Talk:Oral rehydration therapy/Archive 2

The "Three's Company" argument?
Okay, it doesn't always need to be grimly seriously. Yes, we have a serious and important topic here. But elsewhere, sure people can have some fun on wiki, and still do good work, and still hone their skills. So, we have the article List of Three's Company episodes. And look at the level of detail! Seemingly the synopsis of each and every episode. The whole article is 99K.

My point being that if we can spare the space for this, certainly we can spare the space for a good summary of zinc, ReSoMal, etc, etc, etc.

Now, even with that said, an article can be long and unwieldy and hard to read. So, one thing is to make sure we have meaningful sections. And I have wondered, what if the beginning of the article is high school level, the middle is college level, and the bottom is post-doc and as cutting edge as we can make it? Still divided into sections of course. But that way, the reader can go as deeply into the topic as he or she chooses. I'm not entirely sure of this, but it is an idea that intrigues me. Cool Nerd (talk) 03:50, 24 August 2011 (UTC)

scheme to use empty spaces in Coca-Cola crates to distribute ORT salts.
Coke's supply chain could distribute aid to the needy, Marc And Craig Kielburger, Times Colonist, [Victoria & Vancouver Island, Canada], October 2, 2011:

" .  .  .  As Berry watched crates of Coke travel on mules, bicycles and handcars, he noticed a potentially lifesaving resource in the delivery cases: the empty space between bottles.  .  .  "

" .  .  .  In 2008, Berry rekindled ColaLife when he got wind of Coke's participation in Business Call to Action, an event hosted by Britain's then-prime minister Gordon Brown, at which global corporations agreed to actively combat poverty.  .  .  "

" .  .  .  AidPod was the result. It's a wedge-shaped plastic container, kind of like a pencil case, containing medicine like rehydration salts  .  .  .  "

" .  .  .  For now, ColaLife's journey begins in Zambia, with a trial in Coke's distribution centres set to start this month.  .  .  "


 * posted by Cool Nerd (talk) 01:02, 3 October 2011 (UTC)

More on Safe Water System
http://www.ajtmh.org/content/76/2/351.full.pdf+html


 * a fair amount of work, please jump in and help if you have the time. Cool Nerd (talk) 20:57, 12 July 2012 (UTC)

Some history and examples of ORT and Safe Water System (SWS)
Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service, Mark Pendergrast, Boston, New York: Houghton Mifflin Harcourt, 2010.

"Oral Rehydration Therapy and Rice-Water Stools," pages 99-101:

‘At the Matlab outpost of the Cholera Research Lab in East Pakistan, EIS officers were conducting field trials of a revolutionary oral treatment for cholera. In fall 1968 Roger Rochat and Barth Reller arrived at Matlab, where they slept in hammocks on an old prison barge and cared for cholera patients, who lay in a hospital on blue cholera cots with holes cut in the bottom, evacuating nearly continuously into the yellow buckets underneath.

‘Rochat and Reller fed victims a life-giving elixir made with sodium chloride, sodium bicarbonate, glucose, and potassium citrate--salt, baking soda, sugar, and a source of potassium. Dubbed oral rehydration therapy (ORT), the treatment, developed the year before by David Nalin and Richard Cash [emphasis added], proved to be simple and effective, as long as the patients were not already in shock and near death.

‘ORT revolutionized the treatment of cholera, a disease that could otherwise kill from dehydration within twenty-four hours. Only the most severe cases now required IV drips. Mortality rates dropped to 1 percent or less. It was one of the most important medical advances of the twentieth century.

‘“For each patient, we would dump their vomitus into their stool bucket, then make up an ORT solution in the same amount, to replace the lost fluid,” Reller said. “One man set a record by expelling and replenishing fifteen gallons over a forty-eight-hour period.”

‘In mid-December 1968 EIS officers Eli Abrutyn and John Forrest arrived at Matlab to replace Rochat and Reller and to continue the ORT study. “We had the idea that we could make up plasticine packets that could be mixed in a jug with water, like Kool-Aid,” Abrutyn recalled. They made a Super 8 movie of their purchases of ingredients in the local bazaar. . .  ’

"'The Health Educators Told Us,'" pages 269-70:

‘Cholera continued its inexorable spread during the drawn-out seventh world pandemic that had begun in 1961. In November 1990 cholera broke out in southern Malawi, where refugees from the civil war in neighboring Mozambique had fled. The largest camp, built to hold fifty thousand people, then had a refugee population of seventy-four thousand.

‘EIS officer David Swerdlow arrived at the camp alone with a laptop computer and a few lab suppliers. In the sweltering heat, he set about answering two questions. ''Why were so many people dying? How was cholera being spread?''

‘“I found that children were more likely to die,” he said, “so I suggested setting up a tent just for children, with the best nursing care.” He also identified an overreliance on intravenous tubes, often left in place for a week or more, which led to infections and septic shock. Even when they were offered lifesaving oral rehydration solution (ORS), sick refugees weren’t getting enough, so Swerdlow assigned “ORS officers” whose only job was to tell people to drink, drink, drink.

‘But how were people getting cholera in the first place? Deep boreholes provided clean water, although not enough. Swerdlow asked how long refugees waited in line, how they transported the water. Did they wash their hands? Yes, the health educators told us. Where did they wash their hands? In the water buckets. You mean, the same container you drink from? Yes, there is not other place to wash our hands. It was a perfect way to transmit cholera. “Use of narrow mouthed water containers would probably decrease the likelihood of contamination,” he wrote in his report.’

"After One Hundred Years of Solitude," pages 270-72:

[Peru, 1991]

‘ .  .  .  Trujillo, the country’s third-largest city. . .  .  Their case-control study implicated water. The EIS officers then identified multiple problems with the water system of interconnected wells, with only sporadic chlorination. People dug holes to tap illegally into the water lines, reducing water pressure and allowing backflow contamination.

‘Because running water was available only an hour a day in poorer neighborhoods, most families stored water in household containers, which held more fecal coliforms and vibrios than the pipes. As in Malawi, people’s hands were contaminating the same water they dipped into for a drink. In their report, Swerdlow, Mintz, and the FETP trainees recommended improvements in the municipal water system as a long-term solution. In the meantime, peple should boil or disinfect their water and store it in narrow-necked vessels.

‘ .  .  .  Iquitos, a commercial hub at the headwaters of the Amazon. ..

‘ .  .  .  Though residents in the shantytown area where most cases lived knew that they should either boil or chlorinate their water, few did so. Boiling was expensive and time-consuming. Bleach was available but was used mostly for laundry. People said the bleach-treated water tasted bad and feared it might be toxic.

‘[Rob] Quick found that most of those who died of cholera were coming from remote villages, so he enlisted naval speedboats to take his team upriver, where they documented a 13.5 percent case fatality rate in twelve villages. In most other areas of Peru the mortality rater was less than 1 percent. People waited until they were really sick before starting on the four-hour boat ride to Iquitos. Many died en route, while others were beyond help by the time they reached the hospital. ..

‘ .  .  .  Elsewhere in the world, over a billion people depended on unsafe sources for drinking water. Cholera, Shigella, Campylobacter, rotavirus, and other microbes caused waterborne diarrhea that killed more than 2 million children annually.

‘Obviously, the long-term solution would be to fix the world’s infrastructure. ..

‘ .  .  .  In 1992 Eric Mintz noticed a five-gallon jug in a CDC janitor’s closet that, when modified for a spigot, served the purpose. In November that same year in La Paz, Bolivia, on a shoestring budget, Rob Quick introduced the narrow-mouthed container and little bottles of bleach. Families quickly accepted the system. In a subsequent Bolivian study, Quick found that this simple solution resulted in a 44 percent reduction of diarrhea. This was the origin of CDC’s Safe Water System, which has spread throughout the developing world and saved thousands of lives.’

"Hell On Earth," pages 288-291:

[following 1994 Rwandan genocide, where many persons fled to neighboring Zaire (now Democratic Republic of the Congo). And yes, including some of the very persons who had committed genocide.]

‘By early August there were sufficient supplies of oral rehydration salts and intravenous solutions, but as [Scott] Dowell wrote later, "staff responsible for oral rehydration rarely understood that there was a specific quantity of fluid to be given over a specific period of time." One misguided charity had sent Gatorade, which caregivers gave to the dying children, only making them worse. Another center administered intravenous dextrose, which containded no essential sodium and was harmful. Yet another facility had no access to water. . .  ’

‘ .  .  .  Every night the EIS officers discussed a profound ethical dilemma. Many of those they cared for were genocidaires. Were the camps just facilitating their continued reign of terror? There was no easy answer. . .  ’

“Making a Difference in Kenya,” pages 358-362:

‘ .  .  .  Ciara [O’Reilly] and Matt Freeman, a young epidemiologist with the Center for Global Safe Water at Emory University, were there to assess the impact of the Safe Water System (SWS), which had been implemented by CARE (with funding from Coca-Cola) the previous summer in forty-five primary schools in Nyanza Province in Western Kenya. Ciara and Matt had trained local enumerators to administer questionaires to randomly selected students and their parents or guardians. . .  ’

‘ .  .  .  The SWS teaches people to treat their drinking water with diluted bleach and to dispense it from spigots in narrow-topped containers too small for hands to reach in. . .  ’

‘ .  .  .  and they demonstrated how they added a capful of WaterGuard, the diluted bleach solution, to treat new water. . .  ’

