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1981;67;79PediatricsA.R.M.A Alim and David A. Sack
Robert E. Black, Michael H. Merson, Philip R. Taylor, Robert H. Yolken, Md. Yunus,with Rotavirus-Associated Diarrhea
Glucose vs Sucrose in Oral Rehydration Solutions for Infants and Young Children
http://pediatrics.aappublications.org/content/67/1/79the World Wide Web at:
The online version of this article, along with updated information and services, is located on
ISSN: 0031-4005. Online ISSN: 1098-4275.
PrintIllinois, 60007. Copyright © 1981 by the American Academy of Pediatrics. All rights reserved.by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarkedPEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
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P E D IA T R IC S V o l 6 7 N o Ja n u a ry 9 8 79
G lu cose vs Suc ro se in O ra l R ehyd ra tion
So lu tion s fo r In fan ts and Young C h ild ren w ith
R o tav irus -A ssoc ia ted D ia rrhea
Robert E . B la ck M D M PH M ich ae l H . Merson MD
Ph ilip R . Tay lo r
M D R obe rt H . Y olken M D M d.
Yunu s MBBS
A .R .M .A A Iim BS and D av id A . S ack
MD
F rom the In te rna tiona l C en tre fo r D ia rrhoea l D isease R esea rch , B ang ladesh fo rm e rly
C ho le ra R esea rch Labo ra to ry , D acca , B ang ladesh , B u reau o f E p idem io logy , C en te r
fo r D isease C on tro l, A tlan ta , Labo ra to ry o f In fe c tious D iseases , N a tiona l In s titu te s o f
A lle rgy and In fec tious D iseases , B e thesda , M a ry land , and D iv is ion o f G eog raph ic
M ed ic ine , Johns H opk in s U n ive rs ity , B a ltim o re
ABSTRACT . T h e u se o f o ra l re hyd rat ion so lu tion s con -
ta in in g essen tia l elec tro ly tes an d eithe r g lucose o r sucrose
o f eq ua l osm ola lity w as com pared in a doub le -b lin d se -
qu en tial tr ia l o f 784 ch ild ren w ith ro tav iru s-a ssoc iated
d ia rrhea trea ted a t a cen ter in ru ra l B ang ladesh . T he ora l
flu id fa ilu re rate w as 1 1 .5 fo r the sucrose -con ta in ing
so lu tion gro up an d 7 .3 fo r the g lu co se-con tain ing gro up
P
= N S). V om iting w as a
sign if ican t ly
m o re com m on
cau se o f failu re fo r th e g roup treated w ith su crose -co n-
tam in g ora l rehyd ra tion so lu tion and w as assoc ia ted w ith
an increased ra te o f in take of the sw eete r su cro se -con-
tam ing so lu tion . The p urg ing ra te w as n o t d ifferen t fo r
the tw o gro ups . T he ora l flu id fa ilu re ra tes fo r ch ild ren in
the m ost un derw eigh t ca tegory (<60 o f exp ected w eigh t
fo r age) w ere n o t d ifferen t from th ose fo r o ther g rou ps,
a lth ough , as assessed b y pu rg ing ra te an d in itia l d eh ydra -
tion , th e s to o l lo sses o f m em bers o f th is g roup con stitu ted
a grea te r p ro portion o f the ir bo dy w eigh t. G lu cose is th e
pre fe rred carboh ydra te fo r o ral e lectro ly te so lu tions , a -
though su crose can be subs titu ted w ith on ly m in im um
loss o f e fficacy .
Ped ia tr ic s 67:7 9-8 3 , 198 1; g lucose -e lec -
tro ly te so lu tio n ro tav irus m alnu trition and d ia rrhea
sucro se -e lectro ly te so lu tion ora l reh ydra tion .
O ra l rehyd ra tion the rapy w ith a so lu tion co n ta in -
ing g luco se an d e lec tro ly te s has b een su ccessfu lly
used fo r treatm en t o f deh ydra tion resu lting from
acu te d ia rrhea from a ll cau ses in a ll age g rou ps.’ A
few qu estio ns are still unansw ered abou t us in g it
Received fo r pub lic atio n A p ril 4 ,
1980 ; accep ted M ay 12 , 19 80 .
Reprin t reques ts to (R .E .B .) C en te r fo r V acc ine D eve lopm ent,
U n iversity o f M ary land S choo l o f M edic ine , 29 S G reene S t,
B a ltim ore , M D 21201 .
