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Carbohydrates and Electrolytes (Systemic)

This monograph includes information on the following:

1) Dextrose and Electrolytes
2) Oral Rehydration Salts § *
3) Rice Syrup Solids and Electrolytes 

VA CLASSIFICATION
Primary: TN490



Other commonly used names are
oral rehydration salts, ORS-bicarbonate, and ORS-citrate . §
§ Distributed by the World Health Organization (WHO).
Note: For a listing of dosage forms and brand names by country availability, see Dosage Forms section(s).

*Not commercially available in the U.S.

Not commercially available in Canada.



Category:


Electrolyte replenisher—

Indications

Accepted

Diarrhea (treatment) and{15}
Electrolyte depletion (prophylaxis and treatment)—Carbohydrate and electrolytes solutions are indicated for oral replacement of fluids and electrolytes (especially sodium and potassium) in the treatment of clinically evident dehydration caused by diarrhea; to prevent severe dehydration by replacing losses early in the course of diarrhea; and to maintain hydration in the presence of continuing fluid loss. {01} Oral rehydration {25} therapy (ORT) consists of rehydration (the expansion of intravascular volume and deficit replacement {03}); replacement of ongoing abnormal losses of fluids and electrolyte salts from continuing diarrhea and vomiting and normal water losses through skin and respiration {09}; and the maintenance of fluids and electrolytes in the body until adequate nutrition can be restored. {04} Acute diarrhea is not immediately terminated by oral rehydration therapy, but it is usually self-limiting. Some carbohydrate and electrolytes solutions are also used for maintenance of water and electrolytes when food and liquid intake has been discontinued after surgery, and some are indicated for maintenance of hydration only, rather than for rehydration {23}.
—ORT is recommended by the World Health Organization (WHO) Diarrheal Disease Control Program and United Nations Children's Fund (UNICEF) as a fundamental treatment for acute diarrheal disease in infants and children and provides the basis for all national programs of diarrhea control. The WHO formulations of ORS-bicarbonate or ORS-citrate rehydration salts, consisting of preweighed sodium chloride, potassium chloride, sodium citrate or sodium bicarbonate, and dextrose {05}, are distributed in aluminum foil or polyethylene packets to be prepared at home and given at the onset of diarrhea. The solutions are simple to prepare (i.e., the contents of each packet are dissolved in one liter of potable water) and are very effective, inexpensive, and therapeutically appropriate for routine use in prevention and treatment of dehydration from diarrhea of any cause in all age groups. {04} These powders are not widely used or commercially available in the U.S. {23}
—Some commercial carbohydrate and electrolytes solutions available in the U.S. and Canada have a lower sodium content than the recommended WHO formulas. This reflects the concern that the higher sodium content of the WHO solution may cause hypernatremia, especially in developed countries, due to the use of high solute diets and the lower incidence of malnutrition in young children. However, there is no evidence that the WHO solution causes hypernatremia when used as directed. {22} {23} Carbohydrate and electrolytes solutions with a lower sodium content have been found to be as effective as the WHO formulas. {30} {31} {32} {33}
—Intravenous replacement of fluids and electrolytes is not used routinely in treatment of diarrhea, but it may be necessary to treat severe dehydration (fluid loss of 10% or more of body weight) or impending shock {23}.


Pharmacology/Pharmacokinetics

Physicochemical characteristics:
Molecular weight—
    Calcium chloride: 147.02
    Citric acid: 192.12
    Dextrose (anhydrous): 180.16
    Dextrose (monohydrate): 198.17
    Dibasic sodium phosphate: 268.07
    Magnesium chloride: 203.30
    Potassium chloride: 74.55
    Potassium citrate: 324.41
    Sodium bicarbonate: 84.01
    Sodium chloride: 58.44
    Sodium citrate (anhydrous): 258.07
    Sodium citrate (dihydrate): 294.1 {25}

Mechanism of action/Effect:

