The latest UNICEF report says "5000 kids die daily under the age of five in India". An alarming figure despite several initiatives and rapid progress in medical and related health sciences! The more painful is that this happens mainly due to preventable causes. Among the various causes, diarrhoea is the most important reason which accounts for nearly 10-20% of deaths.

Diarrhoea is having loose or watery stools at least three times per day, or more frequently than normal for an individual. Diarrhoea is a common symptom of gastrointestinal infections caused by a wide range of pathogens, including bacteria, viruses and protozoa. Rotavirus is the leading cause of acute diarrhoea, and is responsible for about 40% of all hospital admissions due to diarrhoea among children under five worldwide. Though most episodes of childhood diarrhoea are mild, acute cases can lead to significant fluid loss and dehydration, which may result in death or other severe consequences if fluids are not replaced at the first sign of diarrhoea.

In normal condition the body takes up water and salts through drinks, food and looses them through stool, urine and sweat. The balance is maintained as the water and salts pass back from bowel to the blood. In case of diarrhoea, the bowel does not work in natural way. The more loss of water and salts occur than less absorption of them from bowel. This leads to larger than normal loss of water and salts causing dehydration. There are other reasons too for dehydration of children during diarrhoea. Water constitutes the greater proportion of body weight in children than adults. Young children use more water over the course of the day because of high metabolic rate and their kidneys are less able to conserve water compared to older children and adults. Dehydration can also occur due to vomiting which often accompanies diarrhoea.

Irrespective of cause of diarrhoea, loss of large quantity of water and electrolytes causing dehydration is the main factor responsible for deaths in acute diarrhoea. Hence the management of acute diarrhoea is aimed to prevent dehydration and supplement electrolytes. The International Centre for Diarrhoeal Disease Research, Bangladesh, has been advocating the use of Oral Re-hydration Therapy (ORT) since 1970s with the Oral Re-hydration Salts (ORS). When the ORS solution reaches the small intestine, the sodium and the glucose in the mixture are transported together across the lining of the intestine. The sodium which is now in higher concentration in the intestine, promotes water absorption back into the body from the bowel. (The pathogens responsible for causing diarrhoea damage the intestine causing excessive loss of water and electrolytes than the absorption). The discovery that the sodium and glucose are transported together across the small intestine led to the discovery of ORS. Further research on use of ORS led to development of new formula of ORS. The new formula is known as low osmolarity ORS. The new formula is shown to have additional clinical benefits like decreased stool output and vomiting in addition to preventing dehydration like old ORS. The WHO and UNICEF have been recommending the use of new low osmolarity ORS. Sodium chloride 2.6 g, Sodium citrate 2.9 g, Potassium chloride 1.5 g, Glucose (anhydrous) 13.5 g. The whole quantity is to be dissolved in one litre of recently boiled and cooled water. It is also available at different quantities and it should be dissolved in appropriate quantity of water as instructed on the label of the product. It is important to realise that accurate weighing and thorough mixing and dissolution of ingredients in the correct volume of drinking water is important. Administration of more concentrated solution can result in hypernatraemia. ORS is recommended for both children and adults.

Addition of zinc to ORS
A recent development in diarrhoeal treatment is addition of zinc to the ORS regimen. Zinc is an important micronutrient for child's overall health and development. Zinc is lost in greater quantities during diarrhoea. Replacing the lost zinc help the child recovers and keeps the child healthy in the coming months. The research confirmed that zinc supplementation given during an episode of diarrhoea reduces the duration and severity of the episode. It lowers the incidence of diarrhoea too in the following 2-3 months. It improves appetite and growth. Zinc increases the ORS uptake and reduces the inappropriate drug use with antibiotics and anti-diarrhoeal medications. Realizing the importance of Zinc in the management of childhood diarrhoea, the Govt of India too revised its diarrhoeal treatment guidelines and introduced zinc supplementation. The new guideline recommends the use of 20 mg zinc sulphate dispersible tablets. Dose for children aged between 2 months to 6 months is half tablet (10 mg) while the dose for older children is 1 tablet a day. The tablet is to be dissolved either in breast milk or drinking water before giving to children. It is advised that the child be given the zinc for 14 days beginning from the day diarrhoea starts.

Though there are other drugs like antibiotics and anti-motility agents are often used, none of them have convincing evidence to be effectively stop diarrhoea and safe. Antibiotics are not effective against most diarrhoea causing organisms. Anti-motility drugs though temporarily reduce cramps and pain, but delay elimination of causative organisms and may prolong illness. They are harmful especially in children below five years of age.The current WHO Model Formulary (2008) lists only ORS and zinc as medicines for diarrhoea in children.

The WHO suggests that acute diarrhoea in children should always be treated with ORS according to plan A, B and C. The plan A, B and C is based on degree of dehydration.

Plan (Degree of dehydration)	Management Plan
Plan A (No dehydration)	Nutritional Advice, Increased fluid intake (ORS, soup, rice, water and yoghurt, or even water) and zinc supplementation. Continuing feeding especially breast milk is encouraged. Parents should be advised about the circumstances in which they should seek medical advice.
Plan B (Moderate dehydration)	4 hours treatment plan. 75 ml /kg body weight of oral re-hydration solution over 4 hours period. A larger amount of solution can be given if the child is continued to have frequent stools. In case of vomiting, re-hydration must be discontinued for 10 minutes and then resumed at a slower rate. Breast feeding on demand; for others milk and nutritious food after completing 4 hours of re-hydration. Zinc supplementation as soon as child can eat and completed 4 hours of re-hydration. Re-assess the status of the child after 4 hours. ORS is to be continued, even if the dehydration is controlled, as long as the child continues to have diarrhoea.
Plan C (Severe dehydration)	Hospitalization is necessary. Priority is to start rehydration.

In addition to continuing feeding, the effective treatment plan for childhood diarrhoea includes the use of ORS and zinc. Though zinc is not a prescription drug, its availability is not easy in retail pharmacy. ORS is readily available and often they are flavoured. The flavoured ORS are preferred by children. The combined use of new ORS and zinc is proved to be more effective than simple new ORS. If a strategy is designed to develop a combo pack containing both, the regimen would be more popular and can be effectively used in controlling childhood diarrhoea which would go in a long way in reducing diarrhoeal related deaths in children.


(The authors are with Division of Pharmacy Practice, Department of Pharmacy, Annamalai University, Annamalai Nagar - 608 002)