Study: Intravenous rehydration ‘safe’ for severely malnourished children

Children with critical levels of malnutrition can be safely rehydrated intravenously, according to a new study that calls for a review of the existing global treatment guidelines.

Specialists in child health say decades-old guidelines which advise against intravenous rehydration due to the perceived risk of heart failure were based on expert opinion, but were not backed by scientific evidence.

They say new research suggests the recommended method of oral rehydration can have more adverse effects and that persistently high mortality rates among malnourished children point to the need for change.

"Children with severe acute malnutrition and dehydration are very sick, so it's crucial we can get them the best possible treatment and fast," said Kathryn Maitland, a leading British paediatrician and director of the Centre of African Research and Engagement at Imperial College London.

She told SciDev.Net: "The current recommendations have always been controversial as they were based on the lowest form of evidence — expert opinion.

"Nevertheless, these recommendations have been rigorously taught to clinicians and nutritionists so that they fear giving additional fluid to children."

Globally, it is Report on Food Crises released Tuesday (17 June), says more than 294 million people in 53 countries experienced high levels of acute food insecurity in 2024, driven by conflict, weather extremes and economic shocks.

Maitland and co-researchers from Imperial College, University College London and Médecins Sans Frontières (Doctors Without Borders/MSF), tested different treatment options on nearly 300 children admitted to hospital with severe acute malnutrition in four African countries.

The guidelines prescribe oral rehydration for severe malnutrition, stating that severe dehydration is difficult to detect in children with severe malnutrition and is often misdiagnosed.

It says that giving intravenous fluids puts these children at risk of overhydration and death from heart failure due to fluid overload.

However, the study carried out in Niger, Nigeria, Uganda and Kenya found no evidence of a difference in mortality with intravenous treatment after 96 hours, compared to the standard control strategy.

The study compared the safety of different rehydration strategies for 292 children aged 12 and under hospitalised with severe acute malnutrition and suffering dehydration caused by diarrhoea.

During the trial, no events of heart failure or fluid overload were recorded, indicating that the intravenous approaches to rehydration were not harmful, the researchers say.

After 96 hours, the mortality rate was lower than expected, compared to the standard control strategy — although the researchers acknowledge that this may be due to the close care and monitoring during the trial.

To ensure the trial met stringent ethical requirements, children were closely monitored in special units by dedicated clinical trial teams to identify and treat complications, explained Maitland.

She hopes the findings will help close the evidence gap and spark a review of the guidelines to bring them into line with those for non-malnourished children and improve treatment outcomes.

'Too early'

Laura Ferguson, director of research at the University of Southern California's Institute on Inequalities in Global Health, who did not participate in the research, says these are important findings that highlight the need for more research in this area.

However, she told SciDev.Net: "It's too early to suggest that global guidelines should be changed, as a stronger evidence base will be needed for that."

"It's important to recognize that the study did not find that intravenous fluids decreased mortality relative to current practice, and it requires a sterile environment and equipment, which might not always be available when treating SAM," said Ferguson who led a team of researchers in developing an AI model that predicts malnutrition six months ahead.

She believes further investigation is needed within government health systems where the level of resources available may be more limited than under trial conditions, where children were intensely monitored.

Maitland acknowledged the trial’s limitations but stressed that children had to be observed closely to ensure their safety.

“Every half an hour for the first two hours, and then every hour for up to eight hours the nurse and the doctor was at the bedside.

“That’s the standard of care that was required to make sure that we didn’t harm children.”

The WHO did not respond to a request for comment ahead of publication.