Dr Madhab Chattopadhyay M.Pharm, Ph.D
When diarrhea strikes During the dead hour of night, if anybody in your family starts passing loose motion or vomit very frequently, what do you do ? Run helter-skelter to get a transport for reaching the hospital? Make a hurried search for Enteroquinol or Flagyl tablets ?
Hazards associated with unwise and improper medication It must be emphasized that bringing the patient under the attention of a doctor is no doubt the best and wisest approach. But it may not be always possible. Using the above-mentioned medicines or some other medicines without being advised by a doctor may prove counterproductive for various reasons. First of all, this type of problems most often arises because of indigestion and not due to any infection. So use of any antimicrobial drug may not be required at all. Unnecessary use those drugs may cause irritation of the stomach wall leading to more vomiting and more fluid loss. In case the problem is caused by any infection, use of those drugs or any other drug on your own choice may not help since the symptoms may be the manifestation of a mixed infection. So the random choice of an antiprozoal (Enteroquinol, Flagyl) or antibacterial (Norfloxacin) may suppress the symptoms partially but will definitely not solve the problem. If you use the drugs in improper dose (very likely) you would unknowingly promote the emergence of a drug-resistant variety of the infecting organisms. If the symptoms can be correctly reported to a doctor, he could recognize the nature of the infection and make a correct choice of the drugs. So medication on your own discretion is not and cannot be the right way.
A simple answer to a serious problem You may however alleviate and even overcome the crisis using a simple approach. Before we look into the approach, let us understand why water is crucially important for our survival. Our blood transports oxygen and other nutrients to the cells and also carries the unwanted materials generated by the cells to the kidneys for excretion. Blood is propelled by the pumping action of the heart and spreads all over the body through the network of arteries. It consists of cells (red blood cells, white blood cells, platelets) and chemicals (proteins, carbohydrates, lipids, urea, creatine, creatinine and some other substances). These living and non-living materials impart a certain fluidity to the blood, suitable for pumping by the heart. When somebody frequently passes watery stool and / or vomits, he loses a lot of water poured from the blood into the digestive tract. The problem called dehydration is associated with far- reaching consequences. With the amount of other constituents of the blood remaining the same, loss of fluid invariably leads to loss of fluidity of the blood. Moreover, due to loss of some ions with water, the acidic or alkaline status of the blood, essential for the metabolic activities of our body, is adversely affected. If the problem is not attended in time, the blood turns into a highly viscous fluid not at all suitable for pumping by the heart. The patient dies due to heart failure. This is how villages after villages got depopulated following the outbreak of cholera as described in some classic literature.
It is obvious from the foregoing discussion that the problem can be avoided or solved simply by supplying water with electrolytes. Water is absorbed from the stomach and mixed with the blood. The optimum fluidity of the blood thus can be restored. It is necessary to add some electrolytes to compensate for the loss of ions (sodium, bicarbonate).When a patient is brought to the hospital with dehydration, doctors infuse saline through his vein in order to bring back the blood in its optimally fluid state. If hospitalization is not possible, you can help the patient simply by feeding him a solution of salt and sugar. Half spoonful sugar and a pinch of salt dissolved in a glass of water are sufficient to serve the purpose. You can also add a little bit baking soda to the solution. The remedial measure can be used even if the patient is known to be diabetic. In case diarrhea is associated with vomiting, the solution should be fed very slowly (sip by sip). Feeding should be continued until he feels an urge for urination.
Historical evidence of the success of ORT This remedy well within your reach has been traditionally used for the management of diarrhea. The efficacy of this approach is well-documented. During the political turmoil in Bangladesh (the then East Pakistan) in 1971, refugees started coming to India in multitudes. Unhygienic conditions in the Bongaon refugee camp (24-Paragans, West Bengal) led to the outbreak of cholera. Rate of death shot up to 30% of the infected patients. At this juncture Dr. Dilip Mahalanabish, a Kolkata-based pediatrician, was sent to take care of the situation. Supply of saline was insufficient. But the background of his research on oral rehydration therapy (ORT) enabled him to tide over the crisis simply by feeding the patients salt and sugar solution, The outcome was incredible. The rate of death was reduced to 3%. The life-saving remedy got a popular name “oral saline”. Dr. Mahalanabish used ORT in many other places of the world (Afghanistan, Egypt, Yemen) and achieved success. Though initially met with skepticism, ORT got worldwide recognition. The premier medical journal The Lancet highlighted it as “potentially the most important medical advance of the 20 th century”.