During normal digestion, about 9 liters of fluid a day in adults and about 3 to 6 liters a day in infants and children {22} pass through the duodenum, where most of the dietary sugars, fats, and amino acids are absorbed. The fluid, containing ingested food and liquids and digestive secretions, reaches the ileum mainly as an isotonic salt solution that is similar to plasma in its ionic sodium and potassium content. The ileum absorbs most of this isotonic solution by various active transport mechanisms, but about 1 liter a day is emptied into the colon, where all but about 100 mL is absorbed. The rest is excreted into the feces to prevent desiccation. {08} In addition, cells in the small intestine both absorb and secrete water and electrolytes, but less secretion occurs than absorption, so that the net effect of small-bowel transport is absorption. In acute diarrheal states, various infectious agents produce alterations in the intestinal mucosa, inhibiting absorption or stimulating secretion. {02} {08} The large volume of secretions thus produced {25} cannot be fully absorbed by the colon and are expelled as watery diarrhea. {02} Essential water and salts are lost in stools and vomitus, and dehydration results when blood volume is decreased because of fluid loss from the extracellular fluid compartment. Thirst is the first sign of dehydration when fluid loss is less than 5% of the body weight. Tachycardia, decreased skin elasticity, sunken eyes, hypotension, irritability, oliguria or anuria, severe thirst, and stupor or coma develop rapidly when fluid loss is greater than 5% of the body weight. Shock occurs when the deficit equals about 10% of body weight, and death is caused by greater losses of fluids. {02}

Preservation of the facilitated glucose-sodium cotransport system in the small-bowel mucosa {25} is the rationale of oral rehydration therapy. {03} Glucose is actively absorbed in the normal intestine and carries sodium with it in about an equimolar ratio. Therefore, there is a greater net absorption of an isotonic salt solution with glucose than of one without it. During acute diarrhea, the absorption of sodium is impaired and an isotonic salt solution without glucose can increase stool volume by passing through the intestine unabsorbed. Since the glucose absorption system usually remains intact during diarrheal illnesses, the net absorption of water and electrolytes from an isotonic dextrose-salt or a hypotonic rice-salt {38} solution can equal or exceed diarrheal stool volume, even if the loss is rapid. {02} Sucrose (ordinary sugar) may be substituted for dextrose in the dextrose-based oral rehydration solutions, but twice the amount of sugar is needed for near-equal efficacy. However, excessive use of dextrose or sucrose to increase palatability of the solution or to increase nutritive value for small children may exacerbate diarrhea, because of the osmotic effect of unabsorbed glucose. A solution with 2 to 2.5% dextrose in the dextrose-based oral rehydration solutions is optimal for promoting coupled absorption of sodium from the intestine. {15}

Rice-based oral rehydration solutions use starch rather than dextrose as a base. The ingested starch gradually releases glucose which along with sodium preserves the glucose-sodium transport system in the manner described above. The rice-based formula has the advantage of a lower osmotic effect and provides a few more calories than the dextrose-based electrolytes solution. {34} {35} This formula has also been found to be more effective in reducing stool output and shortening the duration of diarrhea. {34} {36}

Potassium replacement during acute diarrhea prevents below-normal serum concentrations of potassium, especially in children, in whom stool potassium losses are higher than in adults. {03}

When added to oral rehydration solutions, bicarbonate and citrate are equally effective in correcting the metabolic acidosis caused by diarrhea and dehydration. {13} However, citrate is used instead of the bicarbonate in the WHO formulation, to prevent the occurrence of bicarbonate-induced discoloration and decomposition of the dextrose in the packets. {13}

Treatment started early in the course of diarrhea minimizes vomiting, anorexia, lethargy, or coma, which interfere with continued feeding; allows the homeostatic mechanisms of thirst and renal function to remain intact; and avoids the risk of death from severe dehydration. {02} Thirst determines the amount of rehydration required, and normal renal function allows the excretion of any excess water and salts. {02}

Time to peak effect

8 to 12 hours.


Precautions to Consider

Pregnancy/Reproduction

Pregnancy—
Problems in humans have not been documented.

Breast-feeding

Problems in humans have not been documented. Continued breast-feeding during the treatment and maintenance phases of oral rehydration therapy is vital for the management of diarrhea.

Pediatrics

Although oral rehydration therapy appears to be safe and effective in neonates {03}, it has not been evaluated in premature infants. {02} The range of sodium concentrations recommended by the American Academy of Pediatrics Committee on Nutrition is 40 to 60 mEq per liter for maintenance solutions and 75 to 90 mEq per liter for rehydration solutions. {23} To allow adequate intake of free water in the prevention of hypernatremia with the use of WHO ORS-bicarbonate or citrate solutions, feeding (including breast milk) may continue, and/or the infant may be given a separate feeding of plain water after every two doses of undiluted WHO solution. {03} {15}


Geriatrics


Carbohydrate and electrolytes solutions are well tolerated by elderly patients. {18}

Medical considerations/Contraindications
The medical considerations/contraindications included have been selected on the basis of their potential clinical significance (reasons given in parentheses where appropriate)— not necessarily inclusive (» = major clinical significance).