‘ .  .  .  So these two women had thirteen children to care for and were very poor. Yet this woman still managed to buy WaterGuard for their water. . .  ’

‘ .  .  .  More parents had heard about WaterGuard than those interviewed during a baseline survey, though only a few more actually used it at home. . .  ’

‘ .  .  .  Stool samples from the hospital were tested twice a week at the CDC lab in Kisumu to determine what had caused diarrhea and what sort of drug resistance had developed. . .  ’

‘ .  .  .  Ciara’s study found that in children under five, three bacteria together--Shigella, Campylobacter, and Salmonella--accounted for about half of the pathogens identified. The other half was caused by rotavirus, which is impervious to WaterGuard. Ciara also found that the bacteria were highly resistant to three common antibiotics, but responded to others. . .  ’

‘ .  .  .  And CARE (with funding from many public and private organizations) has begun to implement the Safe Water System in an additional two hundred schools in Nyanza Province. Some schools will also get latrines, while others will, in addition, get a borehole well or rainwater harvesting. The idea is to see which interventions are cost-effective and sustainable. . .  ’

‘ .  .  .  As an EIS officer, Sapna had alredy ventured to Azerbaijan to look at mortality surveillance from land mines; to Vietnam to study the impact of Pur, a water treatment product made by Procter & Gamble;. . ’

---

Of the six books listed under “Cholera and other waterborne diseases” (pages 374-75), the last is Bill Bryson’s African Diary, by Bill Bryson (Doubleday, 2002), which Pendergrast describes as “a slight book that briefly covers Homa Bay, Kenya, and the Safe Water System.”


 * posted by Cool Nerd (talk) 15:51, 17 July 2012 (UTC)

Gatorade and other sports drinks as too rich (which makes dehydration worse)?
Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service, Mark Pendergrast, Boston, New York: Houghton Mifflin Harcourt, 2010.

"Hell On Earth," pages 288-291 [Rwanda]:

‘ .  .  .  One misguided charity had sent Gatorade, which caregivers gave to the dying children, only making them worse. . .  ’

'''SURVIVING FIELD STRESS FOR FIRST RESPONDERS Originally aired April 28, 2005''' www.atsdr.cdc.gov/emes/surviving_stress/documents/Script.doc

"THE NEXT MEMBER OF OUR PANEL IS JIM MACDONALD, WHO IS AN ON-SCENE COORDINATOR WITH THE EMERGENCY RESPONSE BRANCH EPA, REGION 7.

" .  .  .  YOU ALSO WANT TO THINK ABOUT THE BALANCE OF WHAT YOU'RE DRINKING AND MAINTAIN A PROPER ELECTROLYTE BALANCE. YOU SHOULD DRINK ONE HALF WATER AND ONE HALF SPORTS DRINK ON SITE DURING RESPONSES. DON'T DRINK JUST ONE OR THE OTHER.

"REMEMBER, WHEN DEHYDRATION GETS SERIOUS, EXTREME FATIGUE IS A PROMINENT SYSTEM, AND IT ACTUALLY CAN LEAD TO EARLY SIGNS OF HEAT EXHAUSTION. .  .  "

THE TREATMENT OF DIARRHOEA: A manual for physicians and other senior health workers, World Health Organization, Department of Child and Adolescent Health and Development, 2005, Page 9 (13 in PDF):

“A few fluids are potentially dangerous and should be avoided [Emphasis added] during diarrhoea. Especially important are drinks sweetened with sugar, which can cause osmotic diarrhoea and hypernatraemia. Some examples are:
 * commercial carbonated beverages
 * commercial fruit juices
 * sweetened tea. Other fluids to avoid [Emphasis added] are those with stimulant, diuretic or purgative effects, for example:
 * coffee
 * some medicinal teas or infusions.”


 * Cool Nerd (talk) 19:23, 27 July 2012 (UTC)

Too much plain water not so great either
Runner's World The Runner's Body: How the Latest Exercise Science Can Help You Run Stronger, Longer, and Faster, Ross Tucker PhD, Jonathan Dugas PhD, with Matt Fitzgerald, Rodale (Macmillan), 2009.

A Black Swan in Fluid Intake: Reasons to Challenge the Paradigm, pages 98-99:  “. . .  hyponatremia. This condition involves dilution of the blood to the degree that sodium levels fall, eventually affecting the balance of fluid across the cells. . .  ”

Drinking according to Common Sense: Obey Your Thirst!, pages 107-108:  “. . .  In fact, humans have a very acute sense of when it is important to drink fluids, and it does not take much to stimulate us to seek water. Thirst is a very deep-seated, physiological desire for water, and it has been shown again and again in lab studies to effectively defend osmolality, not body weight. . .  ”

@@@@

THE TREATMENT OF DIARRHOEA: A manual for physicians and other senior health workers, World Health Organization, Department of Child and Adolescent Health and Development, 2005, page 16 (20 in PDF): “4.5.2 Hyponatraemia “Children with diarrhoea who drink mostly water, or watery drinks that contain little salt, may develop hyponatraemia (serum Na <130 mmol/l). Hyponatraemia is especially common in children with shigellosis and in severely malnourished children with oedema. Severe hyponatraemia can be associated with lethargy and, less often,seizures. ORS solution is safe and effective therapy for nearly all children with hyponatraemia. An exception is children with oedema (see section 8), for whom ORS solution provides too much sodium.”


 * posted by Cool Nerd (talk) 21:13, 4 August 2012 (UTC)

standard home drinks and fluids recommended by WHO
THE TREATMENT OF DIARRHOEA: A manual for physicians and other senior health workers, World Health Organization, Department of Child and Adolescent Health and Development, 2005, pages 9-10 (13-14 in PDF):

4.2.1 Rule 1: Give the child more fluids than usual, to prevent dehydration

"What fluids to give

" .  .  .  Plain clean water should also be given. Other fluids should be recommended that are frequently given to children in the area, that mothers consider acceptable for children with diarrhoea, and that mothers would be likely to give in increased amounts when advised to do so.

"Suitable fluids

"Most fluids that a child normally takes can be used. It is helpful to divide suitable fluids into two groups:

"Fluids that normally contain salt, such as:

• ORS solution • salted drinks (e.g. salted rice water or a salted yoghurt drink) • vegetable or chicken soup with salt.

"Teaching mothers to add salt (about 3g/l) to an unsalted drink or soup during diarrhoea is also possible, but requires a sustained educational effort.

"A home-made solution containing 3g/l of table salt (one level teaspoonful) and 18g/l of common sugar (sucrose) is effective but is not generally recommended because the recipe is often forgotten, the ingredients may not be available or too little may be given.

"Fluids that do not contain salt, such as:

• plain water • water in which a cereal has been cooked (e.g. unsalted rice water) • unsalted soup • yoghurt drinks without salt • green coconut water • weak tea (unsweetened) • unsweetened fresh fruit juice" . . "The general rule is: give as much fluid as the child or adult wants until diarrhoea stops. As a guide, after each loose stool, give:

• children under 2 years of age: 50-100 ml (a quarter to half a large cup) of fluid; • children aged 2 up to 10 years: 100-200 ml (a half to one large cup); • older children and adults: as much fluid as they want."


 * posted by Cool Nerd (talk) 21:13, 9 September 2012 (UTC)

WHO recommends continuing to feed child with diarrhea
THE TREATMENT OF DIARRHOEA, WHO, 2005.

page 10 (14 in PDF):

"4.2.3 Rule 3: Continue to feed the child, to prevent malnutrition

" .  .  .  Continued feeding also speeds the recovery of normal intestinal function, including the ability to digest and absorb various nutrients.  .  .  "

4.3 Treatment Plan B: oral rehydration therapy for children with some dehydration

Page 14 (18 in PDF):

" .  .  .  However, children continued on Treatment Plan B longer than four hours should be given some food every 3-4 hours as described in Treatment Plan A. All children older than 6 months should be given some food before being sent home. This helps to emphasize to mothers the importance of continued feeding during diarrhoea.  .  .  "


 * posted by Cool Nerd (talk) 21:32, 9 September 2012 (UTC).

Error in cited source
I recently reverted an anonymous edit that added the word "HALF" in front of "teaspoon" here. The anon challenged my revert on my talk page here.

He makes a good point. The cited source (see page 9) actually equates 3g of salt to 1 level teaspoon. This is false; I just measured it myself with an accurate measuring spoon and a digital scale. A level teaspoon of table salt is about 6 grams, not 3.

What do we do when a cited reliable source contains an internal error? I suspect that the metric numbers in the source are what the source actually intended, but I am not sure. ~Amatulić (talk) 06:15, 17 September 2012 (UTC)

4 oz OJ for potassium and citrate
I don't know why you all keep deleting my addition to homemade solutions of 4 oz of OJ to 1 L water, one level teaspoonful table salt and 18g/l of common sugar. (which by the way I order for patients in the hospital in Los Angeles). this provides both potassium and citrate... and slightly helps the taste.

These solutions are extremely relevant and frankly save lives, decrease morbidity, lengths of hospital stays, and prevent hospitalizations when people look up oral rehydration solution on wikipedia. We aren't a recipe book, but it's historically relevant to list all the different types of options available and also listing how the sports drinks have way too much sugar and can cause osmotic diarrhea, worsening dehydration.

163.40.12.37 (talk) 05:05, 14 October 2012 (UTC)


 * Wow, this is a real gift, and thank you for your interest in this topic. I myself am not a medical professional, just someone interested and willing to put the time in and do some research.


