Skip to main content
PMC home page
Springer Nature - PMC COVID-19 Collection logoLink to Springer Nature - PMC COVID-19 Collection
. 2021 Mar 28;58(3):266–272. doi: 10.1007/s13312-021-2168-8

Low Osmolarity Oral Rehydration Salt Solution (LORS) in Management of Dehydration in Children

Nimain Mohanty 1,✉, Babu Ram Thapa 2, John Mathai 3, Uday Pai 4, Niranjan Mohanty 5, Vishnu Biradar 6, Pramod Jog 7, Purnima Prabhu 8
PMCID: PMC8005284  PMID: 33713063

Abstract

Justification

The IAP last published the guidelines “Comprehensive Management of Diarrhea” in 2006 and a review in 2016. The WHO in 2002 and the Government of India in 2004 recommended low osmolarity rehydration solution (LORS) as the universal rehydration solution for all ages and all forms of dehydration. However, the use of LORS in India continues to be unacceptably low at 51%, although awareness about ORS has increased from a mere 14% in 2005 to 69% in 2015. Availability of different compositions of ORS and brands in market added to the confusion.

Process

The Indian Academy of Pediatrics constituted a panel of experts from the fields of pediatrics, pediatric gastroenterology and nutrition to update on management of dehydration in children with particular reference to LORS and issue a current practice guideline. The committee met twice at CIAP HQ to review all published literature on the aspect. Brief presentations were made, followed by discussions. The draft paper was circulated by email. All relevant inputs and suggestions were incorporated to arrive at a consensus on this practice guideline.

Objectives

To summarize latest literature on ORT and empower pediatricians, particularly those practicing in rural areas, on management of dehydration by augmenting LORS use.

Recommendations

It was stressed that advantages of LORS far out-weigh its limitations. Increased use of LORS can only be achieved by promoting better awareness among public and health-care providers across all systems of medicine. LORS can also be useful in managing dehydration in non-diarrheal illness. More research is required to modify ORS further to make it safe and effective in neonates, severe acute malnutrition, renal failure, cardiac and other co-morbidities. There is an urgent need to discourage production and marketing all forms of ORS not in conformity with WHO approved LORS, under a slogan “One India, one ORS”.