Except under special circumstances, this medication should not be used when the following medical problems exist:
» Anuria or{37}
» Oliguria{37}    (since normal renal function is required to allow the excretion of any excess water or salt, patients with prolonged anuria or oliguria usually require precise parenteral administration of water and electrolytes {02}; however, transient oliguria is a feature of dehydration due to diarrhea and is not a contraindication for oral rehydration therapy {25})


» Dehydration, severe, with symptoms of shock    (oral rehydration is too slow; rapid intravenous therapy is necessary; symptoms of severe dehydration include severe thirst, rapid heartbeat, decreased skin turgor, hypotension, oliguria or anuria, sunken eyes, loss of body weight, convulsions, stupor, and coma; {02} if symptoms of severe dehydration appear after oral therapy has been attempted, rehydration must be achieved with parenteral therapy)


» Diarrhea, severe    (when amounts of diarrhea exceed 30 {25} mL per kg of body weight per hour, patient may be unable to drink enough fluids to replace continuing loss {02} {37})


» Glucose malabsorption    (diarrhea is exacerbated and dehydration worsened when oral rehydration solutions are given to patients with this problem; volume of stool greatly increases and contains large amounts of glucose; rehydration therapy should be discontinued {02} {04})


» Inability to drink or
» Vomiting, severe and sustained    (parenteral therapy is required for patients unable to drink because of extreme fatigue, stupor, coma, or uncontrollable vomiting {07} {37})


» Intestinal obstruction or{28}{37}
» Paralytic ileus or{28}{37}
» Perforated bowel{28}{37}    (delayed passage of carbohydrate and electrolytes solutions through the gastrointestinal tract may increase risk of gastrointestinal irritation)


Patient monitoring
The following may be especially important in patient monitoring (other tests may be warranted in some patients, depending on condition; » = major clinical significance):

Blood pressure measurements    (recommended to detect shock due to severe dehydration {09} {25})


Body weight    (recommended periodically to determine the degree of rehydration or the recurrence of dehydration {07} {25})


Electrolytes, serum and
pH, serum    (recommended to help determine status of individual ions and acid-base status {09})


Glucose malabsorption tests    (recommended when oral rehydration solution appears to exacerbate diarrhea; infant's feces should be monitored for reducing substances to detect transient monosaccharide malabsorption, which may occur during acute infectious diarrhea; sugar intake should be eliminated or decreased if glucose intolerance is present; intravenous fluid replacement may be required {09} {25})


Observation for signs of rehydration    (observation of patients with frequent diarrhea is recommended every 3 to 6 hours for signs of rehydration, i.e., normal skin turgor, normal urine flow, normal pulse rate and volume, and a sense of well-being {02})


Stool volume measurements    (recommended periodically to determine the dose and continued need for maintenance therapy; the volume of ingested replacement solution should equal the volume of stool losses; if stool volume cannot be measured, an intake of 10 to 15 mL of rehydration solution per kilogram of body weight per hour is suggested {07} {09})




Side/Adverse Effects
The following side/adverse effects have been selected on the basis of their potential clinical significance (possible signs and symptoms in parentheses where appropriate)—not necessarily inclusive:

Those indicating need for medical attention
Incidence rare
    
Hypernatremia (dizziness; fast heartbeat; high blood pressure; irritability; muscle twitching; restlessness; seizures; swelling of feet or lower legs; weakness)

Symptoms of overhydration
    
Puffy eyelids

Note: Therapy may need to be discontinued temporarily. {02}




Those indicating need for medical attention only if they continue or are bothersome
Incidence more frequent
    
Vomiting, mild
Note: Mild vomiting may occur when oral therapy is begun, but therapy should be continued with frequent, small amounts of solution administered slowly. {02} {03}







Patient Consultation
As an aid to patient consultation, refer to Advice for the Patient, Carbohydrates and Electrolytes (Systemic) .
In providing consultation, consider emphasizing the following selected information (» = major clinical significance):

Before using this medication
»   Conditions affecting use, especially:
Other medical problems, especially renal function impairment, severe dehydration, severe and continuing diarrhea, glucose malabsorption, inability to drink, severe and continuing vomiting, intestinal obstruction, paralytic ileus, or perforated bowel

