ORS

2. What is Diarrhea ?

3. Types of serious diarrhoea in
children
Acute watery diarrhea- If <14 days ,sever
dehydration Ecoli,cholera ,malnutrition
 Persistent diarrhea-If >14 days, 20-30 %
death, under nourished and HIV exposed
Dysentery-(atisar) with blood ,with or without
mucus 10%-15 % of deaths

4. Why are children more prone to
diarrhoea
Proportion of water is more in children ,so
dehydration occur early.
Metabolic rate is high and use more water as
compared to adults
Kidney can conserve less water ,so loss is more
Sodium loss can be 70-110 m mol/kg
Chloride and potassium loss is balanced &same

5. Assessment of diarrhea
Did child vomit?
Did child pass urine?
What type of liquids did the child get ?
Did the child get sufficient food before this episode ?
During diarrhea is child getting food that is different
and is less calorie dense?
Look for cough ,fever ,otitis media ,sepsis ,h/o
measles
Weight /nutrition

6. ASSESS:
Degree of Dehydration
DECIDE:
Plan of treatment

7. Does the child have diarrhea?
If yes, ask:
For how long? How many?
Has the child been vomiting
Is there blood in stool?

8. LOOK AT THE CHILD’S GENERAL
CONDITION
IS THE CHILD
◦ Lethargic or Unconscious?
◦ Restless or Irritable?
LOOK FOR SUNKEN EYES
 Look for skin pinch -goes back
promptly/slowly/ very slowly
OFFER THE CHILD FLUID TO DRINK –
THIRSTY
Not able to drink or drinking
poorly?
Drinking eagerly, appears thirsty?
Drinking normally?
LOOK

9. Look at Eyes for Dehydration
Shrunken Eyes
Normal eyes

13. Two or more of the following
Degree of dehydration decided
on:
•Restless, Irritable
•Sunken Eyes
•Drinks eagerly, Thirsty
•Skin Pinch goes back
“slowly”
Some Dehydration Severe Dehydration
•Lethargic or unconscious
•Sunken Eyes
•Not able to drink or drinking
poorly
•Skin Pinch goes back “very
slowly”
OR NO DEHYDRATION

14. No Dehydration: PLAN-A
Some Dehydration: PLAN-B
Severe Dehydration: PLAN-C

15. Treat Diarrhea at Home.
4 Rules of Home Treatment:
GIVE EXTRA FLUID
CONTINUE FEEDING
WHEN TO RETURN [ADVICE TO
MOTHER]
GIVE ORAL ZINC FOR 14 DAYS
PLAN – A

16. Plan-B is carried out at ORT Corner in
OPD/clinic/ PHC
Treat ‘some’ dehydration with ORS (50-100
ml/kg
If the child wants more, give more
After 4 hours:
Re-assess and classify degree of
dehydration.
PLAN – B

17. PLAN -C
Signs of sever dehydration
Child not improving after 4 hours
Refer to higher center –give ORS on way /keep
warm /BF
When child comes back follow up as other children

18. Start I. V. Fluid immediately
PLAN – C

19. Dysentery
Cholera
Severe malnutrition
Associated systemic infection
Antimicrobials should be given during
diarrhea only for:

20. Increase amount of calories during convalescence
with energy dense foods (enrich foods with fats
and sugar)
•Feed an extra meal (for at least 2 weeks after
diarrhea stops)
•Give an extra amount
•Use extra rich foods
•Feed with extra patience
•Give extra breastfeeds as often as child wants

21. Increase amount of calories during convalescence
with energy dense foods (enrich foods with fats
and sugar)
•Feed an extra meal (for at least 2 weeks after
diarrhea stops)
•Give an extra amount
•Use extra rich foods
•Feed with extra patience
•Give extra breastfeeds as often as child wants

22. What Is ORS

23. PRINICIPLE OF ORS
The sodium-coupled co-transport with glucose and
other carrier organic solutes remains intact, even with
viral enteritis associated with epithelial damage .

