Oral rehydration salts utilization in pediatric diarrhea management among Chinese pediatricians: a national survey

Abstract

Background

Oral rehydration salts (ORS) are essential for pediatric diarrhea management. However, not all children with diarrhea receive standardized ORS therapy. This study aimed to assess ORS utilization in the management of pediatric diarrhea among pediatricians in China and to identify factors associated with their ORS prescribing practices.

Methods

A nationwide cross-sectional survey was conducted among 1,788 pediatricians participating in diarrhea training programs across China between August 2021 and April 2023. Data on demographics, professional characteristics, and ORS practices were collected. Chi-squared tests and logistic regression were used.

Results

The overall ORS recommendation rate was 85.96%, with significant regional variation (highest: Central South China, 90.22%; lowest: Northeast China, 77.55%). Only 60.57% of pediatricians preferred reduced osmolarity ORS, with the lowest usage in Northwest China (41.73%). Furthermore, 36.81% used ORS only when the child was already dehydrated, 18.12% mistakenly believed that ORS was restricted to oral administration (rising to 25.52% in North China), and 42.51% incorrectly believed that ORS was exclusively for treating diarrhea (reaching 55.65% in North China). Although 98.61% provided guidance to parents, 21.87% incorrectly supported adding fruit juice or milk to ORS. Multiple logistic regression identified higher professional titles and specialization in pediatric gastroenterology as significant predictors of appropriate ORS prescribing practices.

Conclusions

Deficits exist in the knowledge and practice of ORS in China, especially in specific regions and among certain pediatricians. Future targeted and specific pediatric diarrhea training programs may contribute to more standardized treatment of pediatric diarrhea.

Highlight box.

<bold>Key findings:</bold>

• The overall recommendation rate for oral rehydration salts (ORS) for the management of childhood diarrhea by pediatricians in China was 85.96%. However, there is a lack of knowledge and practice regarding the use of ORS, including misconceptions and inappropriate usage recommendations, as well as disparities in ORS knowledge among pediatricians across regions.

What is known and what is new?

• Childhood diarrhea can be life-threatening without prompt treatment. Its mortality rate has decreased due to ORS, but the utilization rate of ORS remains suboptimal.

• Although most Chinese pediatricians recommend ORS for childhood diarrhea, significant knowledge-practice gaps persist regarding correct timing, preparation, and indications for its use.

What is the implication, and what should change now?

• Implementing more specific and targeted pediatric diarrhea training programs for pediatricians is crucial for improving the management of childhood diarrhea.

Introduction

Diarrhea in children usually resolves within a few days; however, if not treated promptly, it can be life-threatening due to large amounts of fluid and salt lost through stool and vomiting (1). Diarrhea has been extensively recognized as a significant global burden of infectious diseases and is the second leading cause of mortality among children under 5 years of age, resulting in the deaths of approximately half a million children annually, particularly in developing nations (2).

The reduction in diarrhea mortality rates among children over the past three decades has been largely attributed to the widespread adoption and implementation of oral rehydration salts (ORS) (3). However, while the global number of diarrhea deaths among children under 5 years of age has declined by 79.2% from 1990 to 2021, it has been reported that only one-third of children with diarrhea in developing countries receive ORS (2,4). Meanwhile, the only existing research from 2005 in China reported an overall ORS usage rate of 34.62% (5).

These low rates of ORS use are surprising, given that it has been the standard treatment for diarrhea for decades. A potential risk factor affecting the use of ORS in children with diarrhea may stem from the treatment protocols recommended by pediatricians. The World Health Organization recommends that the primary principle of diarrhea treatment is to prevent and treat dehydration; hence, ORS should be initiated at the outset of treatment (6). Pediatricians serve as the pivotal first-contact healthcare providers in the diagnosis and management of childhood diarrhea (7), and it is imperative that they are well-versed in standardized treatment protocols for this condition (8). Therefore, adherence to standardized treatment protocols for childhood diarrhea should be enhanced through targeted training for pediatricians (8,9). However, no large-scale, nationally representative study has yet evaluated pediatricians’ actual use of ORS in clinical practice. Based on this consideration, beginning in 2021, diarrhea training programs have been implemented nationwide in China to promote the standardized treatment of pediatric diarrhea by pediatricians. To inform these efforts, this study conducted the first large-scale evaluation of ORS utilization among Chinese pediatricians, aiming to assess current practices and identify factors associated with their prescribing patterns. We present this article in accordance with the SURGE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0477/rc).