 * Now, even as a medical professional, you still have to cite research, you can't just have argument from authority, I'm sure you realize that. And, I bet you are significantly ahead of the game on the research and citations.


 * I think we should be much more confident and forthright in including criticism of so-called "sports drinks" and spell out that osmotic diarrhea means that the fluid in the gut is too rich in sugar or salt and draws fluid away from the rest of the body. Just like if a person were to drink sea water.


 * To your first question of why people keep deleting your addition, look at the second boxy thing at the top (now below)---which I am questioning whether is a mistake. If current science and medical practice is that a variety of Oral Rehydration Solutions are used, I think are article should accurately reflect that.  I don't think we should artificially clean things up as if we are a corporate publication.  (This is one of my criticisms of wikipedia, that we often seem to drift to a 'corporate' style of communication.)   Cool Nerd (talk) 18:07, 20 October 2012 (UTC)


 * Here's a letter to the editor to the New Eng J Med from '92: http://www.nejm.org/doi/pdf/10.1056/NEJM199202133260715 But of course that's way dated. Cool Nerd (talk) 18:59, 20 October 2012 (UTC)

Former consensus statement from 2009, Please help with research if you can spare the time
This is way back from July 18, 2009: http://en.wikipedia.org/w/index.php?title=Talk:Oral_rehydration_therapy&diff=302822623&oldid=299069213

And I added the part from several days ago, "I question this. If the current science and medical practice . . . "  And I still do. It doesn't look like this currently applies. And I also question consensus in the sense that if we define achieving consensus as success and not achieving consensus as failure, then we may short circuit discussions and conversations which we need to have. For the first step is to have a full and respectful discussion without preconditions. Cool Nerd (talk) 17:42, 22 October 2012 (UTC)

Justification for Citrate?
No mention here on why sodium citrate was added. I presume it's got to do with blood Ph. Any takers? Kortoso (talk) 22:30, 6 May 2013 (UTC)

standard home drinks and fluids recommended by WHO
THE TREATMENT OF DIARRHOEA: A manual for physicians and other senior health workers, World Health Organization, Department of Child and Adolescent Health and Development, 2005, pages 9-10 (13-14 in PDF):

4.2.1 Rule 1: Give the child more fluids than usual, to prevent dehydration

"What fluids to give

" .  .  .  Plain clean water should also be given. Other fluids should be recommended that are frequently given to children in the area, that mothers consider acceptable for children with diarrhoea, and that mothers would be likely to give in increased amounts when advised to do so.

"Suitable fluids

"Most fluids that a child normally takes can be used. It is helpful to divide suitable fluids into two groups:

"Fluids that normally contain salt, such as:

• ORS solution • salted drinks (e.g. salted rice water or a salted yoghurt drink) • vegetable or chicken soup with salt.

"Teaching mothers to add salt (about 3g/l) to an unsalted drink or soup during diarrhoea is also possible, but requires a sustained educational effort.

"A home-made solution containing 3g/l of table salt (one level teaspoonful) and 18g/l of common sugar (sucrose) is effective but is not generally recommended because the recipe is often forgotten, the ingredients may not be available or too little may be given.

"Fluids that do not contain salt, such as:

• plain water • water in which a cereal has been cooked (e.g. unsalted rice water) • unsalted soup • yoghurt drinks without salt • green coconut water • weak tea (unsweetened) • unsweetened fresh fruit juice" . . "The general rule is: give as much fluid as the child or adult wants until diarrhoea stops. As a guide, after each loose stool, give:

• children under 2 years of age: 50-100 ml (a quarter to half a large cup) of fluid; • children aged 2 up to 10 years: 100-200 ml (a half to one large cup); • older children and adults: as much fluid as they want."


 * posted by Cool Nerd (talk) 21:13, 9 September 2012 (UTC)

use of hospital 'ORT Corners' in Kenya, Ethiopia, South Africa

 * This sounds like something midway between inpatient and outpatient. Cool Nerd (talk) 15:45, 2 August 2013 (UTC)

Success Story: Oral Rehydration Therapy (ORT) corners in Kenya, Defeat DD, PATH.

"While leading a group of visitors through a rural hospital in Kenya’s Western Province, Alfred Ochola gently examined a tiny, dehydrated child. If this child had received oral rehydration solution (ORS) maybe 4 or 5 hours before, he explained, she could have been treated as an outpatient. .  .  "

" .  .  .  the hospital superintendant allocated space within the hospital for the reestablishment of an Oral Rehydration Therapy (ORT) corner and equipment including a water heater for water purification, measuring jars, buckets with covers, plastic cups, a 250 liter water storage tank, a weighing machine, a thermometer, and supplies of ORS and zinc. Funds from PATH provide a simple set of supplies: comfortable benches for mothers to use as they administer ORS, plastic containers, a clock, hot plates to boil water and cook porridge. "Alfred’s revitalization of ORT Corners in Kenya has already began to change a bleak picture. When an ORT Corner is established, children ultimately admitted to the hospital with severe dehydration could easily drop to as few as 2 cases per day. It will revolutionize the way health care workers and caregivers approach the treatment of diarrhea. "In just a few months, Alfred has revitalized 22 ORT Corners and trained over 200 health care workers on protocol for administering new, low-osmolarity ORS and zinc treatment. Alfred is also building relationships with the Ministry of Health to ensure a constant supply of zinc tablets and ORS packets. .  .  "

Analysis of the use of oral rehydration therapy corner in a teaching hospital in Gondar, Ethiopia, East Afr Med J., Teka T., Dept. of Paediatrics, Gondar College of Medical Sciences, Ethiopia, Oct. 1995. Abstract "Children under five years of age attending the Paediatrics Department, Gondar College of Medical Sciences, oral rehydration therapy (ORT) corner for acute diarrhoea in the year 1988-90 are analysed using only eight variables. Of 1003 children, 38.1% presented with no dehydration, 61.3% with some dehydration and 0.6% with severe dehydration. .  .  "

-

Oral Rehydration Therapy Corners and the Management of Diarrhoeal illness in children, Health Systems Trust, Carmen Baez, 1998: Vol. 1, issue 23.

"In June 1995, South Africa ratified the United Nations Convention on the Rights of the Child. .  .  .  .  Therefore, the Regional Child Health Coordinator, with the support of the Interim District Management Team (IDMT) is responsible for the planning and implementation of child health programmes, and in particular, the ORT corner project."

---

Oral Rehydration Therapy Corners and the Management of Diarrhoeal illness in children (pamphlet), Initiative for Sub-District Support (South Africa), Carmen Baez, Laura Habgood, David McCoy, David Sanders, Nov. 1999.

> "it is more likely that mothers/caregivers with a positive experience of an ORT corner would start to give ORT at home on subsequent occasions" > "such mothers/caregivers may feel empowered to deal with diarrhoeal illness and become spokespeople within their communities, conveying what they have learnt in the ORT corner to promote the use of ORT"

-

J Pak Med Assoc. 1997 Jan;47(1):3-6. Evaluation of diarrhoea management of health professionals trained at the Diarrhoea Training Unit of Rawalpindi General Hospital. http://www.ncbi.nlm.nih.gov/pubmed/9056728 " .  .  .  There seems to be a lack of interest and willingness to participate actively, as more than 50% of both doctors and LHVs did not consider ORT work as their job.  .  .  "

Rehydration Project recommends continuing to feed child
http://rehydrate.org/

“ .  .  .  Rehydration Project is a private, non-profit, non-sectarian, international development group. We aim to work within the health framework of developing countries. . .  '

" .  .  .  Oral rehydration therapy and continued feeding is a life-saving treatment, which only 39 per cent of children with diarrhoea in developing countries receive. Limited data show little progress since 2000.  .  .  "


 * posted by Cool Nerd (talk) 21:05, 2 August 2013 (UTC)

WHO recommends no solid food during 4-hour initial rehydration period, then continuing to feed child with diarrhea
The Treatment Of Diarrhea, A manual for physicians and other senior health workers, World Health Organization, 2005. See page 9 (13 in PDF) for home products and recipes that can be used to treat and prevent dehydration.

1. INTRODUCTION

page 3 (7 in PDF)

" .  .  .  Repeated attacks of diarrhoea contribute to malnutrition, and diarrhoeal diseases are more likely to cause death in children who are malnourished. Research has shown, however, that the adverse effects of diarrhoea on a child's nutritional status can be lessened or prevented by continuing feeding during the illness.  .  .  "

4. MANAGEMENT OF ACUTE DIARRHOEA (WITHOUT BLOOD)

4.2 Treatment Plan A: home therapy to prevent dehydration and malnutrition

page 10 (14 in PDF):

"4.2.3 Rule 3: Continue to feed the child, to prevent malnutrition

" .  .  .  The infant usual diet should be continued during diarrhoea and increased afterwards. Food should never be withheld and the child's usual foods should not be diluted. Breastfeeding should always be continued. The aim is to give as much nutrient rich food as the child will accept. Most children with watery diarrhoea regain their appetite after dehydration is corrected, whereas those with bloody diarrhoea often eat poorly until the illness resolves. These children should be encouraged to resume normal feeding as soon as possible. When food is given, sufficient nutrients are usually absorbed to support continued growth and weight gain. Continued feeding also speeds the recovery of normal intestinal function, including the ability to digest and absorb various nutrients.  .  .  "

4.3 Treatment Plan B: oral rehydration therapy for children with some dehydration

Page 14 (18 in PDF):

4.3.8 Giving food

"Except for breastmilk, food should not be given during the initial four-hour rehydration period. However, children continued on Treatment Plan B longer than four hours should be given some food every 3-4 hours as described in Treatment Plan A. All children older than 6 months should be given some food before being sent home. This helps to emphasize to mothers the importance of continued feeding during diarrhoea."