Proper use of this medication
Importance of helping infants and small children to drink solution slowly and frequently in small amounts, given with a spoon

Importance of not taking for a longer time than recommended by physician

» Proper dosing

» Proper storage

For patients using the commercial powder form
Adding recommended amount of boiled, cooled drinking water to contents of packet; stirring or shaking container for 2 or 3 minutes to dissolve completely

Not adding more water to the solution after it is mixed

Not boiling solution

Making and using fresh solution each day

For patients using the freezer pop form
Removing from box and not separating before freezing

Freezing pop for best taste; cutting wrapper and pushing from bottom to eat frozen pop

Cutting wrapper and pouring unfrozen pop in glass or cup to drink

For patients using the powder form distributed by the World Health Organization (WHO)
Adding powder to recommended amount of drinking water; shaking container for 2 or 3 minutes to dissolve completely

Not adding more water to the solution after it is mixed

Not boiling solution

Making and using fresh solution each day

Precautions while using this medication
Eating soft foods, such as cereals, bananas, cooked peas and beans, and potatoes, to maintain nutrition

Giving breast milk to breast-fed infants between doses of solution

Checking with physician if diarrhea does not improve in a day or 2 or becomes worse during treatment with this medication

Checking with physician as soon as possible if signs of severe dehydration occur, including doughy skin (decreased skin turgor), sunken eyes, dizziness or lightheadedness, weakness or tiredness, irritability, and weight loss

For patients taking ORS-citrate or ORS-bicarbonate
Drinking water between doses of rehydration solution (except breast-fed infants)

For patients taking the premixed liquid form
Avoiding other electrolyte-containing foods or liquids, such as fruit juices or foods with added salt, until rehydration solutions are discontinued, to prevent excessive electrolyte ingestion {06} or osmotic diarrhea {23}


Side/adverse effects
Signs of potential side effects, especially hypernatremia


General Dosing Information
Infants and young children should be given small, frequent, and slowly {20} administered amounts of oral rehydration fluid. {19} Infants who finish 150 mL of solution per kg of body weight in less than 24 hours should be encouraged to drink plain water to prevent hypernatremia and to quench thirst. {17}

The commercially prepared solutions do not require additional water intake because of the generally lower sodium content. {21}

Rehydration solutions must not be diluted with water, because dilution decreases the absorptive properties of the glucose-sodium cotransport system. {03}

Acute watery diarrhea, dysentery, and persistent diarrhea in children can also result in tissue catabolism, which may in turn lead to malnutrition. This can be further aggravated by the common practice of withholding fluids and nutrition {01} {04} during diarrhea. Although early feeding may result in slightly increased stool volume, nutrient absorption is increased and weight loss is lessened. Therefore, continued feeding (including breast milk) of infants and children and supplementation with plain drinking water during the maintenance phase of oral rehydration therapy are important for maintaining hydration and nutrition in the management of diarrhea.

The oral rehydration solution should be taken alternately with soft foods, such as rice cereal, bananas, cooked legumes, potatoes {02}, or other non–lactose-containing, carbohydrate-rich food {24}. Older children and adults should resume their normal diets as soon as the appetite returns. {02} Other electrolyte-containing foods or liquids such as fruit juices or foods with added salt should be withheld until oral rehydration solutions are discontinued, to prevent excessive electrolyte ingestion or osmotic diarrhea. {06} {23}

Cow's milk should be discontinued only if diarrhea worsens considerably after feeding and the stool becomes acidic and contains reducing substances. This reflects a depression of lactase activity, which {02} may occur when the brush borders of jejunal mucosal cells are damaged. {08} Soy formulas without lactose are given alternately with carbohydrate and electrolytes solutions for the first 24 to 48 hours. {22}

If the initial dehydration is severe, rehydration must be achieved by intravenous administration of an appropriate isotonic electrolyte solution, after which the oral solution may be used for maintenance when tolerance to oral intake has been established. {02} {03}

Parenteral rehydration therapy should be started if symptoms of dehydration reappear after aggressive oral replacement of fluids and electrolytes has been attempted.

