Intravenous rehydration of malnourished children with acute gastroenteritis and severe dehydration: A systematic review

Prevalence and correlates of paediatric guideline non-adherence for initial empirical care in six low and middle-income settings: a hospital-based cross-sectional study

OBJECTIVES

This study evaluated the prevalence and correlates of guideline non-adherence for common childhood illnesses in low-resource settings.

DESIGN AND SETTING

We used secondary cross-sectional data from eight healthcare facilities in six Asian and African countries.

PARTICIPANTS

A total of 2796 children aged 2-23 months hospitalised between November 2016 and January 2019 with pneumonia, diarrhoea or severe malnutrition (SM) and without HIV infection were included in this study.

PRIMARY OUTCOME MEASURES

We identified children treated with full, partial or non-adherent initial inpatient care according to site-specific standard-of-care guidelines for pneumonia, diarrhoea and SM within the first 24 hours of admission. Correlates of guideline non-adherence were identified using generalised estimating equations.

RESULTS

Fully adherent care was delivered to 32% of children admitted with diarrhoea, 34% of children with pneumonia and 28% of children with SM when a strict definition of adherence was applied. Non-adherence to recommendations was most common for oxygen and antibiotics for pneumonia; fluid, zinc and antibiotics for diarrhoea; and vitamin A and zinc for SM. Non-adherence varied by site. Pneumonia guideline non-adherence was more likely among patients with severe disease (OR 1.82; 95% CI 1.38, 2.34) compared with non-severe disease. Diarrhoea guideline non-adherence was more likely among lower asset quintile groups (OR 1.16; 95% CI 1.01, 1.35), older children (OR 1.10; 95% CI 1.06, 1.13) and children presenting with wasting (OR 6.44; 95% CI 4.33, 9.57) compared with those with higher assets, younger age and not wasted.

CONCLUSIONS

Non-adherence to paediatric guidelines was common and associated with older age, disease severity, and comorbidities, and lower household economic status. These findings highlight opportunities to improve guidelines by adding clarity to specific recommendations.

Micronutrient status in children aged 6-59 months with severe wasting and/or nutritional edema: implications for nutritional rehabilitation formulations

Undernutrition remains a global struggle and is associated with almost 45% of deaths in children younger than 5 years. Despite advances in management of severe wasting (though less so for nutritional edema), full and sustained recovery remains elusive. Children with severe wasting and/or nutritional edema (also commonly referred to as severe acute malnutrition and part of the umbrella term "severe malnutrition") continue to have a high mortality rate. This suggests a likely multifactorial etiology that may include micronutrient deficiency. Micronutrients are currently provided in therapeutic foods at levels based on expert opinion, with few supportive studies of high quality having been conducted. This narrative review looks at the knowledge base on micronutrient deficiencies in children aged 6-59 months who have severe wasting and/or nutritional edema, in addition to highlighting areas where further research is warranted (See "Future Directions" section).

Gastroenteritis Rehydration Of children with Severe Acute Malnutrition (GASTROSAM): A Phase II Randomised Controlled trial: Trial Protocol

Background

Children hospitalised with severe acute malnutrition (SAM) are frequently complicated (>50%) by diarrhoea ( ≥3 watery stools/day) which is accompanied by poor outcomes. Rehydration guidelines for SAM are exceptionally conservative and controversial, based upon expert opinion. The guidelines only permit use of intravenous fluids for cases with advanced shock and exclusive use of low sodium intravenous and oral rehydration solutions (ORS) for fear of fluid and/or sodium overload. Children managed in accordance to these guidelines have a very high mortality. The proposed GASTROSAM trial will reappraise current recommendations with mortality as the primary outcome. We hypothesize that liberal rehydration strategies for both intravenous and oral rehydration in SAM children with diarrhoea may reduce adverse outcomes.

Methods

An open Phase II trial, with a partial factorial design, enrolling children in Uganda, Kenya, Nigeria and Niger aged 6 months to 12 years with SAM hospitalised with gastroenteritis (>3 loose stools/day) and signs of moderate and severe dehydration. In Stratum A (severe dehydration) children will be randomised (1:1:2) to WHO plan C (100mls/kg Ringers Lactate (RL) with intravenous rehydration (IV) given over 3-6 hours according to age including boluses for shock), slow rehydration (100 mls/kg RL over 8 hours (no boluses)) or WHO SAM rehydration regime (ORS only (boluses for shock (standard of care)). Stratum B incorporates all children with moderate dehydration and severe dehydration post-intravenous rehydration and compares (1:1 ratio) standard WHO ORS given for non-SAM (experimental) versus WHO SAM-recommended low-sodium ReSoMal. The primary outcome for intravenous rehydration is mortality to 96 hours and for oral rehydration a change in sodium levels at 24 hours post-randomisation. Secondary outcomes include measures assessing safety (evidence of pulmonary oedema or heart failure); change in sodium from post-iv levels for those in Stratum A; perturbations of electrolyte abnormalities (severe hyponatraemia <125 mmols/L or hypokalaemia.

