Written by Joshua Belfer
Spoon Feed
Among children with severe acute malnutrition and gastroenteritis in Africa, IV rehydration was just as safe and effective as oral rehydration, with no increase in mortality or evidence of fluid overload, challenging long-standing WHO guidance to avoid IV fluids in this population.
Old fears, new data
For decades, WHO guidelines have cautioned against IV rehydration in severely malnourished children, fearing cardiac failure or fluid overload. However, those recommendations were based on limited evidence. The GASTROSAM trial, an open-label, multicenter randomized superiority trial in 272 children (6 months–12 years) across four African countries, compared oral rehydration (with IV boluses only for shock) to two IV regimens: rapid (100 mL/kg lactated Ringer’s solution over 3–6 hours) and slow (100 mL/kg LR over 8 hours).
At 96 hours, mortality was similar between groups: 8% oral vs. 7% IV (RR 1.02, 95%CI 0.41-2.52). At 28 days, deaths remained comparable (12% vs. 10%). Importantly, no cases of pulmonary edema or heart failure were observed. Overall, severe adverse events occurred in 23% of the oral group, 21% of the rapid IV group, and 15% of the slow IV group. Severe hyponatremia was less common in the IV arms (45% vs. 16% at 8 hours), and shock occurred less often (9% vs. 5%).
Importantly, limitations include lower-than-expected mortality (11%) (possibly reflecting the high level of monitoring in trial settings) and limited generalizability to lower-resource facilities. Few children had kwashiorkor, a group theoretically at higher risk for cardiac complications.
How will this change my practice?
This study challenges long-standing dogma around rehydration strategies in children with severe malnutrition and dehydration, a group with historically high mortality. While it suggests that IV fluids may be safer than once feared, its true value lies in the nuance. As the authors emphasize, feasibility and generalizability matter. The trial’s low mortality likely reflects the intensive monitoring and dedicated staffing available––conditions that are rarely reproducible in the settings where these children are most often treated. The findings are encouraging, but until similar outcomes are shown in lower-resource environments, the safest path forward may still be a cautious, context-driven approach.
Source
Intravenous Rehydration for Severe Acute Malnutrition with Gastroenteritis. N Engl J Med. 2025 Oct 2;393(13):1257-1268. doi: 10.1056/NEJMoa2505752. Epub 2025 Jun 13. PMID: 40513026; PMCID: PMC7617792.
