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#185 Drinking in the Evidence Around Mild-Moderate Dehydration Management in Kids with Gastroenteritis


CLINICAL QUESTION
QUESTION CLINIQUE
What is the best management of mild-moderate dehydration in children with gastroenteritis?


BOTTOM LINE
RÉSULTAT FINAL
For children with mild to moderate dehydration due to gastroenteritis, oral rehydration is equivalent to IV therapy. Half-strength apple juice is as good as electrolyte maintenance solution and appears to be superior in children ≥24 months. Liquid versus frozen administration is likely a matter of preference.  



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EVIDENCE
DONNÉES PROBANTES
  • Systematic review of 31 Randomized Controlled Trials (RCTs) of mild to moderate dehydration from gastroenteritis in developed countries.1 
    • Oral Rehydration (electrolyte maintenance solutions) versus Intravenous (IV), no significant difference in: 
      • Hospitalization (three RCTs, 136 patients): Relative Risk 0.80 (0.24-2.71). 
      • Return to Emergency Department (three RCTs, 193 patients): Relative Risk 0.86 (0.39-1.89). 
  • RCT of 647 children, mean age 28 months with generally mild dehydration (82% scored ≤1 out of 8 on clinical dehydration scale). Randomized to half-strength apple juice or preferred fluid versuapple-flavored, sucralose-sweetened pediatric electrolyte maintenance solution5 mL administered every 2-5 minutes while in the emergency department.2 
    • Those who vomited received oral ondansetron. 
    • Composite outcome: Treatment failure (including return to care, hospitalization, and IV rehydration). 
      • 17% apple juice versus 25% electrolyte solutionNumber Needed to Treat (NNT)~12.   
      • Treatment equal if age <24 months; if ≥24 months dilute apple juice superior NNT~7.
CONTEXT: 
  • One crossover, open label trial3 of 91 children presenting to ER with mild-moderate dehydration found frozen electrolyte replacement solution preferable to liquid with a NNT of 3. Only the frozen solution was sweetened. 
  • Ondansetron reduces the risk of requiring IV therapy (NNT~5) and hospitalization (NNT~14) in vomiting children.4 
  • Most guidelines currently recommend oral rehydration solutions as first line with frequent small volumes (5 mL every 2-3 minutes)5 and early refeeding once hydrated.6 
  • Oral rehydration solutions are approximately 4x the cost of regular juice (8x the cost of juice diluted 1:1 with water).


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Author(s)
Auteur(s)
  • Alanna Achen MD
  • Christina Korownyk MD CCFP

1. Freedman SB, Pasichnyk D, Black KJ, et al. PLoS One. 2015 Jun 15; 10(6):e0128754.

2. Freedman SB, Willan AR, Boutis K, et al. JAMA. 2016 May 10; 315(18):1966-74.

3. Santucci KA, Anderson AC, Lewander WJ, et al. Arch Pediatr Adolesc Med. 1998 Feb; 152(2):142-6.

4. Allan GM, Wilson E, Ivers N. Can Fam Physician. 2012; 58:167.

5. The Hospital for Sick Children. Acute gastroenteritis in children aged 2 months though 5 years. 2013. Available at: https://www.sickkids.ca/clinical-practice-guidelines/clinical-practice-guidelines/export/CLINS100/Main%20Document.pdf. Last Accessed: February 14, 2017.

6. Guarino A, Ashkenazi S, Gendrel D, et al. J Pediatr Gastroenterol Nutr. 2014 Jul; 59(1):132-52.

Authors do not have any conflicts of interest to declare.