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A more palatable alternative to oral rehydration therapy for kids.

Parents no longer need to struggle to get their kids to drink electrolyte solutions during episodes of mild gastroenteritis; apple juice works just as well.


Recommend that parents give half-strength apple juice to children [greater than or equal to] 24 months of age who are minimally dehydrated following a case of simple viral gastroenteritis. The juice reduces the need for further interventions better than oral hydration therapy.

Freedman SB, Willan AR, Boutis K, et al. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315:1966-1974. (1)


B: Based on a single, good quality randomized controlled trial.


A 3-year-old boy is brought by his mother to the office for vomiting and diarrhea that started in the middle of the night. On examination he is slightly dehydrated, but does not have an acute abdomen or other source of infection. He is drinking out of a sippy cup. What fluids should you recommend?

Acute gastroenteritis is a common cause of vomiting and/or diarrhea in children, leading to 1.5 million outpatient visits and 200,000 hospital admissions annually in the United States. (2) Children with gastroenteritis are at risk for dehydration, and the recommended treatment for anything less than severe dehydration is oral rehydration therapy (ORT) and early resumption of feeding upon rehydration. (2)

In 2002, the World Health Organization recommended an ORT with an osmolarity of 245 mOsm/L. (3) However, cultural preferences, cost, (4) taste, (5) availability, and caregiver and professional preference for intravenous hydration (6-8) have all been barriers to the use of recommended ORT. (2) In fact, a study of ORT preferences in 66 children ages 5 to 10 years found that fewer than half of the children would voluntarily drink the ORT again. (5) This study evaluated the use of diluted apple juice as a more palatable alternative to ORT in children with vomiting and/or diarrhea.


In kids older than 2, apple juice will do

This study was a single-center, single-blind, non-inferiority randomized controlled trial conducted in the emergency department (ED) of a tertiary care pediatric hospital in Canada. The researchers compared the use of half-strength apple juice to a standard ORT for rehydration in simple gastroenteritis. (1) Participants were 6 months to 5 years of age, weighed more than 8 kg (17.7 lbs), and had vomiting and/or diarrhea for less than 96 hours (with [greater than or equal to] 3 episodes over the last 24 hours). They also had a Clinical Dehydration Scale (CDS) Score (9) <5 and a capillary refill of <2 seconds (TABLE). Of the total, 68% of the children had a CDS score of 0, 25.5% scored 1 to 2; and 6.4% scored 3 to 4. Children with chronic gastrointestinal disease or other significant comorbidities that could affect the clinical state (eg, diabetes mellitus) and potential acute abdominal pathology were excluded.

Children were randomized to receive half-strength apple juice (AJ) (intervention group, n=323) or apple-flavored sucralose-sweetened Pediatric Electrolyte (Pharmascience) (control group, n=324), a common electrolyte maintenance solution (EMS). Immediately on triage, each child received 2 L of their assigned solution, to be used while in the ED and then at home. The children received 5 mL of fluid every 2 to 5 minutes. If a child vomited after starting the fluid, he or she was given oral ondansetron.

At discharge, caregivers were encouraged to replace 2 mL/kg of fluid for a vomiting episode and 10 mL/kg of fluid for a diarrhea episode. At home, children in the AJ group could also drink any other preferred fluid, including sports beverages. The EMS group was instructed to drink only the solution provided or a comparable ORT. Caregivers were contacted daily by phone until the child had no symptoms for 24 hours. They were also asked to keep a daily log of vomiting and diarrhea frequency and any subsequent health care visits. At least one follow-up contact occurred with 99.5% of the children.

The primary outcome was treatment failure defined as a composite measure of any of the following occurring within 7 days of the ED visit: hospitalization, intravenous rehydration, further health care visits for diarrhea/vomiting in any setting, protracted symptoms (ie, [greater than or equal to] 3 episodes of vomiting or diarrhea within a 24-hour period occurring >7 days after enrollment), 3% or greater weight loss, or CDS score [greater than or equal to] 5 at follow-up.

Treatment failure occurred in 16.7% of the AJ group compared to 25% of the EMS group (difference, -8.3%; 97.5% confidence interval [CI], -[infinity] to -2; number needed to treat [NNT]=12), consistent with non-inferior effectiveness. The benefit was seen primarily in children [greater than or equal to] 24 months of age. In children <24 months, the treatment failure for AJ was 23.9% compared to 24.1% in the EMS group (P=not significant). In older children ([greater than or equal to] 24 months to 5 years), the treatment failure with AJ was 9.8% compared to 25.9% in the EMS group (difference, -16.2%; 95% CI, -24.2% to -8%; NNT=6.2). Intravenous rehydration in the ED or within 7 days of the initial visit was needed in 2.5% of the AJ group and in 9% of the EMS group (difference, -6.5%; 99% CI, -11.6% to -1.8%; NNT=15.4). There were no differences in hospitalization rate or in diarrhea or vomiting frequency between the 2 groups.


Kids drink more of what they like

This study, in a developed country, found rehydration with diluted apple juice worked just as well as ORT. In children [greater than or equal to] 24 months of age, there were fewer treatment failures.


Infants may not benefit, and ondansetron played a role

In this study, children were only mildly dehydrated. Also, the study did not include infants younger than 6 months of age, and the greatest benefit was in children [greater than or equal to] 24 months of age.

Also noteworthy was the role that oral ondansetron played. Most (67.4%) of the children received an oral dose of ondansetron (0.1 mg/kg). Although expensive, if one dose prevents a hospitalization, it is cost-effective. Previous studies of oral ondansetron show it reduces vomiting (NNT=5); lowers the rate of intravenous hydration in the ED (NNT=5); and reduces the hospitalization rate from the ED (NNT=17). (10)

Lastly, there are a variety of fluid replacement guidelines. In this study, fluid replacement was 2 mL/kg for a vomiting episode and 10 mL/kg for a diarrhea episode.


Given the ease of swapping diluted apple juice for oral rehydration therapy, we see no barriers to implementation.


The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Copyright [C] 2016. The Family Physicians Inquiries Network. All rights reserved.


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

(2.) King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52:1-16.

(3.) Essential medicines and health products information portal. A World Health Organization resource. WHO Drug Information. 2002,16(2). Available at: en/d/Js4950e/2.4.html. Accessed October 20, 2016.

(4.) Cohen MB, Hardin I. Medicaid coverage of oral rehydration solutions. N Engl J Med. 1993;329:211.

(5.) Freedman SB, Cho D, Boutis K, et al. Assessing the palatability of oral rehydration solutions in school-aged children: a randomized crossover trial. Arch Pediatr Adolesc Med. 2010;164:696-702.

(6.) Reis EC, Goepp JG, Katz S, et al. Barriers to use of oral rehydration therapy. Pediatrics. 1994;93:708-711.

(7.) Karpas A, Finkelstein M, Reid S. Parental preference for rehydration method for children in the emergency department. Pediatr EmergCare. 2009;25:301-306.

(8.) Ozuah PO, Avner JR, Stein RE. Oral rehydration, emergency physicians, and practice parameters: a national survey. Pediatrics. 2002;109:259-261.

(9.) Goldman RD, Friedman JN, Parkin PC. Validation of the clinical dehydration scale for children with acute gastroenteritis. Pediatrics. 2008;122:545-549.

(10.) Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev. 2011;CD005506.

Carin E. Reust, MD, MSPH; James J. Stevermer, MD, MSPH

Department of Family and Community Medicine, University of Missouri-Columbia

Jennie B. Jarrett, PharmD, BCPS, MMedEd

University of Pittsburgh Medical Center, St. Margaret Family Medicine Residency Program, Pa


Anne Mounsey, MD

Department of Family Medicine, University of North Carolina, Chapel Hill
Clinical Dehydration Scale (9)

Characteristic       Score:0   Score: 1              Score: 2

General appearance   Normal    Thirsty, restless,    Drowsy, limp,
                               lethargic, but        cold, or sweaty;
                               irritable when        may or may not
                               touched               be comatose

Eyes                 Normal    Slightly sunken       Very sunken
Mucous membranes     Moist     Sticky                Dry
Tears                Present   Decreased             Absent

Total CDS score: 0=no dehydration; 1-4=some dehydration;
[greater than or equal to] 5=moderate/severe dehydration.
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Title Annotation:PURLs[R]
Author:Reust, Carin E.; Stevermer, James J.; Jarrett, Jennie B.
Publication:Journal of Family Practice
Geographic Code:1USA
Date:Dec 1, 2016
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