PED IA TR IC S (ISSN 0031 4005). C opy righ t ©
1981 by th e
A m erican A cad em y o f Ped iatr ics ,
g lob ally . O n e of these is w he ther sucro se can be
subs titu ted fo r g luco se in preparing the so lu tion ;
th is q uestion is im portan t s in ce , in som e coun tries,
suc rose is less expen sive and m ore read ily ava ilab le
than g lu co se . A num ber o f sm a ll, w ell-con tro lled
s tu d ies ca rried ou t to address th is ques tion ind ica te
tha t w h ile su crose can b e subs titu ted , g lucose is
p re fe rab le.25 W e rep ort he re o n the use o f g lucose -
and suc ro se -con tain ing ora l reh ydra tion so lu tio ns
as the rapy fo r a large num ber of ch ild ren w ith
ro tav irus-as soc ia ted d ia rrhea trea ted p rim arily b y
p aram ed ical w ork ers a t a h ealth cen ter in ru ral
B ang lad esh . W e a lso de te rm ined th e fa ilu re ra te s
fo r ch ild ren o f d iffe rin g n u tr itiona l sta te and the
e ffect o f nu trition al sta tu s on the course o f ro tav i-
m s -a sso cia ted d ia rrhea .
MATER IA LS AND METHODS
Pa tien t Popu la tion and Adm iss ion A ssessm en t
T he stu dy w as conduc ted a t th e M atlab T rea t-
m en t C en te r o f th e In terna tion al C en tre fo r D ia r-
rh oea l D isease R esearch , B ang ladesh (IC D D R B )
(fo rm erly the C ho le ra R esea rch Labo ra to ry ) . T h is
cen te r p rov id es trea tm en t fo r gastro in te stin al ill-
n esses to the appro x im ate ly 2 69 ,000 residen ts o f the
f ield re search a rea . M ed ical care a t th e C en te r is
p ro v ided by a pa ram ed ica l s ta ff su pe rv ised by a
phy sic ian . W hen the p atien ts v isited the trea tm en t
cen ter , a b rief h is to ry w as o b ta ined and a physica l
exam ina tion , inc lud in g de term in atio n of body
w eig h t, w as pe rfo rm ed . S e rum sp ec if ic g rav ity w as
de te rm in ed w ith a re frac tom e te r fo r a sm a ll, ran -
dom sam ple o f p atien ts o n adm is sion . O n N ov 17 ,
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A R T IC L E S 8
TABLE
Treated
1
.
w it
A dm issi on C haracte
h G lucose or Sucrose
ri sti cs of Patients
O ral R ehy dr ati on
w i th R otav i rus-A ssociated D iarrhea
Solution
Characteri sti cs O ral Rehydrati on Soluti on
G lucose (n = 385) Sucrose (n = 399)
12.0 (0.25) 12.1 (0.26)
2 4 8 1 3 6 2 6 2 1 3 7
9 7 1 9 8 4
1.6 (0.1) 1.6 (0.08)
1.2 (0.05) 1.3 (0.07)
1.027 (.<0.001)t 1.028 (< 0.001)
9.7 9.0
71.0 (0.5) 71.4 (0.5)
M o n t h s
of age
Sex (M /F)
V om i ti ng bef ore adm issi on (% )
D ay s of diarrhea bef ore adm issi on
D ay s of vom i ti ng bef ore adm ission
A dm issi on speci f i c grav i ty
O ther pathogens (% )
Percent w eight for age
M ean (1 SEM ).
t
n
= 70.
:j : n
= 27.
§
Sa lmone lla , Shige lla , enterotoxigemc Escherichia co li, Vibrio cho lerae .
II
D ischarge w eight as a percentage of H arvard m edian w eight f or chi l d’ s age.
TABLE 2 . O ra l Rehydrati on Fai l ures by D ehy drati on
Status
of Patients* w i th Rotav i rus-A ssociated D iar rhea
T reated w i th Oral Soluti on
Dehydration
Status
O ral Rehydr ati on Soluti on
G lucose Sucrose
N o. of
C a s e s
Failures
No .
N o. of
Cases
Failures
N o .
