Remember Zinc: the gut vitamin for diarrhea

Since the consensus was published in 2005, a lot of doctors forget zinc supplementation as part of the treatment algorithm for diarrhea. Some pediatricians argue that most of their patients were already prescribed multivitamins that contain adequate zinc content that further supplementation may not be necessary. But how sure are they that the mother is giving the multivitamins to their sick child?

In my rural health primary practice, many mothers are surprised that I recommend zinc or other vitamins during illness. Further probing told me that they stop all vitamins once they have a sick child. It was an old practice that was passed down but is now obsolete.

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The following is WHO’s recommendations regarding zinc:

Zinc can be given as a syrup or as dispersible tablets, whichever formulation is available and affordable. By giving zinc as soon as diarrhoea starts, the duration and severity of the episode as well as the risk of dehydration will be reduced. By continuing zinc supplementation for 10 to 14 days, the zinc lost during diarrhoea is fully replaced and the risk of the child having new episodes of diarrhoea in the following 2 to 3 months is reduced.

This was taken from Treatment of Diarrhea 2005.

Remember to supplement zinc during diarrhea and if you are a mother reading this article, ask your pediatrician if you can switch to better forms of zinc than your plain old multivitamins. Also, stress to the caregiver it’s importance so as to greatly increase compliance.

Zinc sulfate drops and syrup are available for free in barangay health centers. We are only one of the 46 countries that have a national policy on this.

Dr. Mella is currently the head of the Committee on Diarrheal Diseases in Olongapo City. This is part of an education campaign to combat diarrhea.

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Gatorade in Diarrhea: not First Line therapy

Gatorade, a popular sports drink, is continually being used by some pediatricians despite the fact that it is not a first line therapy for acute diarrhea or vomiting. It is marketed as a sports drink and should only be used as such.

Gatorade is a fluid high in sugars and low in salts. It is preferred by most infants and toddlers due to the taste but the risk of osmotic diarrhea prevents me from recommending it. Its use can only be recommended if there is no suitable replacement for plain ORS but the quantity required to treat some signs of dehydration is still dependent on the salt content. Compared to ORS, you will need twice the amount of Gatorade to replenish the same amount of fluid deficit. ORS is therefore cheaper and far more effective. If the patient may exhibit NO signs of dehydration, Gatorade can be actually be used. However, there lies no consensus among concerned medical parties and is therefore not recommended. Start oral rehydration salts early to prevent further dehydration instead.

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Other common fluids also exist that are used by Filipina mothers that may be harmful include coffee, carbonated drinks and carbonated juices. I have met many mothers who have given coffee to a sick infant, further increasing the dehydration and the diarrhea. These are mothers who are usually reluctant to seek consult and are the ones that bring their child to attention only when severe dehydration and malnutrition is observed.

Salt is the primary method of treating diarrhea. Rice washings could be salted to provide a better alternative but the WHO recommends early access to ORS since the recipe is often forgotten.

ORS is provided free in barangay health centers and, if there is shortage, is inexpensive when bought in a local drug store. Gatorade and other fluids are far more expensive, less efficacious, and could be harmful to the child.

Dr. Mella is currently the head of the Committee on Diarrheal Diseases in Olongapo City. This is part of an education campaign to combat diarrhea.

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“Q-tingin:” Estimating Fluid Deficit by Physical Examination

Olongapo City – In the published manual of the WHO entitled “Treatment of Diarrhea” (2005), fluid deficits in dehydration and response to therapy need not be calculated using laboratory values but rather by straightforward physical examination.

Diarrhea with NO SIGNS of dehydration can have a fluid deficit of no greater than 5% or 50 ml per kg body weight. Thus a 15 kg child with diarrhea who is alert, drinks normally, and has normal physical exam is estimated to have at most 750ml of fluid deficit and correction of that deficit by increased oral fluid intake or ORS can be beneficial.

Diarrhea with SOME SIGNS of dehydration can have a fluid deficit of 5-10% or 50-100 ml per kilogram of body weight. For a 15 kg child with diarrhea who is restless/irritable, has sunken eyes, thirsty/drinks eagerly, and/or skin pinch that goes back slowly, his fluid deficit is estimated to be in the 750-1500 ml range. The patient should be weighed to detect clinical response as most patients begin to lose weight at this stage of dehydration. ORS, continued feeding, and zinc supplementation is recommended.

Related Story: Mom’s Best Arsenal Against Diarrhea: Oral Rehydration Salts!

Diarrhea with SEVERE SIGNS of dehydration can have a fluid deficit of more than 10% or greater than 100 ml per kilogram body weight. Thus the same 15 kg child above, should he become lethargic or unconscious, have sunken eyeballs, drinks poorly or not able to drink, and/or with a very slow (>2 sec) skin pinch over the abdomen, is likely to have a deficit of more than 1500 ml! This patient should be admitted. IV fluids and ORS are an emergency measure. Death follows if there is no immediate fluid replacement in 24 hours.

