Enteral vs intravenous rehydration therapy for children with gastroenteritis: A meta-analysis of randomized controlled trials

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Fonseca BK, Holdgate A, Craig JC. Arch Pediatr Adolesc Med 2004;158:483-90

Context Acute gastroenteritis is one of the most common problems in childhood and accounts for a large number of hospitalizations. For decades, experts have recommended enteral rehydration to replace fluid and electrolyte losses in children with gastroenteritis.

Objective To review the relative efficacy and safety of enteral vs intravenous (IV) rehydration therapy in treating childhood gastroenteritis.

Design Meta-analysis, using a random effects model.

Main outcome measures Major adverse event rates, treatment failure rates, weight gain with treatment, length of hospital stay, costs of treatment, and satisfaction with treatment.

Study identification MEDLINE, EMBASE, and the Cochrane Controlled Trials Register databases were searched. Known investigators and expert bodies were contacted to locate unpublished and ongoing studies. Studies were selected based on the following criteria: randomized or quasi-randomized trials; children younger than 15 years with a clinical diagnosis of gastroenteritis of less than 1-week duration; interventions with enteral and IV treatment arms; and inclusion of at least one of the outcomes of interest.

Studies reviewed From 841 abstracts reviewed, 21 potential studies were selected. Six studies were excluded because they didn't meet the inclusion criteria, leaving 15 studies describing 16 trials. The trials were evaluated using standard quality measures.

Results 1545 children from 11 countries were included in these trials. Compared with children treated with IV rehydration, children treated with oral rehydration had significantly fewer major adverse events, including death or seizures (relative risk, 0.36; 95% CI, 0.14-0.89), and a significant reduction in length of hospital stay (mean, 21 hours; 95% CI, 8-35). There was no difference in weight gain between the 2 groups (mean, −26 g; 95% CI, −61 to 10). The overall failure rate of enteral therapy was 4.0% (95% CI, 3.0-5.0).

Conclusions For childhood gastroenteritis, enteral rehydration is as effective if not better than IV rehydration. Enteral rehydration by the oral or nasogastric route is associated with significantly fewer major adverse events and a shorter hospital stay compared with IV therapy and is successful in most children.

Comment In this meta-analysis of 16 studies, Fonseca et al found that intravenous rehydration was no more effective than enteral fluids given to children with gastroenteritis, and was associated with 3-fold increase of adverse events. Although the methodology used for the meta-analysis was sound, there are some limitations to this study that limit its applicability to clinical practice. First, the bulk of serious adverse events detected were from a single study conducted in a developing country; there were few adverse events reported in studies from developed countries. In addition, no formal assessment was made of the degree of dehydration among children who were enrolled in the included trials. Finally, much of the use of intravenous fluids is for children with mild degrees of dehydration who are treated as outpatients. The goals of this therapy are to prevent hospitalization, relieve symptoms, and reduce parental anxiety. These outcomes were not the focus of the study by Fonseca et al. However, the key point, that intravenous rehydration is no better than enteral fluids as a treatment for children with dehydration, is valid, and the results of the meta-analysis serves as a reminder that critical evaluation is essential before adopting a new therapy that is more aggressive than the previously used treatment.