A study has called for another look at existing global treatment guidelines in treating children with critical levels of malnutrition, suggesting that dated recommendations against safely rehydrating intravenously – due to a perceived risk of heart failure – were based on expert advice but not backed by scientific evidence, reports SciDev.Net.
The authors said the 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 estimated that there are nearly 20m children under five with severe acute malnutrition (SAM), the worst level of undernourishment, and the majority of these live in South Asia or Sub-Saharan Africa. SAM accounts for almost one third of preventable deaths in children of this age group.
The 2025 Global Report on Food Crises released last month, says more than 294m 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 study, published in the New England Journal of Medicine, found that giving fluids directly into a vein eliminates the need to take such fluids by mouth and leads to a more reliable and quicker recovery.
Hospitalised children who are severely malnourished already have an intravenous line for antibiotics and other drugs, so it was also quicker and easier for hospital staff to administer, said Maitland.
The researchers said the study, conducted under stringent monitoring, showed that rehydrating children using intravenous fluids does not cause harm, with no child suffering heart failure during the trial.
They said those who received oral hydration had more complications, including needing a nasogastric tube to assist with rehydration, more vomiting and need for emergency fluids to correct poor circulation.
Fluid overload
Current World Health Organisation (WHO) guidelines prescribe oral rehydration for severe malnutrition, stating that severe dehydration is difficult to detect in children with severe malnutrition and is often misdiagnosed.
They say giving intravenous fluids puts these children at risk of over-hydration 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 with 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 said.
After 96 hours, the mortality rate was lower than expected, compared with 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, said 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, said these were 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 recognise 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 before publication.
Study details
Intravenous Rehydration for Severe Acute Malnutrition with Gastroenteritis
Kathryn Maitland, San Maurice Ouattara, Hadiza Sainna et al.
Published in New England Journal of Medicine on 13 June 2025
Abstract
Background
International recommendations advise against the use of intravenous rehydration therapy in children with severe acute malnutrition because of the concern about fluid overload, but evidence to support this concern is lacking. Given the high mortality associated with the current recommendations, the adoption of intravenous rehydration strategies might improve outcomes.
Methods
We conducted a factorial, open-label superiority trial in four countries in Africa. Children six months to 12 years old with severe acute malnutrition with gastroenteritis and dehydration underwent randomisation in a 2:1:1 ratio to one of three rehydration strategies: oral rehydration, plus intravenous boluses for shock; a rapid intravenous strategy that consisted of lactated Ringer’s solution (100 ml per kilogram of body weight) administered over a period of 3 to 6 hours, with boluses for shock; or a slow intravenous strategy that consisted of the same solution administered over eight hours, with no boluses. The primary end point was death at 96 hours.
Results
A total of 272 children underwent randomisation; 138 were assigned to the oral strategy, 67 to the rapid intravenous strategy, and 67 to the slow intravenous strategy. Participants were followed for 28 days. A nasogastric tube was used for oral rehydration in 126 of 135 participants (93%) in the oral group and in 82 of 126 (65%) in the intravenous groups. Intravenous boluses were administered at admission in 12 participants (9%) in the oral group, 7 (10%) in the rapid intravenous group, and none in the slow intravenous group. At 96 hours, 11 participants (8%) in the oral group and 9 (7%) in the intravenous groups (5 in the rapid group and 4 in the slow group) had died (risk ratio, 1.02; 95% confidence interval [CI], 0.41 to 2.52; P=0.69). At 28 days, 17 participants (12%) in the oral group and 14 (10%) in the intravenous groups had died (hazard ratio, 0.85; 95% CI, 0.41 to 1.78). Serious adverse events occurred in 32 participants (23%) in the oral group, 14 (21%) in the rapid intravenous group, and 10 (15%) in the slow intravenous group. No evidence of pulmonary oedema, heart failure, or fluid overload was noted.
Conclusions
Among children with severe acute malnutrition and gastroenteritis, no evidence of a difference in mortality at 96 hours was noted between oral and intravenous rehydration strategies.
SciDev.net article – Study challenges treatment of severely malnourished kids (Open access)
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