 * posted by Cool Nerd (talk) 01:33, 6 August 2013 (UTC)

for children with some dehydration, vomiting only rarely prevents successful rehydration
The Treatment Of Diarrhea, A manual for physicians and other senior health workers, World Health Organization, 2005.

'''4.3 Treatment Plan B: oral rehydration therapy for children with some dehydration'''

4.3.2 How to give ORS solution

page 12 (16 in PDF)

" .  .  .  For babies, a dropper or syringe (without the needle) can be used to put small amounts of solution into the mouth. Children under 2 years of age should be offered a teaspoonful every 1-2 minutes; older children (and adults) may take frequent sips directly from the cup.

"Vomiting often occurs during the first hour or two of treatment, especially when children drink the solution too quickly, but this rarely prevents successful oral rehydration since most of the fluid is absorbed. After this time vomiting usually stops. If the child vomits, wait 5-10 minutes and then start giving ORS solution again, but more slowly (e.g. a spoonful every 2-3 minutes)."


 * posted by Cool Nerd (talk) 01:42, 6 August 2013 (UTC)

Adding packets to water and recommending a little on the dilute side.
What every family and community has a right to know about Diarrhoea, UNESCO:

page 5: "  .  .  .  If the mixture is made a little too dilute, no harm can be done, and there is very little loss of effectiveness.  .  .  "


 * Please note: this is not a dated publication. This seems to be a publication for distribution by health workers.  Cool Nerd (talk) 17:17, 24 August 2013 (UTC)

additional references
http://www.csd-i.org/oral-rehydration-techniques/

-

Oral Rehydration Solutions, Travel.gc.ca (Canada), Date modified: 2013-9-5.

•"It is essential to drink extra fluids as soon as diarrhea starts. •"For most healthy adults with uncomplicated travellers’ diarrhea, hydration can be maintained without ORS by drinking diluted juices or sports drinks, purified water, or clear soups. Although it may not be necessary, healthy adults with mild diarrhea can also use ORS if they prefer. •"Dehydration from diarrhea is more of a concern in children, those with underlying medical conditions and the elderly. •"Fluids should be consumed at a rate to satisfy thirst and maintain pale-coloured urine. . .  "

--

http://www.mayoclinic.com/health/dehydration/DS00561/DSECTION=treatments-and-drugs

-

http://books.google.com/books?id=7avpAAAAQBAJ&pg=PA217&lpg=PA217&dq=%22The+discovery+that+sodium+transport+and+glucose+transport+are+coupled%22&source=bl&ots=tpX2HHZ9uk&sig=_4d705w_tmCZO-UnkpDG9lZtNo0&hl=en&sa=X&ei=WiVPUvGGKc7_qAHmn4GIAg&ved=0CC8Q6AEwAQ#v=onepage&q=%22The%20discovery%20that%20sodium%20transport%20and%20glucose%20transport%20are%20coupled%22&f=false

--

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3605518/

-

http://rehydrate.org/ors/ort.htm (seems like they've updated the page, but this is how it previously was)

"The discovery that sodium transport and glucose transport are coupled in the small intestine so that glucose accelerates absorption of solute and water (is) potentially the most important medical advance this century."---The Lancet, Aug. 5, 1978

"ORT is the giving of fluid by mouth to prevent and/or correct the dehydration that is a result of diarrhoea. As soon as diarrhoea begins, treatment using home remedies to prevent dehydration must be started. If adults or children have not been given extra drinks, or if in spite of this dehydration does occur, they must be treated with a special drink made with oral rehydration salts (ORS). .  .  "

" .  .  .  Magic Bullet: The History of Oral Rehydration Therapy  pdf 39 pages 7.4 mb., by Joshua Nalibow Ruxin  .  .  .  "

" .  .  .  The Oral Rehydration Therapy, The Canadian Journal of Paediatrics, 1994; 1(5): 160-164  .  ..

" .  .  .  Acute gastroenteritis is one of the most common illnesses affecting infants and children in Canada and the world. The average child under age 5 experiences 2.2 diarrheal episodes per year. Treatment from resulting dehydration accounts for an estimated 200,000 hospitalizations per year in the U.S. with comparable rates occurring in Canada. Worldwide as many as 4,000,000 children per year die as a result of gastroenteritis and resulting malnutrition.  ..

" .  .  .  Glucose enhances sodium, and secondarily, water transport across the mucosa of the upper intestine5 For optimal absorption, the composition of the rehydration solution is critical. The amount of fluid absorbed depends on three factors: the concentration of sodium, the concentration of glucose and the osmolarity of the luminal fluid. Maximal water uptake occurs with a sodium concentration from 40 to 90 mmol/L, a glucose concentration from 110 to 140 mmol/L (2.0 to 2.5 g/100 mL) and an osmolarity of about 290 mOsm/L, the osmolarity of body fluids. Increasing the sodium beyond 90 mmol/L may result in hypernatremia; increasing the glucose concentration beyond 200 mOsm/L, by increasing the osmolarity of the solution, may result in a net loss of water. CHO to Na ratio should not exceed 2:1 in these solutions.

"For practical purposes in Canada, rehydration can be accomplished using solutions with higher sodium, i.e., 75-90 mmol/L. These are termed rehydration solutions (ORS). Prophylaxis of dehydration and maintenance involve solutions with 45-60 mmol/L of sodium. These are termed maintenance solutions. ..

" .  .  .  This has been done successfully by substituting short chain glucose polymers (starch) from rice and other cereals for glucose in the oral rehydration mixture. In field trials in developing countries, ORS containing glucose polymers, primarily from rice and corn, were found not only to be as effective in correcting dehydration as glucose-based ORS, but also to offer the additional advantage of reducing the amount and duration of diarrhea by 30%, thereby reducing morbidity and costs of treatment and increasing acceptability. The effectiveness in diarrhea typical of North America may be less marked, i.e., reducing stool output by 18%.  ..

" .  .  .  Along with improved oral rehydration solutions have come advances in the field of early refeeding. Fasting has been shown to prolong diarrhea. This may be due to undernutrition of the bowel mucosa which delays the replacement of mucosal cells destroyed by the infection. Although there is general agreement that breast-feeding should continue in spite of diarrhea, early refeeding with a lactose-containing formula is usually well tolerated. Early refeeding should commence 6-12 hours into therapy.

" .  .  .  Mild - If symptoms and signs are limited to decreased urinary output and increased thirst, mild dehydration is suspected. Assessment and treatment under close supervision are indicated. Rehydration consists of ORS or maintenance solution 10 mL/kg/hr with reassessment at 4-hour intervals. Breast-feeding continues. Early refeeding with the child's customary formula at the usual concentration is recommended. Extra ORS or maintenance solution (e.g., 5-10 mL/kg) may be given after each stool if diarrhea persists.

"Moderate - If at least two of the following signs, sunken eyes, loss of skin turgor ("tenting" of abdominal skin lasting less than 2 seconds), or dry buccal mucous membranes are present, moderate dehydration is diagnosed and rehydration consisting of ORS 15-20 mL/kg/hr with direct observation and reassessment at 4-hour intervals. If dehydration is corrected, therapy for ongoing losses and maintenance are continued as outlined above. If not, treatment is repeated as indicated by clinical signs or symptoms.

"Severe - If, in addition to signs of moderate dehydration, there is rapid breathing, lethargy, coma, a rapid thready pulse or "tenting" of the skin lasting more than 2 seconds, severe dehydration and shock are present. Blood pressure should be measured. Prompt intravenous therapy is indicated with rapid infusion of saline plasma or colloid sufficient to replete blood volume (10-20 mL/kg over 30 minutes may be necessary). Intraosseous infusion should be used if an intravenous line cannot quickly be inserted.

"General comments'. Vomiting is not a contraindication to ORT. ORS should be given slowly but steadily to minimize vomiting. Fluids may be administered by nasogastric tube if required. The child's clinical condition should be frequently assessed. A child should never be kept on ORS fluid alone for more than 24 hours. Early refeeding should begin within 6 hours. A full diet should be reinstituted within 24 to 48 hours, if possible. .  .  "

"There are certain contraindications to the use of ORT: • "Protracted vomiting despite small, frequent feedings, • "Worsening diarrhea and an inability to keep up with losses, • "Stupor or coma, • "Intestinal ileus.

"Recommendations • "Dehydration accompanying infantile gastroenteritis should be treated with early oral rehydration and early refeeding strategies. • "Infants with gastroenteritis should be offered maintenance solution to prevent dehydration. Parents and daycare centres should keep maintenance solution on hand in anticipation of episodes of infectious diarrhea. . . . • "Home-made oral rehydration solutions are discouraged since serious errors in formulation have occurred. • "Infants with mild to moderate dehydration should be treated under medical supervision with ORT in preference to intravenous rehydration. • "Infants with severe dehydration should initially be treated with intravenous or intraosseous rehydration. . . . . .  .  "

Recipe

"There are several commercially available products but an inexpensive home-made solution consists of 8 level teaspoons of sugar and 1 level teaspoon of table salt mixed in 1 liter of water. A half cup of orange juice or half of a mashed banana can be added to each liter both to add potassium and to improve taste. If commercial solutions are used, true rehydration solutions should be used and sports drinks should be avoided (especially in younger children) as these solutions contain too much sugar and not enough electrolytes."

