Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis

Linh Nguyen, Mercer University College of Pharmacy

 

According to Centers for Disease Control and Prevention (CDC), acute gastroenteritis with dehydration is common in infants and children. Electrolyte maintenance solution is stated to be first line for oral rehydration therapy (ORT), but its use is limited in the United States. Half-strength apple juice is not in the recommendation for ORT. [1]

According to a guideline for the management of acute gastroenteritis in children by the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition, hypo-osmolar solution is the first line treatment. Half-strength apple juice is not on the list of recommendations. [2]

 

 

Title: Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis [3]
Design Single-center, randomized, single-blind non-inferior trial, intent-to-treat; N= 647
Objective To determine if oral hydration with dilute apple juice/preferred fluids is non-inferior to electrolyte maintenance solution in children with mild gastroenteritis
Study Groups Half-strength apple juice/preferred fluids (n= 323) vs. Electrolyte maintenance solution (apple flavored) (n= 324)
Methods Inclusion criteria: children from 6 – 60 months with ≥ three episodes of vomiting or diarrhea for more than 24 hours but less than 96 hours, weight ≥ 8 kg, and minimal dehydration. Evaluate dehydration by using 8-point Clinical Dehydration Scale. Exclusion criteria: chronic gastrointestinal disease, diabetes, inborn errors of metabolism, prematurity, bilious vomiting, intravenous (IV) rehydration. All patients received assigned solution at emergency department (ED) and will use 2 mL/kg for vomiting episode and 10 mL/kg for diarrheal episode.
Duration October 2010 to April 2015
Primary Outcome Measure Any treatment failure occurs after 7 days: IV rehydration, hospitalization, subsequent unscheduled physician visit, protracted symptoms, crossover, more than 3% weight loss or significant dehydration at follow-up
Baseline Characteristics Half-strength apple juice/preferred fluids (n = 323) Electrolyte maintenance solution (n= 324)
Mean age (month) 28.0 (15.4) 29.0 (16.5)
Boys 173 (53.6%) 158 (48.8%)
No evidence of dehydration 219 (67.8%) 222 (68.5%)
Results Outcome Half-strength apple juice/preferred fluids, % (95%CI) Electrolyte maintenance solution, % (95%CI) Difference, % (95% CI) p value
Overall treatment failure  

16.7 (12.8-21.2)

 

25.0 (20.4-30.1)

−8.3

(-∞ to −2.0)

 

<0.001
Unscheduled health care visit  

12.7 (9.3-16.8)

 

16.1 (12.2-20.5)

 

−3.4 (−10.5 to 3.8) 0.26
Weight loss ≥ 3% in next visit 20.0 (2.5-55.6) 10.0 (0.3-44.5)

 

10.0 (−33.8 to 50.9)

 

0.99
IV rehydration 2.5 (1.1-4.8)

 

9.0 (6.1-12.6)

 

−6.5 (−11.6 to −1.8) 0.001
Hospitalization 0.9 (0.2-2.7) 2.8 (1.3-5.2) −1.9 (−5.4 to 1.3) 0.14
Extended symptomatology 3.0 (1.4-5.7) 1.4 (0.4-3.5) 1.7 (−1.9 to 5.6) 0.26
Crossover 0.6 (0.08-2.2) 2.8 (1.3-5.2)

 

−2.2 (−5.7 to 0.8) 0.06
Adverse Events Common Adverse Events: N/A
Serious Adverse Events: N/A
Percentage that Discontinued due to Adverse Events: N/A
Study Author 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. In many high-income countries, the use of dilute apple juice and preferred fluids as desired may be an appropriate alternative to electrolyte maintenance fluids in children with mild gastroenteritis and minimal dehydration.

 

This study shows that dilute apple juice can also be used as ORT with less treatment failure compared to an electrolyte solution. Therefore, more studies are needed to support the use of dilute apple juice for ORT which allow for better taste and less cost for patients.

 

References

  1. King CK, Glass R, Bresee JS, Duggan C; Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1-16
  2. Guarino A, Ashkenazi S, Gendrel D, Lo Vecchio A, Shamir R, Szajewska H; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition; European Society for Pediatric Infectious Diseases. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014.J Pediatr Gastroenterol Nutr. 2014;59(1):132-152
  3. Freedman SB, Willan AR, Boutis K, Schuh S. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.
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