Diarrhea is the leading cause of morbidity and mortality in children in underdeveloped and developing countries, as well as the cause of family anxiety and heavy cost burden (1,2). Diarrhea occurs and approximately 1.9 million children lose their lives due to diarrhea every year (1,3,4). Acute gastroenteritis is very common in infancy and early childhood. The highest frequency is seen in children between 6 and 18 months of age (5). ,6);Approximately 40% of the causes of diarrhea in children aged five and under are caused by rota virus, 30% are caused by other viruses (norovirus and adenovirus), 20% are caused by bacterial agents (especially Campylobacter jejuni, yersinia, salmonella, shigella, pathogenic E. coli and; Clostridium difficile), and 5% or less is caused by parasites (especially giardia,; crytosporidia, E. histolitica) (5). In developed countries, deaths due to diarrhea occur due to the failure to replace fluid and electrolytes lost in the feces (5). It is due to acute dehydration.; In developing countries, frequent and long-lasting diarrhea attacks cause malnutrition, diarrhea is more frequent and more severe in children with malnutrition, and as a result, deaths due to diarrhea in developing countries are due to both acute dehydration and malnutrition. For this reason, oral liquid formulas have been developed for the treatment of dehydration, which are equally effective in all diarrhea of patients of different ages due to different causes, whose ingredients can be found cheaply and easily everywhere, and are easy to prepare and apply. This form of treatment is important because it is effective and economical, as well as it protects the patient from the complications of unnecessary intravenous fluid therapy. The first study that formed the scientific basis of oral rehydration fluid (ORS) was conducted in 1964. In this study, it was shown that glucose in the environment increases sodium absorption in the ileum (7). In this way, for the first time in the cholera epidemic in Bangladesh in 1967, the development of dehydration was prevented and patients with dehydration were successfully treated by using oral glucose and electrolyte solutions. In the meta-analysis of randomized control studies, intravenous treatment and ORS were compared. No difference was observed in terms of diarrhea frequency, duration, patient's weight gain, and development of hypo- and hypernatremia. As a result, the ORS formula was standardized and used for the first time in 1975 by the World Health Organization (WHO). WHO Standard ORS; It contains sodium 90 mEq/L, potassium 20 mEq/L, chlorine 80 mEq/L, glucose 20 g/L, and its osmolarity is 311 mOsm/L (1,8). However, it has been observed that there is no change in the duration, amount and frequency of stool and hypernatremia may develop. For this reason, different ORS compositions have been tried (amino acid ORS, rice ORS, hypotonic ORS, etc.); Researchers announced in 1987 that rice ORS would prevent osmotic diarrhea and also provide sufficient glucose to support the reabsorption of intestinal secretions. Thus, the duration and amount of diarrhea will decrease.; Following these, WHO developed a new hypoosmolar ORS (contains sodium: 75 mEq/L, potassium 20 mEq/L, chlorine 80 mEq/L, glucose 13.5 g/L,; osmolarity 245 mOsm/L) and is still used today. In a meta-analysis of randomized controlled trials, when hypoosmolar ORS was used, stool quantity, vomiting frequency and I.V. It has been observed that the need for treatment has decreased (7). In Turkey, the use of ORS has increased with the "Control of Diarrheal Diseases" program of the Ministry of Health. In this study, four types of ORS (ORS) used in the treatment of moderately dehydrated children were examined at Hacettepe University İhsan; Doğramacı Children's Hospital Diarrhea Center (1993-2012), which was established among the firsts in Turkey and is currently one of the few diarrhea centers. 1- Hypoosmolar;ORS, 2- 2:1 ORS, 3- Rice ORS, 4- Standard WHO ORS) is intended to be evaluated retrospectively.
