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ORAL REHYDRATION WITH FIZZ BUT NO CHLORIDE
540 in which they would be drunk, and where dilution was required distilled water was used. All drinks tested contained substantial quantities of sugars (table). The proportions of the different sugars varied and the sucrose content was sometimes low. However, total sugar content was as high as 41 equivalent teaspoons of sugar (sucrose) in a volume which would normally be taken by a baby. These drinks can demineralise tooth enamel just as much as sucrose-based drinks.2 The ability of a food to promote dental caries depends on factors such as total sugar content, retentiveness, frequency of use, and presence of cariogenic bacteria in the mouth. The use or absence of preventive measures, such as fluoride, is also a factor. The high sugar content of the drinks we tested indicates that they all have a high cariogenic potential. The fact that they have "no added sugar" does not make them any less dangerous to the teeth, especially when they are used frequently throughout the day. Many mothers will give their baby a drink at bedtime and let him or her sip the drink for a time until the baby goes to sleep. This practice is especially harmful to teeth if the drink contains sugars of any type. Prevention of nursing bottle carries is best achieved by advising mothers how to use these drinks properly. Clinicians should be aware that the major factor determining the effect of these drinks on dental decay will be the frequency of use. Any drink containing sugars, even natural ones, will provide a substrate for oral bacteria to produce acids which may damage the teeth. Mothers should be made aware that frequent use throughout the day, or at bed time, may harm teeth. The drinks should be provided only at meal times, and drinks between meals should be milk (without sugar added) or water.
Department of Child Dental Health, School of Dentistry, University of Leeds,
M. E. J. CURZON ZARA ALEMI M. S. DUGGAL
Leeds LS2 9LU 1
Ripa LW Nursing habits and dental decay in infants: "nursing bottle caries" J Dent Child 1987; 45: 274-75. AJ, Shaw L. Baby fruit juices and tooth erosion. Br Dent J 1978, 162: 65-67.
2. Smith
DECREASE IN ACUTE HEPATITIS B INCIDENCE
CONTINUED IN 1987
SiR,—The sharp decrease in the annual total of acute hepatitis B reports to the Public Health Laboratory Service noted in 19861 was continued in 1987. The total of about 800 cases reported in the year was less than half of the largest annual number (recorded in 1984) and was the smallest observed since a special record for reporting hepatitis B was started in 1974. The decrease was associated with a change in the annual number of cases with a history of drug abuse, from 585 in 1984 to about a quarter of that number in 1987 (figure). Also a fall in the number of homosexual men with acute hepatitis B, from 150 in 1984 to about a third in 1987, contributed to the general decrease. Hepatitis B vaccine has been available in Britain for about five years. Although its use may have accelerated lately it is unlikely to have been administered widely enough-especially among drug abusers-to have brought about such a swift and dramatic change.
lies in the similarity of the routes of the hepatitis B virus and the human immunodeficiency virus (HIV). Warnings about the risk of acquiring HIV infection, leading to a decrease in drug abuse by injection or syringe-sharing or both, might have caused a consequent fall in acute hepatitis B infections.
E1 more probable explanation transmission
of
Hepatitis Epidemiology Unit, Central Public Health Laboratory,
SHEILA POLAKOFF
London NW9 5HT 1. Polakoff S. Decrease in acute hepatitis B incidence Lancet 1987; i: 380.
in
England and Wales in 1985-86.
