- Design
- Systematic review and meta-analysis of randomised controlled trials
- Population
- 3 trials, 484 children with severe acute malnutrition and severe dehydration in LMICs
- Primary outcome
- In-hospital mortality
- Effect
- RR 0.71 (95% CI 0.46–1.10), I² = 0%; severe hyponatraemia RR 0.66 (0.44–0.99)
WHO guidance for children with severe acute malnutrition (SAM) and dehydration favours slow oral or nasogastric rehydration, reserving intravenous fluids for shock, because of concern about fluid overload and heart failure. This systematic review pooled three randomised trials (484 children, 72 with kwashiorkor) from low- and middle-income countries comparing intravenous rehydration with oral rehydration in SAM with severe dehydration from gastroenteritis.
In-hospital mortality had a pooled risk ratio of 0.71 (95% CI 0.46 to 1.10, I² = 0%) with intravenous rehydration, moderate certainty. No fluid overload events were reported, but with so few children the estimate is very imprecise (pooled RR 0.99, 95% CI 0.10 to 9.35). Severe hyponatraemia at 24 hours was less common with intravenous fluids (RR 0.66, 0.44 to 0.99). Data on shock and 28-day mortality came from a single trial.
These trials were too small to show whether intravenous fluids cause or prevent harm, and three trials with a confidence interval crossing 1.0 are not enough to overturn WHO guidance. This is a question India's nutritional rehabilitation centres and paediatric wards face daily.
- Continue to follow WHO and national SAM protocols for rehydration until guidance changes.
- Do not withhold intravenous fluids from a child with SAM who is in shock.
- Monitor sodium in children with SAM and diarrhoea; severe hyponatraemia occurred in both arms.
- Watch for fluid overload by checking respiratory rate, liver size and weight regularly during any rehydration.
Why it matters
It puts the long-held caution about intravenous fluids in severely malnourished children to a trial test, though the evidence is still too thin to settle it.
Don't overread it
The mortality result is not statistically significant and has not changed WHO guidance.
The statistics, in plain English
A risk ratio of 0.71 would mean 29% fewer deaths, but the 95% CI (0.46 to 1.10) includes 1.0, so no difference is also possible. The authors put it as anything from a 54% reduction to a 10% increase in risk. Three trials and 484 children is a small evidence base.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for paediatrics, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free