---

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60870-3/fulltext

" .  .  .  simple salt, sugar, and water remedy for life-threatening diarrhoea put the centre on the map. In the late 1960s and early 1970s, researchers formulated and tested how to use the glucose and electrolyte oral rehydration solution (ORS). In the past three decades, ORS has saved an estimated 50 million lives worldwide, mainly children's, who are most at risk from fatal diarrhoea. Diarrhoeal diseases are the world's second leading cause of child death after the post-neonatal period for children younger than 5 years.  .  .  "

http://content.time.com/time/magazine/article/0,9171,901061016-1543876,00.html


 * posted by Cool Nerd (talk) 18:00, 3 September 2013 (UTC)

Gatorade and other sports drinks as too rich (which makes dehydration worse)?
Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service, Mark Pendergrast, Boston, New York: Houghton Mifflin Harcourt, 2010, subsection "Hell On Earth," pages 288-291 [Rwanda]:

‘ .  .  .  One misguided charity had sent Gatorade, which caregivers gave to the dying children, only making them worse. . .  ’

'''SURVIVING FIELD STRESS FOR FIRST RESPONDERS Originally aired April 28, 2005''' www.atsdr.cdc.gov/emes/surviving_stress/documents/Script.doc

" .  .  .  CDC IS ACCREDITED BY THE ACCREDITATION COUNCIL FOR CONTINUING MEDICAL EDUCATION TO PROVIDE CONTINUING MEDICAL EDUCATION FOR PHYSICIANS.  THE CDC DESIGNATES THIS EDUCATIONAL ACTIVITY FOR 2.0 CATEGORY 1 CREDIT TOWARD THE A.M.A. PHYSICIANS RECOGNITION AWARD.  .  .  "

" .  .  .  I'M KYSA DANIELS YOUR MODERATOR FOR "SURVIVING FIELD STRESS FOR FIRST RESPONDERS" WE'RE BROADCASTING FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION IN ATLANTA, GEORGIA. THIS PROGRAM IS SPONSORED BY THE NATIONAL CENTER FOR ENVIRONMENTAL HEALTH/AGENCY FOR TOXIC SUBSTANCES AND DISEASE REGISTRY, ENVIRONMENTAL PROTECTION AGENCY AND THE PUBLIC HEALTH TRAINING NETWORK. .  .  "

" .  .  .  THE NEXT MEMBER OF OUR PANEL IS JIM MACDONALD, WHO IS AN ON-SCENE COORDINATOR WITH THE EMERGENCY RESPONSE BRANCH EPA, REGION 7.  .  .  "

" .  .  .  YOU ALSO WANT TO THINK ABOUT THE BALANCE OF WHAT YOU'RE DRINKING AND MAINTAIN A PROPER ELECTROLYTE BALANCE. YOU SHOULD DRINK ONE HALF WATER AND ONE HALF SPORTS DRINK ON SITE DURING RESPONSES. DON'T DRINK JUST ONE OR THE OTHER.

"REMEMBER, WHEN DEHYDRATION GETS SERIOUS, EXTREME FATIGUE IS A PROMINENT SYSTEM, AND IT ACTUALLY CAN LEAD TO EARLY SIGNS OF HEAT EXHAUSTION. .  .  "

THE TREATMENT OF DIARRHOEA: A manual for physicians and other senior health workers, World Health Organization, Department of Child and Adolescent Health and Development, 2005, Page 9 (13 in PDF):

“A few fluids are potentially dangerous and should be avoided [Emphasis added] during diarrhoea. Especially important are drinks sweetened with sugar, which can cause osmotic diarrhoea and hypernatraemia. Some examples are:
 * commercial carbonated beverages
 * commercial fruit juices
 * sweetened tea. Other fluids to avoid [Emphasis added] are those with stimulant, diuretic or purgative effects, for example:
 * coffee
 * some medicinal teas or infusions.”


 * posted by Cool Nerd (talk) 21:46, 6 September 2013 (UTC)

Too much plain water not so great either
Runner's World The Runner's Body: How the Latest Exercise Science Can Help You Run Stronger, Longer, and Faster, Ross Tucker PhD, Jonathan Dugas PhD, with Matt Fitzgerald, Rodale (Macmillan), 2009.

A Black Swan in Fluid Intake: Reasons to Challenge the Paradigm, pages 98-99:  “. . .  hyponatremia. This condition involves dilution of the blood to the degree that sodium levels fall, eventually affecting the balance of fluid across the cells. . .  ”

Drinking according to Common Sense: Obey Your Thirst!, pages 107-108:  “. . .  In fact, humans have a very acute sense of when it is important to drink fluids, and it does not take much to stimulate us to seek water. Thirst is a very deep-seated, physiological desire for water, and it has been shown again and again in lab studies to effectively defend osmolality, not body weight. . .  ”

@@@@

THE TREATMENT OF DIARRHOEA: A manual for physicians and other senior health workers, World Health Organization, Department of Child and Adolescent Health and Development, 2005, page 16 (20 in PDF): “4.5.2 Hyponatraemia “Children with diarrhoea who drink mostly water, or watery drinks that contain little salt, may develop hyponatraemia (serum Na <130 mmol/l). Hyponatraemia is especially common in children with shigellosis and in severely malnourished children with oedema. Severe hyponatraemia can be associated with lethargy and, less often,seizures. ORS solution is safe and effective therapy for nearly all children with hyponatraemia. An exception is children with oedema (see section 8), for whom ORS solution provides too much sodium.”


 * posted by Cool Nerd (talk) 21:46, 6 September 2013 (UTC)

standard home drinks and fluids recommended by WHO
THE TREATMENT OF DIARRHOEA: A manual for physicians and other senior health workers, World Health Organization, Department of Child and Adolescent Health and Development, 2005, pages 9-10 (13-14 in PDF):

4.2.1 Rule 1: Give the child more fluids than usual, to prevent dehydration

"What fluids to give

" .  .  .  Plain clean water should also be given. Other fluids should be recommended that are frequently given to children in the area, that mothers consider acceptable for children with diarrhoea, and that mothers would be likely to give in increased amounts when advised to do so.

"Suitable fluids

"Most fluids that a child normally takes can be used. It is helpful to divide suitable fluids into two groups:

"Fluids that normally contain salt, such as:

• ORS solution • salted drinks (e.g. salted rice water or a salted yoghurt drink) • vegetable or chicken soup with salt.

"Teaching mothers to add salt (about 3g/l) to an unsalted drink or soup during diarrhoea is also possible, but requires a sustained educational effort.

"A home-made solution containing 3g/l of table salt (one level teaspoonful) and 18g/l of common sugar (sucrose) is effective but is not generally recommended because the recipe is often forgotten, the ingredients may not be available or too little may be given.

"Fluids that do not contain salt, such as:

• plain water • water in which a cereal has been cooked (e.g. unsalted rice water) • unsalted soup • yoghurt drinks without salt • green coconut water • weak tea (unsweetened) • unsweetened fresh fruit juice" . . "The general rule is: give as much fluid as the child or adult wants until diarrhoea stops. As a guide, after each loose stool, give:

• children under 2 years of age: 50-100 ml (a quarter to half a large cup) of fluid; • children aged 2 up to 10 years: 100-200 ml (a half to one large cup); • older children and adults: as much fluid as they want."


 * posted by Cool Nerd (talk) 21:46, 6 September 2013 (UTC)

JAMA (2004) on different solution for adults with cholera?
CLINICIAN'S CORNER JAMA. 2004;291(21):2632-2635. doi: 10.1001/jama.291.21.2632 http://jama.ama-assn.org/content/291/21/2632.full

Clinical Concerns About Reduced-Osmolarity Oral Rehydration Solution 1. David R. Nalin, MD; 2. Norbert Hirschhorn, MD; 3. William Greenough III, MD; 4. George J. Fuchs, MD; 5. Richard A. Cash, MD

" .  .  .  The new reduced-osmolarity formulation stretches the original compromise to the breaking point. It may be time to promote use of different solutions for patients with cholera, beginning in controlled settings such as cholera treatment centers and hospitals.  .  .  "

" .  .  .  In early studies of adults with cholera, use of oral maintenance solutions with glucose and 100 mEq/L of sodium resulted in an average negative sodium balance of 50 mEq, ranging as low as −200 mEq.9-10 The original WHO formulation containing 90 mEq/L of sodium could not offset sodium losses in adult cholera patients (120-140 mEq/L of cholera stool). The reduced sodium formulation (75 mEq/L) would further aggravate these sodium losses. In a randomized double-blind trial of 300 adults with cholera, more patients given the new solution developed hyponatremia (sodium <130 mEq/L) than those given the standard WHO ORS (odds ratio, 2.1; 95% confidence interval [CI], 1.1-4.1]).  .  .  "


 * posted by Cool Nerd (talk) 17:29, 8 October 2013 (UTC)

--

http://www.ncbi.nlm.nih.gov/pubmed/20863435

1 teaspoon salt per liter water---or is it only one-half teaspoon? Plus other information
http://rehydrate.org/ (looks like the previous edition)

"There are several commercially available products but an inexpensive home-made solution consists of 8 level teaspoons of sugar and 1 level teaspoon of table salt mixed in 1 liter of water. A half cup of orange juice or half of a mashed banana can be added to each liter both to add potassium and to improve taste. .  .  "

--

THE TREATMENT OF DIARRHOEA: A manual for physicians and other senior health workers, World Health Organization, Department of Child and Adolescent Health and Development, 2005, page 9 (13 in PDF):

"A home-made solution containing 3g/l of table salt (one level teaspoonful) and 18g/l of common sugar (sucrose) is effective but is not generally recommended because the recipe is often forgotten, the ingredients may not be available or too little may be given."