MATERIALS and METHODS
The research was conducted at Hacettepe University İhsan; Doğramacı Children's Hospital Diarrhea and Oral Fluid Therapy (AST) Center, which was established in 1985; four types of ORS (1) were used in the treatment of moderately dehydrated children followed between 1993 and 2012. -Hypoosmolar ORS, 2- 2:1 ORS, 3- Rice;ORS, 4- Standard WHO ORS) for comparison, the files were retrospectively examined and the file was made by collecting information. The study was started as a case control, the aim was to compare hypotonic ORS with the other 3 types of ORS, but due to the inability to obtain the necessary information in the file review, the study was changed to the comparison of 4 groups. Between 1993 and 2012, the total number of moderately dehydrated patients with diarrhea was 4192, and 4 types of ORS were used in different periods. In this study, 100 accessible files were examined from each group separately. Permission for the study was obtained from the Hacettepe University Non-Interventional Clinical Research Ethics Committee. Blood pH and bicarbonate levels of dehydrated patients were studied with the Automatic Blood Gas;System AVL 990 device, and serum sodium and potassium levels were studied with the Roche/Hitachi;911 Automatic Analyzer devices. SPSS (Statistical package for social sciences) version 18.0 was used in statistical analyses. Mean values and SD of the clinical and laboratory findings of the patients (age, initial and post-treatment body weight, number of diarrhea and vomiting, Na, K, Hco3 and PH values, recovery times of the patients, etc.) according to 4 different ORS treatment types were determined, Frequency and percentage values are given for categorical variables. While examining categorical variables, Chi-square test was used in the analysis of differences between groups (Yates correction was applied when necessary), Kruskal Wallis test, Post Hoc test was used in the analysis of continuous variables between groups, and Mann-Whitney U test was used in the analysis. Wilcoxon signed rank test was used in the analysis of dependent variables.
DISCUSSION
Although there is no study in the literature on the comparison of 4 types of ORS, the study conducted in our diarrhea center Although the study does not represent the whole country, it has been determined that hypotonic ORS has advantages over other types of ORS. There are differences between ORS types in terms of general characteristics, laboratory findings, and response to treatment. It has been understood that ORS has an important role in the treatment of moderately dehydrated children. In particular, it has been shown that it can be used instead of IV treatment, and its complications have been observed to be less. Others of WHO ORS Unlike r;ORS, it has been observed to have less response to treatment. The reason for this is that since it is a hyperosmolar (311 mmol/L) liquid, water absorption and electrolyte absorption are not optimal. Another complication is the development of hypernatremia. Rice ORS showed superiority in cholera patients compared to WHO ORS. No differences were seen in non-cholera patients. Since the osmolarity of rice ORS is less than WHO ORS, it releases glucose slowly into the intestines and optimizes the absorption of water and electrolytes; and it has been shown that rice ORS is superior in glucose intolerance, especially in rotavirus and cholera diarrhea. 2:1 ORS has been shown to be more effective than WHO ORS. Likewise, due to the decrease in the osmolarity of 2:1 ORS, water absorption and electrolyte absorption become optimal. However, studies comparing rice ORS, 2:1 ORS and hypotonic ORS have been found to be insufficient (60). The data obtained as a result of multiple analysis show that the most important factor determining the rehydration time in hypotonic, rice and WHO ORS cases is the admission HCO3 value. , shows that for 2:1 ORS, the frequency of vomiting is important as well as the HCO3 value. The most important factors on the transition to IV treatment in cases differed between ORS types. It was determined that the HCO3 and pH values for the hypotonic ORS group, the HCO3 value for 2:1; ORS, the frequency of diarrhea for the rice ORS, and the frequency of vomiting for the WHO ORS significantly increased the risk of switching to IV treatment. It is thought that this situation arises from clinical practice rather than the characteristics of ORSs. Since our study is a retrospective file review, the study was restricted because the information in the file could not be fully accessed. Another weakness of the study is that the study, which was planned as a case control, could not be carried out in this way due to the difficulties in accessing the files, and was conducted as the analysis of only 400 cases. In some subgroup studies, statistical studies could not be conducted due to the insufficient number of cases. Some statistical analyzes could not be performed because the information in the application was available for ORS use of some patients, but the information during ORS was not.
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