Case: A 28-month-old boy presents with a three-day history of vomiting and diarrhea. After performing an appropriate history and directed physical examination, you diagnose him with mild gastroenteritis and minimal dehydration. The parents ask if they need to buy an electrolyte maintenance solution or if they could just use some watered-down apple juice to treat his dehydration.

Clinical Question: In children diagnosed with mild gastroenteritis who have minimal dehydration, is dilute apple juice followed by preferred fluids an equivalent way to orally rehydrate compared to an electrolyte maintenance solution?

Background: Acute gastroenteritis is a common childhood illness in the United States. It’s characterized by acute-onset diarrhea with or without nausea, vomiting, fever, and abdominal pain. According to King et al, acute diarrhea results in more than 1.5 million outpatient visits and 200,000 hospitalizations per year.

Children with gastroenteritis are at risk of dehydration. Most cases are mild and self-limited. The Centers for Disease Control and Prevention, American Academy of Pediatrics, American Academy of Family Physicians, and Canadian Paediatric Society (CPS) all recommend oral rehydration solutions (ORS) for mild to moderate dehydration.

CPS has an algorithm for managing acute gastroenteritis in children, located at http://www.cps.ca/documents/position/oral-rehydration-therapy. The emphasis is on ORS followed by an age-appropriate diet after rehydration for those children with mild to moderate dehydration.

Reference: Freedman SB, Willan AR, Boutis K, et al. Effect of dilute apple juice and preferred fluids v. electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974.

• Population: Children presenting to the emergency department between 6 months and 5 years of age with three or more episodes of vomiting or diarrhea in the past 24 hours and symptoms for fewer than 96 hours. The children also needed to weigh at least 8 kg and have minimal dehydration on the Clinical Dehydration Scale (CDS).
  • Excluded: Inflammatory bowel disease, celiac disease, diabetes mellitus, inborn errors of metabolism, prematurity with corrected postnatal age less than 30 weeks, bilious vomiting, hematemesis, hematochezia, clinical concern of an acute abdomen, or a need for immediate intravenous rehydration.
• Intervention: Half-strength apple juice in the emergency department followed by preferred fluids other than electrolyte maintenance solutions upon discharge. This included milk, juices, half-strength apple juice, or sports beverages that are contraindicated in most guidelines.
• Comparison: Apple-flavored, sucralose-sweetened electrolyte maintenance solution in the emergency department and post discharge.
  • Those who vomited in either group received oral ondansetron.
• Outcome:
  • Primary outcomes: Composite measure of treatment failure occurring within seven days.
    1. Hospitalization or IV rehydration
    2. Subsequent unscheduled health care visit (emergency department, urgent care clinic, walk-in clinic, or office)
    3. Protracted symptoms (more than two episodes of vomiting or diarrhea within a 24-hour period occurring more than seven days after enrollment)
    4. Crossover (physician request to administer a solution representing treatment allocation crossover at the index visit)
    5. Three percent or greater weight loss or CDS score of 5 or higher at in-person follow-up
• Secondary outcomes: Frequency of diarrhea and vomiting, percent weight change at 72 to 84 hours, intravenous rehydration at initial visit or a subsequent visit within seven days, hospitalization at initial visit or a subsequent visit.

Authors’ Conclusions: “Among children with mild gastroenteritis and minimal dehydration, initial oral hydration with dilute apple juice followed by their preferred fluids, compared with electrolyte maintenance solution, resulted in fewer treatment failures.”

Key Results: The study enrolled 647 children with a mean age of 28 months. The primary outcome was less treatment failure with half-strength apple juice/preferred fluids versus electrolyte maintenance solution.

• 16.7 percent (95 percent CI, 12.8–21.2) versus 25.0 percent (95 percent CI, 20.4–30.1)
• Difference between groups -8.3 percent (97.5 percent CI, –infinity to -2.0) showing non-inferiority (P<0.001)
• Number needed to treat (NNT) of 12 with half-strength apple juice/preferred fluids to prevent one treatment failure

Secondary outcomes included less IV rehydration in the half-strength apple juice/preferred fluids versus electrolyte solution at index ED visit. No statistical differences were seen in the other secondary outcomes.

• IV rehydration at index ED visit 0.9 percent (95 percent CI, 0.2–2.7) versus 6.8 percent (95 percent CI, 4.3–10.1) (P=0.001)

EBM Commentary

• This was a convenience sample of patients presenting 12 hours per day, six days per week to a single-center tertiary care pediatric hospital. Therefore, the sample of patients included in the study may not be reflective of, or cannot be generalized to, the overall population presenting to the emergency department or other practice locations.
• This study was conduced in Toronto, Ontario, Canada, a high-income country. The results shouldn’t be extrapolated to low- and middle-income countries because children in those countries are at a higher risk of gastroenteritis-related complications. Also, the etiology of gastroenteritis can vary in different geographical locations, limiting the generalizability of this study to those children.
• The primary outcome of treatment failure was a composite of a number of different measures that may not all have the same clinical relevance to the caregiver and patient. In this composite outcome, the most statistically significant difference was seen in IV rehydration rates.
• Allocation was concealed in the emergency department but not at home. Documentation informed parents which treatment group their child was allocated to, eliminating blinding. This has the potential to introduce bias into the study. It’s hard to know in which direction, if any, the bias would deviate the results.
• This was designed as a non-inferiority study. However, the difference observed was greater than their prespecified non-inferiority margin of 7.5 percent. Thus, they actually demonstrated that dilute apple juice/preferred fluids was superior to the electrolyte maintenance solution.

Bottom Line: In children from high-income countries presenting with mild gastroenteritis and minimal dehydration, oral rehydration with dilute apple juice followed by preferred fluids appears to be a reasonable alternative to electrolyte maintenance solutions.

Case Resolution: The boy is offered half-strength apple juice and tolerates it well in the emergency department. After a short period of observation, he’s discharged home with his caregivers. They are advised to continue his usual dietary patterns, including his preferred fluids to replace losses, and are given detailed instructions on when to return to the emergency department.

Thank you to Dr. Anthony Crocco from www.SketchyEBM.com for his help with this review. Dr. Crocco is an associate professor at McMaster University and the medical director and division head of pediatric emergency medicine at McMaster Children’s Hospital in Hamilton, Ontario, Canada.

Remember to be skeptical of anything you learn, even if you read it in the Skeptics’ Guide to Emergency Medicine.