Methods

Study design

This was a nationwide, quantitative, cross-sectional, observational study using a self-administered online questionnaire. Data were collected prospectively between August 2021 and April 2023 from pediatricians attending diarrhea training programs across six major geographic regions of China. The study was coordinated by Children’s Hospital, Zhejiang University School of Medicine.

Ethics statement

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of the Children’s Hospital, Zhejiang University School of Medicine (No. 2021-IRB-156). Informed consent was obtained online from all participants prior to questionnaire administration.

Questionnaire development

A structured questionnaire was developed for this study. The 8 core questions on ORS prescribing practices were derived from World Health Organization (WHO) diarrhea treatment guidelines and relevant literature. The initial draft was reviewed by three senior pediatricians for content validity, clarity, and relevance, and ambiguous wording was revised accordingly. A pilot test was conducted with 10 pediatricians to ensure the questionnaire was understandable and could be completed within an acceptable timeframe. The final questionnaire was administered online in Chinese.

Data collection

An online survey was conducted using the Wenjuanxing online questionnaire platform (https://www.wjx.cn/). A random sample of 1,816 pediatricians was invited from those who had participated in diarrhea training programs across China and completed the pre-training questionnaire. The sample covered all six major geographic regions of China. Participants were invited to complete the questionnaire on-site before the start of each training program. A QR code linking to the questionnaire was displayed, and no reminders were sent. No financial or other incentives were provided for survey completion. Prior to the commencement of the questionnaire, a page was presented that outlined the purpose of the study and sought informed consent from potential participants. To ensure that the collected data were available, we reviewed every questionnaire sheet and verified its appropriateness carefully before questionnaires were accepted. Questionnaires with incomplete or invalid responses (n=28) were excluded. A total of 1,788 valid questionnaires were obtained, yielding a response rate of 98.5%. Only fully completed questionnaires were included in the analysis.

Variables

Independent variables included demographic characteristics such as age range, sex, educational level, professional title, specialty categories, hospital region, hospital tier, hospital attribute, and hospital type. In China, the medical professional title system comprises four levels: junior, intermediate, associate senior, and senior. For analysis, professional titles were categorized into two groups: ‘less than intermediate’ and ‘intermediate or above’. Pediatricians were categorized into two groups: those specializing in pediatric gastroenterology and those in other pediatric specialties. Hospital attributes were classified as either university-affiliated or non-university-affiliated, and hospital types were distinguished between general hospitals and children’s hospitals.

The primary dependent variable used eight questions: “Do you recommend ORS in acute diarrhea?”; “Do you use reduced osmolarity ORS?”; “Is early ORS implementation for diarrhea advised?”; “Do you use ORS only when the child is dehydrated?”; “Do you instruct the patient’s family on the use of ORS?”; “Do you support the patient’s family adding milk or fruit juice to ORS?”; “Is ORS for oral use only?”; and “Is ORS only used to treat diarrhea?”. For each question, the proportion of pediatricians responding “yes” was calculated and reported as a percentage. No composite scoring or weighting was applied.

Statistical analysis

Statistical analyses were performed using SPSS (version 27.0; IBM Corp., Armonk, NY, USA) and Prism (version 10.0; GraphPad Software, La Jolla, CA, USA). Categorical variables were presented as numbers (percentages). Chi-squared (χ²) tests were conducted, followed by the inclusion of variables in a multivariable logistic regression model to identify factors associated with ORS use. The level of significance was set at 5% (two-tailed, P<0.05).

Results

Characteristics of participants

Table 1 shows the demographic and professional characteristics of the surveyed pediatricians. Among the 1,788 pediatricians, the majority (73.77%) were women and nearly one-third (29.31%) held a master’s degree or higher. More than half (54.42%) of participants held intermediate or senior professional titles. Pediatric gastroenterologists comprised 25.06% of the study participants. In terms of hospital affiliation, the majority (69.29%) were employed in tertiary hospitals and a comparable proportion (69.24%) worked at institutions affiliated with universities. In addition, 30.76% were located in children’s hospitals. Geographically, hospitals were distributed across six major regions: East China (32.86%), North China (13.37%), Northeast China (10.96%), Central South China (20.02%), Southwest China (14.99%), and Northwest China (7.78%).

Table 1. Demographic and professional traits of the participants.