-

Guidelines for the control of shigellosis, including epidemics due to Shigella dysenteriae type 1, World Health Organization, 2005, Annex 12 - Preparation of Home Made Oral Rehydration Solution, page 51 (57 in PDF).

"Ingredients: 􀂄 Half a teaspoon of salt (2.5 grams) 􀂄 Six level teaspoons of sugar (30 grams) 􀂄 One litre of safe drinking water"

---

Dehydration, Treatments and drugs, Mayo Clinic Staff, Jan. 7, 2011: "In an emergency situation where a pre-formulated solution is unavailable, you can make your own oral rehydration solution by mixing 1/2 teaspoon salt, 6 level teaspoons of sugar and 1 liter (about 1 quart) of safe drinking water. .  .  "

---

ref name=2010WorldCupTravellersGuide>

A GUIDE ON SAFE FOOD FOR TRAVELLERS, WELCOME TO SOUTH AFRICA, HOST TO THE 2010 FIFA WORLD CUP (bottom left of page 1).

"* If ORS are not available, mix 6 teaspoons of sugar plus one level teaspoon of salt in one litre of safe water («taste of tears») and drink as indicated in the table."

---

updated: 02 August, 2013 Rehydration Project, http://rehydrate.org/

"What if ORS is not available? Give the child a drink made with 6 level teaspoons of sugar and 1/2 level teaspoon of salt dissolved in 1 litre of clean water.

"Be very careful to mix the correct amounts. Too much sugar can make the diarrhoea worse. Too much salt can be extremely harmful to the child.

Making the mixture a little too diluted (with more than 1 litre of clean water) is not harmful."

---

http://www.thecochranelibrary.com/userfiles/ccoch/file/Water%20safety/CD002847.pdf


 * posted by Cool Nerd (talk) 01:09, 24 January 2014 (UTC)

Hello
Hi there. Just noting that the small changes recently made make for edit conflict. While I am working on the page, might it not be easier for all to let me know of the improvements you would wish to see made systemically through the article? I'm more than happy to do the work for you and very glad to learn of new or proper ways to do things. Please let me know or perhaps make the changes when the GOCEinuse tag is off? Is there a problem with that which I am not understanding? If not, I'll press on. Kind regards and happy new year, Myrtle. Myrtlegroggins (talk) 11:12, 2 January 2014 (UTC)
 * Edit conflicts are part of life on Wikipedia. Nobody has exclusive access to an article.  The problems fixed were pretty huge mistakes Bgwhite (talk) 06:45, 3 January 2014 (UTC)
 * I understand. It was big copy edit and hence it took a long time. I tend to find myself fixing the article in general first and then going back over it again. That may not be the way everyone does it and so it may seem I haven't (yet) paid attention to things. Please have a look and see what you think now. I have some expertise in this area so hopefully you see an improvement. Regards once again, Myrtle. Myrtlegroggins (talk) 12:46, 3 January 2014 (UTC)
 * It's a lot of work you did and kudos for taking the time and effort. While your subject expertise is obvious, might I suggest keeping in mind the readership may not necessarily have the subject expertise or background (or even interest) you are assuming. In many cases these articles are the first start for someone interested in a subject. Ensure lead paragraphs concisely state what you are describing and follow up with more detailed descriptions and cites below. Try to avoid overwhelming the reader with assumed knowledge or vocabulary and subject your work to regular, healthy editing.
 * Also, if you feel inspired to do a lengthy edit in the future, remember you can use the Template:In use at the top of the page to indicate the article is receiving a makeover. In any case, great stuff you added and thank you very much for taking so much of your time to do it. Lexlex (傻) (talk) 08:58, 17 January 2014 (UTC)
 * Lexlex, thankyou very much for all your suggestions. I will definitely take them on board and as soon as I can, have another look at the language I used, in order to make sure I am not making any assumptions. I really appreciate advice very much in this case and always. Kind regards, Myrtle. Myrtlegroggins (talk) 08:06, 24 January 2014 (UTC)
 * I took another look today at the article today and I think with everyone's suggestions here, Lexlex and Cool Nerd especially, it's taking shape nicely.

Oral Rehydration Therapy is more than just the fluid itself (per WHO)

 * Here's a WHO publication, from the table of contents, saying that's it's more than just the oral rehydration fluid itself (as important as that may be!)
 * THE TREATMENT OF DIARRHOEA: A manual for physicians and other senior health workers, World Health Organization, Department of Child and Adolescent Health and Development, 2005:


 * 4. MANAGEMENT OF ACUTE DIARRHOEA (WITHOUT BLOOD)
 * 4.2 Treatment Plan A: home therapy to prevent dehydration and malnutrition
 * 4.2.1 Rule 1: Give the child more fluids than usual, to prevent dehydration 4.2.2 Rule 2: Give supplemental zinc (10 - 20 mg) to the child, every day for 10 to 14 4.2.3 Rule 3: Continue to feed the child, to prevent malnutrition 4.2.4 Rule 4: Take the child to a health worker if there are signs of dehydration or other problems


 * Especially since people are going to tend to think, oral rehydration therapy is just the fluid itself, right? No, as helpful as the fluid is, it's only part of oral rehydration therapy.  Cool Nerd (talk) 16:29, 31 January 2014 (UTC)


 * See para 2 of section 'introduction' . I think the greater risk lies with parents not attempting ORT at all, if they think it won't work because they don't happen to have access to the adjuncts like zinc (or safe food for that matter). By far and away, the most important element of ORT is the fluid and the article should not try to suggest otherwise. Also, wiki mos says avoid lists and excessive direct quotes where possible. It is an encyclopaedia, not a "how to" manual.


 * The way I read it, WHO is saying start early, prevent dehydration in the first place. Use home fluids like salted rice water, unsalted rice water, weak unsweetened tea, etc, etc, etc.  Cool Nerd (talk) 22:35, 31 January 2014 (UTC)

And continuing to look for other good sources
http://www.oley.org/documents/ORS%20Article%20-%20Dr.%20Kelly.pdf

http://www.cdc.gov/cholera/treatment/rehydration-therapy.html

Oral rehydration therapy / oral rehydration solution, PATH, "PATH is an international nonprofit organization that transforms global health through innovation."

Pneumonia and Diarrhoea: Tackling the Deadliest Diseases for the World’s Poorest Children. New York: UNICEF; 2012

http://www.unicef.org/media/files/UNICEF_P_D_complete_0604.pdf


 * posted by Cool Nerd (talk) 22:44, 31 January 2014 (UTC)

Controversy and ongoing investigations
section /* Controversy and ongoing investigations */ has been edited to take on a more NPOV based upon the current edit of the Gatorade article. MatthewEHarbowy (talk) 06:00, 4 February 2014 (UTC)

Collaboration with Cool Nerd
This is my discussion with Cool Nerd on my talk page over last couple of weeks after I had completed a major copyedit. I feel Cool Nerd has very strong opinions about this topic, which is great, but sadly, I have found a lack of willingness by Cool Nerd to accept the bulk of evidence and clinical experience and to be distracted by minutiae. Unfortunately the article suffers: for instance, the lead is now way too long and unwieldy. The whole article now needs another copy edit. I'm glad my original edit is archived so it might help someday. That's really all I can say. I have to move on now because my brick wall is getting a dent in it. Good luck everyone - it could be a really good article.Myrtlegroggins (talk) 21:34, 4 February 2014 (UTC)


 * "Thank for your work regarding Oral rehydration therapy. If you have time, there's an issue where some publications recommend 1 teaspoon salt and 6 teaspoons sugar per liter water whereas others recommend only 1/2 teaspoon salt (along with 6 teaspoons sugar). I think we should probably include sources recommending both. Please take a look at this if you have the time and interest. Thanks. Cool Nerd (talk) 11:31 am, 24 January 2014, Friday (12 days ago) (UTC+10)
 * Hi Cool Nerd. Thanks for your message. I am interested to work this out and have an explanation. One thing that occurs to me is to look to see whether the small change in salt has any clinical impact. I'll look into it for sure. Cheers, Myrtle.Myrtlegroggins (talk) 5:55 pm, 24 January 2014, Friday (12 days ago) (UTC+10)Hi, I've made some changes trying to hit the high points sooner. Please feel free to change them back or experiment. I view it very much as a work in progress.With the differing ORS recipes, I think there's a difference. I mean, it's twice as much salt. But even more than that, I don't want us to put ourselves in a position of making clinical judgments. All we can do is pull from WHO, CDC, and other well-regarded publications and summarize in straightforward fashion, at least as it seems to me. And I am not a doctor, I want to be clear about that. Cool Nerd (talk) 6:35 am, 25 January 2014, Saturday (11 days ago) (UTC+10)Cool Nerd, hi again, If you have a moment, could you have a look and see that I have kept all the points you wanted to include? Regards, Myrtle. Myrtlegroggins (talk) 6:25 pm, 25 January 2014, Saturday (11 days ago) (UTC+10)

