Author: Dr. Jeanette Lorme, PGY-1
To Pedialyte or not to Pedialyte?
○ In the Emergency Department, we see pediatric patients with vomiting and diarrhea frequently. We need to be able to give parents guidance about how to best combat dehydration and hopefully prevent any future pokes for IV hydration or potential hospitalization down the road.
○ Parents often ask if they need to be giving their child special electrolyte maintenance therapy drinks (such as Pedialyte) or if milk or sports drinks are adequate.
○ As a resident that is about to become a new parent myself, I was happy to read this article to feel more prepared about keeping my kid hydrated when inevitable bouts with pediatric viral illness pop up in my future.
○ Is dilute apple juice and preferred fluid at home non-inferior to electrolyte maintenance solution in children with mild gastroenteritis?
○ Published in JAMA in 2016, this was a randomized clinical trial that enrolled 624 participants between 6-60 months old with mild to moderate gastroenteritis and dehydration (kids safe for discharge from the Emergency Dept, not those that needed admission) to receive dilute apple juice versus an electrolyte maintenance solution (Pharmascience, basically the Canadian version of Pedialyte). Kids < 6 months were excluded.
○ Children were randomly assigned to receive 2L of half-strength apple juice or 2L of electrolyte solution in the Emergency Dept. Then on discharge, parents with kids assigned to the half-strength apple juice group were instructed to give whatever fluids their child preferred at home (which included milk, sports drinks, fruit juice), while the kids in the electrolyte solution group were to only get the electrolyte maintenance solution at home (no other fluids allowed).
○ Parents were instructed to replace fluid losses in the same way (in the Emergency Dept, they got 5 mL of assigned fluid every 2-5 minutes, and at home parents were instructed to give 2 mL/kg per vomiting episode and 10 mL/kg per diarrheal episode).
○ The primary outcome was measuring the need for hospitalization or IV fluids within 7 days of the initial Emergency Department encounter, kids presenting to the Emergency Department or urgent care or pediatric office again for dehydration, or greater than 4% weight loss or a Clinical Dehydration score of 5 or higher (severe dehydration) at in-person follow up (all of these were considered “treatment failures”).
○ Treatment failure rates for the apple juice/preferred fluids group was 16.7%, while the treatment failure rate for the electrolyte maintenance group was 25%.
○ The apple juice/preferred fluids were found to be non-inferior (p value < 0.001) and superior (p value = 0.006) to the electrolyte maintenance group.
○ Kids with mild gastroenteritis experienced less dehydration when offered dilute apple juice followed by their preferred fluid choice at home compared to those instructed to drink ONLY electrolyte maintenance solution to replace fluid losses.
○ Limitations of the study: This took place in a high-income country (Canada), was a single centered study, and included only one type of flavored electrolyte maintenance solution (maybe kids hate the artificial apple flavoring of Pharmascience?).
○ Significance: Pediatric patients need to drink fluids when they are sick. This study demonstrated that kids will probably drink more of fluids they like including fluids that are already in their routine (even if that means milk or “sugary” sports drinks and juice) instead of electrolyte maintenance therapy solutions like Pedialyte or Pharmascience.
○ Seems like there is no need to make parents spend money on electrolyte maintenance therapy solutions (which can cost about double that of juice) when other fluids they have at home already will work just as well/better.
○ In the past sports drinks were rumored to make osmotic diarrhea worse but this was based on theory and a very small study.
○ Now if parents ask me if they “must give Pedialyte” to a pediatric patient that is sick, I will say no. Encouraging kids > 6 months to drink dilute juice, milk, or sports drinks is acceptable. I’ll encourage parents to give their mildly to moderately dehydrated child > 6 months anything the kid will take and keep down to prevent further dehydration.
○ The use of dilute apple juice and preferred fluids as desired may be an appropriate alternative to electrolyte maintenance fluids in children with mild gastroenteritis and mild dehydration (in kids > 6 months old).
Baby Yoda can have anything he wants in that cup to stay hydrated; it doesn’t have to be just Pedialyte.
○ Freedman SB, Willan AR, Boutis K, Schuh S. 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(18):1966–1974. doi:10.1001/jama.2016.5352