Keywords: Diarrhea, Management, Oral rehydration therapy

Footnotes

Funding

None

Competing interests

None stated

References

  • 1.Bern C, Martines J, Zoysa I d, Glass RI. The magnitude of global problem of diarrheal disease: A ten year update. Bulletin of the World Health Organization. 1992;70:705–14. [PMC free article] [PubMed] [Google Scholar]
  • 2.Global Burden of Diseases GDB dy2016 Diarrheal disease collaborators, Estimates of the global, regional, and national morbidity, mortality and aetiologies of diarrhea in 195 countries: A systematic analysis for global burden of disease Study 2016. Lancet Infect Dis. 2018;18:1211–28. doi: 10.1016/S1473-3099(18)30362-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.International Institute for Population Sciences (IIPS) and ICF. 2017. National Family Health Survey-4, 2015-16:56–9. India. IIPS. Available from: http://www.rchiips.org/nfhs/NFHS-4Reports/India.pdf
  • 4.International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005–06: India: Volume I. IIPS. Available from: http://www.rchiips.org/nfhs/NFHS-3Reports/India.pdf
  • 5.Bhattacharya SK. History of development of oral rehydration therapy. Indian J Public Health. 1994;38:39–43. [PubMed] [Google Scholar]
  • 6.6. World Health Organisation (WHO), United Nations Children Fund (UNICEF) Joint Statement: Clinical management of acute diarrhea. WHO 2004. Available from: https://www.who.int/maternal_child_adolescent/documents/who_fch_cah_04_7/en/. Accessed June 20, 2020.
  • 7.Alam NH, Yunus M, Abu S, et al. Symptomatic hyponatremia during treatment of dehydrating diarrheal disease with reduced osmolarity oral rehydration solution. JAMA. 2006;296:567–73. doi: 10.1001/jama.296.5.567. [DOI] [PubMed] [Google Scholar]
  • 8.Guarino A, Ashkenazi S, Gendrel D, Lo A, Shamir R, Szajewska H. European Society for Paediatric Gastroenterology, Hepatology and Nutrition/European Society for Paediatric Infectious Diseases. Evidence-Based Guidelines for the Management of Acute Gastroenteritis in Children in Europe. J Pediatr Gastroenterol Nutr. 2014;59:132–52. doi: 10.1097/MPG.0000000000000375. [DOI] [PubMed] [Google Scholar]
  • 9.Operario DJ, Houpt E. Etiology of diarrhea: Novel approaches. Curr Opin Inf Dis. 2011;24:464–71. doi: 10.1097/QCO.0b013e32834aa13a. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Hodges K, Gill R. Infectious diarrhea: Cellular and molecular mechanisms. Gut Microbes. 2010;1:4–21. doi: 10.4161/gmic.1.1.11036. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Hirschhorn N, Nalin DR, Cash RA, Greenough WB., 3rd Formulation of oral rehydration solution. Lancet. 2002;360:340–341. doi: 10.1016/S0140-6736(02)09528-4. [DOI] [PubMed] [Google Scholar]
  • 12.Nalin DR, Cash RA. 50 years of oral rehydration therapy: Solution still simple. Lancet. 2018;392:536–8. doi: 10.1016/S0140-6736(18)31488-0. [DOI] [PubMed] [Google Scholar]
  • 13.Patwari AK. Management of diarrhea — Changing trends in last 50 years. Indian Pediatr. 2018;55:63–5. doi: 10.1007/s13312-018-1230-7. [DOI] [PubMed] [Google Scholar]
  • 14.IMNCI Distant Learning Course. Module 4. Diarrhea. 2014; updated guidelines 2017. World Health Organisation Press, Geneva, 2017. Accessed June 20, 2020. Available from: https://www.who.int/maternal_child_adolescent/documents/9789241506823/en/
  • 15.Suh JS, Hahn WH, Cho BS. Recent advances of oral rehydration therapy (ORT) Electrolyte Blood Press. 2010;8:82–6. doi: 10.5049/EBP.2010.8.2.82. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Falszewska A, Szajewska H, Dziechciarz P. Diagnostic accuracy of three clinical dehydration scales: A systematic review. Arch Dis Child. 2018;103:383–8. doi: 10.1136/archdischild-2017-313762. [DOI] [PubMed] [Google Scholar]
  • 17.Fedorwicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev. 2011:CD005506. [DOI] [PMC free article] [PubMed]
  • 18.Ryes JA, Veroniki AA, Florez ID. Antiemetics in children with acute gastroenteritis: A meta-analysis. Pediatrics. 2020;145:e20193260. doi: 10.1542/peds.2019-3260. [DOI] [PubMed] [Google Scholar]