24. Ingredient Standard WHO
ORS mmol/l
Reduced
osmolarity ORS
mmol/l (2002)
Glucose 111 75
Na 90 75
K 20 20
Cl 80 65
Citrate 10 10
Osmolarity
mOsm/kg
311 245

25. Limitation of high osmolarity ORS
Does not lower volume, frequency and duration of
diarrhoea.
Induces vomiting due to taste, so acceptability poor.
More chances of dehydration, more chances of
requiring iv fluid.
Hypernatremia.
Good to correct fluid deficit, not good for
maintenance fluid.

26. LOW OSMOLARITY ORS
Compared to WHO standard ORS , hypo-osmolar
ORS is associated with
a) fewer unscheduled intravenous fluid infusions(33%)
b)lower stool volumes (20%), and
c) less vomiting(30%)

27. Clinical relevance - low osmolarity ORS
Reduction in need of IV therapy results in reduced
hospitalization and in turn results:
Reduced risk of hospital acquired infections.
 Reduced disruption of breastfeeding.
 Reduced use of needles and interventions
 Reduced therapy cost.
 Reduced risk of diarrheal deaths in areas where
IV therapy is not readily available.

28. Rice-based ORS, Maltodextrin-containing and
Amino acid-containing ORS—SUPER ORS
They are not superior to glucose-based ORS for
acute non-cholera diarrhea, provided that feeding
was promptly resumed after initial rehydration of the
child.

29. Flavored/Colored ORS
Studies showed neither an advantage nor
disadvantage for the flavoured and coloured ORS
when compared to the standard ORS with regard to
safety, acceptability and correct use.
Concerns about the type of sweetners ,coloring and
flavouring agents used.
More expensive

30. Limitations for ORS
Altered mental status with concern for aspiration
Abdominal ileus
Underlying disorder that limits intestinal
absorption of ORT (e.g, short gut, carbohydrate
malabsorption)

31. PRACTICAL PROBLEMS
Vomiting: Give less amount more frequently,wait for
10 minutes and try again.Give food in the form of
Kanji,Amylase rich food.
Taste: It is a MEDICINE and the most important
medicine in diarrhea. Convince the parents. First drug
in your prescription.
If affording, flavoured ORS may help.

32. ORS IV fluids
Once ORT has been initiated, intervention with
intravenous hydration is indicated:
If stool output continues to be excessive, and ORT is
unable to adequately rehydrate the child
If there is severe and persistent vomiting, and
inadequate intake of ORS

33. WHO Statement
2006: The World Health Organization states that,
“there is no evidence to support the ongoing use
of IV therapy for the first-line management of
most cases of childhood gastroenteritis.”

34. Safe & effective
Can alone successfully rehydrate 95-97% patients
with diarrhea,
Reduces hospital case fatality rates by 40 - 50%
Cost saving
Reduces hospital admission rates by 50% and
cost of treatment by 90%

35. 39% reduction in need for unscheduled IV fluids
19% reduction in stool output
29% reduction in vomiting
Hahn et al, 2001; WHO/FCH/CAH 0.1.22, 2001

36. Should be given to young infants (< 2m)
including neonates if there is dehydration
In exclusively breastfed young infants with
no dehydration encourage exclusive
breastfeeding more frequently and for longer
Low osmolarity ORS is safe and effective
for all ages

37. Advice to parents
Storing
How to give
Measuring
Home remedies

38. WHY ZINC?

39. IZiNCG advocacy statement (http://www.izincg.org/pdf/IZiNCG_Advocacy-
PrintingFormat.pdf)
Zinc deficiency is widespread in low
and middle income countries like India

40.  Disrupts intestinal mucosa
 Reduces brush border enzymes
 Increases mucosal permeability
 Increases intestinal secretion
Roy 1992, Hoque 2005
Zinc deficiency has direct effects on mucosal
functions

41. 20 mg/day (10 mg/day for infants 2-6 mo) of
zinc supplementation for 14 days starting
as early as possible after onset of diarrhea
WHO/UNICEF Joint statement (2001), IAP
2003, GOI 2007
Recommendations for Use of Zinc in
Acute Diarrhea

42. Preventing and Treating Diarrhea

43. THANK YOU