DEXTROSE AND ELECTROLYTES


Oral Dosage Forms

DEXTROSE AND ELECTROLYTES SOLUTION

Usual adult and adolescent dose
For oral solution dosage form
Rehydration:
Mild dehydration—Oral, initially 50 mL of solution per kg of body weight over four to six {25} hours, the amounts and rates being adjusted as needed and tolerated, depending on thirst and response to therapy. {02} {07} {21}
Moderate dehydration—Oral, initially 100 mL of solution per kg of body weight over six hours, the amounts and rates being adjusted as needed and tolerated, depending on thirst and response to therapy. {02} {07} {21}

Note: Severe dehydration must be treated with intravenous electrolyte solutions.


Maintenance of hydration:
Mild continuing diarrhea—Oral, 100 to 200 mL of solution per kg of body weight over twenty-four hours until diarrhea stops. {02}
Severe continuing diarrhea—Oral, 15 mL of solution per kg of body weight every hour until diarrhea stops. {02}

For freezer pop dosage form—
Rehydration: Oral, freezer pop may be given as frequently as desired.


Usual adult prescribing limits
1000 mL per hour.

Usual pediatric dose
For oral solution dosage form
Rehydration:
Children up to 2 years of age—Oral, initially 150 mL of solution per kg of body weight over twenty-four hours (75 mL per kg of body weight during the first eight hours, and 75 mL per kg of body weight during the next sixteen hours), the amounts and rates being adjusted as needed and tolerated, depending on thirst and response to therapy. {19} {21}
Children 2 to 10 years of age with moderate to severe dehydration—Oral, initially 50 mL of solution per kg of body weight over the first four to six hours, and 100 mL of solution per kg of body weight over the next eighteen to twenty-four hours, the amounts and rates being adjusted as needed and tolerated, depending on thirst and response to therapy. {19} {21}

Note: No more than 100 mL of fluid should be given during any 20-minute period. {19}

Children over 10 years of age—See Usual adult and adolescent dose. {06}

For freezer pop dosage form—
Rehydration:
Children older than 1 year of age—Oral, freezer pop may be given as frequently as desired.
Children up to 1 year of age—Consult physician before use.


Strength(s) usually available
U.S.—


Product
Electrolyte content (mEq/liter)

Na +
K +
Cl-
Citrate
Mg ++
Ca ++
Phosphate
U.S.—
             
Kao Lectrolyte * {43} (OTC)
50
20
  30
     
Naturalyte {40} (OTC)
45
20
35
48
     
Oralyte {42} (OTC)
45
20
35
48
     
Pedialyte {11} (OTC)
45
20
35
30
     
Pedialyte Freezer Pops {44} (OTC)
45
20
35
30
     
Rehydralyte {12} (OTC)
75
20
65
30
     
Resol * {10} (OTC)
50
20
50
34
4
4
5
Canada—
             
Lytren * {12} (OTC)
50
25
45
30
     
Pedialyte {14} (OTC)
45
20
35
30
     

Note: Resol is available to hospitals only.
Generic name product is available in the U.S.

* Dextrose content = 20 grams per liter.
 Dextrose content = 25 grams per liter.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer.


ORAL REHYDRATION SALTS


Oral Dosage Forms

ORAL REHYDRATION SALTS (FOR ORAL SOLUTION) USP

Usual adult and adolescent dose
Rehydration
Mild dehydration: Oral, initially 50 mL of solution per kg of body weight over four to six {25} hours, the amounts and rates being adjusted as needed and tolerated, depending on thirst and response to therapy. {02} {07} {21}
Moderate dehydration: Oral, initially 100 mL of solution per kg of body weight over six hours, the amounts and rates being adjusted as needed and tolerated, depending on thirst and response to therapy. {02} {07} {21}

Note: Severe dehydration must be treated with intravenous electrolyte solutions.


Maintenance of hydration
Mild continuing diarrhea: Oral, 100 to 200 mL of solution per kg of body weight over twenty-four hours until diarrhea stops.
Severe continuing diarrhea: Oral, 15 mL of solution per kg of body weight every hour until diarrhea stops. {02}


Usual adult prescribing limits
Up to 1000 mL per hour.

Usual pediatric dose
Rehydration
Mild or moderate dehydration: Oral, initially 50 to 100 mL per kg of body weight during the first four hours, the dosage being adjusted to 100 mL per kg of body weight per day until diarrhea stops, the amounts and rates being adjusted as needed and tolerated, depending on thirst and response to therapy. {25}


Strength(s) usually available
U.S.—


Product
Electrolyte Content (mEq/liter)

Na +
K +
Cl -
Bicarbonate
Citrate
U.S.—
         
Not commercially available.
         