Discussion

If the trial shows that rehydration strategies for non-malnourished children are safe and improve mortality in SAM this could prompt revisions to the current treatment recommendations or may prompt future Phase III trials.

Effectiveness of the WHO Protocol for the Management of Shock in Children With Severe Acute Malnutrition

Background The WHO protocol for the management of shock in children with severe acute malnutrition (SAM) is not supported by physiological evidence. In this study, we aimed to assess the effectiveness of the WHO treatment protocol in the management of shock in children with SAM. Methodology This cohort study included children aged 2-60 months with WHO-defined SAM and fulfilling the WHO criteria for identification of shock. The exclusion criteria included severe anemia (hemoglobin <4 g/dL), congenital anomalies, congenital heart defects, and chronic diseases. The WHO treatment protocol for the management of shock was used, and features of resolution of shock were assessed at eight and 24 hours. Oliguria was recorded at eight and 24 hours along with in-hospital mortality. Multiple logistic regression was used to determine predictors of mortality. Results Of 53 children, 40 (75.4%) were discharged and 13 (24.5%) expired. We observed significant resolution of features of shock at 24 hours compared to eight hours (35 (71.4%) vs. 10 (18.8%), p < 0.0001). Further analysis revealed a significant resolution of features of shock (p = 0.03) at 24 hours in both fluid-responsive (24 vs. 10) and fluid-refractory children (11 vs. 27) compared to eight hours. Multivariate analysis revealed that mechanical ventilation was positively related to death (odds ratio (OR) = 85, 95% confidence interval (CI) = 8.49, 860, p < 0.0001), and inotrope scores <20 (OR = 0.053, 95% CI = 0.004, 0.64, p = 0.021) and blood transfusion (OR = 0.025, 95% CI = 0.001, 0.61, p = 0.024) had favorable outcomes. Conclusions The WHO protocol for the management of shock in children with SAM is effective in fluid-responsive shock whereas evidence was inconclusive in fluid-refractory shock.

Determinants of mortality among under-five children admitted with severe acute malnutrition in Addis Ababa, Ethiopia

BACKGROUND

Management of severe acute malnutrition (SAM) has been a program priority in Ethiopia, but it remains the leading cause of mortality in under-five children. Hence, this study aimed to identify the incidence density rate of mortality and determinants among under-five children with severe acute malnutrition in St. Paul's Hospital Millennium Medical College, 2012 to 2019.

METHODS

A retrospective cohort study was conducted and data were collected using a structured checklist from 673 charts, of which 610 charts were included in the final analysis. The Kaplan-Meier survival curve with Log-rank test was used to estimate the survival time. Bi-variable and multi-variable Cox proportional hazard regression models were fitted to identify determinants of death. Schoenfeld residuals test was used to check a proportional hazard assumption. Goodness of fit of the final model was checked using Nelson Aalen cumulative hazard function against Cox-Snell residual.

RESULTS

In this study, 61 (10%) children died making the incidence density rate of death 5.6 (95% CI: 4.4, 7.2) per 1000 child-days. Shock (Adjusted Hazard Ratio) [AHR] =3.2; 95% CI: 1.6, 6.3)), IV fluid infusion (AHR = 5.2; 95% CI: 2.4, 10.4), supplementing F100 (AHR = 0.12; 95%CI: 0.06, 0.23) and zinc (AHR = 0.45; 95% CI: 0.22, 0.93) were determinants of death.

CONCLUSION

The overall proportion of deaths was within the range put forth by the Sphere standard and the national SAM management protocol. Shock and IV fluid infusion increased the hazard of death, whereas F100 & zinc were found to decrease the likelihood death. Children with SAM presented with shock should be handled carefully and IV fluids should be given with precautions.