These fluid deficit estimation can be used in many etiologies of dehydration such as hyperemesis and severe exercise. Reference used in this article was provided by WHO and can be downloaded from this link:

Treatment of Diarrhea.Manual for Health Workers

Dr. Mella is currently the head of the Committee on Diarrheal Diseases, Olongapo City Health Office

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Oral Rehydration Therapy Should be Taught in Schools

Afable Medical Center – I became flustered as I heard one of the mothers say “No” when asked whether she gave Oresol (an old brand and short name for Oral Rehydrating Salts) to her child who had 3 days of watery diarrhea. I really tought they teach this at the grade school level as I was taught in Las Pinas about Oresol during grade 2. I poked around the history and found that the mother received primary education but was never taught how to prepare ORS. I apologized for my behavior and realized that I was lucky enough that I knew how to prepare ORS at a young age. Most people aren’t and I shouldn’t be judgemental.

I didn’t grow up rich but I did attend a private school. It was the cheapest private school at that time. My mother had to make ends meet just to pay the tuition and I had to be a good student just to stay at that school. I think I taught my mother ORS. It was simple. Just drop the tablet, shake it, drink it and you’ll feel better. No dosing, just drink when you have diarrhea or vomiting. I learned it can be bought without a prescription since our Home Economics teacher made us buy one as an assignment.

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It’s a simple remedy that stays in the mind once taught and sticks once practiced. Although as a doctor, I prescribe it with more on dosage control to effectively put out dehydration but as an educator, I think what my school has done for me during grade school should be practiced in all private and public K-12 schools. The information can help save lives since Oral rehydration solutions should be administered promptly especially to kids less than five years of age to prevent death.

Fact: In the Philippines, most teenagers who became pregnant early are grade-school or high school drop outs. Due to poverty, dropping out can’t be helped especially in urban areas. Poverty in rural areas is different in highly urbanized cities. Cost of living is higher in urban areas and places strain on both parents and students. If health maintenance education like Oral Rehydration Therapy can be taught early in school, we can target this population effectively and prevent more under-five deaths.

But this grade-schoolers aren’t five years old or below, you might ask. Yup, but they are future parents.

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Fact: ORS overdose especially in diarrhea is rare or probably nonexistent. I haven’t encountered one and I would be able to spot it since I’m a doctor. Free and cheap ORS (even the flavored ones) are hard to swallow because of the taste. Glucose found in ORS isn’t sweet. As an experiment, I have attempted to swallow 500ml of it as fast as I could and ended up vomiting it. We can only take a few amounts of it at one time. Letting the child sip it, placing it in droppers, or using teaspoons to administer it is safe. It only takes a little to create clinical improvement. It is safe in all situations.

Theoretically, an overdose can only happen if the child suffers different morbidities. At that time, the child would probably have been admitted for other reasons that would not preclude the use of ORS.
Teaching a child how to treat himself/herself using ORS is as easy as drop, shake, and sip. No need for a thorough explanation.

If symptoms persist, consult your doctor. We can then give more thorough instructions depending on weight and dehydration severity. Other measures can then be initiated but we can be assured that once ORS was started at home, the patient is likely to be away from danger.

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Sunscreen: the Ultimate Skin Whitening Cream

East Bajac Bajac, Olongapo City – After getting exfoliative dermatitis from the simple hydroquinone experiment on me, I’m starting to ponder on what seems to be a better alternative to get fairer skin. Then it hit me – sunscreen! It was a physiological afterthought.

Fact: Melanocyte production is induced by the sun. People who don’t get enough sunlight do have whiter skin due to lack of stimulus. Genetic variation is all about production. Each individual has skin that has a unique reaction to sunlight. Continue reading

Preventive Medicine is a Priority!

Afable Medical Center, Olongapo – 55 year old patient presented in the outpatient department at 1 in the morning with a chief complaint of chest pain. He’s an insulin-dependent diabetic with Coronary Artery Disease, Hypertension Stage 2, Dyslipidemia, and Obesity. He refused all the necessary interventions except for an ECG. He refused oxygen and pain relievers but took Isordil. The ECG revealed an incomplete RBBB, an AV Block type 1, and sinus bradycardia.

To the medically uninitiated, these all translates to a walking time bomb. He has SYNDROME X written all over his chart. He was a PhilAm US Navy retiree with Type A personality. During my conversation with him, he keeps muscling me out citing that a VA primary care physician has already prescribed him too many medications. I know better not to argue but referred him back to his physician after negotiating initial management. With his type of morbidity, he doesn’t have long to live. Continue reading