Oral rehydration therapy of childhood diarrhoea in Finland

Abstract

Tutkimuksessa selvitettiin neljässä kliinisessä tutkimuksessa Suomeen soveltuvan ripulijuoman optimaalista koostumusta, erityisesti sokeripitoisuutta ja osmolariteettia, sekä suun kautta annetun nesteytyksen ja maitohappobakteerivalmisteen (LGG:n)yhteiskäyttöä. Neuvolakyselytutkimuksella pyrittiin selvittämään lasten ripulintaudin kotihoitokäytäntöjä sekä tilastotietojen perusteella arvioimaan ripulitaudin merkittävyyttä lasten sairastuvuuden aiheuttajana Suomessa.

Tuloksista voidaan päätellä, että ripulijuoman nesteytysominaisuudet paranevat, mikäli sokeripitoisuutta "kevennetään" lähelle tasoa 84 mmol/l ja osmolariteettia lähelle 224 mosmol/l. Suomalaisen ripulijuoman koostumus on muutettu löydöksiä vastaavaksi.

Suun kautta annettava "kevennetty" ripulijuoma ja LGG lyhensivät kumpikin itsenäisesti ripulin kestoa. Hoidoilla oli myös merkittävä yhteisvaikutus. LGG:n teho oli paras, jos hoito annettiin nestehoidon alussa. Mahdollisesti kerta-annos LGG:tä on riittävä.

Lasten ripulitaudin kotihoitokäytännöt ovat selvästi parantuneet 20 viime vuoden aikana. Vuonna 1978 sairaalaan otetuista ripulilapsista vain 3% oli saanut kotona ripulijuomaa, vastaava luku oli 70% vuonna 1996. Ripulijuoman käyttöaste kotihoidossa oli vielä suhteellisen alhainen 37%. Paastottaminen oli jyrkästi vähentynyt 67%:n tasolta vuonna 1978 seitsemään prosenttiin nykyisessä tutkimuksessa.

Lasten ripulikuolleisuus Suomessa on edelleen vähentynyt viimeisen 10 vuoden aikana. Yli puolet kuolemista tapahtuivat kotona tai matkalla sairaalaan, korostaen tehokkaan kotihoidon ja oikein ajoitetun hoitoonhakeutumisen tärkeyttä.

Ripuliin sairastuvuus on pysynyt ennallaan tai mahdollisesti hieman lisääntynyt vuosina 1985-1995. Samaan aikaan keskimääräinen ripulin hoitoaika sairaalassa on lyhentynyt vuorokaudella osoituksena suun kautta annettavan nestehoidon ja keskeytymättömän ruokinnan tehokkuudesta. Tehostunut ripulin hoito ja parantunut yleinen hygieniataso eivät enää vähennä ripuliin sairastuvuutta Suomessa. Tämän päämäärän saavuttamiseksi tarvitaan muita toimenpiteitä, kuten esimerkiksi rotavirusrokotteen liittäminen rokotusohjelmaan.

The discovery of ORT has been considered one of the greatest therapeutic advances of this century. During the 1990s several investigators have expressed concern at the low use of this treatment mode in the developed world. Some criticism of it has focused on the composition of ORS, especially the optimal sodium content. In the late 1980s experimental studies showed that a reduction in glucose concentration and osmolarity of these solutions increased their efficacy. The latest development in the treatment of acute diarrhoea is the use of live microbial feed supplements (probiotics) which may promote intestinal health.

The present study was designed to investigate various compositions of ORS for use in Finland, with special interest in reduced glucose concentration and osmolarity and combined use of ORT and probiotic therapy. It was also sought to form a picture of current home case management practices and the significance of acute paediatric diarrhoea in Finland.

In a search for an optimal glucose concentration and osmolarity for ORS 431 children aged 1 to 36 months suffering from acute gastroenteritis received either the isotonic ORS with a glucose concentration of 144 mmol/l and an osmolarity of 304 mosmol/l then used in Finland (170 patients), hypotonic ORS with a glucose concentration of 84 mmol/l and osmolarity 224 mosmol/l (197 patients) or an ultrahypotonic ORS with a glucose concentration of 64 mmol/l and osmolarity 204 mosmol/l (64 patients) (studies I, II and IV). The hypotonic ORS was found to be the most effective, resulting in shorter duration of diarrhoea and hospital stay, fewer diarrhoeal stools in the hospital and reduced consumption of ORS during maintenance therapy in comparison with the standard ORS. This difference was also clearly seen among patients suffering from rotavirus diarrhoea. There were no differences between the two solutions with regard to weight gain, need for unscheduled intravenous therapy, electrolyte balance, recovery from acidosis or urine sodium excretion during hospital stay. It may be concluded that the absorptive properties of ORS are enhanced if the glucose concentration is reduced close to 84 mmol/l and osmolarity close to 224 mosmol/l. Further reduction of glucose concentration to 64 mmol/l was not seen here to improve absorption. In the comparison of the hypotonic with the ultrahypotonic ORS, consumption of ORS during maintenance, weight gain, number of diarrhoeal stools in the hospital, duration of diarrhoea in the hospital and recovery from acidosis were equal. The glucose concentration in the solution currently used in Finland has been reduced to 84 mmol/l in 1999.

Another 53 patients received hypotonic ORS without a base precursor (citrate) and 54 patients a similar solution with 10 mmol/l citrate, to establish whether the base precursor is essential in the composition of a hypotonic ORS (study III). The patients receiving the hypotonic ORS with citrate recovered faster from acidosis and consumed less ORS. The duration of diarrhoea and the number of diarrhoeal stools in the hospital, weight gain and need for unscheduled intravenous therapy were no different between the groups. The results were similar in patients positive for rotavirus. However, in this group the duration of vomiting and hospital stay were significantly shorter in the citrate ORS group. Use of a base precursor is recommendable even in the hypotonic ORS, but in situations where these ingredients are not available due to limited resources or otherwise, use of an ORS without a base or base precursor may be considered adequate.

To investigate the influence of LGG therapy and to determine the optimal timing of its administration in relation to ORT, 93 patients received LGG (study IV). Twenty-eight patients received one single dose at commencement of rehydration therapy and 33 continued to receive LGG twice a day throughout the hospital stay. Thirty-two patients received an initial dose of placebo and thereafter "late-onset LGG therapy", and 30 received placebo preparation throughout the study. LGG and hypotonic ORS both had an independent shortening effect on the duration of diarrhoea, and they also evinced significant interaction. The results suggest that one single early dose of LGG might suffice.