Gastroenteritis Rehydration Of children with Severe Acute Malnutrition (GASTROSAM): A Phase II Randomised Controlled trial: Trial Protocol

Background: Children hospitalised with severe acute malnutrition (SAM) are frequently complicated (>50%) by diarrhoea ( ≥3 watery stools/day) which is accompanied by poor outcomes. Rehydration guidelines for SAM are exceptionally conservative and controversial, based upon expert opinion. The guidelines only permit use of intravenous fluids for cases with advanced shock and exclusive use of low sodium intravenous and oral rehydration solutions (ORS) for fear of fluid and/or sodium overload. Children managed in accordance to these guidelines have a very high mortality. The proposed GASTROSAM trial is the first step in reappraising current recommendations. We hypothesize that liberal rehydration strategies for both intravenous and oral rehydration in SAM children with diarrhoea may reduce adverse outcomes. Methods An open Phase II trial, with a partial factorial design, enrolling Ugandan and Kenyan children aged 6 months to 12 years with SAM hospitalised with gastroenteritis (>3 loose stools/day) and signs of moderate and severe dehydration.  In Stratum A (severe dehydration) children will be randomised (1:1:2) to WHO plan C (100mls/kg Ringers Lactate (RL) with intravenous rehydration given over 3-6 hours according to age including boluses for shock), slow rehydration (100 mls/kg RL over 8 hours (no boluses)) or  WHO SAM rehydration regime (ORS only (boluses for shock (standard of care)).  Stratum B incorporates all children with moderate dehydration and severe dehydration post-intravenous rehydration and compares (1:1 ratio) standard WHO ORS given for non-SAM (experimental) versus WHO SAM-recommended low-sodium ReSoMal. The primary outcome for intravenous rehydration is urine output (mls/kg/hour at 8 hours post-randomisation), and for oral rehydration a change in sodium levels at 24 hours post-randomisation. This trial will also generate feasibility, safety and preliminary data on survival to 28 days. Discussion. If current rehydration strategies for non-malnourished children are safe in SAM this could prompt future evaluation in Phase III trials.

Association between cholera treatment outcome and nutritional status in children aged 2-4 years in Nigeria

SETTING

Cholera can aggravate or precipitate malnutrition, and children with severe acute malnutrition (SAM) have a higher incidence and longer duration of diarrhoea.

OBJECTIVE

To describe 1) characteristics of and treatment outcomes in children aged 2-4 years with cholera, 2) the case fatality rate (CFR) in all children treated, and 3) the associations between nutritional status, hydration status, treatment administered and hospital outcomes.

DESIGN

An observational cohort study of children admitted to one cholera treatment centre in Maiduguri, Nigeria, with a focus on children aged 2-4 years. CFRs were examined by cross tabulation and mean length of stay (LOS) using analysis of variance.

RESULTS

SAM was identified in 24% of children aged 2-4 years. The CFR for children aged 2-4 years was 1.4%. As the sample size was small, we did not find any association between nutritional status and death due to cholera. The proportion of children discharged within 2 days was 79%, and the longest stay was 8 days. In general, health facility LOS increased with severity of malnutrition.

CONCLUSION

Our study found that nutritional status affected the LOS, but was unable to find an association between malnutrition and fatality among children aged 2-4 years.

The effect of abdominal massage (I Love You method) on the gastric function of preterm infants hospitalized in the neonatal intensive care units: a randomized clinical trial

OBJECTIVES

Preterm infants often suffer from nutritional problems because of gastrointestinal problems. Massage could make the infants feel more peace and comfort, but limited studies have focused on the effects of massage on the gastric function. This study aimed to investigate the effects of abdominal massage on the gastric function of preterm infants.

METHODS

A randomized controlled trial compared gastric function of preterm infants with and without massage therapy. The preterm infants were randomly allocated to control and massage groups. The massage group received the abdominal massage before feeding, twice a day, for 15 min, over 5 days. Furthermore, the gastric function was compared between the control and experimental groups. The data were analyzed using SPSS software (Version 15.0).

RESULTS

The average weight in both groups had no significant (p>0.05) changes before and after the study, and both groups showed a negative trend in the weight gain. The abdominal circumference, the frequency of vomiting episodes, the residual volume, and defecation frequency were significantly (p<0.05) different between the two groups after the intervention.

CONCLUSIONS

The abdominal massage could be an effective nonmedicinal method to reduce the gastrointestinal problems in the preterm infants. The abdominal massage could be offered to the preterm infants as an inexpensive, available, and feasible method to alleviate gastrointestinal problems as well as improve the gastric function.

Early management of hypokalaemia in severely malnourished children under five could help to reduce deaths in developing countries

AIM

This study evaluated the factors associated with hypokalaemia and their outcomes, in severely malnourished children under 5 years of age.

