Intravenous rehydration in children with severe malnutrition: a systematic review and meta-analysis

BackgroundThe comparative efficacy and safety of intravenous rehydration (IVR) and oral rehydration (OR) strategies in children with severe acute malnutrition (SAM) remains uncertain. MethodsWe systematically reviewed randomized clinical trials (RCTs) comparing the use of IVR and oral rehydration (standard of care) in children with SAM hospitalized with severe dehydration secondary to gastroenteritis. The primary outcome was in-hospital mortality. Secondary outcomes included fluid overload events, development of shock requiring intravenous boluses, development of neurological complications; severe electrolyte abnormalities at 24 hours and day 28 mortality. FindingsWe identified 3 RCTs, comprising 484 participants with severe malnutrition including 72 children with the kwashiorkor phenotype: (2 some risk of bias; 1 low risk of bias). The risk ratio (RR) for in-hospital mortality with IVR versus OR was 0.71 (95% confidence interval [CI], 0.46-1.10; I2=0.0%) with moderate certainty of evidence. No fluid overload events were reported, pooled RR 0.99 (95% CI 0.10-9.35). Pooled RR of severe hyponatremia at 24 hours (grouped by threshold (sodium < 125 or <130mmol/L)) was 0.66 (95% CI 0.44-0.99). Only one trial reported RR for shock development; hypernatremia (sodium >145mmol/l) and 28-day mortality with IVR versus OR RRs of 0.56 (95% CI 0.21-1.48); 2.05 (95% CI 0.50-8.58) and 0.85 (95% CI 0.44-1.65) respectively. Subgroup analyses for in-hospital mortality were carried out for region and risk of bias rating giving p=0.85 and p=0.54 for heterogeneity respectively. ConclusionThe estimated effect of using IVR versus OR in children with SAM with severe dehydration ranges from a 54% relative reduction to a 10% relative increase in the risk of death with IVR resulting in fewer adverse events. (PROSPERO number, CRD42025637956.) Key QuestionsO_ST_ABSWhat is already known on this topicC_ST_ABSInternational guidelines advise against giving intravenous rehydration to children with severe acute malnutrition due to concerns about fluid overload. Evidence to support this recommendation is weak, specifically in children in African with severe dehydration due to diarrhoea What this study addsWe systematically reviewed evidence comprising of 484 children in 3 randomised trials, and estimated that intravenous rehydration resulted in a 54% relative reduction to a 10% relative increase in the risk of death No evidence of fluid overload or cardiac failure was reported in any trial How might this study affect research, practice or policyThe guidance on intravenous rehydration should be reconsidered in light of the findings of this review and considering the safety of intravenous rehydration Simplification of the rehydration guidelines for severe dehydration to remove the distinction between malnourished and non-malnourished children would facilitate ease of implementation.