Canada—
         
Gastrolyte * (OTC) {28}  60
20
60
10
 
Rapolyte (OTC) {27}  90
20
80
30
 
Other—
         
ORS-bicarbonate
90
20
80
30
 
ORS-citrate
90
20
80
  30
* Dextrose content = 17.8 grams per liter.
 Dextrose content = 20 grams per liter.


Packaging and storage:
Store below 30 {26} °C (86 °F), preferably between 15 and 30 °C (59 and 86 °F). Store in a tight container.

Preparation of dosage form:
Packets distributed by WHO—To one quart or liter of drinking {39} water, add contents of one packet containing sodium chloride, potassium chloride, sodium bicarbonate or citrate, and dextrose. Stir or shake well for 2 or 3 minutes to dissolve.

Packets available commercially—Add 200 mL (7 ounces) of boiled, cooled tap water to the contents of one packet containing sodium chloride, potassium chloride, sodium bicarbonate, and dextrose. Stir or shake well for 2 or 3 minutes to dissolve. {27}

To prepare extemporaneous oral rehydration solution—Add 3.5 grams (0.5 teaspoonful) sodium chloride (table salt), 1.5 grams (1.2 teaspoonfuls) potassium chloride or potassium salt, 2.5 grams (0.5 teaspoonful) sodium bicarbonate (baking soda), and 40 grams (4 tablespoonfuls) sucrose (table sugar) to one liter of potable water. {01} {06}

Stability:
The constituted solution may be stored in a refrigerator for up to a maximum of 24 hours after constitution, after which time the unused portion should be discarded.

ORS-bicarbonate can be stored up to 3 years if the product is dry, filled and sealed in a dry atmosphere in air-tight aluminum laminate, and stored at temperatures below 30 °C. In conditions other than these, the product may deteriorate (caramelize) and change color (yellow to brown).

ORS-citrate can be stored for at least 3 years. If moisture is absorbed, the product will lump or harden with no change in color and no effect on its dissolution in water. {25}

Additional information:
The WHO oral rehydration solution contains sodium chloride 3.5 grams, potassium chloride 1.5 grams, sodium bicarbonate 2.5 grams or sodium citrate (dihydrate) 2.9 grams, and dextrose 20.0 grams, per liter of water. {05}


RICE SYRUP SOLIDS AND ELECTROLYTES


Oral Dosage Forms

RICE SYRUP SOLIDS AND ELECTROLYTES SOLUTION

Usual adult and adolescent dose
See Dextrose and Electrolytes Solution.

Usual pediatric dose
See Dextrose and Electrolytes Solution.

Strength(s) usually available
U.S.—


Product
Electrolyte Content (mEq/liter)
Na +
K +
Cl -
Citrate
U.S.—
       
Infalyte * (OTC)  50
25
45
36
Canada—
       
Not commercially available.
       
* Rice syrup solids content = 30 grams per liter.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer.

Stability:
The manufacturer of the rice-based oral electrolytes solution recommends that the product be refrigerated and used within 48 hours after opening. {37}



