Abstract

1. Background

A diarrhea lasting for seven days or less is classified as acute diarrhea (1). Accounting for an annual 1.7 million deaths worldwide, diarrhea is the leading cause of mortality in children under 5 years old (2). It is responsible for over a quarter of all childhood mortality worldwide (3). This disease negatively impacts quality of life and could lead to high health costs (4). Dehydration is the immediate cause of death in most cases and if appropriately treated, mortality can be averted almost completely (5). Despite this fact, mortality due to diarrhea is still considerably high (5, 6).

Diarrhea dehydration was treated by intravenous (IV) infusion of fluids until the 1970s, but it was costly and impractical in low-resource settings (5). Therefore, oral rehydration solution (ORS) was introduced and developed for widespread use and since then millions of children and adults with diarrhea were saved (7). ORS has been termed as “the most important advance in this century” and has kept its fame even after the turn of the century. However, there have been controversies regarding its ideal composition due to the fact that its formulation does not seem universal for children of all ages with gastroenteritis or other causes within all geographical regions (8).

As nations launched diarrhea control programs, they faced with many problems in making ORS accessible with high coverage levels, which was partly due to inadequate manufacturing capacity. Control programs promoted using additional fluids and home-made solutions like rice water to prevent development of dehydration in an attempt to improve fluid provision in early diarrhea episodes (9). As diarrhea can cause serious short- and long-term complications, it is necessary to educate women on how to prevent the disease and to take care of children with diarrhea (10) as most diarrhea episodes are treated at home by mothers (11).

Accordingly, various research and experiments have been performed to alter the composition of ORS to achieve an ideal formula (9). Moreover, appropriate nutrition habits play an important role in controlling diarrhea (12). Rice-based oral rehydration solution has proved to be effective in the treatment of diarrhea and dehydration (13, 14). Some studies have altered the composition of current ORS formula replacing glucose with rice components, which has also been effective in treating diarrhea (13).

In previous studies, rice-based ORS (R-ORS) has been compared with the world health organization (WHO) recommended glucose-based ORS (G-ORS) in treating children with acute diarrhea and contradictory results have been reported. In a research to investigate the efficacy of R-ORS compared to G-ORS, in treating children with acute watery diarrhea, R-ORS was more effective in reducing the duration of diarrhea and hospital stay, although no significant effect was found on stool output or intravenous fluid administering frequency (15). Some other studies have found no significant difference between R-ORS and G-ORS in the treatment of children with diarrhea (13-16).

The WHO guidelines for treatment of diarrhea in children emphasize on continued feeding together with prescription of ORS and supplementary zinc therapy. However, conflicting viewpoints exist regarding optimal diet and dietary ingredients for children with diarrhea (1). Nonetheless, we found no studies investigating the effect of rice soup along with ORS in the treatment of diarrhea; therefore, the question still comes to mind whether rice soup ORS is effective in treating children with acute diarrhea.

2. Objectives

This study aimed to investigate the effects of simultaneous consumption of G-ORS and rice soup compared with consumption of G-ORS only in the treatment of acute diarrhea in 8 to 24-month- old children.

3. Patients and Methods

This study was a single blind randomized controlled clinical trial conducted from June 2013 to February 2014. The sample population included children hospitalized in the pediatric ward of 22nd of Bahman hospital, Gonabad, Iran with acute diarrhea and having normal sodium and potassium ion ranges in their blood serum. To decide on the number of patients needed, a pilot study was performed on 10 children (5 in each group). The stool output frequency in the second 24 hours was considered and the following results were obtained: µ₁ = 2.8, µ₂ = 2.1, S₁ = 0.25, S₂ = 0.94. Accordingly, with a type I error probability of 0.05 and a power of 0.80, the sample size was estimated as 16 patients for each group. However, we recruited 20 patients in each group, with a total of 40 patients for the two groups (Figure 1).

Children hospitalized with acute diarrhea and fulfilling the inclusion criteria were assigned into two groups of control (G-ORS) and experimental (G-ORS along with rice soup) in 10 blocks of 4 using balanced block randomization (five blocks for each group).

The inclusion criteria were age of 8 to 24 months, having no comorbidities, experiencing an acute diarrhea and having a normal range of sodium and potassium in serum. Moreover, during the study children were not supposed to consume anything that would aggravate diarrhea (such as artificial fruit juices, very sweet foodstuffs, etc.) and were to adhere to the prescribed regimen.

The exclusion criteria included: the child being incapable to continue the study from a medical point of view, child’s parents unwillingness to continue the study, non-adherence of child to the prescribed regimen, diarrhea being associated with severe vomiting (of more than 2 times per day) and requirement of antibiotics administration.

