Abstract

Background: Rehydration strategies in children with severe acute malnutrition (SAM) and severe dehydration are extremely cautious. The World Health Organization (WHO) SAM guidelines advise strongly against intravenous fluids unless the child is shocked or severely dehydrated and unable to tolerate oral fluids. Otherwise, guidelines recommend oral or nasogastric rehydration using low sodium oral rehydration solutions. There is limited evidence to support these recommendations. Methods: We conducted a systematic review of randomised controlled trials (RCTs) and observational studies on 15 th June 2017 comparing different strategies of rehydration therapy in children with acute gastroenteritis and severe dehydration, specifically relating to intravenous rehydration, using standard search terms. Two authors assessed papers for inclusion. The primary endpoint was evidence of fluid overload. Results: Four studies were identified, all published in English, including 883 children, all of which were conducted in low resource settings. Two were randomised controlled trials and two observational cohort studies, one incorporated assessment of myocardial and haemodynamic function. There was no evidence of fluid overload or other fluid-related adverse events, including children managed on more liberal rehydration protocols. Mortality was high overall, and particularly in children with shock managed on WHO recommendations (day-28 mortality 82%). There was no difference in safety outcomes when different rates of intravenous rehydration were compared. Conclusions: The current 'strong recommendations' for conservative rehydration of children with SAM are not based on emerging evidence. We found no clinical trials providing a direct assessment of the current WHO guidelines, and those that were available suggested that these children have a high mortality and remain fluid depleted on current therapy. Recent studies have reported no evidence of fluid overload or heart failure with more liberal rehydration regimens. Clinical trials are urgently required to inform guidelines on routes and rates of intravenous rehydration therapy for dehydration in children with SAM.

Highlights

  • Severe acute malnutrition (SAM) is directly responsible for over 500,000 child deaths per year and plays a significant contributing factor in the deaths of many more[1]

  • Whilst the guidelines indicate that signs of severe dehydration in severe acute malnutrition (SAM) are unreliable markers of hydration status the Kilifi study showed that signs of severe dehydration were more common in those with diarrhoea (35% versus 8%) and was a risk factor for mortality (crude odds ratio 1.7; 95% confidence interval (CI) 1.1, 2.6; p = 0.012)

  • Study selection The search produced 599 studies After screening and evaluation, four studies were identified that investigate use of intravenous fluid treatment in children with severe malnutrition complicated by dehydration, incorporating a total of 883 patients

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Summary

Introduction

Severe acute malnutrition (SAM) is directly responsible for over 500,000 child deaths per year and plays a significant contributing factor in the deaths of many more[1]. The World Health Organization (WHO) SAM guidelines advise strongly against intravenous fluids unless the child is shocked or severely dehydrated and unable to tolerate oral fluids. Methods: We conducted a systematic review of randomised controlled trials (RCTs) and observational studies on 15th June 2017 comparing different strategies of rehydration therapy in children with acute gastroenteritis and severe dehydration, relating to intravenous rehydration, using standard search terms. There was no evidence of fluid overload or other fluid-related adverse events, including children managed on more liberal rehydration protocols. We found no clinical trials providing a direct assessment of the current WHO guidelines, and those that were available suggested that these children have a high mortality and remain fluid depleted on current therapy.

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