Juice, Other Drinks Can Manage Mild Gastroenteritis in Children

Norra MacReady

May 03, 2016

Simple remedies such as dilute apple juice may be more effective than an electrolyte solution for treating mild pediatric gastroenteritis, according to findings published online April 30 in JAMA.

In a study of 647 children in Canada, patients with mild gastroenteritis and minimal dehydration experienced fewer treatment failures when offered half-strength apple juice followed by their preferred drinks compared with children given a standard electrolyte maintenance solution, report Stephen B. Freedman, MDCM, and colleagues.

"These results challenge the recommendation to routinely administer electrolyte maintenance solution when diarrhea begins," they write.

Dr Freedman, from the Section of Emergency Medicine and the Section of Gastroenterology, Department of Pediatrics, and Alberta Children's Hospital Research Institute, University of Calgary, Alberta, Canada, and coauthors enrolled children who presented to the emergency room with symptoms of mild gastroenteritis between October and April of the 2010 to 2015 calendar years. Eligible patients were 6 to 60 months of age, weighed at least 8 kg, and had had at least three episodes of vomiting or diarrhea within the previous 24 hours, with symptoms lasting no more than 96 hours.

The children had a mean age of 28.3 months (standard deviation, 15.9 months) and included 331 boys. The investigators randomly assigned children to receive half-strength apple juice or an apple-flavored electrolyte maintenance solution, with each fluid administered in 5-mL aliquots every 2 to 5 minutes. Children who vomited received ondansetron.

After discharge, children in the study group could receive their preferred fluids such as juice, milk, or sports drinks. Children in the control group continued to receive the electrolyte maintenance solution to replace all fluid losses. Caregivers were instructed to provide the designated fluid in a dose of 2 mL/kg per vomiting episode and 10 mL/kg per episode of diarrhea. They also received diaries and were asked to record details such as symptom frequency and follow-up clinicians' visits.

Of 323 children who received juice and preferred fluids, 54 (16.7%) experienced some form of treatment failure (95% confidence interval [CI], 12.8% - 21.2%) compared with 81 of 324 children treated with the electrolyte solution (25.0%; 95% CI, 20.4% - 30.1%; P < .001). Treatment failure was defined as a composite of intravenous rehydration, hospitalization or an unscheduled physician visit, protracted symptoms, crossover, or loss of 3% of body weight or other symptom of significant dehydration, occurring within 7 days of enrolment.

Secondary outcomes, including intravenous rehydration and hospitalization, were more frequent among children treated with the electrolyte solution. Intravenous rehydration was required by eight children in the apple juice/preferred fluids group (2.5%; 95% CI, 1.1% - 4.8%) and 29 children in the electrolyte solution group (9.0%; 95% CI, 6.1% - 12.6%; P = .001).

The authors suggest that children in the apple juice group were more willing to drink their fluids than the children receiving the electrolyte solution, which was probably less palatable despite the addition of sucralose and apple flavoring. Children older than 24 months derived the greatest benefit from the apple juice/preferred beverage intervention.

For clinicians concerned about the sugar content in apple and other juices, episodes of diarrhea in the current study were "not significantly different between study groups despite the permitted use of high-glucose fluids in the apple juice/preferred fluids group," the authors write. "These results provide pragmatic evidence that in children with minimal dehydration, promoting fluid consumption is more important than glucose load consumed." They observed no significant episodes of hyponatremia.

The authors did caution that because the study was conducted in a high-income nation, the findings cannot be extrapolated to children in middle- and low-income countries, who are at higher risk for complications related to gastroenteritis. It is also not clear whether the results can be generalized to other settings that may use other types of electrolyte maintenance solutions.

"In many high-income countries, the use of dilute apple juice and preferred fluids may be an appropriate alternative to electrolyte maintenance solution use in children with mild gastroenteritis and minimal dehydration," they conclude.

The authors have disclosed no relevant financial relationships.

JAMA. Published online April 30, 2016. Full text

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