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Intravenous rehydration in children with severe malnutrition and severe dehydration: a systematic review and
Juan Emmanuel Dewez1, San Maurice Ouattara2, Temmy Sunyoto3
1London School of Hygiene and Tropical Medicine, London, UK.
Insights
Intravenous rehydration (IVR) may reduce mortality in children with severe acute malnutrition (SAM) and severe dehydration compared to oral rehydration (OR). IVR also appears to lead to fewer adverse events, though evidence certainty is moderate.
Area of Science:
- Pediatric critical care
- Nutritional science
- Infectious disease epidemiology
Background:
- Severe acute malnutrition (SAM) coupled with severe dehydration presents a critical challenge in pediatric healthcare.
- Gastroenteritis is a common cause of severe dehydration in children with SAM, necessitating effective rehydration strategies.
Purpose of the Study:
- To systematically review and meta-analyze the efficacy and safety of intravenous rehydration (IVR) versus oral rehydration (OR) in children with SAM and severe dehydration.
- To compare in-hospital mortality, fluid overload, shock development, electrolyte abnormalities, and 28-day mortality between IVR and OR strategies.
Main Methods:
- Systematic review and meta-analysis of randomized controlled trials (RCTs).
- Included studies focused on hospitalized children with SAM and severe dehydration secondary to gastroenteritis in lower-to-middle-income countries.
- Primary outcome was in-hospital mortality; secondary outcomes included fluid overload, shock, and electrolyte abnormalities.
Main Results:
- Three RCTs with 484 participants were analyzed. The pooled risk ratio for in-hospital mortality (IVR vs. OR) was 0.71 (95% CI 0.46 to 1.10) with moderate certainty of evidence.
- IVR was associated with a reduced risk of severe hyponatremia (pooled RR 0.66; 95% CI 0.44 to 0.99) at 24 hours.
- No significant differences were found in fluid overload events, and limited data existed for shock development and 28-day mortality.
Conclusions:
- The findings suggest a potential benefit of IVR over OR in reducing mortality for children with SAM and severe dehydration, ranging from a 54% reduction to a 10% increase.
- IVR demonstrated a trend towards fewer adverse events, including severe hyponatremia.
- Further research may be needed to definitively establish the superiority of IVR, given the moderate certainty of evidence.
Objectives:
To compare the efficacy and safety of intravenous rehydration (IVR) versus oral rehydration (OR) strategies in children with severe acute malnutrition (SAM) and severe dehydration.
Design:
Systematic review and meta-analysis.
Setting:
Lower-to-middle-income countries.
Patients:
Children with SAM are hospitalised with severe dehydration secondary to gastroenteritis.
Interventions:
Randomised trials of IVR and OR (standard of care) MAIN OUTCOME MEASURES: Primary: in-hospital mortality. Secondary: fluid overload events, development of shock requiring intravenous boluses, severe electrolyte abnormalities at 24 hours and day 28 mortality.
Results:
We identified three RCTs comprising 484 participants with severe malnutrition (72 had kwashiorkor, two had some risk of bias, and one had low risk of bias). The pooled risk ratio (RR) for in-hospital mortality for IVR versus OR is 0.71 (95% CI 0.46 to 1.10; I2=0.0%) with moderate certainty of evidence. No fluid overload events were reported, pooled RR 0.99 (95% CI 0.10 to 9.35). The pooled RR of severe hyponatraemia (sodium <125 or <130 mmol/L) at 24 hours was 0.66 (95% CI 0.44 to 0.99). Only one trial reported RR for shock development, hypernatraemia (sodium >145 mmol/L) or 28-day mortality with IVR versus OR (RRs 0.56, 95% CI 0.21 to 1.48; RR 2.05, 95% CI 0.50 to 8.58 and RR 0.85, 95% CI 0.44 to 1.65, respectively). Subgroup analyses for in-hospital mortality were carried out for region and risk of bias rating, giving p=0.85 and p=0.54 for heterogeneity, respectively.
Conclusions:
The estimated effect of using IVR versus OR in children with SAM with severe dehydration ranges from a 54% relative reduction to a 10% relative increase in the risk of death, with IVR resulting in fewer adverse events.
Prospero Registration Number:
CRD42025637956.
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