Oral Rehydration SolutionContaining Amylase Resistant Starch in Severely Malnourished Children.
Oral Rehydration SolutionContaining Amylase Resistant Starch in Severely Malnourished Children.
Severe malnutrition is associated with a high rate of mortality, even when using the latest
 WHO recommendations. Watery diarrhea as observed in cholera is an additional vital risk to
 those children. The fragility of the children together with the complexity of the
 pathophysiology and the simplicity of the medical environment where the treatment is
 delivered are serious constraints for the development of new therapies. Dehydration is a
 special immediate risk in those children who already displayed altered body distribution of
 water with potassium, magnesium, zinc and other nutrient deficiency. Dehydration is also
 often associated with a decrease in appetite. In addition, the intestinal function is altered
 both by the infectious agent and the nutritional status of the child. Recommended therapy for
 those children comprises oral rehydration with ReSoMaL (modified ORS for use in severely
 malnourished children recommended by WHO), at a relatively low rate, with permanent
 monitoring; in addition, breastfeeding should not be interrupted and feeding with F100 (Milk
 based formula diet for use in severely malnourished children recommended by WHO) is
 recommended. Recently, amylase-resistant starch added to a standard WHO-ORS has been shown to
 reduce the duration and severity of adults with cholera. The rationale for using
 amylase-resistant starch was that when starch enters the colon it is metabolized by the
 bacteria. The short-chain fatty acids thus produced stimulate sodium absorption in the colon,
 just like glucose stimulates water absorption in the small intestine. In addition, this
 treatment would be of particular interest in malnutrition because short-chain fatty acids are
 specific energetic substrate for the colon.In the present project, we propose to test the
 hypothesis that addition of amylase-resistant starch to the already recommended treatment of
 severely malnourished children with cholera reduces the severity and duration of diarrhea;
 this could be achieved through the effect of short-chain fatty acids on colonic sodium
 absorption. In addition, a better recovery from malnutrition could be achieved through the
 energy provided by short-chain fatty acids to the colon and improved appetite through
 improved rehydration. Thus, the aim of the study is to measure the effect of
 amylase-resistant starch added to an already accepted treatment (with minimal changes) at the
 rehydration and rehabilitation phases of the treatment. A total of 210 children aged 6 mo to
 60 mo will be studied in three groups : a) glucose based ORS and amylase-resistant starch; b)
 glucose based ORS without amylase resistant starch ; c) rice based ORS . The major outcome
 variables on the first phase (diarrhoeal duration and stool output), and second phase (food
 intake, weight gain) will be compared between the two treatment groups. The result of the
 study if found effective in reducing the duration of diarrhoea, enhance recovery from
 diarrhoea and malnutrition in severely malnourished children, will contribute to better case
 management of these children.
STUDY DESIGN This is a randomized controlled clinical trial.

 Subjects

 Inclusion criteria:

 1. History of acute watery diarrhoea of <72 hrs.

 2. Either sex.

 3. Age - 6m to 60 months

 4. Some or severe dehydration.

 5. Wt for Ht <70% of NCHS median: with or without edema.

 6. Dark field examination positive for Vibrio cholerae.

 7. Consent given by the patient or legal guardian.

 Exclusion criteria:

 1. Bloody diarrhoea.

 2. Severe infection (e.g. severe pneumonia, clinical sepsis, meningitis).

 3. Those who received antibiotics/antimicrobial for the current illness Sample Size Sample
 size is calculated on the basis of duration of diarrhoea of recently completed study
 with WHO-ORS vs. ReSoMaL in severely malnourished children with diarrhoea (65±46 vs.
 61±45). Expecting 35% reduction of duration of diarrhoea with the proposed new treatment
 considering 5% level of significance and 80% power, the sample size in each group is 70.
 Considering the stool weight, with reference of (stool wt. 158±95 when treated with WHO
 ORS) in severely malnourished children with cholera, the sample size was estimated to be
 65 in each group, expecting 30% reduction in stool weight during the first 24 hours with
 the new treatment and considering 5% level of significance and 80% power. Finally we
 consider to study 70 patients in each treatment group.

 Randomization

 After enrollment into the study the patients will be randomized to receive one of the
 following three solutions:

 1. Modified glucose based WHO ORS

 2. Modified glucose WHO ORS plus 50 g/L amylase resistant starch.

 3. Modified rice based ORS

 Since a significant proportion of children might present with ALRI, randomization will be
 stratified into two strata:

 1. Children with ALRI

 2. Children without ALRI Accordingly, two randomization list will be prepared. The
 randomization list will be prepared using random table of permuted block of variable
 length.

 Baseline information

 A baseline history and examination will be obtained in order to:

 4determine the subject's eligibility for inclusion in the study; 4collect the relevant
 data prior to beginning the study.

 The baseline history and examination will include:

 4identification of the patient; 4a description of the symptoms prior to admission and
 their duration; 4detail of any treatment given for the illness before admission;
 4results of physical examination including the state of hydration.

