NGOnut discussion summaries - ORS v Resomal, Lactose intolerance, and split peas

O.R.S OR RESOMAL

Question

Does anyone have any data documenting the superiority of a reduced sodium, higher potassium ORS over the standard WHO ORS? The few studies which we have found seemed to indicate no great excess risk with standard ORS.

Edited from responses to this question.

The reason for advocating a low sodium high potassium ORS in severe malnutrition is to prevent heart failure. The risk of sodium overload is particularly marked with kwashiorkor cases where research shows that heart failure can be induced with relatively low sodium intakes. Such levels may be easily reached by rehydrating a severely malnourished child with standard WHO ORS. The issue may not be so critical in marasmic children. This is the reason why a new ORS formulation (RESOMAL) was developed. Although the idea for this formulation began circulating amongst NGOs in 1993, it has still not been officially endorsed by WHO and will not be until the long-awaited WHO manual on Treatment of Malnutrition' is published.

Although RESOMAL formula is new, it is based on principles which have been known for years. Previous versions of the WHO manual on diarrhoea management in severe malnutrition, recommend giving water between ORS feeds (this is like diluting ORS). In a way, RESOMAL just reproduces in a glass the mixing which used to happen previously in the stomach of the child and adds a potassium supplement. The attraction of RESOMAL is that it is much easier to handle, hence its great success in emergency situations. Other advantages of RESOMAL are that it has additional sugar and Magnesium, Zinc and Copper. RESOMAL should only be used in hospital and its introduction should not imply that it is any better than standard ORS for well nourished children. There is absolutely no risk of inducing heart failure in moderately malnourished children with standard ORS at whatever dose, and community programmes should continue to use standard ORS A respondent from Latin America pointed out that higher potassium ORS is not available in that part of the world. He agreed that in theory, modified ORS (RESOMAL) should be better for severely malnourished dehydrated patients. However concern was expressed, about advocating that the standard WHO ORS not be used with malnourished patients. This, he pointed out, may have dangerous outcomes as in many countries acceptance of the standard WHO ORS by health workers and the population at large has taken many years and much efforts. Care should be taken he says, not to undermine these efforts. Modified ORS must become readily available before recommending that it substitute standard WHO ORS. He suggests that a useful approach is recommending low sodium , high potassium ORS when it is available otherwise continue using standard WHO ORS. This respondent's personal experience and that of several of his colleagues is that excellent clinical results rehydrating malnourished children with the standard WHO ORS have Been achieved.

LACTOSE INTOLERANCE

Question

My understanding is that a low-lactose feed is recommended for young babies and children hospitalised with severe diarrhoea who may or may not be malnourished. But is this best achieved by giving them, i) lactose-free milk, ii) yoghurt made from ordinary milk, iii) F75/FlOO or iv) something else?

Edited from responses to this question

1. Babies and children with diarrhoea should be breastfed.
2. There is some risk of secondary lactose intolerance in babies with severe diarrhoea, especially if they are not breastfed and also malnourished. However, there is no need to put any infant with diarrhoea on low-lactose feeds unless they exhibit distinct signs of lactose intolerance. These signs are explosive and watery diarrhoea, acid 'bums' bottom and distended abdomen but absence of fever.
3. In the specific case of young non-breasted infants with severe diarrhoea and signs of lactose intolerance, there are 3 options;
   1. diluted lactose containing milk (or infant formula) feeds;
   2. yoghurt and/or other foods fermented with Lactobacilli;
   3. lactose-free milk.
4. When questions of cost, logistics and safety are taken into account, expert opinion is divided as to which of these three options is most appropriate in emergency situations.

A further respondent emphasised that diluted lactose containing milks should be given only under close observation as the symptoms of full-blown secondary lactase deficiency tend to persist unless lactose intake is drastically reduced in which case intake of any lactose containing food will is unsuitable. For this condition soya formula is a good alternative. The respondent points out that full blown pictures are uncommon and many infants with apparent lactase deficiency after a few days of diluted feeds are back to full lactose containing feeds.

SPLIT PEAS

Dear NGO Nut

A Danish company recently visited us in UNHCR to brief us about pre-cooked yellow spur peas. I wanted to share this potentially positive development in the food production sector with interested purchasers/distributors of food.

The idea of a pre-cooked yellow split pea was developed by the company in response to their learning about the frequent scarcity of fuel for cooking that often occurs in relief operations. This is a particular problems when pulses (such as those from temperate zones) take over an hour to cook.

Pre-cooked yellow split peas were therefore developed. These peas have been dehulled and split after which they were treated with steam. This has reduced the cooking time to 20-30 minutes. Moreover they do not have the typical green pea flavour but taste rather neutral, resembling lentils, which are acceptable in a wide range of countries. WFP has carried out field tests in 26 countries with positive results. UNHCR has also carried out some field tests in Tanzania and Ethiopia where the peas were evaluated as tasteful, with an average cooking time of 30 minutes. Soaking is not required which therefore allows greater retention of micro-nutrients. The price is 340 USD/MT and is about 1% more expensive than the untreated variant. Introduction of the product needs to be accompanied with an information campaign to inform users about the shorter cooking time and the fact that soaking is not required.

Arnold Timmer
UNHCR, Geneva