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Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children

  1. Seokyung Hahn1,*,
  2. Yaejean Kim2,
  3. Paul Garner3

Editorial Group: Cochrane Infectious Diseases Group

Published Online: 21 JAN 2002

Assessed as up-to-date: 27 NOV 2001

DOI: 10.1002/14651858.CD002847


How to Cite

Hahn S, Kim Y, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD002847. DOI: 10.1002/14651858.CD002847.

Author Information

  1. 1

    Seoul National University Hospital, Medical Research Collaborating Center, Seoul, Korea, South

  2. 2

    Fred Hutchinson Cancer Research Centre, Department of Infectious Diseases, Seattle, USA

  3. 3

    Liverpool School of Tropical Medicine, International Health Group, Liverpool, Merseyside, UK

*Seokyung Hahn, Medical Research Collaborating Center, Seoul National University Hospital, 2nd Floor, 28 Yongon-dong Chongno-gu, Seoul, 110-744, Korea, South. hahns@snu.ac.kr.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 21 JAN 2002

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Characteristics of included studies [ordered by study ID]
Bangladesh 1995a

MethodsRCT


Participants55 children 2 to 15 months old

Randomized after 1 day of rehydration

Dehydration status not known


Interventions
  1. Low L-alanine and glucose ORS (255 mosmol/L)
  2. IV
  3. WHO standard ORS


OutcomesStool output (24 h, 96 h)

Unscheduled IV

Fluid intake

Food intake

Vomiting

Body weight

Stool frequency


Notes

Bangladesh 1995b

MethodsRCT (double blind)


Participants50 children 5 to 24 months old with diarrhoea and mild to moderate dehydration

Some with cholera


Interventions
  1. Low osmolarity glucose ORS (249 mosmol/L)
  2. WHO standard ORS


OutcomesStool output (24 h, 48 h)

Stool frequency

Fluid intake

Patients vomiting


Notes

Bangladesh 1996a

MethodsRCT (double blind)


Participants46 children 6 to 30 months with diarrhoea and mild to moderate dehydration (WHO)


Interventions
  1. Low osmolarity sucrose ORS (198 mosmol/L after full hydrolysis -> 257 mosm/L)
  2. WHO standard ORS


OutcomesStool output (24h, 48 h)

ORS intake

Unscheduled IV

Urine output

Stool frequency


Notes

CHOICE 2001

MethodsRCT (double blind)


Participants671 children
1 to 24 months old with diarrhoea and some more severe dehydration.


Interventions(1) Low osmolarity glucose ORS
(245 mosmol/L)

(2) WHO standard ORS


OutcomesStool output (24 h and total)

ORS intake (24 h, total)

Vomiting in first 24 h

Unscheduled IV in the first 24 h

Frequency of hyponatraemia at 24 h

Duration of diarrhoea


Notes

Colombia 2000

MethodsRCT


Participants140 boys 1 to 36 months old with diarrhoea and mild or moderate dehydration


Interventions
  1. Low osmolarity glucose ORS (245 mosmol/L)
  2. WHO standard ORS


OutcomesStool output rate at 24 h

Fluid and food intake

Weight gain

Sodium and potassium levels

Urine and vomit outputs

Vomiting

Unscheduled IV


Notes

Egypt 1994

MethodsRCT, no details given


Participants61 children 3 to 24 months old with diarrhoea and moderate dehydration (WHO definition)


Interventions
  1. Low osmolarity glucose ORS (210 mosmol/L)
  2. WHO standard ORS
  3. IV infusion


OutcomesStool volume at 24 h

Fluid intake

Weight gain at 6 h

Hyponatraemia;

Duration of diarrhoea


Notes

Egypt 1996b

MethodsRCT (double blind)


Participants190 boys 1 to 24 months with diarrhoea and dehydration (WHO criteria).


