Dilute Apple Juice Beats Electrolyte Solution

Contrary to what I have been telling parents for years, dilute apple juice was actually better for oral rehydration than electrolyte solution in children 6-60 months with acute gastroenteritis.  This is a major dogma-busting article.

JAMA. 2016 Apr 30. doi: 10.1001/jama.2016.5352. [Epub ahead of print]

Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial.

Freedman SB1, Willan AR2, Boutis K3, Schuh S3.

Author information:

1Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada.

2Ontario Child Health Support Unit, Hospital for Sick Children Research Institute, Dalla Lana School of Public Health, University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada.

3Division of Pediatric Emergency Medicine, The Hospital for Sick Children and Child Health Evaluative Sciences, Toronto, Ontario, Canada4Hospital for Sick Children Research Institute, Department of Pediatrics, University of Toronto, Faculty of Medicine, To.




Gastroenteritis is a common pediatric illness. Electrolyte maintenance solution is recommended to treat and prevent dehydration. Its advantage in minimally dehydrated children is unproven.


To determine if oral hydration with dilute apple juice/preferred fluids is noninferior to electrolyte maintenance solution in children with mild gastroenteritis.

Design, Setting, and Participants:

Randomized, single-blind noninferiority trial conducted between the months of October and April during the years 2010 to 2015 in a tertiary care pediatric emergency department in Toronto, Ontario, Canada. Study participants were children aged 6 to 60 months with gastroenteritis and minimal dehydration.


Participants were randomly assigned to receive color-matched half-strength apple juice/preferred fluids (n=323) or apple-flavored electrolyte maintenance solution (n=324). Oral rehydration therapy followed institutional protocols. After discharge, the half-strength apple juice/preferred fluids group was administered fluids as desired; the electrolyte maintenance solution group replaced losses with electrolyte maintenance solution.

Main Outcomes and Measures:

The primary outcome was a composite of treatment failure defined by any of the following occurring within 7 days of enrollment: intravenous rehydration, hospitalization, subsequent unscheduled physician encounter, protracted symptoms, crossover, and 3% or more weight loss or significant dehydration at in-person follow-up. Secondary outcomes included intravenous rehydration, hospitalization, and frequency of diarrhea and vomiting. The noninferiority margin was defined as a difference between groups of 7.5% for the primary outcome and was assessed with a 1-sided α=.025. If noninferiority was established, a 1-sided test for superiority was conducted.


Among 647 randomized children (mean age, 28.3 months; 331 boys [51.1%]; 441 (68.2%) without evidence of dehydration), 644 (99.5%) completed follow-up. Children who were administered dilute apple juice experienced treatment failure less often than those given electrolyte maintenance solution (16.7% vs 25.0%; difference, -8.3%; 97.5% CI, -∞ to -2.0%; P < .001 for inferiority and P = .006 for superiority). Fewer children administered apple juice/preferred fluids received intravenous rehydration (2.5% vs 9.0%; difference, -6.5%; 99% CI, -11.6% to -1.8%). Hospitalization rates and diarrhea and vomiting frequency were not significantly different between groups.

Conclusions and Relevance:

Among children with mild gastroenteritis and minimal dehydration, initial oral hydration with dilute apple juice followed by their preferred fluids, compared with electrolyte maintenance solution, resulted in fewer treatment failures. In many high-income countries, 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 minimal dehydration.

Trial Registration:

clinicaltrials.gov Identifier: NCT01185054.

PMID: 27131100 [PubMed - as supplied by publisher]

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