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Reference - JAMA 2016 Apr 30 early online (level 2 [mid-level] evidence)
Oral rehydration solution is the initial treatment for most children with gastroenteritis and acute diarrhea, as it serves to prevent and treat associated dehydration (J Pediatr Gastroenterol Nutr 2014 Jul;59(1):132). Electrolyte maintenance solution can be costly and the taste is unacceptable to many children (Pediatrics 1994 May;93(5):708). As a result, some children (even those with mild symptoms) become increasingly dehydrated, and as a result are taken to the emergency department to receive intravenous rehydration. A recent randomized noninferiority trial investigated whether the need for subsequent intravenous rehydration could be reduced by giving children with acute gastroenteritis half-diluted apple juice (or similar preferred fluid) instead of electrolyte maintenance solution.
Six-hundred forty-seven children aged 6 months to 5 years old with acute gastroenteritis and minimal dehydration were randomized to half-diluted apple juice/preferred fluids vs. electrolyte maintenance solution to replace fluid losses. The children were initially treated in the Emergency Department with the assigned fluid and based on the child’s progress, the attending physician could either discharge the patient on the study liquid, request a change to the alternative study liquid, or begin intravenous fluids. The primary composite outcome of treatment failure was defined as any of the following within 7 days of study initiation: hospitalization or IV rehydration, subsequent unscheduled physician visit for same episode of vomiting or diarrhea, protracted symptoms, physician request to change to alternative study liquid, and ≥ 3% weight loss or Clinical Dehydration Scale score of ≥ 5 at in-person follow-up.
Comparing apple juice/preferred fluids vs. electrolyte maintenance solution, treatment failure was observed in 16.7% vs. 25% (p = 0.006, NNT 12). Intravenous rehydration occurred at the initial emergency department visit in 0.9% vs. 6.8% (p < 0.001, NNT 17) and IV rehydration occurred within 7 days in 2.5% vs. 9% (p = 0.001, NNT 16). In a subgroup analysis based on age, children aged ≥ 24 months had a significant reduction in treatment failure comparing apple juice/preferred fluids vs. electrolyte maintenance solution (9.8% vs. 25.9%, p < 0.05, NNT 7), whereas children < 24 months had no significant difference in treatment failure. There were no significant differences in hyponatremia (reported in 1 child in each group), hospitalization rates, rate of subsequent unscheduled medical visits, extended symptomatology including diarrhea and vomiting frequency, crossover at the initial emergency visit, and weight loss or dehydration at follow-up.
While current guidelines for fluid replacement in children with acute gastroenteritis and diarrhea recommend using electrolyte solutions and recommend against fluids with abundant simple sugars (MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16), the present study demonstrates that diluted apple juice or similar preferred fluid reduces the need for intravenous rehydration. One reason fluids with high sugar content are viewed cautiously is their potential to induce osmotic diarrhea. However, this is not the only study that found the frequency of diarrheal stools was not significantly affected by high-sugar fluids in this setting (Nutr J 2005 Aug 9;4:23, JPEN J Parenter Enteral Nutr 2006 Sep-Oct;30(5):433). One limitation of the present trial was the lack of blinding of the parents regarding the assigned home therapy which may have influenced their decision to obtain additional care. Also patient adherence, treatment crossover, and total volume of fluids consumed at home, as well as electrolyte levels at revisit were not assessed. Overall these results indicate that a child’s preferred fluid may be a more effective option for rehydration than a less palatable electrolyte solution.
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