5 Best of 2016: Pediatrics Viewpoints

William T. Basco, Jr, MD, MS


December 23, 2016

Most Widely Read Viewpoints of 2016

At the end of each year, I like to revisit some of the most widely read pediatric viewpoints from the previous 12 months. The articles that I selected for 2016 cover a range of clinical problems and patient ages, from young children (gastroenteritis and viral respiratory infections) to adolescents (waning Tdap protection and postural orthostatic tachycardia syndrome). This year, a pair of studies on vitamin D in pregnancy have particular relevance to pediatrics, as well. The popularity of these topics—as determined by you, our readers—and the comments they generated underscore how important they are in pediatric practice.

Treatment of Mild Gastroenteritis

Freedman and colleagues[1] evaluated whether diluted apple juice might be as effective as oral rehydrating solution (ORS) in the outpatient treatment of children with dehydration. The question is important, given that the cost and the taste of standard ORS are potential limiting factors to its use.

This study enrolled children aged 6-60 months at one medical center in Canada. Study children had diarrhea or vomiting for < 96 hours and were considered to have "minimal" dehydration. The children were randomly assigned to receive either ORS or diluted apple juice, followed by "preferred fluids"—essentially, whatever the parents could get the child to drink, including milk.

In the emergency department (ED), immediately after randomization, children in the intervention group received half-strength apple juice, whereas those in the control group received an apple-flavored ORS. The protocol was for the children to receive 5-mL aliquots of their assigned fluid every 2-5 minutes.

After ED discharge, the parents were given instructions for administering the same fluid at home to replace losses. The children were to receive 2 mL/kg for each episode of vomiting as well as 10 mL/kg for each diarrheal episode. Children in the ORS group were expected to receive only ORS.

The children were followed daily by telephone, and caregivers recorded symptoms and healthcare use in a diary. The primary outcome was a composite measure of whether any of the following occurred within 7 days of enrollment:

  • Hospitalization or any requirement for intravenous hydration;

  • An unscheduled physician encounter;

  • Symptoms occurring > 7 days after enrollment;

  • Physician decision to switch enrollment groups; or

  • ≥ 3% weight loss.

The trial enrolled 647 children, with equal numbers of children (322) in the two groups for the final analysis. The mean age at enrollment was 28.3 months, and the study children had experienced a median of five episodes of vomiting and a median of three episodes of diarrhea in a 24-hour period. Approximately 28% of the children had received the rotavirus vaccine.

Overall, the failure rate in the diluted apple juice/preferred fluids group was 16.7% (95% confidence interval [CI], 12.8%-21.2%). This compared with a 25% failure rate (95% CI, 20.4%-30.1%) in the ORS group. When secondary outcomes were examined, fewer children in the treatment group received intravenous rehydration during the initial ED visit (0.9%) compared with those in the ORS group (6.8%). Hyponatremia occurred in one child in each group.

With respect to the subcomponents of the primary outcome, some rates were higher among the ORS group, but the CIs overlapped, producing nonsignificant differences. Other outcomes, such as unscheduled healthcare visits, ED visits, and number of diarrhea and vomiting episodes, were all statistically significantly different. Intravenous rehydration was required by 9% of the ORS group at some point after the index visit, compared with 2.5% of the half-strength apple juice group—a statistically significant difference.

The authors concluded that in a high-resource country and among children with minimal dehydration, half-strength apple juice followed by the child's preferred fluids was not inferior to an ORS.


I suspect that this article was so widely read because the practice that is already probably common—getting children to drink whatever they will drink when faced with gastrointestinal losses—performed no worse than ORS. Certainly, these findings are very applicable to many office-based visits for gastroenteritis symptoms, in which the child may have experienced several vomiting or diarrhea episodes but does not appear clinically dehydrated.

the practice that is already probably common—getting children to drink whatever they will drink when faced with gastrointestinal losses—performed no worse than ORS.

The researchers carefully pointed out the limitations in the generalizability of these findings. This study did not enroll profoundly or even moderately dehydrated children, and these data may not apply as well to children in low-resource countries. The working hypothesis (which has a good deal of face validity) is that because the half-strength apple juice is more palatable, the children will take more and therefore are less likely to incur undesirable healthcare outcomes. This was very much a pragmatic trial, and the data appear to support this approach for the right patient in the outpatient setting.


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