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Relevant Article

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Freedman, S. B., Willan, A. R., Boutis, K., & Schuh, S. (2016). Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis. Jama, 315 (18), 1966-1974.

Background

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Gastroenteritis is a common pediatric complaint in the emergency department (ED), accounting for 1.5 million ED visits, over 200,000 admissions, and 300 deaths in the US annually.1 It’s a daily challenge for providers to determine the best strategy for rehydrating pediatric patients with vomiting and diarrhea. In developing countries, oral rehydration therapy (ORT) is the mainstay of treatment.1 However, the taste of ORT doesn’t exactly make kids beg for more, and in developed countries, pediatric patients with even fairly mild dehydration are often treated with parenteral fluids.1 In their study, Freedman et al. sought to determine if diluted apple juice and preferred fluids was non-inferior to ORT in children with mild dehydration secondary to acute gastroenteritis.2

Methods

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This study was a single-center, randomized, single-blind, non-inferiority trial conducted in a tertiary care emergency department in Toronto. Children eligible for enrollment were 6-60 months of age, and presented with 3 or more episodes of vomiting in the past 24 hours. Inclusion criteria were weight greater than 8kg, minimal dehydration as determined by a score of less than 5 on the Clinical Dehydration Scale, and capillary refill time of less than 2 seconds. Exclusion criteria were a history of gastrointestinal disease, chronic diseases such as diabetes which could worsen or complicate their presentation, prematurity of less than 30 weeks, bilious vomiting or hematemesis/hematochezia, acute abdomen on exam , or immediate clinical indication for intravenous (IV) hydration.

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Subjects received either half strength diluted apple juice or an apple flavored ORT solution. Participants were also given 2 liters of the assigned fluid to use after discharge at home. The children were given 5mL of the fluid every 2-5 minutes in the ED and oral ondansetron was administered for vomiting. The physician re-evaluated the child throughout the ED visit and could advance care to include IV hydration if clinically indicated. At discharge, the caregiver was instructed to administer fluids based on losses; 2mL/kg per emesis and 10mL/kg for each episode of diarrhea. The children in the juice/preferred fluids group were allowed to replace losses with fluids based on their usual diet. These included milk, sports beverages or diluted juices. The ORT group utilized that solution for all losses. The caregivers received daily phone calls from nurses until the child was well for 24 hours. A registered letter was sent if the caregiver was not reachable by telephone. Treatment failure was defined as the need for IV hydration, hospitalization, unexpected doctor visit, protracted symptoms or treatment crossover within 7 days.

Results

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A total of 647 children were enrolled. Baseline characteristics were equivalent and nearly all caregivers were reachable for follow-up. The treatment failure rate was 16.7% in the apple juice/preferred fluids group and 25% in the ORT solution group (97.5% CI -∞ to -2.0%, p<.001 for inferiority, p = .006 for superiority), thus demonstrating non-inferiority of apple juice/preferred fluids compared to ORT. In addition, IV fluids were used less often in patients receiving apple juice or preferred fluids. However, there was no difference between groups in hospitalization rates and diarrhea/vomiting frequency.

Relevance to Emergency Medicine

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Treatment for mild gastroenteritis that improves patient comfort, decreases cost, and tastes good – what’s not to like! Refusal to drink ORT solution, likely due to taste, is one factor leading to IV hydration in the ED. This study demonstrates that oral rehydration can be accomplished with dilute apple juice followed by preferred oral fluids, and refutes the notion that oral fluids with sugar will worsen symptoms. Ondansetron has previously been demonstrated is a useful adjunctive therapy for children with continued vomiting and mild dehydration.3

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Another factor identified in the preference for IV hydration over ORT in developed countries is the perception of both parent and provider is that administration of parenteral fluids is more rapid.2 Still other studies have shown that if a patient receives IV fluids during an ED visit, the caregiver will then expect the same treatment on subsequent visits.4 On your next shift, before writing that order for IV fluids for mild gastroenteritis, consider an attempt at oral rehydration with dilute apple juice. This may require some education of the caregiver, but will likely be efficacious, and result in better patient comfort at a lower cost.

References

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Managing Acute Gastroenteritis Among Children - cdc.gov. (n.d.). Retrieved March 26, 2017, from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm
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Freedman,  S. B., Willan,  A. R., Boutis,  K., Schuh,  S. (2016). Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis. Jama, 315(18), 1966–1974.
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Colletti,  J. E., MD, Brown,  K. M., MD, Shariefff,  G. Q., MD, Barata,  I. A., MD, Ishmine,  P., MD. (2010). The Management of Children with Gastroenteritis and Dehydration in the Emergency Department. JEM, 38(5), 686–698.
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Nir,  V., Nadir,  E., Schechter,  Y., Kline-Kremer,  A. (2013). Parents’ Attitudes toward Oral Rehydration Therapy in Children with Mild-to-Moderate Dehydration. The Scientific World Journal, 2013 1–3. doi:10.1155/2013/828157
[PubMed: 24302874]