Navi Mumbai 410209, Maharashtra, India. [email protected] Justification: The IAP last published the guidelines “Comprehensive Management of Diarrhea” in 2006 and a review in 2016. The WHO in 2002 and the Government of India in 2004 recommended low osmolarity rehydration solution (LORS) as the universal rehydration solution for all ages and all forms of dehydration. However, the use of LORS in India continues to be unacceptably low at 51%, although awareness about ORS has increased from a mere 14% in 2005 to 69% in 2015. Availability of different compositions of ORS and brands in market added to the confusion. Process: The Indian Academy of Pediatrics constituted a panel of experts from the fields of pediatrics, pediatric gastroenterology and nutrition to update on management of dehydration in children with particular reference to LORS and issue a current practice guideline. The committee met twice at CIAP HQ to review all published literature on the aspect. Brief presentations were made, followed by discussions. The draft paper was circulated by email. All relevant inputs and suggestions were incorporated to arrive at a consensus on this practice guideline. Objectives: To summarize latest literature on ORT and empower pediatricians, particularly those practicing in rural areas, on management of dehydration by augmenting LORS use. Recommendations: It was stressed that advantages of LORS far out-weigh its limitations. Increased use of LORS can only be achieved by promoting better awareness among public and health-care providers across all systems of medicine. LORS can also be useful in managing dehydration in non-diarrheal illness. More research is required to modify ORS further to make it safe and effective in neonates, severe acute malnutrition, renal failure, cardiac and other co-morbidities. There is an urgent need to discourage production and marketing all forms of ORS not in conformity with WHO approved LORS, under a slogan “One India, one ORS”. Keywords: Diarrhea, Management, Oral rehydration therapy. iarrhea is the second leading cause of death recommended as safe and effective to correct dehydration after pneumonia among children below 5 in diarrhea, including cholera in adults as well as children years of age in India [1, 2]. The 4th National [6]. The Government of India followed the lead and DFamily Health Survey reported that 9.2% of approved the same composition of LORS as a single under-5 children had diarrhea during the preceeding two rehydration solution. weeks [3]. The situation remained same even after a Multi-centric studies in India and Bangladesh decade, as the incidence was 9% in 2005 [4] Death in established safety and efficacy of LORS in non-cholera as diarrhea is mainly from dehydration and its complications. well as cholera related diarrhea without significant sympto- Therefore, appropriate rehydration therapy remains the matic hyponatremia [7]. The European Society for cornerstone in management. Advances in molecular Pediatric Gastroenterology and Nutrition (ESPGHAN) as technology have helped to better understand the etiology well as the North Americal Society for Pediatric and pathophysiology of diarrhea. It helped concep- Gastroenterology and Nutrition (NASPGHAN) committee tualizing and improving oral rehydration therapy. also endorsed safety and efficacy of LORS for use in WHO launched global diarrheal diseases control diarrhea [8]. program with oral rehydration therpay (ORT) as its core BACKGROUND strategy in year 1978 [5]. Being concerned with hypernatremia, especially in children having non-cholera Mechanisms of diarrhea: There are four main diarrhea, single low osmolar ORS (LORS) formulation mechanisms. Secretory diarrhea: Toxin induced active was recommended as an universal solution by WHO and out-put of fluid into small intestine as in cholera and UNICEF in a joint statement in which LORS was entero-toxogenic E. Coli (ETEC). It can result in severe INDIAN PEDIATRICS 266 VOLUME 58__MARCH 15, 2021 INDIAN A CADEMY OF PEDIATRICS LORS IN PEDIATRIC DEHYDRATION dehydration, metabolic acidosis and dyselectrolytemia Significantly lower stool electrolyte losses (Na+, K+, due to rapid loss of fluid, bicarbonate and electrolytes, bicarbonate) in non-cholera diarrhea was recognized. Of especially potassium [9]. particular concern was that sodium loss in rotavirus diarrhea was much less (52 mmol/L) than in cholera (90 Osmotic diarrhea: Mucosal damage leads to unabsorbed mmol/L), resulting in a much higher incidence of substances, mainly carbohydrates in small intestine. It hypernatremia with conventional ORS [9,10]. The earlier results in high osmotic load and consequent passive WHO ORS had poor acceptance by mothers for not movement of fluid and electrolytes into the lumen. An reducing incidence of vomiting and stool volume [11]. example is rotavirus-induced temporary lactose LORS, having lower osmolarity (245 mOsm/L) than intolerance. Other etiological agents include norovirus, plasma (290 mMol/L), facilitated absorption of sodium and astrovirus and enteroviruses. water faster (Table I). Active absorption of glucose and Bloody diarrhea: Diarrhea with visible blood in the stool amino acids was promoted. Not only LORS replaced fluid is called dysentery and is associated with systemic and electrolytes faster, it also decreased luminal volume by symptoms like fever and crampy abdominal pain. quick absorption, thus reducing chance of vomiting and Common infective causes include Shigella, Salmonella, stool volume across all ages. It also helped in reducing the enteroinvasive E.coli and Entamoeba histolytica, while need for unscheduled supplemental intravenous therapy [6] non-infective causes include inflammatory bowel disease There were initial hesitation and resistance to change and milk protein allergy. The large bowel is despite recommendations from the American Academy of predominantly involved and usually it does not cause Pediatrics (AAP), WHO, ESPGHAN and NASPGHAN to dehydration. use LORS by parents and caregivers but the acceptance improved fast [12,13]. Malabsorptive diarrhea: The classic examples are - diffuse mucosal disease, defects in pancreas and/or PROCESS biliary system, celiac disease, giardiasis and cystic The Indian Academy of Pediatrics constituted a panel of fibrosis. There is defective digestion or absorption of experts from the field of general pediatrics, pediatric nutrients, minerals and vitamins, resulting in malnutrition gastroenterology and nutrition to update on management or failure to thrive. Dehydration and electrolyte of diarrhea in children with particular reference to LORS. imbalance are seen only in prolonged and severe disease. The committee met on August 5, 2018 and on June 23, Watery diarrhea: It typically emanates from small bowel, 2019 in Mumbai, and reviewed all published literature either by abnormal secretory or osmotic process. and reports of expert bodies on the relevant aspects on Concentration of electrolytes in luminal contents remains managing dehydration with ORS. Brief presentations in a state of equilibrium with that of blood. Any change in were made and followed by discussions. A draft practice this bi-directional flow, either by increased secretion or guideline was compiled and circulated by email to all decreased absorption or both, result in excess fluid members. Several useful inputs were received which entering large intestine. Diarrhea results if the fluid were incorporated to arrive at a consensus document. exceeds maximal absorptive capacity of colon [10]. Finally the guideline was placed before the IAP Executive Body Meeting, 2020 which was approved. Basis for shifting to low-osmolar ORS (LORS): With improved infrastructure, water supply and better sanitation, RECOMMENDATIONS incidence of cholera decreased considerably over time. On Rehydration in Watery Diarrhea the other hand, Rotavirus diarrhea was recognized as a major etiological agent for acute diarrhea in children. Current management practice in diarrhea follows WHO Table I Electrolyte Composition of Plasma, Stool and Oral Rehydration Solution (ORS) [6,11] Composition (mMol/L) Composition Na K Cl HCO3 Citrate Glucose Osmolarity Human plasma 135 5 – 25 – 90 290 Cholera stool 105 25 30 30 – – – Non-cholera stool 52 25 14 14 – – – Conventional ORS 90 20 80 – 10 111 311 Low osmolar ORS 75 20 65 – 10 75 245 ReSoMal 45 40 76 – 7 125 300 INDIAN PEDIATRICS 267 VOLUME 58__MARCH 15, 2021 INDIAN A CADEMY OF PEDIATRICS LORS IN PEDIATRIC DEHYDRATION Key Recommendations Strategies Need to be Operationalized Nation-wide for Increasing LORS