Interventions
  1. Low osmolarity glucose ORS (245 mosmol/L)
  2. WHO standard ORS


OutcomesStool output (24 h and total)

Fluid intake

Sodium

Potassium

Weight gain

Children who vomited

Mean weight gain

Duration of diarrhoea

Treatment failures


Notes

India 1984a

MethodsRCT


Participants65 infants 0 to 3 months old with acute non-cholera diarrhoea and dehydration


Interventions
  1. Low osmolarity glucose ORS (270 mosmol/L)
  2. WHO standard ORS (330 mmol/L)
  3. IV Ringer's lactate therapy


OutcomesStool output (8 h, 24 h)

Weight gain

Fluid intake

Unscheduled IV

Haematologic and electrolyte measures

Urine output

Duration of diarrhoea after hospitalization


Notes

India 2000a

MethodsRCT
(double blind)


Participants70 children 3 to 24 months with acute non-cholera diarrhoea and some dehydration.


Interventions1. Low osmolarity glucose ORS (224 mosmol/L)

2. WHO standard ORS


OutcomesNumber (%) of patients cured within 10 days

Duration of diarrhoea

Stool output (g/kg/d)

Intake of ORS (ml/kg/d)

Fluid intake (ORS + water + liquid food)

% of weight gain

Mean serum electrolytes


Notes

India 2000b

MethodsRCT (double blind)


Participants170 children

3 months to 5 years old with acute cholera and non-cholera diarrhoea and some to severe dehydration


Interventions
  1. Low osmolarity glucose ORS (245 mosmol/L)
  2. WHO standard ORS


OutcomesRehydration frequency (stool/4h)

Rehydration ORS consumed (L)

Rehydration duration (h)

Maintenance frequency (stools/4h)

Maintenance ORS consumed (L)

Maintenance duration (h)

Overall frequency (stool/4h)

Overall ORS consumed (L)

Overall duration (h)

Weight gain (%)

Caloric intake (kcal/kg/d)

Serum sodium (mEq/L)

Urine output (boys) (ml/k/h)

Intravenous fluid (ml/kg)


Notes

Mexico 1990a

MethodsRCT


Participants186 children 1 to 36 months old with diarrhoea and dehydration


Interventions
  1. Low osmolarity glucose ORS-90 (240 mosmol/L)
  2. WHO standard ORS


OutcomesNeed of IV

Sodium

Potassium concentration


Notes

Panama 1982

MethodsRCT


Participants94 well nourished children 3 months to 2 years old with diarrhoea and dehydration


Interventions
  1. Low osmolarity glucose ORS (251 mosmol/L)
  2. WHO standard ORS (331 mosmol/L)
  3. IV


OutcomesStool output (8 h and total illness)

Unscheduled IV

Fluid and electrolyte intake

Weight gain

Duration of diarrhoea after discharge

Hyponatraemia

Serum sodium

Stool electrolyte


Notes

USA 1982

MethodsRCT


Participants52 well nourished children 3 months to 2 years old with diarrhoea and dehydration


Interventions
  1. Low osmolarity glucose ORS (251 mosmol/L)
  2. WHO standard ORS (331 mosmol/L)
  3. IV


OutcomesStool output (8 h and total illness)

Unscheduled IV

Fluid and electrolyte intake

Weight gain

Duration of diarrhoea after discharge

Hyponatraemia

Serum sodium


Notes

WHO 1995

MethodsMulticentred RCT (double blind)


Participants447 children aged 1 to 24 months admitted to hospital with diarrhoea and mild to moderate dehydration (WHO classification)


Interventions
  1. Low osmolarity glucose ORS (224 mosmol/L)
  2. WHO standard ORS


OutcomesStool output at 24 h

Fluid intake

Mean daily consumption of formula milk and semi-solid food.

Weight gain

Serum sodium on admission and at 24 h

Need for unscheduled IV


NotesBrazil, Peru, Mexico, India

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Australia 1990They compared ORS-26 (total 340 mosmol/L, sodium 26 mmol/L, glucose 2.7%) and ORS-60 (total 240 mosmol/L, sodium 60 mmol/L, glucose 1.8%). The ORS-26 was not WHO standard ORS.

Australia 1993They compared Glucolyte (total 343 mosmol/L, sodium 26 mmol/L, glucose 145 mmol/L) and Gastrolyte (total 240 mosmol/L, sodium 60 mmol/L, glucose 90 mmol/L). The Glucolyte was not WHO standard ORS. This was not an RCT but a open-label study.