Variable	Frequency (n=1,788)	Percentage
Gender
Male	469	26.23
Female	1,319	73.77
Educational level
Less than master	1,264	70.69
Master or above	524	29.31
Professional title
Less than intermediate title	815	45.58
Intermediate title or above	973	54.42
Hospital tiers
Secondary hospital	549	30.71
Tertiary hospital	1,239	69.29
Hospital attribute
University-affiliated	1,238	69.24
Non-university-affiliated	550	30.76
Hospital types
General Hospital	1,238	69.24
Children’s Hospital	550	30.76
Specialty categories
Non-pediatric GE	1,340	74.94
Pediatric GE	448	25.06
Hospital regions
East China	588	32.86
North China	239	13.37
Northeast China	196	10.96
Central South China	358	20.02
Southwest China	268	14.99
Northwest China	139	7.78

GE, gastroenterologist.

Do you recommend ORS in acute diarrhea?

When asked whether they recommend ORS for acute diarrhea, the vast majority of pediatricians (85.96%) responded yes (Table 2). Regional recommendation rates varied considerably, with the highest rate observed in Central South China (90.22%) and the lowest in Northeast China (77.55%) (Figure 1). The χ² test revealed significant differences in educational level, professional title, hospital tier, hospital attribute, hospital type, and specialty category (Table 3). Multivariable logistic regression analysis indicated higher professional titles [odds ratio (OR) =1.62, P=0.001] and specialization in pediatric gastroenterology (OR =2.76, P=0.001) as factors significantly associated with ORS recommendation (Table 4).

Table 2. Summary of questionnaire questions.

Questionnaire questions	Yes, n (%)	No, n (%)	P
Do you recommend ORS in acute diarrhea?	1,537 (85.96)	251 (14.04)	0.001
Do you use reduced osmolarity ORS?	1,083 (60.57)	705 (39.43)	0.001
Is early ORS implementation for diarrhea advised?	1,593 (89.09)	195 (10.91)	0.001
Do you use ORS only when the child is dehydrated?	658 (36.81)	1,130 (63.19)	0.001
Do you instruct the patient’s family on the use of ORS?	1,763 (98.61)	25 (1.39)	0.001
Do you support the patient’s family adding milk or fruit juice to ORS?	391 (21.87)	1,397 (78.13)	0.001
Is ORS for oral use only?	324 (18.12)	1,464 (81.88)	0.001
Is ORS only used to treat diarrhea?	760 (42.51)	1,028 (57.49)	0.001

ORS, oral rehydration salts.

Figure 1.

Regional disparities in ORS knowledge and prescribing practices among pediatricians in China. ORS, oral rehydration salts.

Table 3. ORS recommendation rates by demographic and professional characteristics.

Factors	Recommend ORS use?		P
	No, n (%)	Yes, n (%)
Educational level			0.001
Less than master	195 (15.42)	1,069 (84.58)
Master or above	56 (10.69)	468 (89.31)
Professional title			0.001
Less intermediate	139 (17.06)	676 (82.94)
Intermediate/above	112 (11.51)	861 (88.49)
Hospital tiers			0.001
Secondary hospital	95 (17.30)	454 (82.70)
Tertiary hospital	156 (12.59)	1,083 (87.41)
Hospital attribute			0.001
Non-university-affiliated	185 (14.94)	1,053 (85.06)
University-affiliated	66 (12.00)	484 (88.00)
Hospital types			0.001
General Hospital	196 (15.83)	1,042 (84.17)
Children’s Hospital	55 (10.00)	495 (90.00)
Specialty categories			0.001
Non-pediatric GE	224 (16.72)	1,116 (83.28)
Pediatric GE	27 (6.03)	421 (93.97)

GE, gastroenterologist; ORS, oral rehydration salts.

Table 4. The multiple logistic regression for factors influencing pediatricians’ perception on ORS.

Factors	Recommended use?		Hypotonic ORS?		Oral only?		Diarrhea only?		Early ORS use？
	OR	P	OR	P	OR	P	OR	P	OR	P
Educational level	1.18	0.38	1.45	0.004	1.71	0.001	1.02	0.85	1.15	0.52
Professional title	1.62	0.001	2.46	0.001	1.67	0.001	0.58	0.001	1.36	0.04
Hospital tiers	1.12	0.49	1.24	0.08	1.12	0.45	1.01	0.94	1.35	0.09
Hospital attribute	0.94	0.72	1.03	0.83	0.92	0.61	0.98	0.85	1.23	0.32
Hospital types	1.29	0.14	1.15	0.25	1.01	0.95	1.03	0.77	0.71	0.06
Specialty categories	2.76	0.001	1.92	0.001	0.95	0.75	0.90	0.40	2.41	0.001

OR, odds ratio; ORS, oral rehydration salts.

Do you use reduced osmolarity ORS?

