New evidence supports safe use of intravenous rehydration in children with severe acute malnutrition

Malnourished children with diarrhoea often suffer from severe dehydration and secondary infections. But international guidance on rehydrating children with severe acute malnutrition (SAM) differs from that for children who need rehydration treatment for gastroenteritis but who aren’t classed as severely malnourished. Rather than having intravenous fluids, children with SAM are recommended to be given rehydration solutions orally, often via a nasogastric tube. This is based on an expert opinion that children with SAM have a weaker functioning heart and may not be able to tolerate intravenous rehydration or standard saline solutions – which can in some cases lead to complications, such as fluid overload and heart failure. These recommendations for rehydrating children with SAM are the subject of debate because of their conservative nature. The GASTROSAM study aimed to explore different rehydration options for these children.

The randomized controlled trial, led by Professor Kathryn Maitland of Imperial College London's Institute of Global Health Innovation, published in the NEJM on June 13, compared standard oral rehydration with intravenous rehydration in 292 children under 12 years of age hospitalized for SAM in Niger, Nigeria, Uganda and Kenya. Most of the children were recruited at sites where Médecins Sans Frontières teams work. In Niger, the study was supervised by the Epicentre center in Niger, in close collaboration with MSF Switzerland.

Children eligible for the study, whose parents have given informed consent, and who were severely dehydrated have been randomized into three groups and received one of three interventions:

• Current standard of care recommended by the WHO, based on oral rehydration with the use of intravenous fluids only in cases of shock (control).
• Rapid intravenous rehydration, typically used for non-malnourished children
• Slow intravenous rehydration, the same volume of fluid as for rapid intravenous rehydration but administered slowly 

Key points from this study

The trial could not evidence a reduction in mortality after 96 hours with the intravenous rehydrationstrategies compared to the standard control strategy. Notably, mortality overall among children in the trial was lower than anticipated, likely reflecting the intensive care and close monitoring they received during the trial. 

Important to note, there was no apparent signal of harm with the intravenous rehydration strategies. Also, the standard oral strategy often involved the use of a nasogastric tube to administer rehydration fluids, which was associated with more episodes of vomiting and shock.

The trial results therefore indicate that intravenous rehydration can be safely administered to children with severe acute malnutrition, suggesting that a re-evaluation of global guidelines may now be warranted.

©Oliver Barth