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Oral rehydration therapy (ORT) has been the preferred treatment for mild gastroenteritis (GE) globally for decades. Solutions containing glucose and electrolytes are undoubtedly effective, but there's a problem: they taste awful (ever tried one?). Young children who are feeling unwell are even less likely to drink something unpleasant than they would when well, so many carers abandon attempts to force it down: the result, sometimes, is the eventual need for intravenous fluids. Could this be prevented by giving something more palatable?
Researchers from Toronto, Canada set out to see whether dilute apple juice was as good as standard electrolyte maintenance solution (EMS), here sweetened with sucralose (Freedman S, et al. JAMA. 2016; doi:10.1001/jama.2016.5352). In a non-inferiority trial, they randomised over 640 children aged 6 months to 5 years presenting to a single large children's emergency department (ED). To qualify they needed to have mild GE, ie, no or only minimal dehydration clinically, and no other complicating conditions. The study was single-blind, so the caregivers knew what they were giving after discharge from the ED, and they were given specific instructions: the apple juice group could drink what they wanted, while the EMS group were asked to stick with a rehydration schedule. They were followed up by telephone contact after 48–72 hours. No lab tests were done. Treatment failure was defined as the need for admission or IV fluids, re-attendance, or symptoms persisting >7 days.
They found that the apple juice group did better (17% were treatment failures vs 25% in the EMS group: p<0.001 for inferiority, p=0.006 for superiority). IV fluids were given to 2.5% of the apple juice group and 9% of the EMS group. The difference was greatest for older children, perhaps because they are more fussy about what they drink. The higher sugar content of apple juice, which in theory could cause a pro-diarrhoeal osmotic effect, did not seem to be a problem.
It is important not to extrapolate these findings to low-income countries, and where the nature and severity of GE is very different. But here in the West, we can now feel more reassured about what many of us are saying to parents already: if the child won't drink electrolyte solution, ask them to drink dilute juice instead.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
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