Oral rehydration and feeding : state of the art in diarrhea management

The situation is slowly changing, and it is the developing rather than the developed world that is leading the way. Physicians in developed countries may feel that oral rehydration solution (ORS) and continued feeding are not important in the context of high living standards and generally good nutritional status of children. This situation has had unfortunate repercussions in parts of the developing world where pediatricians, often drawing on Western education and medical texts, frequently impede acceptance of oral rehydration therapy and continued feeding. Is there any basis for reservations about the use of ORS and continued feeding during diarrhea? To answer this question, it is important to realize that the patient"s clinical hydration status is the best indicator of the success of any given therapy. The patient"s stools or laboratory tests may contribute useful information, but should not be relied upon exclusively as an indicator of success. The studies cited indicate that patients given oral fluids and food during diarrhea do better, as determined by weight gain and return of appetite, than patients treated with intravenous fluids and withholding of food. The slight increase in initial stool output seen in some patients treated orally (although not in many) should not distract the clinician from noting the more effective recovery of the patients treated in this fashion. There is clearly a role for both ORS and intravenous (IV) therapy in the management of acute diarrhea. This review of a number of issues makes it clear, however, that in those patients who can take ORS (more than 90% of all patients presenting with diarrheal dehydration), oral rehydration therapy is as good as or better than IV therapy -- physiologically, nutritionally, and psychologically. IV therapy should be reserved for those few patients who are in shock, who have paralytic ileus, or in whom purging rates are so high or vomiting so great that the oral intake cannot keep up with the stool losses. Patients initially begun on IV therapy should rapidly be switched to ORS once they are able to drink. Feeding is a further critical element in the management of the child with diarrhea. Its early implementation will help to avoid the serious nutritional consequences of diarrhea, and may shorten the duration of the episode. Any increase in stool output due to early feeding will be of limited duration and should not discourage the adoption of this very important practice. Many topics related to the management of acute diarrhea are currently under investigation, such as identification of the best foods for use during and after diarrhea, the use of non-human milk in non-breast-fed children with diarrhea, and the use of cereal-based ORS. These unanswered questions do not alter the conclusion that rehydration with ORS solution and continued feeding are the optimal management strategies for the vast majority of children with diarrhea, including those with diarrhea-induced dehydration. (Author abstract)