Case: A 28-month-old boy presents with a three-day history of vomiting and diarrhea. After performing an appropriate history and directed physical examination, you diagnose him with mild gastroenteritis and minimal dehydration. The parents ask if they need to buy an electrolyte maintenance solution or if they could just use some watered-down apple juice to treat his dehydration.

Clinical Question: In children diagnosed with mild gastroenteritis who have minimal dehydration, is dilute apple juice followed by preferred fluids an equivalent way to orally rehydrate compared to an electrolyte maintenance solution?

Background: Acute gastroenteritis is a common childhood illness in the United States. It’s characterized by acute-onset diarrhea with or without nausea, vomiting, fever, and abdominal pain. According to King et al, acute diarrhea results in more than 1.5 million outpatient visits and 200,000 hospitalizations per year.

Children with gastroenteritis are at risk of dehydration. Most cases are mild and self-limited. The Centers for Disease Control and Prevention, American Academy of Pediatrics, American Academy of Family Physicians, and Canadian Paediatric Society (CPS) all recommend oral rehydration solutions (ORS) for mild to moderate dehydration.

CPS has an algorithm for managing acute gastroenteritis in children, located at http://www.cps.ca/documents/position/oral-rehydration-therapy. The emphasis is on ORS followed by an age-appropriate diet after rehydration for those children with mild to moderate dehydration.

Reference: Freedman SB, Willan AR, Boutis K, et al. Effect of dilute apple juice and preferred fluids v. electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974.

• Population: Children presenting to the emergency department between 6 months and 5 years of age with three or more episodes of vomiting or diarrhea in the past 24 hours and symptoms for fewer than 96 hours. The children also needed to weigh at least 8 kg and have minimal dehydration on the Clinical Dehydration Scale (CDS).
  • Excluded: Inflammatory bowel disease, celiac disease, diabetes mellitus, inborn errors of metabolism, prematurity with corrected postnatal age less than 30 weeks, bilious vomiting, hematemesis, hematochezia, clinical concern of an acute abdomen, or a need for immediate intravenous rehydration.
• Intervention: Half-strength apple juice in the emergency department followed by preferred fluids other than electrolyte maintenance solutions upon discharge. This included milk, juices, half-strength apple juice, or sports beverages that are contraindicated in most guidelines.
• Comparison: Apple-flavored, sucralose-sweetened electrolyte maintenance solution in the emergency department and post discharge.
  • Those who vomited in either group received oral ondansetron.
• Outcome:
  • Primary outcomes: Composite measure of treatment failure occurring within seven days.
    1. Hospitalization or IV rehydration
    2. Subsequent unscheduled health care visit (emergency department, urgent care clinic, walk-in clinic, or office)
    3. Protracted symptoms (more than two episodes of vomiting or diarrhea within a 24-hour period occurring more than seven days after enrollment)
    4. Crossover (physician request to administer a solution representing treatment allocation crossover at the index visit)
    5. Three percent or greater weight loss or CDS score of 5 or higher at in-person follow-up
• Secondary outcomes: Frequency of diarrhea and vomiting, percent weight change at 72 to 84 hours, intravenous rehydration at initial visit or a subsequent visit within seven days, hospitalization at initial visit or a subsequent visit.

Authors’ 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.”