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Public health effectiveness depends on both coverage and
efficacy of treatment. This trial dealt with the latter. Fluid
management of acute diarrhoea includes two stages. If possible,
hydration should be properly maintained through adequate
provision of fluid, to prevent fluid loss. If dehydration occurs,
replacement therapy should be promptly initiated, and continuing
losses should be maintained adequately to prevent further water
and electrolyte imbalances [12, 21, 22, 38]. The main reason for
conducting the clinical trial was to assess whether the RBG,
prepared the way mothers do it in the village , could be
considered safe as an oral hydration solution at the community
level. The trial was an extreme test for a beverage intended to
be used at the home level, where children with diarrhoea have no
or only mild dehydration that is not severe enough for hospital
admission. Based on the outcomes, RBG was not only as efficacious
as the standard ORS currently in use by the Ministry of Health,
but was actually more so. Mildly to moderately dehydrated
children who were given RBG gained more weight, took less time to
rehydrate, and had lower faecal output than children given ORS.
TABLE 3. Serum sodium on admission and discharge of
RBG and WHO patients
sodium on admission
sodium on discharge
|% (No.) normal range
|% (No.) elevated
RBG group p < .01; WHO group p = .09.
TABLE 4. Sodium in the faeces on admission and
discharge in the RBG and WHO groups
(n = 4)
(n = 6)
|On admission (mEq/L)
|mean ± SD
||27 ± 19
||36 ± 21
|On discharge (mEq/L)
|mean ± SD
||9 ± 4
||27 ± 15
NS = not significant.
a. t test.
The physiological mechanism that underlies the afficacy of
rice-based beverages to rehydrate children is related to the
continuous movement of water and electrolytes in and out of the
gastrointestinal lumen, which responds to passive and active
forces, the latter fueled basically by glucose. To give an idea
of the magnitude of fluid flux, consider that, in a healthy
adult, about 8 L fluid/day enters the small bowel and only 100 ml
is normally excreted in stools. Only 25% of the fluid entering
the small bowel is ingested; the remainder is secreted by the
intestine . An even greater proportion of fluid is secreted
into the lumen during diarrhoea, which is caused more by an
increased secretion of fluid into the gut than by reduced
absorption of water .
Several studies show that the stool output is markedly reduced
when cooked rice is given as part of an oral rehydration solution
because of the slow liberation of glucose molecules from starch,
the main carbohydrate present in rice [39, 40]. After ingestion,
50 g rice powder releases more than twice the amount of glucose
present in standard ORS but contributes a considerably lower
osmolar load to the solution [41 43]. The presence of glucose
allows for greater reabsorption of sodium than would be possible
with standard ORT, as the amount of glucose that can be added,
keeping the equimolar ratio with sodium, is limited by the
osmolar load of both elements. Thus, efficient reabsorption of
electrolytes from fluid secreted into the intestinal lumen will
prevent hyponatraemia over the short term, even in the face of
increased losses during diarrhoea.
Our findings are in line with the results of clinical trials
that used rice-based oral rehydration solutions with salts added
according to WHO recommendations [31, 32, 39, 40, 44]. The almost
complete lack of sodium in our test beverage (3 mEq/L) and the
addition of a seemingly high amount of sugar (60 g/L) made these
outcomes surprising to clinicians. The arguments were that a
beverage lacking sodium would produce hyponatraemia, and that the
amount of sugar added would make a hyperosmolar solution, which
would worsen diarrhoea.
Actually, theoretical calculations showed that twice as much
sugar would be required to produce a slightly hyperosmolar
solution . In fact, the added sucrose, as well as the natural
starch present in the rice gruel, provides glucose, which
enhances the carbohydrate sodium transport mechanism [45-47],
thereby increasing the uptake of sodium and water secreted by the
enterocyte to the intestinal lumen during diarrhoea . We
found that faecal sodium was 66% lower on discharge in the
children fed RBG, despite similar faecal sodium concentrations on
admission in both the RBG and the ORS groups, and only 2%
difference in serum sodium levels at discharge.
On the other hand, serum sodium at discharge was significantly
higher in the control group. Although no children had clinical
signs of hypernatraemia, this finding was reported by other
authors when rehydrating children with the standard WHO solution
[48, 49]. The high levels of sodium in the formulation of the
oral rehydration mixture proposed by WHO were based on experience
in treating the most devastating of the secretory diarrhoeas,
cholera, which causes heavy losses of sodium, leading to clinical
hyponatraemia [4, 50 53]. However, where cholera is not endemic,
such as in Mexico, most diarrhoeas, even the secretory ones due
to rotavirus and E. coli, are not associated with heavy losses of
sodium [54-56]. We identified a specific enteropathogen in only
14 patients (16% of the whole group), none associated with heavy
loss of sodium.
Despite its relevance for only a small proportion of
diarrhoeas [57 59], the utility of having a single solution for
managing all cases of diarrhoea led to the widespread use of the
WHO formula [38, 60]. Before our study, two trials of rice
water-based beverages without added salts and with a very low
sodium concentration, similar to the one that we tested, were
conducted in Singapore and India, both reporting success [55,
61]. However, ours is the first trial to test a rice-powder
solution with no added electrolytes but with added sugar.
Earlier findings regarding the widespread use and
acceptability of the RBGs add significantly to the rationale for
their inclusion in home-based strategies for the management of
diarrhoea. An ethnographic study indicated that only 18% of
mothers used standard ORS, but 80% used the rice-powder gruel in
the home management of diarrhoea . Similar findings were
described in national surveys [62- 64] and worldwide .
Mothers commonly give their children rice-powder beverages to
treat diarrhoea. They should now be taught that these beverages
can also be given to prevent dehydration or to maintain
In summary, the rice-powder gruel, with added sugar but
without added electrolytes, tested in this study, prepared
according to mothers' practices, was effective in returning
hydration status to normal without causing hypernatraemia in
mildly to moderately dehydrated children with acute diarrhoea.
The authors acknowledge the support received for this study
from the resident medical and nursing staff of the Oral Hydration
Ward of the Hospital Infantil de México, as well as the
participation of Drs. H. Viais, D. Bross, and L. Posadas in the
care of the hospitalized patients. The contribution of Drs. M.
Latham, R. Cash, J. Snyder, and J. Calva to the discussion of the
study design and the interpretation of the results is also fully
This study was carried out in partial fulfillment for the
Ph.D. degree in International Nutrition of one of the authors
Financial support for this research was provided in part by
the Applied Diarrheal Disease Research Project of Harvard
University by means of a cooperative agreement with the US Agency
for Inter national Development. Financial and logistical support
was also received from the Hospital Infantil de México and the
Instituto Nacional de la Nutrición, Mexico.
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