4. Results

From a total of 40 children, 19 (47.5%) were male and 21 (52.5%) female. The mean age was 14.35 ± 5.63 months with a minimum of 8 months and a maximum of 24 months. Twelve (30%) children had slight dehydration, 28 (70%) moderate dehydration, and no case had severe dehydration.

No significant difference was found between the groups regarding age, gender, admission weight and nutrition type (breastfeeding or formula), the degree of dehydration (mild or moderate), serum sodium and potassium levels, urine specific gravity at the onset of hospitalization, vomiting, pulse rate and respiratory rate (Table 1).

Also, no significant difference was observed between the two groups regarding diarrhea duration prior to the treatment. However, the duration of diarrhea was significantly shorted in G-ORS + rice soup group than that of the G-ORS group (22.30 ± 4.78 hours vs. 34.55 ± 5.82 hours, P < 0.001) (Table 2).

Furthermore, a significant difference was found between the groups for stool output during the first 24 hours (P < 0.001) and the second 24 hours (P = 0.03) after the treatment. Moreover, the stool output of G-ORS + rice soup group was less than that of G-ORS group during the first and second 24 hours (Table 2). For receiving intravenous fluids, the results showed no significant difference between the groups during the first 24 hours (P = 0.95) as well as in the second 24 hours (P = 0.87) after the treatment (Table 2). In analysis of covariance, no significant difference was found between the two group averages for stool output during the first 24 hours (P < 0.001) and the second 24 hours (P = 0.03), diarrhea duration (P < 0.001) and hospital stay (P < 0.004) after adjusting the confounding variable of serum sodium.

5. Discussion

In the present study, taking G-ORS along with rice soup was more effective in decreasing children’s duration of diarrhea compared with taking G-ORS. This finding was consistent with some previous studies (15, 19). A randomized clinical trial revealed that although R-ORS is effective in the treatment of diarrhea caused by vibrio cholerae, its effect does not exceed that of G-ORS (16). A study on rats having diarrhea from sorbitol found that the duration of diarrhea in gruel-based and rice-starch groups decreased compared with that of the control group (20). In another study, diarrhea duration in the group received enriched glucose with amylase-resistant starch was less than that of the G-ORS group (21). However, another study did not find any significant difference in diarrhea results between the group receiving G-ORS and the one receiving R-ORS (13). Probably the type of rice or the amounts used in different studies were different from each other. A study conducted on rats pointed out that different types of rice have different effects on diarrhea (22).

Our results revealed no significant difference for administering intravenous fluids during the first and second 24 hours of rehydration between the group received rice soup and G-ORS compared to the G-ORS only group. Therefore, these findings concur with those of another research (15), but in some studies intravenous fluid needed during rehydration in the R-ORS group was significantly less than that in the G-ORS group, which is probably due to the difference in amount and the procedure of preparing rice (14, 23).

In the present study, the frequency of stool output was significantly less in the intervention group both in the first and second days after the treatment. This finding was also in line with some previous investigations that compared the effects of R-ORS and G-ORS (23, 24). Yet, there is another study that showed no significant difference in the stool output frequency of the two groups (15). Glucose in rice is slowly released and quickly absorbed in the small intestine. Then, it increases the water and electrolyte absorption, which consequently decreases stool output, reduces diarrhea duration and shortens the amount of IV fluid replacement. Since glucose available in ORS ingredients is completely present inside the lumen of the small intestine and has no important effect in water and electrolyte intake (9). On the other hand, the pectin available in rice absorbs a large quantity of water in the intestine and consequently causing stool to become fairly hard (25).

Furthermore, the results revealed that the duration of hospital stay in children receiving rice soup was less than that of the control group. This finding corresponds with some other studies (15, 19). As the duration of diarrhea in the experimental group decreased, the duration of hospital stay lessened.

In conclusion, the findings pointed out that stool output frequency and the volume of intravenous transfusion decreased in the both groups, but R-ORS was more effective in lessening diarrhea duration, duration of hospital stay and stool output frequency compared to the use of G-ORS alone. Therefore, since rice soup is rather inexpensive, it can be prescribed with G-ORS to decrease both hospital expenses and complications of acute diarrhea.

One limitation of the study was that diarrhea duration was reported by mothers prior to children’s hospital stay. Mothers were required to report a rough estimate of diarrhea duration as we could not practically measure it exactly. Another limitation was that samples only consisted of children from one hospital, which reduces the generalizability of our findings. Thus, performing a multicentral study is recommended. Since the volume of intravenous fluids was registered based on nursing reports, there is the chance of potential error in measurement and registration as another limitation of study.

Acknowledgments

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