Cochrane for Clinicians

Putting Evidence into Practice

Oral Rehydration Solutions for the Treatment of Acute Watery Diarrhea


Am Fam Physician. 2017 Dec 1;96(11):700-701.

Author disclosure: No relevant financial affiliations.

Clinical Question

What are the most appropriate oral rehydration solutions for the treatment of acute watery diarrhea?

Evidence-Based Answer

Oral rehydration solutions are distinguished by high or low osmolarity and by whether they are made with complex (i.e., polymer) or simple (i.e., glucose) carbohydrates. When oral rehydration solutions with high osmolarity (310 mOsm per L or greater) are compared, polymer-based solutions may result in lower stool output in the first 24 hours and shorter duration of diarrhea than glucose-based solutions. They may also reduce the need for unscheduled intravenous fluids in persons with noncholera diarrhea (number needed to treat [NNT] = 27). When oral rehydration solutions with low osmolarity (270 mOsm per L or less) are compared, the evidence is insufficient to demonstrate a difference between polymer-based and glucose-based solutions. Regardless of osmolarity, polymer-based solutions do not appear to reduce vomiting and electrolyte disturbances compared with glucose-based solutions.1 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Oral rehydration solutions are essential in the management of acute watery diarrhea. The original oral rehydration solution formulation, introduced by the World Health Organization (WHO) in 1979, consisted of glucose and other electrolytes with an osmolarity of 310 mOsm per L. It improved signs of dehydration but did not reduce stool volume loss or diarrhea duration, and the high osmotic load potentiated fluid losses and electrolyte imbalances. Since 2004, the WHO has recommended low-osmolarity glucose-based oral rehydration solutions.2

Starch polymers contain a complex carbohydrate such as rice or wheat. These are slowly broken down into glucose, which may improve transport of sodium and water across the intestinal epithelium. This review sought to determine whether polymer-based oral rehydration solutions, at either high or low osmolarity,

Author disclosure: No relevant financial affiliations.

The practice recommendations in this activity are available at

The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the U.S. Air Force, the Department of Defense, or the U.S. government.


show all references

1. Gregorio GV, Gonzales ML, Dans LF, Martinez EG. Polymer-based oral rehydration solution for treating acute watery diarrhoea. Cochrane Database Syst Rev. 2016;(12):CD006519....

2. United Nations Children's Fund (UNICEF)/World Health Organization (WHO). Diarrhoea: why children are still dying and what can be done. 2009. Accessed April 25, 2017.

3. King CK, Glass R, Bresee JS, Duggan C; Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1–16.

4. Committee on Nutrition 2012–2013. Oral therapy for acute diarrhea. In: Kleinman RE, Greer FR, eds. Pediatric Nutrition: Policy of the American Academy of Pediatrics. 7th ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2014.

5. National Institute for Health and Care Excellence. Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management. Clinical guideline [CG84]. April 2009. Updated February 2014. Accessed April 11, 2017.

6. World Health Organization/United Nations Children's Fund. Oral rehydration salts: production of the new ORS. Geneva, Switzerland: World Health Organization; 2006. Accessed April 25, 2017.

7. Farthing M, Salam M, Lindberg G, et al. Acute diarrhea in adults and children: a global perspective. World Gastroenterology Organisation Global Guidelines. February 2012. Accessed April 12, 2017.

8. Gottlieb T, Heather CS. Diarrhoea in adults (acute). BMJ Clin Evid. 2011;2011.

9. Guarino A, Ashkenazi S, Gendrel D, Lo Vecchio A, Shamir R, Szajewska H. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014. J Pediatr Gastroenterol Nutr. 2014;59(1):132–152.

10. Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966–1974.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.

A collection of Cochrane for Clinicians published in AFP is available at



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