Bangladesh 1978They compared two isotonic sucrose (111 mmol/L) based and glucose (111 mmol/L) based ORS solutions. They did not use reduced osmolarity ORS.

Bangladesh 1991Maltodextrin containing ORS and WHO standard ORS were compared. They did not clearly report the composition of fluid or exact osmolarities but only mentioned 50 g of maltodextrin was added in the place of glucose which suggests no reduced osmolarity ORS was used.

Bangladesh 1996bIn this RCT, they compared WHO standard ORS (311 mosmol/L) and low osmolar ORS (249 mosmol/L). This was excluded because the study was performed in adult patients.

Bangladesh 1999This is a RCT comparing WHO standard ORS and low osmolarity ORS. This was excluded because this study was performed in adult patients.

Costa Rica 1987They compared solution A (WHO standard ORS, 311 mosmol/L) and solution B (Pedialyte total 309 osmol/L). They did not use reduced osmolarity ORS.

Ecuador 1995This community study was not a RCT but a crossover design in 4 communities. They compared glucose based ORS (310 to 330 mosmol/L) and rice based ORS (220 to 240 mosmol/L).
None of their outcomes were relevant for this review.

Egypt 1996aThe intervention group was maltodextrin ORS, and therefore does not meet the inclusion criteria.

Finland 1985ORS-60 (total 304 mosmol/L, sodium 60 mmol/L, glucose 144 mmol/L) and WHO standard ORS (total 331 mosmol/L) were used. ORS-60 was not a reduced osmolarity ORS.

Finland 1986They compared two glycin supplemented ORS (total osmolarity 360 mmol/L and 280 mmol/L) and an ORS with sodium 60 mmol/L (total osmolarity 304 mmol/L). They did not use reduced osmolarity ORS or WHO standard ORS.

Finland 1993Two ORS-60 solutions (sodium 60 mmol/L, each) were compared. One is isotonic (304 mosmol/L and has higher glucose concentration (144 mmol/L), the other hypo-osmolar solution (224 mosmol/L) has 84 mmol/L of glucose. They did not use WHO standard ORS.

Finland 1997They compared one standard ORS (sodium 60 mmol/L, total 304 mosmol/L) and the low osmolarity ORS (sodium 60 mmol/L, total 224 mosmol/L). They did not use WHO standard ORS.

Finland 1998Two hypotonic ORS with osmolarities of 224 osmol/L (sodium 60 mmol/L, glucose 84 mmol/L) and 204 mosmol/L (sodium 60 mmol/L, glucose 64 mmol/L) were compared. They did not use WHO standard ORS and this was not a RCT but an alternate allocation trial.

France 1990They compared solution A (total 326 osmol/L, sodium 49 mmol/L glucose 110 mmol/L) and solution D (total 240 osmol/L, sodium 60 mmol/L, glucose 90 mmol/L). They did not use WHO standard ORS.

Guinea-Bissau 1999This is a community-based RCT where they used WHO standard ORS of 311 osmol/L and reduced osmolarity ORS of 224 osmol/L. None of their outcomes were relevant for this review.

India 1978In this RCT, they used solution A (sodium 90 mmol/L, potassium 15 mmol/L, chlorine 75 mmol/L, bicarbonate 30 mmol/L, glucose 90 mmol/L) and B (sodium 50 mmol/L, potassium 15 mmol/L, chlorine 50 mmol/L, bicarbonate 15 mmol/L, glucose 170 mmol/L. Both solutions have total osmolarity of 300 mosmol/L.

India 1984bIn this randomized study, they compared WHO standard ORS (sodium 90 mmol/L, potassium 20 mol/L, bicarbonate 30 mmol/L, chlorine 80 mmol/L, and glucose 111 mmol/L, total 331 mmol/L) and glycin fortified ORS of which osmolarity is not lower because 111 mmol/L of glycine was added.

Iran 1983They compared sucrose high sodium (sodium 90 mmol/L, sucrose 111 mol/L, total 331 osmol/L) and sucrose low sodium (sodium 58 mmol/L, total 278 osmol/L) ORS. They did not use WHO standard ORS.