  • 19.Walker CL, Black RE. Zinc for the treatment of diarrhea: Effect on diarrhea morbidity, mortality and incidence of future episodes. Int J Epidemiol. 2010;39:i63–i69. doi: 10.1093/ije/dyq023. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Lazzerini M, Wanzira H. Oral zinc for treating diarrhea in children. Cochrane Database Syst Rev. 2016;12:CD005436. doi: 10.1002/14651858.CD005436.pub5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Ashworth A, Khanum S, Jackson A, Schofield C. Guidelines for inpatient treatment of Severe Acute Malnurished Children. WHO, Geneva 2003. Accessed June 20, 2020. Available from: https://www.who.int/bulletin/volumes/94/9/15-162867/en/
  • 22.WHO. Guideline: Updates on Management of Severe Acute Malnutrition in Infants and Children. Geneva: World Health Organization: 2013. Accessed June 20, 2020. Available from: https://www.who.int/publications/i/item/9789241506328 [PubMed]
  • 23.Bhatnagar S, Lodha R, Choudhury P, et al. IAP guidelines 2006 on Hospital Based Management of Severely Malnourished Children (adapted from WHO Guidelines) Indian Pediatr. 2007;44:443–61. [PubMed] [Google Scholar]
  • 24.Alam NH, Hamadani JD, Dewan N, Fuchs GJ. Efficacy and safety of a modified oral rehydration solution (ReSoMaL) in the treatment of severely malnourished children with watery diarrhea. J Pediatr. 2003;143:614–9. doi: 10.1067/S0022-3476(03)00500-6. [DOI] [PubMed] [Google Scholar]
  • 25.Kumar R, Kumar P, Aneja S, Kumar V, Rehan HS. Safety and efficacy of low-osmolarity ORS vs, modified rehydration solution for malnourished children for treatment of children with severe acute malnutrition and diarrhea: A randomized controlled trial. J Trop Pediatr. 2015;61:435–41. doi: 10.1093/tropej/fmv054. [DOI] [PubMed] [Google Scholar]
  • 26.Houston KA, Gibb JG, Maitland K. Oral rehydration of malnourished children with diarrhea and dehydration: A systematic review. Wellcome Open Research. 2017;2:66. doi: 10.12688/wellcomeopenres.12357.3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Barbi E, Marzuillo P, Neri E. Fever in children: Pearls and pitfalls. Children (Basel) 2017;4:81. doi: 10.3390/children4090081. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Government of India. National Guidelines for Clinical Management of Dengue. 2015. Accessed June 20, 2020. Available from: http://pbhealth.gov.in/denguenationalguidelines2014.pdf
  • 29.Cruz Espinoza LM, McCreedy E, Holm M, et al. Occurrence of typhoid fever complications and their relation to duration of illness preceding hospitalization: A systematic literature review and meta-analysis. Clin Infect Dis. 2019;69:S435–S448. doi: 10.1093/cid/ciz477. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Ibadin OM, Airauhi L, Omoigberale AI, Abiodun PO. Association of malarial parasitaemia with dehydrating diarrhea in Nigerian children. J Health Popul Nutr. 2000;18:115–8. [PubMed] [Google Scholar]
  • 31.Ishikawa T, Tamura H, Ishiguro H, Yamaguchi K, Minami K. Effect of oral rehydration solution on fatigue during outdoor work in a hot environment: a randomized crossover study. J Occup Health. 2010;52:209–15. doi: 10.1539/joh.L9156. [DOI] [PubMed] [Google Scholar]
  • 32.LeFevre AE, Mohan D, Mazumder S, et al. Diarrhea no more: Does zinc help the poor? Evidence on the effectiveness of programmatic efforts to reach poorest in delivering zinc and ORS at scale in UP and Gujarat, India. J Glob Health. 2016;6:021001. doi: 10.7189/jogh.06.021001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Lanters LM, Das JK, Bhutta ZA. Systemic review of strategies to increase ORS use at household level. BMC Public Health WHO. 2013;13:S28. doi: 10.1186/1471-2458-13-S3-S28. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Santosham M, Chandran A, Fitzwater S, Fischer-Walker C, Baqui AH, Black R. Progress and barriers for the control of diarrheal disease. Lancet. 2010;376:63–7. doi: 10.1016/S0140-6736(10)60356-X. [DOI] [PubMed] [Google Scholar]
  • 35.Bachewar N, Thawani V, Gharpure K. Are ORS brands in India using the name of WHO judiciously? Indian J Pharmacol. 2006;38:439–41. doi: 10.4103/0253-7613.28219. [DOI] [Google Scholar]
  • 36.Kumar GS, Kar SS, Jain A. Health and environmental sanitation in India: Issues for prioritizing control strategies. Indian J Occup Environ Med. 2011;15:93–6. doi: 10.4103/0019-5278.93196. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Indian Pediatrics are provided here courtesy of Nature Publishing Group

RESOURCES