METHODS

We focused on 407 severely malnourished children under five who were admitted to the Dhaka Hospital, International Centre for Diarrhoeal Disease Research, Bangladesh, from April 2011 to June 2012. The cases were 139 with hypokalaemia, and the comparisons were 268 without hypokalaemia.

RESULTS

Cases were older than the comparisons, with a poor socio-economic status and a higher death rate of 12% vs 7%. They were more likely to present with a history of measles, diarrhoea, lethargy, lower pulse rates, hyponatraemia, metabolic acidosis, hypocalcaemia, hypomagnesaemia, higher height or length, severe underweight, severe wasting and leucocytosis on admission. At discharge, cases had lower potassium levels and a higher proportion had persistent hypokalaemia. Cases received longer treatment with ampicillin and micronutrients. After adjusting for confounders, hypokalaemia was independently associated with poor socio-economic status, diarrhoea, lower pulse rates, hypocalcaemia, metabolic acidosis and leucocytosis.

CONCLUSION

Identifying simple clinical signs, like diarrhoea and lower pulse rates, and laboratory parameters, such as hypocalcaemia and metabolic acidosis, may enable the early management of hypokalaemia in severely malnourished children under 5 years. This could reduce morbidity and mortality.

Evaluation of the treatment guidelines, practices and outcomes of complicated severe acute malnutrition in children aged 0-59 months in sub-Saharan Africa: a study protocol for the SAMAC study

Introduction

in hospitals across Africa, the case fatality rates of severe acute malnutrition (SAM) have remained consistently high (over 20%), despite the existence of the WHO treatment guideline. This has been attributed to inconsistencies in the implementation of the WHO treatment guidelines in sub-Saharan African countries. In spite of this awareness, the SAM treatment guidelines adopted by various sub-Saharan African countries and hospitals are unknown. Knowledge of the exact treatment practices employed in the management of SAM in different hospitals in sub-Saharan Africa is not known. This study aims to investigate the admission criteria, in-patient treatment guidelines and practices and outcomes of complicated SAM in sub-Saharan African children aged 0-59 months.

Methods

this is an observational study which involves the extraction of admission, treatment and discharge data from the medical records of infants and children aged 0-59 months diagnosed and treated for complicated SAM in sub-Saharan Africa. This information is being used to develop a comprehensive database on the treatment of complicated SAM across sub-Saharan Africa. Information on the national and hospital guidelines for the treatment of complicated SAM is also collected.

Results

results of this study will serve as a useful resource on the true reflection of the treatment of complicated SAM across sub-Saharan Africa and will provide valuable information for optimising SAM treatment.

Conclusion

in order to advocate best practice and reduce SAM-related mortality in sub-Saharan Africa, the identification of the different diagnostic and treatment methods and respective outcomes across different hospitals and countries is imperative.

Diarrhea, Dehydration, and the Associated Mortality in Children with Complicated Severe Acute Malnutrition: A Prospective Cohort Study in Uganda

OBJECTIVE

To assess predictors of diarrhea and dehydration and to investigate the role of diarrhea in mortality among children with complicated severe acute malnutrition.

STUDY DESIGN

A prospective cohort study, nested in a probiotic trial, was conducted in children with complicated severe acute malnutrition. Children were treated according to World Health Organization and national guidelines, and diarrhea and dehydration were assessed daily. Multiple linear and log-linear Poisson regression models were used to identify predictors of days with diarrhea and dehydration, respectively, and multiple logistic regression was used to assess their role in mortality.

RESULTS

Among 400 children enrolled, the median (IQR) age was 15.0 months (11.2-19.2 months), 58% were boys, and 61% had caregiver-reported diarrhea at admission. During hospitalization, the median (range) number of days with diarrhea was 5 (0-31), the median duration of hospitalization was 17 days (1-69 days), and 39 (10%) died. Of 592 diarrhea episodes monitored, 237 were admission episodes and 355 were hospital acquired. During hospitalization, young age was associated with days with diarrhea, and young age and HIV infection were associated with dehydration. Both days with diarrhea and dehydration predicted duration of hospitalization as well as mortality. The odds of mortality increased by a factor of 1.4 (95% CI, 1.2-1.6) per day of diarrhea and 3.5 (95% CI, 2.2-6.0) per unit increase in dehydration score.

CONCLUSIONS

Diarrhea is a strong predictor of mortality among children with complicated severe acute malnutrition. Improved management of diarrhea and prevention of hospital-acquired diarrhea may be critical to decreasing mortality.

