Intravenous versus oral rehydration in severe malnutrition: the evidence cannot yet decide

Design

Systematic review and meta-analysis of randomised trials (PROSPERO registered)

Population

484 children with severe acute malnutrition and severe dehydration in lower- and middle-income countries (3 trials)

Primary outcome

In-hospital mortality, intravenous vs oral rehydration

Effect

RR 0.71 (95% CI 0.46 to 1.10); severe hyponatraemia at 24 hours RR 0.66 (95% CI 0.44 to 0.99)

This systematic review compared intravenous rehydration with oral rehydration, the standard of care, in children with severe acute malnutrition and severe dehydration from gastroenteritis. It pooled three randomised trials with 484 children in lower- and middle-income settings, 72 of them with kwashiorkor.

In-hospital mortality was lower with intravenous rehydration, but the interval was wide: risk ratio 0.71 (95% CI 0.46 to 1.10; I-squared 0%), with moderate certainty. No fluid overload events were reported (RR 0.99, 95% CI 0.10 to 9.35), and severe hyponatraemia at 24 hours was less frequent (RR 0.66, 95% CI 0.44 to 0.99). Only one trial reported shock, hypernatraemia or 28-day mortality, with imprecise results. The authors summarise the effect as ranging from a 54% relative reduction to a 10% relative increase in death.

This does not overturn the existing recommendation for cautious, mainly oral rehydration in severe malnutrition, because intravenous fluids carry known risks in these children. The trials were few and small, and the review does not tell you when to switch. Until clearer data exist, follow the national or WHO protocol in your unit.

• Follow your unit's protocol for severe acute malnutrition with dehydration; this review does not change it.
• Assess for shock and signs of circulatory failure early, since intravenous fluid is reserved for those cases in standard guidance.
• Monitor sodium, fluid balance and signs of overload in any child given intravenous fluid.
• Record the rehydration route and outcome so local audit can contribute to the evidence.

Why it matters

It questions how firmly the preference for oral rehydration rests on trial evidence, without yet providing grounds to change it.

Don't overread it

The interval includes both a large benefit and a modest harm, and it does not alter any guideline; the three trials were small.

The statistics, in plain English

A risk ratio of 0.71 means 29% fewer deaths, but an interval from 0.46 to 1.10 includes no effect and a 10% increase. With only 484 children, the trials were not large enough to tell. An I-squared of 0% means the three trials agreed with each other, but that does not make the pooled estimate precise.

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.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.