N one to m i ld
M oderate to
217
42
14 6.5
5 11.9
201
33
22 10.9
5 15.2
severe
T otal 259 19 7.3
234
27 11.5
I ncludes only patients w i th diarrhea w hi l e hospi tal i zed.
i ng rate, si x in each group; (2) inadequate correcti on
of ini ti al dehy drati on, tw o in each group; (3) v om-
i ti ng, one in glucose group and 12 in sucrose group;
and (4) abdom inal di stention or combinations of
these causes, ten in glucose group and seven in
sucrose group. V om i ti ng, by i tsel f , w as signi f i cantl y
more comm on reason f or f ai l ure for the SO RS
group than for the G O RS group
(x =
6.6,
P
<.025).
Th is w as parti cularl y the case f or the nondehy -
drated to m i ldl y dehydrated patients, among w hom
there w ere one of 14 GO RS f ai l ures and ten of 22
SO RS f ai l ures because of vom i ti ng P =
.016,
Fisher ’ s ex act test, one tai l ed). I n f act, signi f i cantl y
m ore of the SO RS-treated patients (47.4%) than of
the G O RS-treated cases (36.6% ) vom i ted w hi le hos-
pi tal i zed (x 2 = 8.8, P
< .001).
H ow ev er , 88 o f t h e
patients w ho vom i ted in the hospi tal w ere success-
f ul l y treated w i th one of the oral rehydrati on solu-
tions.
A compari son of oral f l uid intake rates dur ing the
total course of therapy show ed one possible mech-
anism for the increased rate of vom i ti ng for the
SO RS groups. T he nondehy drated to m i ldl y dehy-
drated patients receiv ing the SO RS soluti on drank
at a signi f i cantl y faster rate (6.9 ± 0.3 m l/k g/hr)
than those receiv ing the GO RS soluti on (5.9
±
0.3
ml/kg /hr) t = 2.1,
P
< .05). A m ong m oderatel y to
sev erel y dehydrated patients, the SO RS group alsO
tended to consume the f luid f aster, but the rates for
the tw o groups (6.2
±
.06
vs 4.9 ± 0.4) w ere not
signi f i cantl y di f f erent. Furthermore, the mean in-
take rate in the f i rst eight hours of therapy for ten
of the patients w i th no or m i ld dehydrati on w ho
w ere SO RS f ai l ures w as 16.1 ni l /kg/hr. T his w as
almost tw ice that of that group as a w hole (t = 1.94,
P
< .10). T he purging rates for both dehydrati on
categor ies of the tw o treatment groups w ere sim i lar
(T able 3).
W hen the chi l dren w i th rotav i rus-associated diar-
rhea w ere grouped by thei r w eight at di scharge as
a percentage of the ref erence populati on median
w eight f or thei r age, each category had sim i lar
f ai l ure rates w i th G O RS and SORS. Furthermore,
the fai l ure rates f or al l the nutr i ti onal categories
w ere sim i lar f or G ORS, SO RS, or the tw o combined
(T able 4).
Chi l dren in each of the f our nutri ti onal categor ies
had sim i lar m ean durati ons of diarrhea before and
during thei r hospi tal i zati on. T here w as a trend to-
w ard a higher purging rate in the f i rst eight hours
of therapy in underw eight chi l dren w hen patients
w ere grouped by body w eight. T his trend may
correlate w i th the observ ation that the low er the
category of nutr i ti onal status the higher the pro-
porti on of moderatel y to sev erel y dehydrated pa-
ti ents as assessed on adm ission and by percentage
gain in body w eight af ter rehydrati on (T able 4).
IS USSION
W i th a large study populati on, w e conf i rmed re-
sui ts obtained in earl i er studies of much few er pa-
ti ents cared f or pr imari l y by phy sicians. B oth these
resul ts and ours indicate that sucrose can be sub-
sti tuted f or glucose in the oral rehy drati on treat-
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TA B L E 4 .
N utritional Status, Severity of D iarrhea, and Rates at W hich O ral Rehydration Therapy Failed for
Patients w ith R otavirus-A ssociated D iarrhea
Weight/Age
)
Total
Patients
M oderate-Severe
D ehydration (% ) Purging
Rate First 8 hr T otal D iarrhea
D uration (hr)
O ral T herapy
Failure (% )
A ssessed on G ain of 5% ml/hr
nd/hr/kg
A dmission B ody W eight
< 60.0 57 26* 25t 27 (3) 4.9 (0.6) 64
5.3
60.0-69.9 158 15 14
27 (2) 4.3 (0.6) 62 9.5
70.0-79.9
168
18 21 29 (2) 4.1 (0.3) 63
10.1
80.0
90 6 9
30 (3) 4.1 (0.5) 59 10.0
Percentage of patients w ith moderate-severe dehydration greater for < 60 group vs allother (Fisher’ s exact test [FET ]
= .01) or < 60 group vs 80 group (FET = .0004).
t
Percentage of patients w ith moderate-severe dehydration greater for < 60 groups vs all other (FET
= .04) or
< 60
group vs 80 group (FET = .007).
