Oral rehydration therapy (ORT) is a type of fluid replacement used to prevent and treat dehydration, especially due to diarrhea. It involves drinking water with modest amounts of sugar and salts, specifically sodium and potassium. Oral rehydration therapy can also be given by a nasogastric tube. Therapy can include the use of zinc supplements to reduce the duration of diarrhea in infants and children under the age of 5. Use of oral rehydration therapy has been estimated to decrease the risk of death from diarrhea by up to 93%. Earliest known medication was done by Hemendra Nath Chatterjee in 1953 and he published it in The Lancet the results of using ORS to treat people with mild cholera.
Side effects may include vomiting, high blood sodium, or high blood potassium. If vomiting occurs, it is recommended that use be paused for 10 minutes and then gradually restarted. The recommended formulation includes sodium chloride, sodium citrate, potassium chloride, and glucose. Glucose may be replaced by sucrose and sodium citrate may be replaced by sodium bicarbonate, if not available, although the resulting mixture is not shelf stable in high-humidity environments. It works as glucose increases the uptake of sodium and thus water by the intestines, and the potassium chloride and sodium citrate help prevent hypokalemia and acidosis, respectively, which are both common side effects of diarrhea. A number of other formulations are also available including versions that can be made at home. However, the use of homemade solutions has not been well studied.
Oral rehydration therapy was developed in the 1940s using electrolyte solutions with or without glucose on an empirical basis chiefly for mild or convalescent patients, but did not come into common use for rehydration and maintenance therapy until after the discovery that glucose promoted sodium and water absorption during cholera in the 1960s. It is on the World Health Organization's List of Essential Medicines. Globally, , oral rehydration therapy is used by 41% of children with diarrhea. This use has played an important role in reducing the number of deaths in children under the age of five.
Medical uses
ORT is less invasive than the other strategies for fluid replacement, specifically intravenous (IV) fluid replacement. Mild to moderate dehydration in children seen in an emergency department is best treated with ORT. Persons taking ORT should eat within six hours and return to their full diet within 24–48 hours.
Oral rehydration therapy may also be used as a treatment for the symptoms of dehydration and rehydration in burns in resource-limited settings.
Efficacy
ORT may lower the mortality rate of diarrhea by as much as 93%. Case studies in four developing countries also have demonstrated an association between increased use of ORS and reduction in mortality. ORT using the original ORS formula has no effect on the duration of the diarrheic episode or the volume of fluid loss, although reduced osmolarity solutions have been shown to reduce stool volume.
Treatment algorithm The degree of dehydration should be assessed before initiating ORT. ORT is suitable for people who are not dehydrated and those who show signs and symptoms of mild to moderate dehydration. People who have severe dehydration should seek professional medical help immediately and receive intravenous rehydration as soon as possible to rapidly replenish fluid volume in the body.
Contraindications ORT should be discontinued and fluids replaced intravenously when vomiting is protracted despite proper administration of ORT; or signs of dehydration worsen despite giving ORT; or the person is unable to drink due to a decreased level of consciousness; or there is evidence of intestinal blockage or ileus. ORT might also be contraindicated in people who are in hemodynamic shock due to impaired airway protective reflexes. Short-term vomiting is not a contraindication to receiving oral rehydration therapy. In persons who are vomiting, drinking oral rehydration solution at a slow and continuous pace will help resolve vomiting.
Preparation
WHO and UNICEF have jointly developed official guidelines for the manufacture of oral rehydration solution and the oral rehydration salts used to make it (both often abbreviated ORS). They also describe other acceptable solutions, depending on material availability. Commercial preparations are available as prepared fluids and as packets of powder ready to mix with water.
A basic oral rehydration therapy solution can also be prepared when packets of oral rehydration salts are not available.Rehydration Project, Homemade Oral Rehydration Solution Recipe. The molar ratio of sugar to salt should be 1:1 and the solution should not be hyperosmolar. The Rehydration Project states, "Making the mixture a little diluted (with more than 1 litre of clean water) is not harmful."
The optimal fluid for preparing oral rehydration solution is clean water. However, if this is not available, the usually available water should be used. Oral rehydration solution should not be withheld simply because the available water is potentially unsafe; rehydration takes precedence.
When oral rehydration salts packets and suitable teaspoons for measuring sugar and salt are not available, the WHO has recommended that homemade gruels, soups, etc., may be considered to help maintain hydration. A Lancet review in 2013 emphasized the need for more research on appropriate home made fluids to prevent dehydration. Sports drinks are not optimal oral rehydration solutions, but they can be used if optimal choices are not available. They should not be withheld for lack of better options; again, rehydration takes precedence. But they are not replacements for oral rehydration solutions in nonemergency situations.