ORAL REHYDRATION WITH FIZZ BUT NO CHLORIDE
SiR,—Chloride is an essential extracellular anion, and it is important in maintaining normal acid-base balance, extracellular fluid volume, and normal growth during infancy. Although chloride losses in acute gastroenteritis vary, depending upon the severity of the diarrhoea, the presence of vomiting, and the infecting agent,2 every untreated patient has a net chloride deficit. In moderately severe diarrhoeal dehydration in children, the anion deficit (chloride + bicarbonate) may be as much as 28 mmoljkg.3 We were therefore surprised to see the introduction of a new oral rehydration solution which lacks chloride. ’Dioralyte’ effervescent tablets (Rorer) provide, in appropriate solution, sodium 35, potassium 20, citrate 55, and glucose 200 mmol/1; the data sheet recommends them for use in infants and children. The complete substitution of citrate for chloride is a major departure from previous, physiologically based, and highly successful oral rehydration solutions. We know of no evidence to suggest that a chloride-free solution confers any advantage, or indeed that it is even safe for infants and children. The manufacturers recommend that dioralyte tablets may be given alone for at least 24-48 h; we suggest that the use of such a solution may give rise to clinical chloride deficiency. Attention was recently drawn to an important syndrome, specific to chloride depletion, in six babies with failure to thrive, muscular weakness, constipation, and delayed motor development after receiving a low-chloride formula feed.4 One of the major symptoms of chloride depletion in these babies was severe anorexia. It seems inappropriate to administer a solution which may both exacerbate a well-recognised and important feature of acute gastroenteritisS,6 and jeopardise expansion of extracellular fluid volume.1.4 This effervescent, chloride-free preparation seems unnecessary, and is a potentially dangerous way of putting some fizz into oral
rehydration. Institute of Child Health, University of Birmingham, Nuffield Building, Birmingham B16 8ET 1. 2.
3.
4.
5. 6.
I. W. BOOTH D. E. SMITH
Simopoulos AP, Bartter FC.
The metabolic consequences of chloride deficiency. Nutr Rev 1980; 38: 201-05. Molla AM, Rahman M, Sarker SA, Sack DA, Molla A Stool electrolyte content and purging rates in diarrhoea caused by rotavirus, enterotoxigenic E coli and V cholerae in children. J Paediatr 1981; 98: 835-38. Dell RB. Pathophysiology of dehydration. In Winters RW, ed. The body fluids in pediatrics Boston: Little, Brown, 1973: 134-54. Roy S III, Avant BS Jr. Hypokalemic metabolic alkalosis in normotensive infants with elevated plasma renin activity and hyperaldosteronism. Role of dietary chloride deficiency. Pediatrics 1981; 67: 423. Hoyle B, Yunus M, Chen LC Breast feeding and food intake among children with acute diarrhoeal disease. Am J Clin Nutr 1980; 33: 2365-71. Mata LJ, Kromal RA, Urrutin JJ, Garcia B. Effect of infection on food intake and the nutritional state: perspectives as viewed from the village. Am J Clin Nutr 1977, 30: 1215-27
SCREENING FOR OVARIAN CANCER BY CA-125 MEASUREMENT
Acute hepatitis B reports 1975-87.
to
Public Health
Laboratory Service,
SIR,-Mr Jacobs and colleagues (Feb 6, p 268) suggest for ovarian cancer, at present the biggest challenge in gynaecological oncology, that the way forward is the development of an efficient "screening test". This approach is attractive because the detection of symptomless early stage disease would improve the prognosis. In the absence of such a test more than 70% of patients present with metastasis beyond the pelvis and are incurable. As Jacobs et al
Department of Child Dental Health, School of Dentistry, University of Leeds,
M. E. J. CURZON ZARA ALEMI M. S. DUGGAL
Leeds LS2 9LU 1
Ripa LW Nursing habits and dental decay in infants: "nursing bottle caries" J Dent Child 1987; 45: 274-75. AJ, Shaw L. Baby fruit juices and tooth erosion. Br Dent J 1978, 162: 65-67.
2. Smith
DECREASE IN ACUTE HEPATITIS B INCIDENCE
CONTINUED IN 1987
SiR,—The sharp decrease in the annual total of acute hepatitis B reports to the Public Health Laboratory Service noted in 19861 was continued in 1987. The total of about 800 cases reported in the year was less than half of the largest annual number (recorded in 1984) and was the smallest observed since a special record for reporting hepatitis B was started in 1974. The decrease was associated with a change in the annual number of cases with a history of drug abuse, from 585 in 1984 to about a quarter of that number in 1987 (figure). Also a fall in the number of homosexual men with acute hepatitis B, from 150 in 1984 to about a third in 1987, contributed to the general decrease. Hepatitis B vaccine has been available in Britain for about five years. Although its use may have accelerated lately it is unlikely to have been administered widely enough-especially among drug abusers-to have brought about such a swift and dramatic change.
lies in the similarity of the routes of the hepatitis B virus and the human immunodeficiency virus (HIV). Warnings about the risk of acquiring HIV infection, leading to a decrease in drug abuse by injection or syringe-sharing or both, might have caused a consequent fall in acute hepatitis B infections.
