Intravenous rehydration in children with severe malnutrition and severe dehydration: a systematic review and meta-analysis
File(s)
Published online version
Author(s)
Dewez, Juan Emmanuel
Ouattara, San Maurice
Sunyoto, Temmy
Mogaka, Christabel Kemunto
Coldiron, Matthew E
Type
Journal Article
Abstract
Objectives To compare the efficacy and safety of intravenous rehydration (IVR) versus oral rehydration (OR) strategies in children with severe acute malnutrition (SAM) and severe dehydration.
Design Systematic review and meta-analysis.
Setting Lower-to-middle-income countries.
Patients Children with SAM are hospitalised with severe dehydration secondary to gastroenteritis.
Interventions Randomised trials of IVR and OR (standard of care)
Main outcome measures Primary: in-hospital mortality. Secondary: fluid overload events, development of shock requiring intravenous boluses, severe electrolyte abnormalities at 24 hours and day 28 mortality.
Results We identified three RCTs comprising 484 participants with severe malnutrition (72 had kwashiorkor, two had some risk of bias, and one had low risk of bias). The pooled risk ratio (RR) for in-hospital mortality for IVR versus OR is 0.71 (95% CI 0.46 to 1.10; I2=0.0%) with moderate certainty of evidence. No fluid overload events were reported, pooled RR 0.99 (95% CI 0.10 to 9.35). The pooled RR of severe hyponatraemia (sodium <125 or <130 mmol/L) at 24 hours was 0.66 (95% CI 0.44 to 0.99). Only one trial reported RR for shock development, hypernatraemia (sodium >145 mmol/L) or 28-day mortality with IVR versus OR (RRs 0.56, 95% CI 0.21 to 1.48; RR 2.05, 95% CI 0.50 to 8.58 and RR 0.85, 95% CI 0.44 to 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.
Conclusions The 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 registration number CRD42025637956.
Design Systematic review and meta-analysis.
Setting Lower-to-middle-income countries.
Patients Children with SAM are hospitalised with severe dehydration secondary to gastroenteritis.
Interventions Randomised trials of IVR and OR (standard of care)
Main outcome measures Primary: in-hospital mortality. Secondary: fluid overload events, development of shock requiring intravenous boluses, severe electrolyte abnormalities at 24 hours and day 28 mortality.
Results We identified three RCTs comprising 484 participants with severe malnutrition (72 had kwashiorkor, two had some risk of bias, and one had low risk of bias). The pooled risk ratio (RR) for in-hospital mortality for IVR versus OR is 0.71 (95% CI 0.46 to 1.10; I2=0.0%) with moderate certainty of evidence. No fluid overload events were reported, pooled RR 0.99 (95% CI 0.10 to 9.35). The pooled RR of severe hyponatraemia (sodium <125 or <130 mmol/L) at 24 hours was 0.66 (95% CI 0.44 to 0.99). Only one trial reported RR for shock development, hypernatraemia (sodium >145 mmol/L) or 28-day mortality with IVR versus OR (RRs 0.56, 95% CI 0.21 to 1.48; RR 2.05, 95% CI 0.50 to 8.58 and RR 0.85, 95% CI 0.44 to 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.
Conclusions The 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 registration number CRD42025637956.
Date Issued
2026-05-20
Date Acceptance
2026-04-27
Citation
Archives of Disease in Childhood, 2026
ISSN
0003-9888
Publisher
BMJ
Journal / Book Title
Archives of Disease in Childhood
Copyright Statement
© Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY. Published by BMJ Group.
License URL
Publication Status
Published online
Date Publish Online
2026-05-20