Reduced-osmolarity
In 2003, WHO and UNICEF recommended that the osmolarity of oral rehydration solution be reduced from 311 to 245 mOsm/L. These guidelines were also updated in 2006. This recommendation was based on multiple clinical trials showing that the reduced osmolarity solution reduces stool volume in children with diarrhea by about twenty-five percent and the need for IV therapy by about thirty percent when compared to standard oral rehydration solution. The incidence of vomiting is also reduced. The reduced osmolarity oral rehydration solution has lower concentrations of glucose and sodium chloride than the original solution, but the concentrations of potassium and citrate are unchanged.
The reduced osmolarity solution has been criticized by some for not providing enough sodium for adults with cholera. Clinical trials have, however, shown reduced osmolarity solution to be effective for adults and children with cholera. They seem to be safe but some caution is warranted according to the Cochrane review.
+ Formula for the WHO standard and low-osmolar-oral rehydration solution Component Standard Low-osmolarg/Loz/Lg/Loz/LNaCl (salt)3.50.1232.60.092Trisodium citrate dihydrate2.90.1002.90.100KCl (NoSalt)1.50.0531.50.053Anhydrous glucose200.70513.50.480Total27.90.98120.50.725
+ Molar composition for the WHO standard and low-osmolar-oral rehydration solution ComponentStandardLow-osmolarAcceptable rangemmol/Lmmol/Lmmol/LGlucose11175<111Sodium907560–90Potassium202015–25Chloride806550–80Citrate10108–12Total311245200–310
Administration
ORT is based on evidence that water continues to be absorbed from the gastrointestinal tract even while fluid is lost through diarrhea or vomiting. The World Health Organization specify indications, preparations and procedures for ORT.
WHO/UNICEF guidelines suggest ORT should begin at the first sign of diarrhea in order to prevent dehydration. Babies may be given ORS with a dropper or a syringe. Infants under two may be given a teaspoon of ORS fluid every one to two minutes. Older children and adults should take frequent sips from a cup, with a recommended intake of 200–400 mL of solution after every loose movement. The WHO recommends giving children under two a quarter- to a half-cup of fluid following each loose bowel movement and older children a half- to a full cup. If the person vomits, the caregiver should wait 5–10 minutes and then resume giving ORS. ORS may be given by aid workers or health care workers in refugee camps, health clinics and hospital settings. Mothers should remain with their children and be taught how to give ORS. This will help to prepare them to give ORT at home in the future. Breastfeeding should be continued throughout ORT.
Associated therapies
Zinc
As part of oral rehydration therapy, the WHO recommends supplemental zinc (10 to 20 mg daily) for ten to fourteen days, to reduce the severity and duration of the illness and make recurrent illness in the following two to three months less likely. Preparations are available as a zinc sulfate solution for adults, a modified solution for children and in tablet form.
Feeding
After severe dehydration is corrected and appetite returns, feeding the person speeds the recovery of normal intestinal function, minimizes weight loss and supports continued growth in children. Small frequent meals are best tolerated (offering the child food every three to four hours). Mothers should continue to breastfeed."Community health worker training materials for cholera prevention and control." CDC. A child with watery diarrhea typically regains their appetite as soon as dehydration is corrected, whereas a child with bloody diarrhea often eats poorly until the illness resolves. Such children should be encouraged to resume normal feeding as soon as possible. Once diarrhea is corrected, the WHO recommends giving the child an extra meal each day for two weeks, and longer if the child is malnourished.
Children with malnutrition
Dehydration may be overestimated in wasted children and underestimated in edematous children.National Guidelines for the Management of Severely Malnourished Children in Bangladesh , Institute of Public Health Nutrition, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of the People's Republic of Bangladesh, May 2008, "Step 3. Treat/prevent dehydration" and "Step 4. Correct electrolyte imbalance," pages 21–23 (22-24 in PDF). Care of these children must also include careful management of their malnutrition and treatment of other infections. Useful signs of dehydration include an eagerness to drink, lethargy, cool and moist extremities, weak or absent radial pulse (wrist), and reduced or absent urine flow. In children with severe malnutrition, it is often impossible to reliably distinguish between moderate and severe dehydration. A severely malnourished child who has signs of severe dehydration but who does not have a history of watery diarrhea should be treated for septic shock.
The original ORS (90 mmol sodium/L) and the current standard reduced-osmolarity ORS (75 mmol sodium/L) both contain too much sodium and too little potassium for severely malnourished children with dehydration due to diarrhea. ReSoMal (Rehydration Solution for Malnutrition) is recommended for such children. It contains less sodium (45 mmol/L) and more potassium (40 mmol/L) than reduced osmolarity ORS. It can be obtained in packets produced by UNICEF or other manufacturers.