Assessment of Myocardial Function in Kenyan Children With Severe, Acute Malnutrition: The Cardiac Physiology in Malnutrition (CAPMAL) Study

Importance

Mortality among African children hospitalized with severe malnutrition remains high, with sudden, unexpected deaths leading to speculation about potential cardiac causes. Malnutrition is considered high risk for cardiac failure, but evidence is limited.

Objective

To investigate the role of cardiovascular dysfunction in African children with severe, acute malnutrition (SAM).

Design, Setting, and Participants

A prospective, matched case-control study, the Cardiac Physiology in Malnutrition (CAPMAL) study, of 88 children with SAM (exposed) vs 22 severity-matched patients without SAM (unexposed) was conducted between March 7, 2011, and February 20, 2012; data analysis was performed from October 1, 2012, to March 1, 2016.

Exposures

Echocardiographic and electrocardiographic (ECG) recordings (including 7-day Holter monitoring) at admission, day 7, and day 28.

Main Outcomes and Measures

Findings in children with (cases) and without (controls) SAM and in marasmus and kwashiorkor phenotypes were compared.

Results

Eighty-eight children (52 with marasmus and 36 with kwashiorkor) of the 418 admitted with SAM and 22 severity-matched controls were studied. A total of 63 children (57%) were boys; median age at admission was 19 months (range, 12-39 months). On admission, abnormalities more common in cases vs controls included severe hypokalemia (potassium <2.5 mEq/L) (18 of 81 [22%] vs 0%), hypoalbuminemia (albumin level <3.4 g/dL) (66 of 88 [75%] vs 4 of 22 [18%]), and hypothyroidism (free thyroxine level <0.70 ng/dL or thyrotropin level >4.2 mU/L) (18 of 74 [24%] vs 1 of 21 [5%]) and were associated with typical electrocardiographic changes (T-wave inversion: odds ratio, 7.3; 95% CI, 1.9-28.0; P = .001), which corrected as potassium levels improved. Fourteen children with SAM (16%) but no controls died. Myocardial mass was lower in cases on admission but not by day 7. Results of the Tei Index, a measure of global cardiac function, were within the reference range and similar in cases (median, 0.37; interquartile range [IQR], 0.26-0.45) and controls (median, 0.36; IQR, 0.28-0.42). Echocardiography detected no evidence of cardiac failure among children with SAM, including those receiving intravenous fluids to correct hypovolemia. Cardiac dysfunction was generally associated with comorbidity and typical of hypovolemia, with low cardiac index (median, 4.9 L/min/m2; IQR, 3.9-6.1 L/min/m2), high systemic vascular resistance index (median, 1333 dyne seconds/cm5/m2; IQR, 1133-1752 dyne seconds/cm5/m2), and with few differences between the marasmus and kwashiorkor manifestations of malnutrition. Seven-day continuous ECG Holter monitoring during the high-risk initial refeeding period demonstrated self-limiting significant ventricular arrhythmias in 33 of 55 cases (60%) and 6 of 18 controls (33%) (P = .049); none were temporally related to adverse events, including fatalities.

Conclusions and Relevance

There is little evidence that African children with SAM are at greater risk of cardiac dysfunction or clinically significant arrhythmias than those without SAM or that marasmus and kwashiorkor differed in cardiovascular profile. These findings should prompt a review of current guidelines.

Persistent diarrhoea: current knowledge and novel concepts

BACKGROUND

Persistent diarrhoea (PD), defined as diarrhoeal symptoms for longer than 2 weeks, still forms a substantial disease burden in children under 5 years of age. This article provides an overview of the current knowledge of PD and discusses novel concepts.

METHODS

A literature search on PD was performed which focused on evidence on epidemiology, pathophysiology and management of the disease.

RESULTS

The prevalence of PD has potentially decreased over the last decades. Debate remains around the role of specific bacterial, viral and parasitic infections with PD. PD is associated with malnutrition and a compromised immune system, including that caused by HIV infection. Management includes fluid resuscitation and improving nutritional status. There is a lack of evidence on the use of antibiotic therapy for PD. There is increasing interest in nutrient-based interventions, including pre- and/or probiotics that can modify the microbiome and thereby potentially prevent or improve the outcome of PD in children.

CONCLUSION

As PD remains a significant health burden, multicentre clinical trials are needed to inform future treatment guidelines.

ABBREVIATIONS

PD, persistent diarrhoea; EED, environmental enteric dysfunction; IBD, inflammatory bowel disease; WHO, World Health Organization.

Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review

Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM.

Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18 ^th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration.

Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities.

Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines

Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review

Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM. Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18 th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration. Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities. Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines.