Reply to letter of Vinhas et. al. on oral rehydration for infantile diarrhea (letter)

We thank Dr. Vinhas et al. for some very pertinent comments on our paper on oral rehydration in infantile diarrhea. The use of the nasogastric tube was preferred for the following reasons: 1) when rapid rehydration was essential 2) when a reduction in variability of fluid administration was desired and 3) to reduce the chance of vomiting. Vomiting is also less likely if the child sleeps while receiving the fluid through a nasogastric tube and is not disturbed. We agree that for mass use fluid administered as a drink is the method of choice when rehydration can be begun early; the use of the nasogastric tube should be limited to severely dehydrated infants in cases where quick rehydration is necessary. The question of salt overload requires a detailed analysis. Although Dr. Vinhas et al. did not mention the severity of the dehydration we assume that most of the children had milder dehydration as they were well enough to drink. Even so while attempting adequate hydration in a few of the severe cases through a nasogastric tube with the solution recommended by WHO periorbital edema occurred in some of them. According to Dr. Vinhas in children receiving the oral fluids by mouth amelioration of thirst limits the intake. In our experience however this is not always so and on many occasions the children continued to drink excessive amounts and developed periorbital edema. It is pertinent to mention that the estimated episodes of diarrhea in Asia Africa and Latin America in 1975 totalled 348.2 million in children aged under 2 years. Therefore if hypernatremia occurs even in 1 in 1000 it will lead to a problem of salt overload in an enormous number of children. We strongly feel that a recommended oral fluid for mass use in the field where supervision is inadequate should have a higher margin of safety and that the low sodium solution being equally effective should serve this purpose. (authors modified)