Rehydration of Two Patients with Secondary Glucose Intolerance by Using Rice-Oral Rehydration Solution (R-ORS)

To the Editor: The clinical importance of temporary glucose malabsorption during childhood diarrheal diseases has increased in recent years. The use of standard World Health Organization (WHO)-recommended glucose-ORS (G-ORS) may increase stool output with worsening signs of dehydration in these cases. It is one of the limited indications for intravenous (i.v.) fluid treatment in diarrheal dehydration (1). All patients with loose, watery, explosive stools during G-ORS treatment are tested for secondary glucose intolerance at Hacettepe University Ihsan Doğramaci Children's Hospital Diarrhea Training and Treatment Unit, as also suggested by Beattie et al. (2). Patients diagnosed as having glucose intolerance are mostly hospitalized for i.v. fluid replacement. Recently, we treated two of our patients with glucose intolerance by using precooked rice-oral rehydration solution prepared by WHO (R-ORS, osmolarity 250 mosm/L, containing 50 g instant rice powder per liter with an electrolyte content equivalent to WHO G-ORS) in 24 h without necessitating i.v. fluid treatment. The first patient was a 5.5-month, 5,500-g girl who had acute watery diarrhea for 3 days. Her stool frequency (number of stools per hour) was 0.25/h on admission, and she was moderately dehydrated according to WHO criteria. Her admission blood pH and bicarbonate levels were 7.33 and 10.2 mmol/L, respectively. The serum sodium, chloride, and potassium levels were within the normal range. She was put on 100 ml/kg WHO G-ORS for 4-6 h in addition to breastfeeding. After the infant had consumed 600 ml of G-ORS, her stool frequency increased to 1/h, with watery and explosive stool. Her signs of dehydration persisted and the control blood pH level revealed deterioration (pH = 7.28). She was then given R-ORS 100 ml/kg for 4-6 h as well as breastfeeding. Meanwhile, stool was examined for reducing substance by glucostick and was found to be positive at >0.5%. Rehydration was completed within 12 h, during which she had taken 1,200 ml R-ORS. The stool frequency decreased to 0.5/h. By discharge, she had gained 650 g (12%), and the blood pH and bicarbonate values were 7.40 and 17.3, respectively. The second patient was a 7.5-month, 9,000-g boy who also had acute watery diarrhea for 12 h, with a stool frequency of 0.2/h. He was also moderately dehydrated according to WHO criteria (1). His blood pH and serum bicarbonate values on admission were 7.28 and 12.9 mmol/L, respectively. The serum sodium, chloride, and potassium levels were within the normal range. He was similarly put on 100 ml/kg WHO G-ORS for 4-6 h in addition to breastfeeding. His stool frequency after 5 h of rehydration with G-ORS (900 ml of G-ORS taken) increased to 1/h. The control blood pH, serum bicarbonate levels, and signs of dehydration failed to show any improvement. His stool was also positive for glucose with the glucostick test (>0.5% glucose). R-ORS was then administered at 100 ml/kg for 4-6 h as well as breastfeeding. Rehydration was completed within 12 h with 1,800 ml of R-ORS, and the signs of dehydration resolved. The stool frequency decreased to 0.1/h. He had gained 500 g (5%) by discharge, and his blood pH and serum bicarbonate values were 7.34 and 17.3 mmol/L, respectively. The stools of both patients were tested for reducing substance 12 h after discharge for the presence of glucose and were found to be negative. During rehydration therapy, G-ORS may increase stool output because of its relatively higher osmolarity (310 mosmol/L) compared with blood (290 mosmol/L) (3). Having a lower osmolarity, R-ORS has been shown to be more effective in decreasing stool output (3). In both of our patients, R-ORS was administered because of their increased stool frequency during G-ORS treatment. Meanwhile, the patients were diagnosed as having glucose intolerance. Since their signs of dehydration resolved, treatment was continued and they were successfully rehydrated. During acute watery diarrhea, destruction of the glucose carrier system may lead to transient glucose intolerance causing G-ORS treatment failure (4,5). The complete hydrolysis of rice yields not only glucose but also nonstarch components and amino acids, including glycine, that enhance sodium absorption independently (3,6,7). Amino acids may also help in the regeneration of the intestinal mucosa. On the other hand, the metabolism of starch by colonic bacteria may produce short-chain fatty acids that in turn stimulate sodium and water reabsorption (8). Along with these factors, the lower osmotic pressure of R-ORS may explain the success in our patients. In cases with suspected or proven glucose intolerance, R-ORS may be considered as an alternative mode of therapy to i.v. treatment. Kadriye Yurdakök; Elif Özmert Diarrhea Training and Treatment Unit Department of Social Pediatrics Hacettepe University Ihsan Doğramaci Children's Hospital Ankara, Turkey