 Assessment of dehydration This will be done according to the modified WHO guideline used
 in ICDDR,B. (Appendix-III).

 Laboratory tests After admission blood for Hct, total protein, glucose, and serum
 electrolytes will be sent before initiation of the assigned ORS. Serum electrolytes will
 be repeated after 24 and 48 hours after initiation of ORS therapy. Stool sample will be
 sent for microscopy (including cryptosporidium and giardia) and culture for shigella,
 salmonella, Vibrio cholerae and ELISA for rotavirus will be done. Other relevant
 investigations like Total WBC count, Differential count and urine microscopy will be
 done routinely. Chest X-ray and/or Blood culture will be done, if necessary.

 For all blood tests 3 ml of blood will be drawn from a suitable vein in the hand.

 Estimation of fecal Starch and SCFAs Feces from 50 patients will be collected in
 buckets. The first 24 h collected feces will be weighed and aliquot will be taken and
 stored at -20o C until the analysis of SCFAs by HPLC. The second and third stool samples
 will be collected from 24-48 h and 48-72 h respectively. The feces will be weighed and
 aliquot will be stored at -20oC for the determination of SCFAs.

 Fecal starch will be measured enzymatically with a starch-assay kit (Total Starch Assay
 Procedure, Megazyme, Warriewood, Australia).

 Case Management (Acute Phase) After randomization the children will be treated following
 the standardized protocol for management of severely malnourished children used at
 ICDDR,B hospital (2,12).

 Fluid Therapy (oral) Dehydration assessment will be done according to the WHO guideline
 modified for in our last multicentre clinical trial of reduced osmolarity ORS in adult
 cholera and children with watery diarrhoea (17). In children with some dehydration, the
 fluid deficit will be corrected with the assigned ORS @ 10 ml/kg/hour for the first two
 hours, then 5 ml/kg/hour until the deficit will be corrected. In addition, on going
 stool losses will be corrected @ 5-10 ml/kg/ after each watery stool. For high purging
 patient, the ORS intake will be adjusted according to the on going stool loss. ORS
 therapy will be continued until diarrhoea ceased. Randomization of patient, taking
 consent and darkfield report collection will not take more than 20 minutes. If delayed
 more than 20 minutes the children will be offered glucose based ORS and subsequently
 switched over to the assigned ORS. Children with severe dehydration, initial rehydration
 will be done with IV fluid (cholera saline; Na 133 mmol/L, Cl 98 mmol/L, K 13 mmol/L and
 Acetate equivalent to HCO3 48 mmol/ L) until the patient is out of shock or
 disappearance of signs of severe dehydration then the rest of rehydration will be done
 as for rehydration in patients with some dehydration as described above.

 Infection Control

 As a routine practice in ICDDR,B hospital the antibiotic treatments for the study
 children are as follows:

 Children without apparent extraintestinal infection will receive Inj ampicillin @ 100
 mg/kg/24 h in 4 divided doses and Inj. gentamicin @ 5mg/kg/24h in 2 divided doses for 5
 days. Patients with lower respiratory tract infection will receive Inj: ceftriaxone 75
 mg/kg/24 h I/M or I.V one daily doses and Inj. gentamicin 5 mg/kg/24 h in 2 divided
 doses for 5 days. All patients will receive erythromycin 50 mg/kg/24 h in 4 divided
 doses for 3 days. Patients with oral thrush will be treated with oral nystacin
 suspension 100,000 units (1ml) 6 hourly until cured.

 Diet Mother's will be advised to continue breast feeding. Supplementary feeding with
 F100 diet will be given @ 10 ml/Kg/ Feed two hourly for day 1 and increased slowly up to
 150 Kcal/ Kg/Day over 7 days according to the patient's demand. If the child has a poor
 appetite, or is weak, or has painful stomatitis/glossitis, the food will be introduced
 through nasogastric tube until the patient will take normal oral feeding. In addition to
 F100, semisolid food (Rice, lentil, vegetable etc.) will be given to older children
 during convalescent and rehabilitation phase.

 Vitamin and Mineral Supplements ( As a routine hospital practice in ICDDRB) Children
 without xeropthalmia and above 1yr of age, will be given vit A 200,000 units and 6-12
 months age children will be given 100,000unit on admission. Children with xeropthalmia
 the same dose will be given on admission, 2nd day and on discharge. Folic acid 1.25 mg
 and elemental zinc 2 mg/kg will be given for 15 days. In addition children will be given
 multivitamin supplements (1 ml contains it A palmitate 5000 IU, vitamin D 1000 IU,
 thiamine hydrochloride 1.6 mg, riboflavin 1 mg, pyridoxine hydrochloride 1 mg,
 nicotinamide 10 mg, calcium D-pantothenate 5 mg, ascorbic acid 50 mg). 1 ml twice daily
 for 15 days for 1 yr. and above and half the dose will be given to infants less than <1
 yr. of age.