Revised: 05/21/1998



References
  1. Drugs in the management of acute diarrhea in infants and young children. WHO Drug Information. April-June 1985; pp 11-7.
  1. Pierce NF, Hirschhorn N. Oral fluid—A simple weapon against dehydration in diarrhea. WHO Chronicle 1977; 31: 87-93.
  1. Finch MF, Younoszai KM. Oral rehydration therapy. South Med J 1987; 80[5]: 609-13.
  1. The management of diarrhea and use of oral rehydration therapy—A joint WHO/UNICEF statement. Indian J of Med Sci 1986; 40[7]: 187-91, Second ed., World Health Organization, Geneva 1985.
  1. News from WHO's Diarrheal Diseases Control Programme. WHO Chronicle 1984; 38[5]: 212-6.
  1. Facts and Comparisons. March 1986: 17a. Minerals and electrolytes, oral.
  1. Behrman R, Vaughan V, eds. Nelson textbook of pediatrics. Thirteenth Ed., 1987 Philadelphia: W.B. Saunders & Co, pp 199-202.
  1. Wyngaarden J, Smith L, ed. Cecil Textbook of Medicine, Eighteenth Ed. Philadelphia: W.B. Saunders & Co., 1988: 712-20.
  1. Gellis S, Kagan B, eds. Current pediatric therapy. 11. Philadelphia: W.B. Saunders & Co, 1988: 176-9, 609-11, 757-9.
  1. Resol (Wyeth) product information, PDR, 1987.
  1. Pedialyte and Rehydralyte (formerly Pedialyte RS) (Ross) monographs. PDR, 1992.
  1. Lytren (Mead Johnson) product information, rev 1990, 1992 CPS.
  1. Salazar-Lindo E, Sack B, Chea-Woo E, et al. Bicarbonate versus citrate in oral rehydration therapy in infants with watery diarrhea: A controlled clinical trial. J Pediatr 1986; 108: 55-60.
  1. Pedialyte product information, Ross, 1992 CPS.
  1. Hirschhorn N. The treatment of acute diarrhea in children. An historical and physiological perspective. Am J Clin Nutr 1980; 33: 637.
  1. Per phone call to Wyeth on 9/4/92 by ac.
  1. Anonymous. Oral rehydration solutions. Medical Letter 1983 (Feb); 25: 19-20.
  1. Cunha B, Guerrant R. Infectious diarrhea in the elderly. Geriatrics 1983; 38[4]: 95-101.
  1. Swedberg J, Steiner J. Oral rehydration therapy in diarrhea—Not just for third world children. Postgrad Med 1983; 74 [5]: 335-41.
  1. Swedberg J, D'Arcy P. Treatment and prevention of diarrhoeal diseases: pharmaceutical involvement. Internat Pharm J No 1, Jan-Feb 1987.
  1. Jonas D, Larson T. Use of oral rehydration solutions in treatment of infectious diarrhea. Minnesota Pharmacist Nov 1987.
  1. Manufacturer comment, 1988 revision.
  1. Manufacturer comment, 1988 revision.
  1. American Academy of Pediatrics/Committee on Nutrition. Use of oral fluid therapy and posttreatment feeding following enteritis in children in a developed country. Pediatrics 1985; 75[2]: 358-61.
  1. Panel comment, 1988 revision.
  1. Pharmacopeial Forum 13(6): 3149-55, Nov-Dec, 1987.
  1. Rapolyte (Richmond Pharm.—Canada) label information. Faxed to USP 5/15/89.
  1. Gastrolyte (Rorer—Canada), 1992 CPS.
  1. Naturalyte product information, United Beverages, Inc. rec 9/3/92, rev 5/12/92, U.S.
  1. Pizano D, Castillo B, Posada G, et al. Efficacy comparison of oral rehydration solutions containing 90 or 75 millimoles of sodium per liter. Pediatr 1987; 79[2]: 190-5.
  1. Isolauri E. Evaluation of an oral rehydration solution with Na+ 60 mmol/L in infants hospitalized for acute diarrhea or treated as outpatients. Acta Paediatr Scand 1985; 74[5]: 643-9.
  1. Bhargava S, Sachdev H, Gupta D, et al. Oral rehydration of neonates and young infants with dehydrating diarrhea—comparison of low and standard sodium content in oral rehydration solutions. J Pediatr Gastroenterol Nutr 1984; 3[4]: 500-5.
  1. Valasquez-Jones L, Becerra F, Faure A, et al. Clinical experience in Mexico with a new oral rehydration solution with lower osmolality. Clin Ther 1990; 12(suppl A): 95-103.
  1. Guandalini S. Current controversies in oral rehydration solution formulation. Clin Ther 1990; 12(suppl A): 38-46.
  1. Molla A, Ahmed S, Greenough W. Rice-based oral rehydration solution decreases the stool volume in acute diarrhoea. Bull WHO 1985; 63[4]: 751-6.
  1. Pizarro D, Posada G, Sandi L, et al. Efficacy of purified rice polymers and peptides for oral rehydration in infants. Gastroenterol 1990; 98: A197.
  1. Ricelyte product information, Mead Johnson, rec 12/90, U.S.
  1. Per phone call to Mead Johnson 12/7/90 ac.
  1. Panel comments, 1990 revision.
  1. Naturalyte (NBI-U.S.) rec 4/94.
  1. Per call to Mead Johnson 4/20/94.
  1. Oralyte product information (Rugby—US), Rec 4/95.
  1. Kao Lectrolyte product information (Pharmacia—US), Rec 6/97.
  1. Pedialyte Freezer Pops label information (Ross—US), Rec 5/97.

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