Hi, Okay, you've asked if it's kept all the points? No, I'm sorry. I'd rather not use the valuable real estate of the opening paragraph on the history. I'd rather discuss what ORT is right now, including that it's more than just the solution itself. Now, this said, I am in favor of experimentation and continued research. So, yes, I'm in favor of trying things. And it is remarkable that ORT is (widely?) regarded as one of the most relevant health advances (the last thirty years?). But I still do want the right now. Unfortunately, it will probably be the middle of the week before I can put a good chunk of time in it. Cool Nerd (talk) 8:31 am, 26 January 2014, Sunday (10 days ago) (UTC+10)
 * Cool Nerd, I appreciate and I admire how invested you are in this article. I feel that you see it in your mind's eye in a very particular way. However, I'm honestly not seeing a great deal of willingness to compromise on your part at the moment, especially when it comes to adopting an encyclopaedic structure for the article, so I'll wish you happy editing and move on. My only other suggestions would be firstly, to try to avoid too many direct quotes and a "how to" tone in the article and also try to avoid overly long sentences for the sake of readability. Kind regards, Myrtle. Myrtlegroggins (talk) 1:08 pm, 26 January 2014, Sunday (10 days ago) (UTC+10)Hi Myrtle, you said you were going to graciously bow out. Actually, I'd rather you be in there helping. I think there are some real issues that well warrant some additional research. Cool Nerd (talk) 8:31 am, 1 February 2014, last Saturday (4 days ago) (UTC+10)Hi there. When I did the copy edit, I read the available scientific literature and it seemed to me that the main concepts were covered in the article. Perhaps you can explain again what you feel are the unresolved issues? Myrtle Myrtlegroggins (talk) 8:35 pm, 1 February 2014, last Saturday (3 days ago) (UTC+10)

Okay, the differing recipes, whether the fluid itself and starting early is by far the most important part, because some contexts really emphasize the zinc (and maybe the continued eating as well), the JAMA editorial that the original compromise has been pushed to the breaking point. Specially, that the reduced-osmolarity solution, whereas it's okay and certainly better than nothing, is not the best formula for adults with cholera. This editorial is now almost ten years old. I would hope that there's been some work and some investigation since then, but maybe not. Again, I am not a doctor. I am just very interested in these issues. Cool Nerd (talk) 4:26 am, Yesterday (UTC+10) I understand your concerns. Perhaps I can help by giving some practical background experience and expertise. With respect to differing recipes: there could be several explanations - for instance, the advice given to the SA soccer folk might have been directed towards unwell adult sports tourists whereas, the WHO is more concerned with feeble sick children in refugee camps - so, differing recipes for differing potential patient groups; or, there are errors or elements of misinformation about - this is possible, not everyone is lovely and precise as you or I :-). If we take the case of parents making up an ORT fluid, they will use what they have available at the time to save their child's life, even boiled rice water.The differences in the recipes that you have noted are not likely to have any major clinical impact. Yes, the amount of sugar may be double that of in another, but, when mixing a half or one teaspoon of sugar in 1000 ml water, the difference in the overall concentration (as a *portion* of the much greater amount of water) is is minimal. If it were a half or one teaspoon of sugar in 10 or 100 ml water, it would be a very different case. In a real world sense, these differences are able to be tolerated. I think I did point out in my copy edit the existence of different recipes.With respect to the fluid versus the adjuncts (eating and zinc), I can, without any doubt, say that however a previous document is written or seems to say, the fluid is definitely the most important element in preventing deaths from cholera. If a baby or child is dehydrated from the fluid lost in the diarrhoea, no amount of feeding or zinc supplementation will make any difference to whether the child lives or dies. There is good physiological reasoning behind this and no one would ever do a head to head trial of food and or zinc versus ORT fluid because to do so would be a criminal act. I can't say strongly enough that the article must *not* suggest in any way or form that the ORT fluid is not the most important element.If I understand correctly, the 'reduced osmolality' data was used specifically to provide manufacturing guidelines for the pre-prepared powders. True, in the future, the manufacturing guidelines may take account of differing patient groups as you suggest and be revised again. However, Wiki can only say what is true of today, that's the nature of an encyclopaedia. It can't speculate what might be determined to be right or wrong in the future.To move forward, I think we need to first carefully look at this: https://en.wikipedia.org/wiki/Wikipedia:MOSINTRO#Introductory_text and work on the lead of the article, probably combining both our concepts of what it should be.Myrtlegroggins (talk) 7:37 am, Yesterday (UTC+10) Hi, the part with the differing recipes refers to salt. Some recommend one teaspoon (and not only the pamphlet for the World Cup), and some recommend one-half. Looking at it one way, it's double the amount. Looking at it from the other direction, it's a reduction of 50%. I'm not at all ready to say this doesn't matter.

I personally agree with you that starting the fluid early and often is the single most important thing, but. . we've got to go with the references. And diving into the references with a specific question, even a very good specific question, that is often harder than one might think.

I really like the approach with writing, assume my reader is slightly smarter than I am. They just don't happen to know this particular information. So, I don't need to talk down to them or overexplain in any manner. I can just present the information in a very straightforward manner. So, even a parent with little formal information, with what affects their child, the parent is likely to be very smart indeed. And this parent is likely to have a healthy interplay between officialdom information and facts on the ground so to speak, perhaps a healthier interplay than I have. Again, they're slightly smarter, I try to approach it that way.

I think an introduction becomes a no man's land that few people read. Whereas with the lead, as long it's well-written without too much repetitive information, people will keep reading it. Cool Nerd (talk) 5:35 am, Today (UTC+10)


 * Ok, good luck with it. I'll put our discussion on the talk page of the article so everyone can see where you are up to with the collaboration side of things. Myrtle. Myrtlegroggins (talk) 7:23 am, Today (UTC+10)"

minutiae?
Wow. And I will try to respond to some of this.

Some authoritative sources recommend one liter water, 6 teaspoons sugar, and one teaspoon salt.

Other authoritative sources recommend one liter water, 6 teaspoons sugar, and 1/2 teaspoon salt.

Looked at from one direction, this is a doubling of the amount of salt. Looked at from the other direction, it's a reduction of 50%. This could well be clinical significant, and/or either end point could be bumping up against too much or too little.

As always, let's try and find additional good sources. I mean, what else can we do? Cool Nerd (talk) 22:47, 4 February 2014 (UTC)

bulk of evidence and clinical experience?
I'm assuming this applies to the differing recipes. Or the idea that starting and continuing with slow to moderate drinking of the fluid is more important by far than the zinc supplements, continuing to eat if possible, and watching for signs of dehydration. This makes sense to me personally, but we have got to have the sources to back this up. WHO does emphasize starting early to hopefully prevent dehydration, and we do currently include a goodly number of the same home recipes they include.

Even if we get a doctor onboard who works with kids at risk of dehydration, and I really hope we do---we cannot include anyone's unpublished clinical experience as a source. Cool Nerd (talk) 23:09, 4 February 2014 (UTC)

Lead
The lead is too long and as it stands, lends itself to being divided into a lead and introduction. Myrtlegroggins (talk) 11:50, 4 February 2014 (UTC)


 * Some wiki articles have short leads, others have longer leads. The problem I have with an 'introduction' is that it becomes kind of a wilderness hardly anyone ever reads, whereas people will read a lead as long as it's reasonably well-written and not too repetitive.  Cool Nerd (talk) 22:17, 7 February 2014 (UTC)

Recommendations
This article would benefit from following the standardized layout in WP:MEDMOS, and the sources should largely comply with WP:MEDRS. Lesion ( talk ) 11:04, 8 February 2014 (UTC)

ReSoMal for children with malnourishment
(from Archive 1)

National Guidelines for the Management of Severely Malnourished Children in Bangladesh, Institute of Public Health Nutrition, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh, May 2008. '''Step 3. Treat/prevent dehydration, page 21 (22 in PDF) a) Diagnosis “ .  .  .  Dehydration may be over estimated in a marasmic/wasted child and underestimated in a kwashiorkor/oedematous child. Therefore, assume that children with watery diarrhoea may have dehydration.” b) Treatment:''' “The standard oral rehydration salts (ORS) solution (90 mmol sodium/L) and the newly modified WHO-ORS (75 mmol sodium/L) contains too much sodium and too little potassium for severely malnourished children. Instead give special Rehydration Solution for Malnutrition (ReSoMal) (For recipe see Annex 2). . .  ”  page 22 (23 in PDF)  “If diarrhoea is severe then new WHO-ORS (75 mmol sodium/L) may be used because the loss of sodium in the stool is high and symptomatic hyponatraemia can occur with ReSoMal. “Low blood volume can coexist with oedema. Do not use the IV route for rehydration except in cases of shock and then do so with care, infusing slowly to avoid flooding the circulation and overloading the heart (see Section 7).” '''Step 5. Treat/prevent infection''' page 24 (25 in PDF) “. . .  In severe acute malnutrition the usual signs of infection, such as fever, are often absent, and infections are often hidden. Therefore routinely treat all severely malnourished children on admission with broad-spectrum antibiotics. . .  ”


 * posted by Cool Nerd (talk) 17:49, 10 February 2014 (UTC)

Back to basics
Surely the point of ORT is to supply severely dehydrated people (including children) with useful amounts of clean water, sugar and salt? Arguing about different recipes for DIY rehydration solutions from various bodies is missing the point. A pinch of salt in 200ml of orange juice diluted to 500ml with water makes an excellent rehydration solution. There are no hard and fast rules here. --31.185.203.0 (talk) 19:21, 17 March 2014 (UTC)
 * I agree there's most probably range of good rehydration solutions. All the same, I do want to see a reference.  Cool Nerd (talk) 21:13, 1 April 2014 (UTC)

More on zinc
THE TREATMENT OF DIARRHOEA: A manual for physicians and other senior health workers, WHO, 2005.