E1 more probable explanation transmission
of
Hepatitis Epidemiology Unit, Central Public Health Laboratory,
SHEILA POLAKOFF
London NW9 5HT 1. Polakoff S. Decrease in acute hepatitis B incidence Lancet 1987; i: 380.
in
England and Wales in 1985-86.
ORAL REHYDRATION WITH FIZZ BUT NO CHLORIDE
SiR,—Chloride is an essential extracellular anion, and it is important in maintaining normal acid-base balance, extracellular fluid volume, and normal growth during infancy. Although chloride losses in acute gastroenteritis vary, depending upon the severity of the diarrhoea, the presence of vomiting, and the infecting agent,2 every untreated patient has a net chloride deficit. In moderately severe diarrhoeal dehydration in children, the anion deficit (chloride + bicarbonate) may be as much as 28 mmoljkg.3 We were therefore surprised to see the introduction of a new oral rehydration solution which lacks chloride. ’Dioralyte’ effervescent tablets (Rorer) provide, in appropriate solution, sodium 35, potassium 20, citrate 55, and glucose 200 mmol/1; the data sheet recommends them for use in infants and children. The complete substitution of citrate for chloride is a major departure from previous, physiologically based, and highly successful oral rehydration solutions. We know of no evidence to suggest that a chloride-free solution confers any advantage, or indeed that it is even safe for infants and children. The manufacturers recommend that dioralyte tablets may be given alone for at least 24-48 h; we suggest that the use of such a solution may give rise to clinical chloride deficiency. Attention was recently drawn to an important syndrome, specific to chloride depletion, in six babies with failure to thrive, muscular weakness, constipation, and delayed motor development after receiving a low-chloride formula feed.4 One of the major symptoms of chloride depletion in these babies was severe anorexia. It seems inappropriate to administer a solution which may both exacerbate a well-recognised and important feature of acute gastroenteritisS,6 and jeopardise expansion of extracellular fluid volume.1.4 This effervescent, chloride-free preparation seems unnecessary, and is a potentially dangerous way of putting some fizz into oral
rehydration. Institute of Child Health, University of Birmingham, Nuffield Building, Birmingham B16 8ET 1. 2.
3.
4.
5. 6.
I. W. BOOTH D. E. SMITH
Simopoulos AP, Bartter FC.
The metabolic consequences of chloride deficiency. Nutr Rev 1980; 38: 201-05. Molla AM, Rahman M, Sarker SA, Sack DA, Molla A Stool electrolyte content and purging rates in diarrhoea caused by rotavirus, enterotoxigenic E coli and V cholerae in children. J Paediatr 1981; 98: 835-38. Dell RB. Pathophysiology of dehydration. In Winters RW, ed. The body fluids in pediatrics Boston: Little, Brown, 1973: 134-54. Roy S III, Avant BS Jr. Hypokalemic metabolic alkalosis in normotensive infants with elevated plasma renin activity and hyperaldosteronism. Role of dietary chloride deficiency. Pediatrics 1981; 67: 423. Hoyle B, Yunus M, Chen LC Breast feeding and food intake among children with acute diarrhoeal disease. Am J Clin Nutr 1980; 33: 2365-71. Mata LJ, Kromal RA, Urrutin JJ, Garcia B. Effect of infection on food intake and the nutritional state: perspectives as viewed from the village. Am J Clin Nutr 1977, 30: 1215-27
SCREENING FOR OVARIAN CANCER BY CA-125 MEASUREMENT
Acute hepatitis B reports 1975-87.
to
Public Health
Laboratory Service,
SIR,-Mr Jacobs and colleagues (Feb 6, p 268) suggest for ovarian cancer, at present the biggest challenge in gynaecological oncology, that the way forward is the development of an efficient "screening test". This approach is attractive because the detection of symptomless early stage disease would improve the prognosis. In the absence of such a test more than 70% of patients present with metastasis beyond the pelvis and are incurable. As Jacobs et al