Intravenous rehydration in malnourished children with severe dehydration: still an open question

Design

Systematic review and meta-analysis of randomised trials, PROSPERO registered

Population

484 children with severe acute malnutrition and severe dehydration from gastroenteritis in lower and middle-income countries

Primary outcome

In-hospital mortality

Effect

Intravenous vs oral rehydration RR 0.71 (95% CI 0.46 to 1.10); severe hyponatraemia RR 0.66 (0.44 to 0.99)

A systematic review of randomised trials compared intravenous with oral rehydration in children with severe acute malnutrition hospitalised with severe dehydration from gastroenteritis, in lower and middle-income settings. Three trials with 484 children were included; 72 had kwashiorkor.

In-hospital mortality was lower with intravenous rehydration but not significantly so: RR 0.71 (95% CI 0.46 to 1.10; I² 0%), moderate certainty. That interval runs from a 54% reduction to a 10% increase. No fluid overload events were reported. Severe hyponatraemia at 24 hours was less frequent with intravenous fluids (RR 0.66, 95% CI 0.44 to 0.99). Shock, hypernatraemia and day-28 mortality were reported by one trial each, with wide intervals.

The data do not support changing the accepted cautious approach to intravenous fluids in malnutrition, but they weaken the assumption that intravenous rehydration is more dangerous than oral in these children. Larger trials are needed.

• Follow your national or WHO protocol for severe acute malnutrition; this review does not overturn it
• Use oral or nasogastric rehydration with a suitable solution where the child can take it, and watch closely for signs of overload or shock
• Monitor sodium in children receiving rehydration, since severe hyponatraemia was less frequent with intravenous fluids in these trials
• Treat shock according to protocol, and reassess after each fluid step
• Refer children with kwashiorkor or any deterioration early to a facility with inpatient capacity

Why it matters

It questions a long-standing caution on intravenous fluids in malnutrition, a high-mortality group common in Indian wards.

Don't overread it

Three small trials with an interval that includes harm cannot justify routine intravenous rehydration.

The statistics, in plain English

A risk ratio of 0.71 would mean 29% fewer deaths with intravenous fluids, but the confidence interval (0.46 to 1.10) includes no difference and even a modest increase, so the review cannot say which is safer. With only 484 children, a few deaths either way would change the answer.

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