2. ESSENTIAL CONCEPTS CONCERNING DIARRHOEA 2.5 Zinc "Zinc deficiency is widespread among children in developing countries and occurs in most part of Latin America, Africa, the Middle East, and South Asia. .  .  "

"Numerous studies have now shown that zinc supplementation (10-20 mg per day until cessation of diarrhoea) significantly reduces the severity and duration of diarrhoea in children less than 5 years of age. Additional studies have shown that short course supplementation with zinc (10-20 mg per day for 10 to 14days) reduces the incidence of diarrhoea for 2 to 3 months.

"Based on these studies, it is now recommended that zinc (10-20 mg/day) be given for 10 to 14 days to all children with diarrhoea." . . 4. MANAGEMENT OF ACUTE DIARRHOEA (WITHOUT BLOOD) 4.2 Treatment Plan A: home therapy to prevent dehydration and malnutrition 4.2.2 Rule 2: Give supplemental zinc (10 - 20 mg) to the child, every day for 10 to 14 days "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." 4.3 Treatment Plan B: oral rehydration therapy for children with some dehydration 4.3.7 Giving Zinc "Begin to give supplemental zinc, as in Treatment Plan A, as soon the child is able to eat following the initial four-hour rehydration period." . . 7. MANAGEMENT OF PERSISTENT DIARRHOEA 7.5 Give supplementary multivitamins and minerals "All children with persistent diarrhoea should receive supplementary multivitamins and minerals each day for two weeks. Locally available commercial preparations are often suitable; tablets that can be crushed and given with food are least costly. These should provide as broad a range of vitamins and minerals as possible, including at least two recommended daily allowances (RDAs) of folate, vitamin A, zinc, magnesium and copper." . . 8. MANAGEMENT OF DIARRHOEA WITH SEVERE MALNUTRITION 8.3.1 Initial diet. . .  • skimmed milk powder 25 g • vegetable oil 20 g • sugar 60 g • rice powder (or other cereal powder) 60 g, and • water to make 1000 ml. . .   8.3.3 Vitamins, minerals and salts "The following mixture of salts should be added to every two litres of both liquid diets described above.  KCl 3.6 g K3 citrate 1.3 g MgCl2.6H2O 1.2 g Zn acetate.2H20 130 mg CuSO4.7H2O 22 mg NaSeO4.10H2O 0.44 mg KI 0.20 mg  "Vitamin A should be given as described in section 9.3. Multivitamin mixtures that provide at least two RDAs of all vitamins should be added to the diet or given separately. Supplementary iron should be given when weight gain is established (see also section 7.5)."


 * posted by Cool Nerd (talk) 22:19, 8 April 2014 (UTC)

Excellent history - Magic bullet: the history of oral rehydration therapy
It is difficult to find social histories of medical treatments sometimes. The paper Magic bullet: the history of oral rehydration therapy by J N Ruxin is already being used in the article but it could be summarized more fully, and this paper itself is a useful summary of a range of social issues. I am making a note here to highlight this.  Blue Rasberry  (talk)  16:27, 23 April 2014 (UTC)

Looking for recent (2014) research and news items.
http://allafrica.com/stories/201404240438.html

---

http://rehydrate.org/ (towards top)

Journal of Global Health - 2013 June; 3(1): 010403. - doi: 10.7189/jogh.03.010403

'Diarrheal disease is a leading cause of morbidity and mortality among children under five. Although oral rehydration solution (ORS) has tremendous therapeutic benefits, coverage of and demand for this product have remained low in many developing countries. This study surveyed caregivers and health care providers in India and Kenya to gather information about perceptions and use of various diarrhea treatments, assess reasons for low ORS use, and identify opportunities for expanding ORS use.

'"Children are dying for lack of basic healthcare knowledge among citizens and health workers, and this is especially true of children with diarrhoea. Previous studies have shown that only 1 in 10 children with diarrhoea in India receive increased fluids to prevent death from dehydration, contributing to more than a million deaths every year. Almost 4 in 10 receive less to drink than normal, thereby tragically *increasing* their risk of death as compared with carrying on as normal. By contrast, more than 1 in 3 are inappropriately given antibiotics, which are not generally recommended for childhood diarrhoea. . . '


 * posted by Cool Nerd (talk) 16:36, 3 May 2014 (UTC)

Family Practice Notebook, readily available alternatives
http://www.fpnotebook.com/peds/Pharm/OrlRhydrtnSltn.htm

V. Preparations: Alternative - Half-strength gatorade

A. Not ideal (not an exact substitute, low in sugar)

1. Could be used for brief Diarrhea as temporizing measure

B. Ingredients

1. Sodium: 55 mEq/L

2. Carbohydrates: 7 g/L

3. Potassium: 15 mEq/L

'''VI. Preparations: Alternatuve - Simple replacement formula'''

A. Not ideal

1. Does not include Potassium Replacement

B. Components

1. Salt 1/2 tsp

2. Sugar 6 tsp

3. Water 1 Liter [34 oz.]

'''VII. Preparations: Alternative - Homemade Cereal Based ORS'''

A. Not ideal

1. Risk of errors in preparation

B. Advantages

1. Better nutrient absorption

2. Easy and safe to prepare

C. Preparation

1. Solution should be thick, but pourable and drinkable

D. Ingredients

1. 1/2 cup of dry, precooked baby rice cereal

2. 2 cups water

3. 1/4 teaspoon salt


 * And although this source doesn't directly state it, also the idea of getting started early with what's readily available to hopefully prevent dehydration or limit its severity. Cool Nerd (talk) 17:13, 13 June 2014 (UTC)

We are not a how to guide and do not give medication dosing info per WP:MEDMOS Doc James  (talk · contribs · email) (if I write on your page reply on mine) 23:40, 16 June 2014 (UTC)

And in specific case of cholera, CDC recommends continuing to feed child
http://www.cdc.gov/haiticholera/pdf/chw_trainingmaterialsforcholera.pdf

"Continue to breastfeed your baby if they have watery diarrhea, even when traveling to get treatment."

"Adults and older children should continue to eat frequently." — Preceding unsigned comment added by Cool Nerd (talk • contribs) 21:16, 2 August 2013 (UTC)

in specific case of cholera (and perhaps other cases), CDC recommends that ORS with questionable water is better than no ORS at all
Community Health Worker Training Materials for Cholera Prevention and Control, CDC, slides at back are dated 11/17/2010, page 7 in PDF. "Note: If no fuel is available for boiling water or if no chlorine products are available to treat water to make it safe, community members should still make ORS with the water they have because ORS with any water can save lives." — Preceding unsigned comment added by Cool Nerd (talk • contribs) 21:23, 2 August 2013 (UTC)

Added mEq units for WHO/UNICEF preparation
Common OTC electrolyte replacements use equivalents and do not list grams so it can be difficult to compare otherwise. please check notes and verify my conversions

— Preceding unsigned comment added by Zephalis (talk • contribs) 19:45, 14 July 2015 (UTC)

Am I understanding this right?
Someone had to discover the "therapy" of drinking water when you're dehydrated? — Preceding unsigned comment added by 75.72.206.153 (talk) 19:57, 11 December 2015 (UTC)

Recommended usage of homemade solutions.
The following short paragraph on the page is incorrect in both spirit and substance:

> In situations where an oral rehydration solution is not available, homemade solutions are sometimes used.[7]However, there is currently insufficient evidence to recommend usage of these homemade solutions.[8]

Homemade solutions (aka Recommended Home Fluids, RHF's) are absoutely recommended when oral rehydration solution is not available. Clearly this is true. What is one to do? Not make a homemade solution when a child might die without it? In fact, this page lists various RHF's, as does the WHO guidelines. Secondly, the second reference to the study "The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality", does NOT say there's insufficient evidence to reccomend RHF's. Here's what it says:

- Conclusions ORS is effective against diarrhoea mortality in home, community and facility settings; however, there is insufficient evidence to estimate the effectiveness of RHFs against diarrhoea mortality.

There's simply not enough evidence to make any estimate of the effectiveness of RHFs. However, this is a known factor about RHFs. Since RHFs are made at home in villages, often far from anywhere they could report (even if they wanted to), it's difficult to measure their use, and therefore, their effectiveness. This is discussed at length in *Questioning the Solution: The Politics of Primary Health Care and Child Survival* ("Chapter 7: The Oral Rehydration Debate: ORS Packets or Home", Link to PDF). — Preceding unsigned comment added by CoolHandLouis (talk • contribs) 00:58, 25 June 2016 (UTC)

Food based Oral Rehydration Therapy
Sugar can be substituted with same weight of flour See https://www.researchgate.net/publication/310768571_Food_based_Oral_Rehydration_Therapy_Towards_a_Better_Cholera_Treatment — Preceding unsigned comment added by 75.51.147.76 (talk) 02:12, 23 May 2019 (UTC)