Mexico 1988Appears to contain same patients as Mexico 1990a.

Mexico 1990bAppears to contain same patients as Mexico 1990a.

Myanmar 1991They compared WHO standard ORS (311 mmol/L) and maltodextrin/glycine/clycyl-clycine ORS (326 mmol/L). They did not use reduced osmolarity ORS.

Russia 1997They compared WHO standard ORS (331 mmol/L), low ORS (224 mmol/L), and IV fluid infusion, and secondarily lactobacillus GG or placebo. None of their outcomes were relevant for this review.

Turkey 1985This is not an RCT but a comparison of data between two separate studies using ORS-60 and ORS-90.

Turkey 1986This is not an RCT but a comparison between treatment effects of ORS-60 (sodium 60 mmol/L) in malnourished infants with infectious diarrhoea and in a previous study of well-nourished patients. This paper is not an RCT but a comparison of data between two separate studies.

USA 1972They used two hypotonic solutions. This is not an RCT. They did not use WHO standard ORS.

USA 1986They used solution A (sodium 50 mmol/L, glucose 111 mEq/L, 389 mosmol/L) and B (sodium 50 mmol/L, glucose 111 mEq/L, 278 mosmol/L). Solution A had 111 mEq/L of glycine additionally. They did not use WHO standard ORS.

 
Comparison 1. Reduced osmolarity ORS compared to WHO standard ORS

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Need for unscheduled intravenous fluid infusion111996Odds Ratio (M-H, Fixed, 95% CI)0.59 [0.45, 0.79]

 2 Stool output111776Std. Mean Difference (IV, Fixed, 95% CI)-0.23 [-0.33, -0.14]

 3 Episode of vomiting during rehydration61305Peto Odds Ratio (Peto, Fixed, 95% CI)0.71 [0.55, 0.92]

 4 Presence of hyponatremia after rehydration61120Peto Odds Ratio (Peto, Fixed, 95% CI)1.44 [0.93, 2.24]

 5 Need for unscheduled intravenous fluid infusion (sensitivity analysis)71688Odds Ratio (M-H, Fixed, 95% CI)0.61 [0.46, 0.82]

 6 Stool output (sensitivity analysis)61550Std. Mean Difference (IV, Fixed, 95% CI)-0.21 [-0.31, -0.11]

 
Comparison 2. Reduced osmolarity ORS (stratified by sodium concentration) compared to WHO standard ORS

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Need for unscheduled intravenous fluid infusion91925Odds Ratio (M-H, Fixed, 95% CI)0.59 [0.44, 0.78]

    1.1 60 to 74 mmol
4584Odds Ratio (M-H, Fixed, 95% CI)0.70 [0.43, 1.15]

    1.2 75 mmol to 84 mmol
51341Odds Ratio (M-H, Fixed, 95% CI)0.53 [0.37, 0.76]

 2 Stool output71591Std. Mean Difference (IV, Fixed, 95% CI)-0.20 [-0.30, -0.10]

    2.1 60 to 74 mmol
4586Std. Mean Difference (IV, Fixed, 95% CI)-0.31 [-0.47, -0.15]

    2.2 75 to 84 mmol
31005Std. Mean Difference (IV, Fixed, 95% CI)-0.13 [-0.26, -0.01]

 3 Episodes of vomiting61305Odds Ratio (M-H, Fixed, 95% CI)0.70 [0.54, 0.91]

    3.1 60 to 74 mmol
2104Odds Ratio (M-H, Fixed, 95% CI)0.59 [0.24, 1.47]

    3.2 75 to 84 mmol
41201Odds Ratio (M-H, Fixed, 95% CI)0.71 [0.54, 0.93]

 4 Presence of hyponatraemia61171Odds Ratio (M-H, Fixed, 95% CI)1.45 [0.93, 2.26]

    4.1 60 to 74 mmol
3190Odds Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.2 75 to 84 mmol
3981Odds Ratio (M-H, Fixed, 95% CI)1.45 [0.93, 2.26]