Systematic review of the evidence of cardiac dysfunction and intravenous fluid use among children with severe acute malnutrition and severe dehydration

Clinical Snapshot

Key Findings

• P Value: Not reported

• Effect Size: 0% incidence of fluid overload across all studies

• Primary Outcome: No cases of fluid overload observed in 251 children with SAM receiving intravenous fluids

• Nnt Or Sensitivity: 100% of studies (8/8) found decreased left ventricular mass; 87.5% (7/8) found diastolic dysfunction; 0% found systolic dysfunction

• Confidence Interval: Not reported

Clinical Application

Requires echocardiographic capability and careful fluid monitoring, feasible in most Australian paediatric centres Relevant for remote and Indigenous communities where malnutrition may coexist with gastroenteritis. May inform RACGP guidelines for remote practice and influence hospital protocols for managing malnourished children Children with severe acute malnutrition presenting with dehydrating illnesses, particularly relevant in resource-limited settings and remote Australian communities

Abstract

BACKGROUND: A sizeable proportion of cholera attributed mortality occurs among children with severe acute malnutrition (SAM). International guidelines severely limit the use of intravenous fluids among children with SAM and cholera due to their perceived vulnerability to fluid overload. We reviewed the cardiac function evidence and studies of intravenous fluid use among children with SAM. METHODS: Two systematic reviews of Chinese, English, French and Spanish language papers published after the last Global Task Force for Cholera Control recommendations on the treatment of children with cholera and SAM (2017) were conducted. The first included studies of cardiac function among children presenting to hospital with SAM. The second included studies of intravenous fluid use among children with dehydrating diarrhoea and SAM. RESULTS: Among eight echocardiographic studies of cardiac function in children with SAM at presentation to hospital, all found left ventricular mass to be decreased but none found systolic function to be impaired. Seven of the eight studies assessing diastolic function found some degree of mild-to-moderate impairment. Two echocardiographic studies monitored responsiveness to intravenous fluid resuscitation and found no evidence of fluid overload. Finally, four studies gave intravenous fluids to children with SAM and either shock or dehydration. Collectively, these studies included 251 children with SAM given intravenous fluid. No cases of fluid overload were observed. CONCLUSION: No evidence to support decreased systolic function among children with SAM and no documented cases of fluid overload during intravenous rehydration of these children were identified. These data call into question guidelines that severely restrict intravenous fluids among children with SAM and highly dehydrating conditions such as cholera.

References

1. 1.Narra, R., Alberti, K., Ciglenecki, I., Allen, B. G. S., de Polnay, K., & Tickell, K. D. (2026). Systematic review of the evidence of cardiac dysfunction and intravenous fluid use among children with severe acute malnutrition and severe dehydration. BMJ Paediatrics Open, 11(1), e004405. https://doi.org/10.1136/bmjpo-2025-004405