American Academy of Pediatrics Committee on Nutrition: Use of oral fluid therapy and posttreatment feeding following enteritis in children in a developed country.

The 1982-1983 report by the United Nations Children’s Fund (UNICEF) on the State of the World’s Children recommended widespread implementation of oral rehydration as one of the four strategies projected to save the lives of 20,000 children each day.’ In the developing countries, oral rehydration has been shown to be an effective, simple, and inexpensive therapy for dehydration caused by severe enteritis in infants.28 The modern concepts of oral fluid therapy for diarrheal diseases evolved in part from the clinical observation that orally administered glucose-electrolyte solutions can replace diarrheal fluid losses in cholera. Previous laboratory investigation had demonstrated the presence of a cotransport system of sodium with glucose or other actively transported small organic molecules in the small intestine in animals and in man. Clinical studies suggest that this sodiumglucose cotransport system remains intact not only when the pathophysiologic agent is an enterotoxin, such as that elaborated by Vibrio cholerae or enterotoxigenic strains of Escherichia coli, but also with inflammation such as that associated with rotavirus, Campylobacter jejuni, E coli, and Yersinia enterocolitica. 4-8 These observations have provided a physiologic rationale for an appropriately efficient ratio of sodium to glucose in formulating solutions to be used in the developing countries for oral therapy in the treatment of infants with lifethreatening diarrheal dehydration. The question we address in this commentary is that of the appropriate implementation of oral hydration therapy in a developed country. Pediatricians and others concerned with the health of children in this country are not usually confronted with the problem of obtaining uncontaminated water nor with the management of large numbers of severely malnourished young infants with multiple health problems. Our usual problem is the management of mild, moderate, and (less frequently) severe diarrheal dehydration in an otherwise normal infant. The outstanding presenting complaints are often decreased intake of food and fluid and the presence of vomiting. The goal of our management is to support the infants (and their parents) over the two to three days of acute illness and avoid complications that might result from dehydration or from the measures to prevent dehydration. Pediatricians in this country are very sensitive to the possibility that the infants under their supervision might develop hypernatremic dehydration as a consequence of decreased fluid intake or as a result of the administration of inappropriate fluids.9’5 Pediatricians are also concerned with the cost of hospital care of infants and the potential complications of “hospitalization” and parenteral fluid therapy per Se. With the foregoing points in mind, the following recommendations for oral fluid therapy seem sound for a “developed” country. The recommendations are for patients of all ages, but in the older patient (those with weight greater than 10 kg), allowance should be made for lower maintenance water requirements per kilogram of body weight. The cornposition and the indications for use of two types of oral solutions are shown in the Table. The World Health Organization’s oral rehydration solution (WHO-ORS) is an exceedingly useful product, which has probably saved the lives of many thousands of children.’6 The solution, containing 90 rnEqJL of sodium, is appropriate for rapid rehydration of dehydrated infants-regardless of the initial osmolality of the infant’s body fluids. However, this solution alone is not suitable for provision of water and solute for maintaining fluid balance