Use of a single solution for oral rehydration and maintenance therapy of infants with diarrhea and mild to moderate dehydration.

OBJECTIVE: To compare the efficacy of two commonly used solutions in the rehydration of infants with mild to moderate dehydration caused by acute diarrhea in the United States. DESIGN AND SETTING: Double-blind, parallel-group, randomized study performed at Children's Hospital Medical Center. PATIENTS: Sixty infant boys (< or = 2 years old), with mild (< or = 5%) or moderate (6 to 9%) dehydration caused by acute diarrhea of less than 1 week's duration were included in the study. INTERVENTIONS: Infants were randomly assigned to receive treatment with either a glucose-based oral rehydration solution (ORS) (Pedialyte, Ross Laboratories, Columbus, OH) or a rice syrup solids-based ORS (Infalyte, Mead Johnson Nutritional Group, Evansville, IN). After rehydration was achieved, patients entered a maintenance phase during which, in addition to a maintenance ORS, breast milk or a soy-based formula was offered; infants older than 1 year were also given a lactose-free diet. OUTCOME MEASURES: Rehydration was judged clinically. Infants remained on a metabolic bed during the study in to separate and quantitate urine and stool output. Therefore, in addition to clinical outcome, we compared intake, output and apparent absorption and retention of fluid, sodium, and potassium between groups. RESULTS: All patients were successfully rehydrated using an ORS without the use of intravenous fluids. No differences were detected between treatment groups in time to rehydration, percentage of weight gain after rehydration, consumption of ORS to achieve rehydration, or stool output. However, the apparent sodium absorption (net intake less fecal output) was greater in the Infalyte group than the Pedialyte group during the first 24 hours. CONCLUSION: The two maintenance oral electrolyte solutions (Pedialyte and Infalyte) most commonly used in the United States are effective as rehydration solutions for infants with mild to moderate dehydration. We speculate that a strategy for oral rehydration therapy in the United States, based on the use of a single solution during the rehydration and maintenance phase, might gain additional acceptance by practicing pediatricians and family physicians.

Escherichia coli enterotoxin (STa) binds to receptors, stimulates guanyl cyclase, and impairs absorption in rat colon.

To determine the contribution of the colon in Escherichia coli heat-stable enterotoxin-mediated diarrheal disease, toxin binding, guanyl cyclase activation, and toxin-induced water flux in the rat colon and ileum were compared. Scatchard analysis suggested a single class of heat-stable enterotoxin receptors with an affinity constant of binding of 10(9) L/mol in both colonocytes and ileocytes; however, the number of toxin receptors per cell was 3.5-fold greater in coloncytes than ileocytes (8.32 +/- 1.33 x 10(5) vs. 2.33 +/- 0.28 x 10(5) receptors per cell; P = 0.02). Heat-stable enterotoxin stimulated guanyl cyclase activation in an identical dose-dependent manner in proximal colonic and ileal membranes, with similar sensitivity and maximum response. Heat-stable enterotoxin also inhibited net water flux to a similar degree in both colon and ileum (-47.8 vs. -48.4 microL.cm-1.h-1, respectively) at a dose of 8 nmol/L. At this dose in the colon, because of a higher baseline of absorption, absorption continued, but at a diminished level. At this dose in the ileum, heat-stable enterotoxin induced net secretion. These data are consistent with the concept that heat-stable enterotoxin-induced diarrheal disease results from a decreased absorptive capacity in the colon in the face of increased small intestinal fluid secretion.

Focal cerebral deficits in severe hypomagnesemia.

Hypomagnesemia has been associated with multiple neurologic abnormalities, including irritability, seizures, paralysis, and choreiform movements. A patient with short gut syndrome who developed severe hypomagnesemia during an intercurrent diarrheal illness is reported. This patient had a transient neurologic syndrome consisting of hemiparesis, mental status changes, and aphasia which resolved as the magnesium levels returned to normal. Neurologic abnormalities of this child were largely secondary to severe hypomagnesemia and should be included in the list of neurologic abnormalities that can result from this metabolic derangement.

Mechanisms of increased susceptibility of immature and weaned pigs to Escherichia coli heat-stable enterotoxin.

Pigs demonstrate an increased sensitivity and susceptibility to Escherichia coli heat-stable enterotoxin (STa) in the 1st wk of life and immediately after weaning. To determine the possible mechanisms for this increased susceptibility, we compared STa binding, guanylate cyclase activation, and photoaffinity cross-linking to porcine jejunal brush border membranes prepared from immature (less than or equal to 1 wk of age) versus adult pigs as well as 3-wk-old weaned versus unweaned pigs. The STa binding capacity of immature pigs was nearly twice that of adult pigs (11.73 +/- 1.52 versus 6.00 +/- 0.96 x 10(-11) mol/L, p less than 0.001), and the STa binding capacity of weaned pigs was nearly three times greater than that of unweaned pigs (17.48 +/- 2.10 versus 4.86 +/- 1.02 x 10(-11) mol/L, p less than 0.001). Scatchard analysis suggested a single class of STa receptor, with an association of binding constant of approximately 10(9) L/mol at all ages. Maximum guanylate cyclase response (expressed as pmol cyclic GMP generated/mg brush border membrane protein/min) was greater in immature versus adult pigs (1312 +/- 831 versus 320 +/- 92, p less than 0.02). Weaned pigs had a greater maximum guanylate cyclase activation than unweaned pigs (1126 +/- 692 versus 624 +/- 298); however, this difference was not statistically significant. Autoradiograms demonstrated specific cross-linking of 125I-STa to a number of distinct radiolabeled bands (62, 66, 84, 92, 160, and 165 kD). There was a difference in the size and trypsin sensitivity of these radiolabeled bands as a function of age and weaning. Treatment with trypsin decreased the intensity of the 160 to 165-kD bands while increasing the intensity of the 62- to 66- and 84- to 92-kD bands. These differences in STa binding, guanylate cyclase activation, and STa receptor size may increase the susceptibility of pigs during the 1st wk of life and at weaning to STa-mediated diarrheal disease.

Hypophosphatemia in the nutritional recovery syndrome.

We studied the incidence of hypophosphatemia in patients during the nutritional recovery syndrome. The charts of 150 patients receiving a complete nutritional assessment for 18 months were reviewed; 45 met established nutritional risk criteria. Only 9 of these 45 had serial phosphorus values measured during nutritional repletion, and 5 of these 9 patients had hypophosphatemia (phosphorus levels less than 0.97 mmol/L). Anthropometric measurements of arm circumference and arm muscle circumference were less than the fifth percentile in all patients developing hypophosphatemia. We concluded that hypophosphatemia is an underrecognized complication of nutritional repletion and that anthropometric measurements may be predictive of patients at risk. All patients with significant malnutrition should be evaluated for this complication of refeeding.