Date: Tue, 18 Aug 1998 11:26:18 -0400

From: Steve_Collins_at_po330a01atsmtplink.unicef.org

(Forgive me if this is a duplicate post..e-mail problems)

Hullo there Ngo-nutters,

Could somebody give me a little advice on the best ORS formula to use

for rehydrating severely malnourished children (both marasmic and

oedematous) in a situation in some provinces in the DPRK where there

is no KCL available. The question is: is it better to double dilute

the WHO formula ORS and add the glucose as per the unpublished WHO

manual in which case the sodium is nice and low and there is some

extra energy available from the added glucose but the potassium

concentration is halved, or alternatively to use the straight WHO

strength?

I thought that was probably best to use the diluted ORS + glucose in

the oedematous cases despite the potassium problem, as I would guess

the sodium load is the more critical, whereas with the marasmics the

sodium situation is not quite so critical and the standard WHO ORS

probably as good. But I don't really know enough about the

relationship between Na, K and water balance to really be sure. So

any advice would be most gratefully received.

Thanks

Steve Collins

p.s. Of course it would be better to try and get the KCL or

ReSoMal_but I'm not holding my breath on that

Date: Fri, 14 Aug 1998 09:59:26 +0100

From: Michael Golden <m.goldenatabdn.ac.uk>

Subject: Ngonut: Re: where there is no KCl

Dear Steve,

Where one is lacking a key ingredient, clearly the compromise necessary

should be short term and demonstrably an expedient. Kcl is cheap. It would

be a pity if those who you train in North Korea got the idea that this was

perfectly acceptable. I think that when one is in a training situation

there is an added onus to manage the patients without cutting corners - and

when you do to make it quite clear that this is not at all desirable.

Having said this, the majority of patients with marasmus can be managed

perfectly well with standard WHO-ORS. They can also be treated with

solutions of lower sodium concentration.

The real compromise comes with oedematous malnutrition: here experience is

much more mixed and controversial - it does seem that there is a

geographical difference in the detrimental effects of excess sodium in

these patients.

The physiological data showing raised intracellular sodium, lowered

incracellular potassium, changes in the activity of the sodium pump (in

opposite directions in marasmus and kwashiorkor), membrane leakiness and

abnormal renal metabolism of sodium seem to have been found everywhere they

have been investigated. Perhaps the differences lies in the sensitivity of

the myocardium to volume overload in the different geographical areas.

Our colleagues in Banglasesh and Guatamala use standard ORS and report

reasonable results; although George Fuchs reports that when he uses a

standard protocol which includes, among other things, the avoidance of IV

fluids wherever possible and giving the ORS much more slowly there is a

47% reduction in mortality (from 17% to 9%) - the degree that this is

related to lower sodium load used is not clear, but is a distinct

possibility. (please comment on this George).

The experience was quite different in Uganda and Jamaica, the patients

there and those we now treat in central Africa seem to be very sodium

sensitive. One of the problems is in clinically differentiating heart

failure from pneumonia. In Burundi recently we had an outbreak of deaths

which the pediatrician diagnosed as "recovery pneumonia" and treated with

antibiotics to no avail - the mortality came down when we corrected the

protocol and systematically used the low-sodium F75 formula. I suspect

that many of the deaths ascribed to chest infection may in fact be cardiac

deaths.

Potassium and magnesium are important - but they are in the diet and will

be given in adequate amounts as soon as you start to give the patient the

formula diets. Hypoglycaemia is also a real threat.

So, I would use WHO-ORS in this situation, for the oedematous children I

would dilute it 50-50 with 10% sucrose (gives more energy per Osmole than

glucose, is as easily absorbed and is much cheaper and more readily

available). If there is any shortage of staff or confusion I would use the

same formula for the marasmics as well. I would also start to get the

diet into within a few hours of starting treatment.

In short - I agree with your analysis and what you intend to do.

Peace and love.

Prof. Michael H.N.Golden

Date: Sun, 23 Aug 1998 21:36:57 -0400

From: Steve_Collins_at_po330a01atsmtplink.unicef.org (Steve Collins)

Subject: Re: Ngonut: Re: where there is no KCl

Mike,

Thanks very much for your reply re the ORS. I agree with your

concerns over the quality of information given out during training and

certainly always try to make it very clear that it is better to use

ORS solutions containing potassium. There will soon be Resomal in

DPRK which is a good thing for the malnourished, however the huge

difficulties in targeting here makes me a little worried that the

ReSoMal will find it's way into general use. It will be important to

ensure that quantities distributed are appropriate and it's use well

monitored

Thanks again for the advice

cheers

steve