Monday, September 21, 2015

We have the solution what is the problem?

Monday, September 21, 2015

One simple scientific invention which has really made a difference to hundreds of thousands of lives, which in real sense is from bench to door step and which is extremely simple logistically is Oral rehydration solution and therapy.

This path breaking simple solution since 1979 has saved millions of lives. In early 80s 5 million children under the age of 5 died globally of diarrhea and the current figure stands at 670000. Currently, in India 300000 children die of diarrheal disease annually. This has been largely possible because of ORT only. That is why this has been regarded as the most important invention of the century.

If we look at the figures of percentage usage of ORS by patients of diarrhea in India, it is a very surprisingly low of 26%, when we have a simple solution of this kind, what are the problems in its usage?

What are the problems blocking wider usage of this solution?

  1. Despite very well laid down guidelines by WHO and local academic bodies, the physicians have more faith in prescribing antibiotics for watery diarrhea. Many of us share the views of the parents that childhood illnesses cannot be cured unless there is at least one antibiotic in the prescription.
  2. The present day low osmolality ORS does reduce the stool output and avoid usage of intravenous fluids, it does not effectively “control” diarrhea, the end point of treatment being perceived as stoppage of diarrheal losses rather abruptly.
  3. The physicians do not accord it a place of pride that it deserves. A very cursory mention, at the bottom of prescription without the details of methods of usage , makes it a poor runner in the race.
  4. Failure of the family to view this as "Medicine". Something not expensive, containing "some sugar and salt" and so widely talked of on TV, is not their concept of medicine.
  5. Vomiting associated with diarrhea and poor acceptability by kids may be a problem.
  6. Availability in remote areas may be an issue.

How can we increase its usage?

  • By spending time with parents and trying to explain to them that maintenance of hydration and nutrition are the 2 prime aims of treatment. There are anti diarrheal drugs available which decrease the peristaltic movements of the intestine and seemingly stop diarrhea abruptly, they cause harm to the child, they will bloat his tummy and may cause respiratory embarrassment.
  • Most of the watery, acute diarrheal episodes are viral in nature, hence antibiotics do not work and are self limited; replacement of fluids is the key to management. (Many bacterial watery diarrhea are toxin mediated and antibiotics are unnecessary in them too)
  • Parents have this notion that if you gave nothing by mouth the diarrhea will stop, that is why they starve the child and avoid giving fluids. We have a very large role to play here to explain to them that acute watery diarrhea is NOT because of failure of the digestive process, and that even in the phase of ongoing losses the intestines continue to absorb fluids and foods. (The continued absorption of salt coupled with glucose in critical proportion is the basis of ORT helps us to prevent and effectively treat dehydration.) A child who is fighting an illness needs extra energy, hence continued supply of nutrients. And this also helps the repair process.
  • Vomiting is one factor which precludes its use; it is very well known that small, frequent sips of ORS help to prevent vomiting. If a child vomits ORS, it is prudent to wait for 10 minutes and try again.
  • Poor acceptability of fluids in phase of dehydration can be a red flag sign. It is expected of our body to crave for fluid when we are dehydrated, if the thirst mechanism is not working we need to get to our doctor. A dehydrated kid avidly drinks and does not let the mother remove the cup to even refill.
  • In very remote and inaccessible area availability may certainly be an issue; administrative logistics have to seriously look in to this.

A wonderful epoch making discovery has been delivered to our door step, we shall need more efforts to bring it to lips.