 Hypoglycemia (blood glucose <3 mmol/L) will be managed with 50 ml 10% glucose orally or
 by nasogastric tube. Hyponatraemia (serum sodium, <115mmol/L with or without symptoms
 will be managed with Inj. 3% Nacl 12 ml/kg I/V slowly over 4 hrs. Children with serum
 sodium between 115 - 125 with symptoms will be treated with 3% NaCl in addition to
 adjunct therapy, if needed.

 Measurements All intakes ( ORS, water, and food) and outputs (stool, urine and vomit)
 will be measured every 6 hours until diarrhoea stops or upto 7 days . Body weight and
 vital signs will also be measured 6 hourly.

 Study withdrawal

 Reasons for withdrawal

 1. Any patient developing severe complication such as severe pneumonia, clinical
 sepsis, meningitis requiring intensive care.

 2. Parents/legal guardian withdraws consent.

 3. Patients who will continue diarrhoea more than 7 days

 Management of withdrawal cases The withdrawal cases will be transferred to general ward
 or ICU and appropriate management will be provided according to routine hospital
 practice. Regular follow-up will be done and final outcome of the children will be
 recorded.

 Data collected up to the time of withdrawal will be included for analysis.

 Management after cessation of diarrhoea ( Convalescent / Rehabilitation Phase) All
 patients after cessation of diarrhoea and control of other associated infection will be
 transferred to nutrition rehabilitation unit(NRU) They will be managed with F100 diet
 according to their requirements. Older children will get semisolid food in addition to
 F100. During the stay at NRU Vital signs and body weight will be measured once in the
 morning daily. Food intake will be measured in every feed until the children stay at
 NRU. After seven days the patients will be discharged from the nutrition rehabilitation
 unit and will be followed up for next fifteen days at home. They will be supplied with
 standard diet according to the protocol. The health workers will visit every alternate
 day and will interview the mother about any illness and approximate amount of diet the
 child consumed. The health worker will carry a portable electronic balance with a
 precision of 1 g and record the body weight of the child.

 Definition End of study ( acute phage)- The study end point will be considered when
 diarrhoea stops or 7 days of initiation of the ORS whichever comes first.

 Cessation of diarrhoea - Diarrhoea will be considered to have stopped when the last
 watery stool is passed followed by soft or formed stool and/or no stool for 12 hours.

 Hypokalaemia- Hypokalaemia is defined as serum potassium level <3.5 mmol/l. Persistence
 of hypokalaemia - If the serum potassium level is <3.5 mmol/l on admission and it
 remains at the level even after 48 hours of therapy with ORS, it will be considered as
 persistence of hypokalaemia.

 Over hydration - As there are no standard criteria for defining over hydration, we have
 developed a working definition of over hydration for this protocol based on previous
 study reports and our clinical experience. Over hydration will be considered in a child
 who has more than a 5% weight gain than expected after correction of dehydration and /
 or at least any one of the following signs:

 Development of periorbital oedema; Increased heart rate (>160/min); Increased
 respiration rate (>60/min); {in the absence of signs suggestive of pneumonia(fever, CXR
 abnormalities etc.)} Hypoglycaemia - will be defined as blood glucose £ 3 mmol/l

 Hyponatraemia - will be defined as serum sodium < 130 mmol/l

 Severe pneumonia:

 Patient aged 6 m - 12 m

 - respiratory rate > 50/minute with chest in drawing

 Patient aged 13 m - 60 m

 - respiratory rate > 40/minute with chest indrawing (WHO guideline)

 - 'ORS failure' - If after randomization any patient needs I/V rehydration therapy will
 be labelled as ORS failure.

 Organization of the trial

 Study site - The study will be done in the study ward of the Clinical Service Centre of
 ICDDR,B.

 Study schedule - The study period will be 2 years from starting.

 Recruiting and training of study personnel - First one month.

 Data collection - 23 months ( Estimated on the basis of bed allotment per protocol and
 patient availability)

 Data analysis and reporting - 3 months

 OUTCOME VARIABLES

 Primary Duration of diarrhoeal course and stool output.

 Secondary

 1. Calorie intake per day

 2. Daily weight gain

 3. Time to attain 80% weight for height SIGNIFICANCE If the ORS containing amylase
 resistant starch is found to reduce the severity diarrhoea and increase the
 recovery in patients with acute diarrhoeal illness in severely malnourished
 children, it will have a major public health significance as regard to better case
 management for malnourished children with diarrhoea.
Inclusion Criteria:

 1. History of acute watery diarrhoea of <72 hrs

 2. Either sex

 3. Age - 6 months to 60 months

 4. Some or severe dehydration

 5. Wt for Ht <70% of NCHS median: with or without edema

 6. Dark field examination positive for Vibrio cholerae

 7. Consent

 Exclusion Criteria:

 1. Bloody diarrhoea

 2. Severe infection (e.g. severe pneumonia, clinical sepsis, meningitis) 3.Those who
 received antibiotics/antimicrobial for the current illness