:j : M ean
(1 SEM ).
82 G L UCOSE
VS SUCRO SE IN OR L REHYDR T ION SO LUT IONS
TA B L E 3 .
Purging Rates (ml/kg/hr) for Patients w ith Rotavirus-A ssociated D iarrhea
by D ehydration Status and O ral R ehydration Solution U sed
T ime Period D ehydration Status
N one to M ild M oderate to Severe
Glucose Sucrose G lucose Sucrose
(n = 217) (n = 201) (n = 42) (n = 33)
First 8-hr period 3.7 (0.3)* 4.2 (0.3) 5.7 (0.7) 5.7 (0.7)
First day 3.5 (0.2) 3.6 (0.2) 5.7 (0.5) 5.6 (0.6)
T otal treatment period 3.2 (0.2) 3.4 (0.2) 4.6 (0.4) 4.7 (0.4)
M ean (1 SEM ); no significant differences betw een glucose- and sucrose-treated patients
in any time period in either category of cases by dehydration status.
ment solution with only a minimal loss of eff icacy.25
T he trend w e observed tow ard a slightly larger
number of failures for the SORS- treated group w as
similar
to that observed by other investigators in
these smaller studies, but even with our much larger
population the failure rates w ere not signif icantly
different.
I n our study, treatment w ith SO RS was associ-
ated for the first time w ith signif icantly higher rates
of vomiting. T his largely accounted for the higher
number of SO RS failures, especially for the non-
dehydrated to mildly dehydrated patients. T he
vomiting may have resulted from an increased rate
of intake of the sucrose-containing solution because
of its greater sw eetness and thus more appealing
taste. Rapid intake in a few cases may have led to
gastric distention and vomiting. A n alternative ex-
planation could be that rapid enzymatic hydrolysis
of sucrose could result in double the number of
osmoles in the upper intestine than w ould occur
from the glucose solution. Resultant intraluminal
fluid accumulation and intestinal distention could
have caused vomiting. A lthough vomiting w as an
important cause of oral rehydration failures,
88% of the children who vomited in the hospital
were successfully treated w ith oral therapy. A s ob-
served by others studying rotavirus2 and entero-
toxin-associated arr4’ w e found no difference
in purging rates for the tw o solutions despite the
fact that patients receiving SOR S tended to drink
faster.
W e also confirmed earlier reports2’3”2 that a glu-
cose- or sucrose-containing electrolyte solution can
be used to treat rotavirus-associated and secretory
diarrhea w ith similar success. T his is reasurring
since rotavirus is the leading cause of diarrhea in
infants and young children at our treatment center.9
O ur overall rates of patients requiring intravenous
therapy after treatment w ith the oral solutions are
a little higher than those reported from other stud-
ies of rotavirus-associated diarrhea, w hich probably
can be attributed to the more difficult circum-
stances in the rural center w here our paramedical
personnel w ere faced w ith treating more patients
w ith less supervision.
D espite the fact that children w ith rotavirus-as-
sociated diarrhea have comparable durations of
diarrhea regardless of their nutritional status, the
fluid lost in diarrheal stool may represent a greater
proportionate loss in children with a low body
weight due to young age or malnutrition. T he con-
sequent greater dehydration puts the underweight
child at higher risk of death and in more need of
effective rehydration therapy. T he equal success of
oral rehydration for children of varied nutritional
status should further support the use of this therapy
for chronically undernourished children w ith diar-
rhea in developing countries.
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A R T IC L E S 83
I MP L I T I ONS
T he w orld heal th com muni ty i s currentl y try ing
to promote w idespread use of oral rehydrati on ther-
apy as an integral part of prim ary heal th care.’ 3
T he decision of w hether to use glucose-or sucrose-
containing soluti ons in country program s must be
based on a num ber of f actors including cost and
avai l abi l i ty of i ngredients and comparati ve ef f i cacy .
