Children with gastroenteritis can be better treated with apple juice than oral rehydration solution (ORS). A new study published in JAMA on 30th April shows the initial administration of diluted apple juice gave better treatment results than ORS. Children with mild gastroenteritis and minimal dehydration admitted to the emergency department when given diluted apple juice were less likely to encounter treatment failure, compared to those given ORS or electrolyte maintenance solutions. Such children did not need to undergo intravenous fluids treatments e.g., IV rehydration.

In the United States about 178.8 million cases of acute gastroenteritis occur every year, which results in 473,832 hospitalizations. In children the occurrence of acute diarrhea results in 1.5 million outpatient visits and 200,000 hospitalizations. Gastroenteritis in children is also the cause of nearly 300 deaths in the US every year. Children with gastroenteritis are usually treated with oral rehydration therapy (ORT) which includes rehydration with the help of oral rehydration solutions (ORS).

Stephen B Freedman, MDCM, at the University of Calgary in Canada, was the lead author of the study. The study was a single-blind non-inferiority trial carried out from 2010 to 2015 at a pediatric emergency department in Toronto, Canada. The study participants included children from the age of 6-60 months brought to the emergency department with gastroenteritis and minimal dehydration. The mean age of the test group was 28.3 months.

According to Freedman, “These results challenge the recommendation to routinely administer electrolyte maintenance solution when diarrhea begins.”

Current research provides some very contrary results when it comes to treating gastroenteritis and apple juice. Apple juice is known to have a higher percentage of fructose than glucose which may engulf the absorptive capacity of the intestines and worsen diarrhea. Additionally research has shown unpasteurized apple juice can lead to numerous food borne illnesses. Such contradicting history of apple juice in diarrhea was also one of the reasons the researchers chose the specific drink.

The current study also claims evidence on the use of apple juice and occurrence of diarrhea is minimal and their results show the frequency of diarrheal stools was not different between the two groups. So even though high-glucose fluids were being consumed in the apple juice/preferred fluids group, there was no great difference in stool regularity.

“The use of beverages with high sugar content has traditionally been discouraged because of their potential to induce an osmotic diarrhea. However, studies evaluating this issue have found the effect to be minimal,” said Freedman. “These results provide pragmatic evidence that in children with minimal dehydration, promoting fluid consumption is more important than the glucose load consumed.”

The aim of the study was to determine if oral hydration with dilute apple juice is inferior or superior to electrolyte maintenance solutions, like ORS. The long-lasting objective of the study was to improve oral rehydration success in children with minimal dehydration.

The trial consisted of 647 randomized children. As part of the study, about 323 of the participants were given half-strength apple juice or preferred fluids, while the other half i.e., 324 participants, were given apple-flavored electrolyte maintenance solution. Both groups were given fluids which had the same color and taste. About 51.1% of the participants were boys i.e., 331 and 68.2% had no evidence of dehydration. The initial oral hydration was carried out with dilute apple juice, which was followed up with their preferred fluids combined with electrolyte maintenance solutions.

Following discharge it was found the group given the diluted apple juice was more likely to recover and drink any of their preferred drinks. Meanwhile, the ORS group, which was given the electrolyte maintenance solution, had to keep on consuming the electrolyte maintenance solution for a long time in order to replace their electrolyte losses. Another surprisingly result seen was the benefits of apple juice were greater in slightly older children i.e., over the age of 24 months. The children in the ORS group had a 14% increased risk of diarrhea, while 7% had an increased risk of vomiting. In the same way the chances of hospitalization were seen to be 0.9% in the diluted apple juice group, but 2.8% in the ORS group.

Electrolyte maintenance solution or ORS does not come cheap and its taste is not preferred by children. A majority of children often brought to the emergency department have to undergo intravenous rehydration, since the children refuse to drink the ORS because of its taste. On the basis of the results the researchers hypothesized children can drink diluted apple juice along with other preferred fluids during gastroenteritis, which would increase their treatment success chances and decreased the rate of intravenous rehydration therapy. Giving children electrolyte maintenance solutions or ORS may need additional treatments and do not recover early and easily.

The study was limited by its exclusion of a high-risk children group, which may have severe gastroenteritis and dehydration which is a serious problem in a majority of the third world countries. Similarly, the study was carried out in a high-income country so it cannot be applied to the general population.

“This was a single-center study and the control solution was an apple-flavored, sucralose-sweetened electrolyte maintenance solution; generalizability of study results to other settings and electrolyte maintenance solutions is uncertain,” said Freedman.