The Bottom Line
Children with mild gastroenteritis who got dilute apple juice initially followed by preferred fluids had fewer treatment failures than children given electrolyte maintenance solution probably because the latter tastes terrible.
What They Did
- This was a non inferiority trial. Patients with mild AGE were randomized to half-strength apple juice/preferred fluids (n=323) or apple-flavored electrolyte maintenance solution (n=324) and did oral rehydration therapy.
- Kids could get ondansetron
- Patients were followed daily by nurse phone calls until they were asymptomatic for 24 hours. The nurse was blinded to which treatment arm the child was in.
- In the ED the first group got dilute apple juice and could then choose what they wanted at home.
- The primary outcome was treatment failure defined as any of the following happening within 7 days:
- IV rehydration
- Unscheduled physician encounter
- Protracted symptoms
- Crossover to the other group
- 3% or more weight loss or significant dehydration at in-person follow-up
- Overall they noted that the dilute apple juice group had treatment failure less often than those given electrolyte maintenance solution (16.7% vs 25.0%; difference, −8.3%; 97.5% CI, − to −2.0%; P < .001 for inferiority and P = .006 for superiority)
- Fewer apple juice/preferred fluids kids received IV rehydration (2.5% vs 9.0%; difference, −6.5%; 99% CI, −11.6% to −1.8%)
- Hospitalization rates and diarrhea and vomiting frequency were not significantly different between groups (secondary outcomes)
What You Can Do
- Recognize that this study was only in mild gastroenteritis – so you need to know how to assess hydration status!
- The original recommendation for electrolyte solution to be started once diarrhea begins was based on an unblinded study with a NNT=16 – see Duggan et al. for more
- Note that this was a single center trial in an industrialized nation – different rules apply in resource poor countries
- Know that this was constructed to account for non-inferiority. This is interesting because I suspect that authors thought that electrolyte solution was superior going in. maybe some of this was due to the thought that sugar containing solutions cause more diarrhea – recent research has called this practice into question.
- Finally, note that Pedialyte tastes terrible. Seriously, this mom’s blog says it all and she compares the flavor to “candy coated death.”