Our study conf i rms the f inding of others that, al -
though glucose is preferred, sucrose can be used in
an oral soluti on w hich is saf e and ef fecti ve f or
treatment of diarrhea.
KNOWLEDGMEN T S
W e w ould l i k e to acknow ledge the support of the
I nternational C entre f or D iar rhoea D i seases Research,
B angladesh (f orm erl y the Cholera R esearch L aboratory )
and the I nternati onal Center f or M edi cal Research (N a.
tional I nsti tutes of H eal th Grant 5R 07A 110048-17).
W e
al so w ish to express our grati tude f or the technical
assi stance of M r S. H uda and M r S. Rahm an and the
nursing
care prov ided by the staf f of the M atlab T reat-
m ent C enter .
R E F E R EN E S
1. Pierce N F, H i rschhorn N : O ral f l uid-A si mple w eapon
against dehy dration in diarrhea. WHO Chron 31:87, 1977
2. Sack D A , Chow dhury A M A K , Eusof A , et al : Rehydration
i n rotav i rus diarrhoea: A double-bl ind com pari son of sucrose
w ith glucose electrol y te soluti on. Lancet
2:280, 1978
3. N al i n D R ,
Lev ine M M , M at s L , e t a l: C o m par ison o f su cr ose
w ith glucose in oral therapy of i nf anti le diarrhoea. Lancet
2:
277, 1978
4. Palm er D L , K oster V T ,
Islam
A FM , et al : Com pari son of
sucrose and glucose in the oral electrol y te therapy of cholera
and other sev ere di arrheas.
N Eng l JMed 297:1107, 1977
5. Chatterj ee A , M ahalanabi s D , Jalan K N , et al : Evaluation
of a sucrose/el ectrol y te soluti on f or oral rehydrati on
in
acute
i nf ant il e di ar rhea.
Lancet
1:1333, 1977
6. Y ol ken RH , K im H W , C hen T , et al : Enzym e-l inked im m u-
noassay (EL I SA ) f or detecti on of hum an reov i rus-l i ke agent
o f i nf an ti l e g ast ro en ter it is.
Lancet
1:263, 1977
7. Y ol ken RH , W yatt RG , K apik ian A Z . El i sa for rotavirus.
Lancet 2:819, 1977
8. M erson M H , Sack RB , K ibria A K M B , et al : E f f i cacy of
pool i ng strai ns f or l aboratory diagnosi s of enterotox i geni c
Escherichia co li (E TE C) di arrhoea. J Clin Microbio l 9:493,
9 9
9. B lack RE, M erson M H , Row e B , et al : Epidem iology of
enterotoxigenic Escherichia co li i n rural
Bangladesh.
Pro -
ceedings o fthe 14 th Jo int Conference on Cho lera , US-Japan
Cooperati ve M edical Science Program , K aratsu,
1978
10. Y olk en RH , Stopa RI . A nalysi s of nonspeci f i c reactions in
enzyme-linked
immunosorbent
assay
testi ng f or hum an ro-
tavirus. J Cliii Micro bio l 10:703, 1979
11. Sack D A , I slam 5, B row n K H , et al : Oral therapy i n chi ldren
w i th cholera: A double bl ind com pari son of sucrose w i th
glucose electrol y te oral soluti on.
J P edi atr
96:20, 1980
12. Tay lor PR, M erson M H , B lack R E, et a : O ral rehydrati on
therapy f or treatm ent of rotav i rus diarrhea in a rural treat-
m ent center i n B angl adesh. Arch D is Child 55:376, 1980
13. C ontrol of d iarrheal
diseases:
W H O ’ s program m e takes
shape. WHO Chron 32:369, 1978
O N E V LU TING THE TE H ING O F R E D ING
Y ou can teach w hat i s testable and test w hat
reassured that you have accom pl i shed something
i s teachable and be f al sel y
Edi torial note: T his comm ent appl i es equal l y w el l to pediatri c recerti f i cati on.
From T eacher speak ing, Optio ns in Educa tion, N ati onal Publ i c R adio.
Submi tted by E.K .M .
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1981;67;79Pediatrics
A.R.M.A Alim and David A. Sack Robert E. Black, Michael H. Merson, Philip R. Taylor, Robert H. Yolken, Md. Yunus,
with Rotavirus-Associated DiarrheaGlucose vs Sucrose in Oral Rehydration Solutions for Infants and Young Children
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