Concluding remarks It is important to note that glucose promotes the absorbance of sodium from the intestine. So both sugar and salts are required to prepare the oral rehydration solution. Some ready-made mixtures for the preparation of ORS are commercially available. But even when you have no access to them, do not get nervous when somebody gets diarrhea. Sugar and salt are available in every kitchen. Use them to prepare ORS and ask the patient to take it. If the problem is very serious, medical intervention will be required later on, but you would get enough time to look for a doctor while helping the patient to restore the fluidity of his blood.
Dr Subhajit Bhattacharjee, a General Practitioner at Agarpara, Kolkata, has reviewed this article and also made some valuable additions to the article as follows. On behalf of me and the editorial board, I convey to him heartful thanks and gratitude. Hope Megh Peon will get similar cooperation from him in its next issues.
Some Additional points
Dr Subhajit Bhattacharjee MBBS
Diarrhea in children could be very dangerous and life-threatening. But ORT will help you if you are unable to get a doctor. Give the child a drink made with 6 level teaspoons of sugar and half- teaspoon of salt dissolved in 1 litre of clean water. Be very careful to add the correct amounts. Too much sugar can make the diarrhea worse. Too much salt can be extremely harmful to the child. Making the mixture a little more diluted (with more than 1 litre of clean water) is not harmful.
Diarrhea usually cures itself in three to four days with rehydration (drinking a lot of liquids). The real danger is the loss of liquid and nutrients from the child’s body, which can cause dehydration and malnutrition.
A child with diarrhea should never be given any tablets, antibiotics or other medicines unless prescribed by a trained health worker.
The best treatment for diarrhea is to (1) drink lots of liquids and oral rehydration salts (ORS), properly mixed with clean water from a safe source, and (2) take zinc tablets or syrup for 10–14 days.
The well-known term ORS (oral rehydration salts) is a special combination of dry salts that is mixed with safe water. It can help replace the fluids lost due to diarrhea.
When should ORS be used? When a child passes three or more loose stools in a day start giving him/her ORS. In addition, give children over 6 months of age 20 milligrams of zinc per day (tablet or syrup) and give children under 6 months of age 10 milligrams per day (tablet or syrup). It should be continued for 10–14 days,
Where can ORS be obtained? In most countries, ORS packets are available in the health centres, pharmacies, markets and shops.
How is the ORS drink prepared? Put the contents of the ORS packet in a clean container. Check the packet for directions and add the correct amount of clean water. Too little water could make the diarrhea worse. Add water only. Do not add ORS to milk, soup, fruit juice or soft drinks. Do not add sugar. Stir well, and feed it to the child from a clean cup. Do not use a bottle.
How much ORS drink to give? Encourage the child to drink as much as possible. A child under the age of 2 years needs at least 1/4 to 1/2 of a large (250-millilitre) cup of the ORS drink after each watery stool. A child aged 2 years or older needs at least 1/2 to 1 whole large (250-millilitre) cup of the ORS drink after each watery stool.
What, if ORS is not available? Give the child a drink made with 6 level teaspoons of sugar and 1/2 level teaspoon of salt dissolved in 1 litre of clean water. Be very careful to mix the correct amounts. Making the mixture a little too diluted (with more than 1 litre of clean water) is not harmful.
Note: Zinc supplementation is a critical new intervention for treating diarrheal episodes in children. Recent studies suggest that administration of zinc along with new low osmolarity oral rehydration solutions / salts (ORS), can reduce the duration and severity of diarrheal episodes for up to three months. The World Health Organization (WHO) and UNICEF recommend daily 20 mg zinc supplements for 10 – 14 days for children with acute diarrhea, and 10 mg per day for infants under six months old, to curtail the severity of the episode and prevent further occurrences in the ensuing two to three months.