When asked about their use of reduced osmolarity ORS, 60.57% of pediatricians indicated a preference for this formulation (Table 2). Regional disparities were noted, with the highest usage rate recorded in Central South China and the lowest in Northwest China (41.73%) (Figure 1). The χ² test revealed significant differences in educational level, professional title, hospital tier, hospital attribute, hospital type, and specialty category (Table S1). Multivariable logistic regression analysis further identified that educational level (OR =1.45, P=0.004), professional title (OR =2.46, P=0.001), and specialty category (OR =1.92, P=0.001) demonstrated a significant positive association with the use of reduced osmolarity ORS among participants.

Is early ORS implementation for diarrhea advised?

A significant majority of the pediatricians surveyed (89.09%) endorsed the use of ORS at the initial stage of diarrhea as a preventive measure against dehydration. However, 36.81% reported using ORS only when the child was already dehydrated (Table 2). Regional differences were observed, with lower rates of early ORS use in North China (80.75%) and Northeast China (87.24%) (Figure 1). The χ² test revealed significant differences in educational level, hospital tier, hospital attribute, and specialty category (Table S2). In the multivariable logistic regression presented in Table 4, professional title (OR =1.36, P=0.04) and specialty category (OR =2.41, P=0.001) were significantly associated with advising the early implementation of ORS.

Is ORS for oral use only?

Although ORS can be administered via bottles, droppers, spoons, or nasogastric tubes, a notable proportion of pediatricians (18.12%) held the misconception that ORS is restricted to oral administration, with a higher prevalence in North China (25.52%) (Table 2 and Figure 1). The χ² test revealed significant differences in educational level and professional title (Table S3). Multivariable logistic regression analysis further identified lower educational level (OR =1.71, P=0.001) and lower professional title (OR =1.67, P=0.001) as factors significantly associated with this misconception (Table 4).

Is ORS only used to treat diarrhea?

In addition to being suitable for treating diarrhea, ORS can also be used for vomiting and as adjunctive therapy for febrile illnesses (10). However, 42.51% of pediatricians held the misconception that ORS is solely applicable for the treatment of diarrhea (Table 2), with the highest prevalence observed in North China (55.65%) (Figure 1). Moreover, the χ² test and multivariable logistic regression analysis (Table S4 and Table 4, respectively) indicated that higher professional titles were significantly associated with a more comprehensive understanding of the indications for ORS.

Do you instruct the patient’s family on the use of ORS?

Most pediatricians (98.61%) reported providing guidance to family members on ORS use (Table 2). The χ² test revealed significant differences in professional title (Table S5). However, approximately one-fifth of pediatricians (21.87%) incorrectly supported adding juice or milk to ORS (Table 2). No statistically significant differences were observed among the variables examined for this question (Table S6).

Discussion

Although pediatricians are theoretically well-versed in the use of ORS, this study revealed various issues that contradict this expectation. These findings suggest a gap between theoretical knowledge and practical application in clinical environments. The overall rate of recommended ORS usage was 85.96%. However, 60.57% of pediatricians favored the use of reduced osmolarity ORS, and 36.81% administered ORS only when children with diarrhea exhibited signs of dehydration. Furthermore, 18.12% mistakenly believed that ORS is restricted to oral administration, and 42.51% held the incorrect belief that ORS is exclusively for managing diarrhea. Although the majority of pediatricians provided guidance to parents on ORS administration, more than 20% incorrectly supported the addition of fruit juice or milk to the ORS mixture. This practice is clinically discouraged because adding fruit juice or milk to ORS alters the carefully balanced osmolarity of the reduced osmolarity solution, thereby negating its rehydration benefit and potentially worsening osmotic diarrhea. Finally, significant geographical disparities were observed in the levels of ORS knowledge among pediatricians across different regions.

In 2022, a study conducted in Nigeria revealed that the overall ORS usage rate was only 39.6% (11). A common explanation for such low ORS use is the lack of knowledge regarding diarrhea treatment among caregivers of children with diarrhea (12,13). However, evidence from India indicated that even among children with diarrhea who reach healthcare facilities, the ORS usage rate remains below 50%. This indicates that insufficient ORS use cannot be attributed solely to caregivers’ lack of knowledge; rather, healthcare providers may also play a critical role in the underutilization of ORS (14).

Various barriers may contribute to the suboptimal provision of ORS by pediatricians. First, healthcare facilities may be unable to supply ORS. This issue is particularly concerning in regions where diarrhea remains a leading cause of mortality among children under 5 years old, as highlighted in studies conducted in Nigeria and Uganda (15,16). However, with the advancement of economic conditions and healthcare standards in China, ORS is now readily accessible in most regions, suggesting that supply issues are no longer the primary barrier to its use in China(17). Additionally, pediatricians may lack a comprehensive understanding of standardized treatment protocols for childhood diarrhea (18). A prior study from Israel demonstrated that the awareness of American Academy of Pediatrics guidelines among pediatricians was 73%, with a 60% adherence rate to these guidelines (19). To investigate this, our study was conducted to ascertain knowledge deficits among pediatricians in diarrhea management and to inform more targeted future training programs.

