Watching children come to her clinic severely dehydrated despite taking ORS (oral rehydration solution) prompted Hyderabad-based paediatrician Dr Sivaranjini Santhosh to look into what they were having. She found that these tetrapacks often did not have the right sugar-salt ratio. In fact, they had added sugar that made them no different from other flavoured drinks.
“A true ORS formulation uses a specific, low amount of glucose to help the body absorb sodium and water. Excessive sugar in drinks disrupts this process, creating a high concentration in the gut that pulls water from the body. The excess sugar can draw more water into the bowels, leading to a severe kind of diarrhoea and fluid loss,” she says. The problem? It leads to more dehydration and diarrhoea in already sick children — something that can turn fatal in the absence of timely medical care. That’s why she decided to begin her campaign against flavoured drinks posing as ORS.
It took eight years for the country’s apex food regulator (Food Safety and Standards Authority of India [FSSAI]) to stop all fruit-based, non-carbonated, ready-to-drink beverages from using the term ORS in their trademarked name. But her battle continues as the Delhi High Court has stayed the operation of the order after the Johnson & Johnson subsidiary, JNTL Consumer Health, submitted that products worth Rs 155-180 crore have already been manufactured or are in the supply chain.
Dr Santhosh says over the last decade or so, many fake products had entered the Indian market. “Even if a product carries the warning ‘not ORS’, people still think that it is an ORS solution because that’s what the brand name suggests,” she says. So, what exactly is ORS and why is it so important to maintain the sugar and salt proportion in the formulation?
Simple solution, complex science
The oral rehydration solution — a simple glucose-electrolyte mixture — can reduce deaths and hospitalisation due to acute diarrhoeal diseases, especially in children under the age of five. The glucose in ORS helps the small intestine absorb sodium and water more effectively and offset fluid loss. This is possible because a specific transport mechanism for sodium and glucose remains intact even during diarrhoea. By facilitating rehydration, ORS can prevent serious complications such as dizziness, low blood pressure and organ damage. Its timely use is especially critical for children and the elderly who are more vulnerable to rapid fluid loss.
ORS is the result of ground-breaking work by Indian paediatrician Dr Dilip Mahalanabis during the Bangladesh liberation war of 1971. It helped save millions of lives in the following decades. With a deficiency of saline to treat cholera patients in the refugee camps during the war, Dr Mahalanabis started administering patients with the simple salt, water and sugar solution, asking them to consume it till their condition improved. This reduced the case fatality in the refugee camps from 30 per cent to just one per cent. That’s why it was hailed as “the most important medical advancement of the 20th century.”
“The composition of the ORS is based on the daily sodium and potassium requirement and what is lost in the stool — earlier for cholera and now for the more common diarrhoeal diseases. The glucose in the solution facilitates the absorption of salts in the ORS, which in turn pull in the water, helping in quick rehydration,” says Dr Harish Chellani, former head of the department of paediatrics at Safdarjung hospital. “However, any additional glucose and the change in concentration shifts the osmotic pressure. So, the water gets drawn out of the cells and into the gastrointestinal tract. This actually worsens the diarrhoea. This is the reason the ORS has to stick to the WHO formulation.”
The harms of added sugar
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Nearly eight per cent of children under the age of five globally die due to diarrhoea. In India, the prevalence of diarrhoea in this age group is at 9.2 per cent, according to data from the National Family Health Survey.
Dr Sisir Paul, clinical director at Madhukar Rainbow Hospital, says, “For most cases of diarrhoea, you do not need antibiotic therapy. It is the resulting dehydration that has to be managed as it can lead to hypertension, kidney failure and death. Providing ORS solution is an effective way to prevent complications, especially in remote areas where access to health facilities can be limited.”
All the more reason why these life-saving packets cannot have too much sugar. “The absorption of the water will not happen properly if the WHO formula is not followed,” says Dr Ramesh Aggarwal, professor of neonatology at the All India Institute of Medical Sciences (AIIMS), Delhi. Dr Chellani argues that high sugar drinks may prompt children to drink more. “People say that the WHO formulation is not tasty and children might not drink it even when they have diarrhoea but that is not true. The use of ORS is actually self-limiting — children will continue to drink it as long as they are dehydrated. The problem with a sweetened, flavoured drink is that children may continue to drink it beyond their requirement. This can not only be dehydrating, it also exposes the children unnecessarily to more salts and sugars.” He says people should avoid giving children aerated beverages during such an episode. “Many believe that lemon-aerated beverages can help when the stomach is tender but in reality, they can distend the stomach and increase the risk of vomitting, leading to further fluid loss.”
How to prepare ORS
The WHO had an older high osmolarity formulation — meant for those with cholera that causes higher sodium loss — and a new low osmolarity formula.
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Studies have shown that the low osmolarity formula can reduce unscheduled requirement for IV by 33 per cent, stool output by 20 per cent and vomitting by 30 per cent in children. WHO has recommended the use of this formula since 2003. For this solution, you need 2.6 grams of sodium chloride, 13.5 grams of glucose, 1.5 grams of potassium chloride and 2.9 grams of trisodium citrate.
This is usually available as a packet of powder that has to be mixed in a litre of water. Such packets are available across all government healthcare centres and with ASHA workers for free. Similar products can be purchased at any neighbourhood medical store. Smaller packets meant for a glass of solution and reconstituted solution in tetra packs are also available but one has to ensure that it is the WHO recommended formulation.
Once made, the solution can be used for up to 24 hours, after which a new solution should be prepared. Dr Aggarwal warns that “the sachets should be mixed with the amount of water specified on the pack — mixing it with too little or too much water can change the concentrations. It is easy to mix the one-litre packs as people usually have one litre bottles available at home.” He cautions people against trying to divide the powder in a sachet on their own to mix two or three batches of solution. “If you divide the powder on your own, then there is no way to tell how much salt and sugar is going in. It is best to mix the entire pack,” says Dr Aggarwal. Dr Paul advises against gulping down the powder with water as it changes the composition. All three experts warn against preparing the solution at home. “These packets are easily available everywhere now. Parents should use these salts to ensure that the concentrations are maintained,” says Dr Chellani.
How to identify genuine products
Experts say it is best to use ORS salt sachets readily available at government health facilities or neighbourhood stores instead of buying tetra packs. Most of these sachets will mention “as per WHO recommended formulation.” While not all tetra packs are sweetened drinks, the salt sachets are likely to reduce the risk of ending up with products that do not adhere to the concentrations. Sachets usually cost less than Rs 22 as the price of the ORS in India is capped at Rs 1.11 per gram of salt and a packet usually contains over 20 grams of powder.
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