A 2004 survey of French pediatricians indicated that only 63% supported rehydration using ORS, whereas a 2000 multicenter European study revealed that only 16% of pediatricians advocated for early ORS administration (20,21). In contrast, a 2010 study from Lebanon demonstrated that 92.4% of pediatricians prescribed ORS for rehydration purposes (22). However, approximately 14% of pediatricians in our study did not endorse the use of ORS, with the prevalence of non-recommendation being most pronounced in northern and northeastern China. Therefore, future training programs should emphasize the importance of ORS, with a particular focus on enhancing education in northern and northeastern China. In addition, the World Health Organization recommends the use of reduced osmolarity ORS (also commonly referred to as hypotonic ORS in some contexts, with osmolarity lower than that of plasma) to mitigate the risk of hypernatremia. Studies have demonstrated that the use of reduced osmolarity ORS can reduce stool output, shorten the duration of diarrhea, and decrease the rate of intravenous fluid administration, thereby conferring significant clinical benefits (23). However, our study revealed that only 60.57% of pediatricians prioritized the use of reduced osmolarity ORS, with an even lower adoption rate of less than 45% observed in Northeast and Northwest China. Therefore, it is essential to enhance the promotion and guidance of reduced osmolarity ORS in subsequent diarrhea training programs and encourage more pediatricians to opt for this treatment, especially in Northeast and Northwest China.

The study also uncovered that pediatricians exhibit a certain degree of knowledge deficiency regarding the timing, method, and indications for the use of ORS, with significant regional variations observed. These disparities may be attributable to multiple factors, including differences in economic development, healthcare resource allocation, and access to continuing medical education across regions (24,25). In addition, regional variation in disease burden and clinical exposure to pediatric diarrhea may affect physicians’ practical experience with ORS, and the uneven distribution of pediatric gastroenterology specialists may leave some regions without local experts to disseminate best practices (26). Thus, future training programs must place greater emphasis on strengthening these knowledge points, and the content should be more targeted to meet the specific needs of different regions.

Higher academic qualifications, senior professional titles, and specialization in pediatric gastroenterology, along with hospital-related factors, were found to be associated with better ORS practice patterns, suggesting that as the professional quality of pediatricians improves, ORS utilization may become more standardized. The strong association between pediatric gastroenterology specialization and ORS prescribing practices indicates that subspecialty expertise could serve as a benchmark for training general pediatricians—for instance, pediatric gastroenterologists could be involved as trainers in continuing education programs, sharing their evidence-based practices on ORS use, particularly in regions with lower utilization rates.

When interpreting the findings of this study, it is imperative to consider its inherent strengths and limitations. A primary constraint was the use of a cross-sectional study design, which restricts the ability to establish temporal relationships and infer causality. Accordingly, all reported associations should be interpreted as statistical correlations rather than causal effects. In addition, although the questionnaire was reviewed by experts and pilot-tested to ensure content and face validity, formal reliability testing was not performed. The use of binary (yes/no) response options may have oversimplified the assessment, and questions containing the word ‘only’ may have introduced a response bias toward ‘no’, potentially leading to an overestimation of knowledge levels. Clinical experience-related factors—such as years since graduation, residency training background, and the volume of pediatric diarrhea cases managed—were not collected, and their absence may have introduced confounding. Readers should therefore interpret the association between professional title and ORS prescribing practices with caution. Finally, this study focused solely on pediatricians in China, which may limit the generalizability of the findings to other countries or regions.

Conclusions

In summary, although ORS is a crucial intervention for the treatment of pediatric diarrhea, deficits remain in both knowledge and practice, particularly in certain regions and among specific pediatrician demographics. Future training programs must place greater emphasis on improving understanding of the appropriate timing, methods, and indications for ORS use, and the content should be targeted to meet the specific needs of different regions. Future longitudinal or interventional studies are warranted to investigate the potential causal mechanisms underlying the associations observed in this study.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of the Children’s Hospital, Zhejiang University School of Medicine (No. 2021-IRB-156). Informed consent was obtained online from all participants prior to questionnaire administration.

Data Sharing Statement

Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0477/dss

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DOI: 10.21037/tp-2026-0477