Should dextrose-containing intravenous fluids be avoided in the initial resuscitation of children with severe acute malnutrition (SAM)?

Dextrose-Containing IV Fluids Should NOT Be Routinely Avoided in SAM Resuscitation

Recent high-quality evidence from 2026 demonstrates that standard isotonic crystalloids (including those with dextrose) can be safely used for resuscitation in children with severe acute malnutrition (SAM), contradicting older restrictive guidance. The landmark GASTROSAM trial found no evidence of fluid overload with standard rehydration approaches, and hypoglycemia remains a critical concern requiring glucose provision 1.

Key Evidence Supporting Dextrose Use

The GASTROSAM Trial Changes the Paradigm

The 2026 GASTROSAM trial—a phase 2 superiority RCT across four African countries—fundamentally challenges traditional SAM fluid management 1. This study demonstrated:

• No fluid overload events occurred with either oral or intravenous rehydration strategies in 272 children with SAM and severe dehydration
• No evidence of pulmonary edema or heart failure was observed
• Mortality at 96 hours was similar between oral (8%) and IV strategies (7%)
• The trial included both rapid IV (100 mL/kg over 3-6 hours) and slow IV (over 8 hours) strategies

A parallel component comparing WHO-ORS versus ReSoMal found similar outcomes with standard ORS, supporting simplification of guidelines 2.

Hypoglycemia: The Real Killer in SAM

Hypoglycemia is strongly associated with mortality in SAM and requires glucose provision 3. In a Malawian cohort study, hypoglycemia had an adjusted relative risk of death of 10.8 (95% CI: 1.6-69.5) 3. Another study confirmed that adherence to prevention and treatment of hypoglycemia was significantly associated with survival (p < 0.001) 4.

Current Guideline Landscape

Sepsis Guidelines (Not SAM-Specific)

The 2020 Surviving Sepsis Campaign guidelines recommend balanced/buffered crystalloids over 0.9% saline for initial resuscitation in children with septic shock 5. These guidelines:

• Suggest crystalloids rather than albumin (weak recommendation, moderate quality evidence)
• Recommend against starches (strong recommendation)
• Do not specifically address dextrose content
• Were designed for general pediatric sepsis, not SAM populations

Pediatric Life Support Guidelines

The 2020 and 2025 PALS guidelines suggest 20 mL/kg fluid boluses for severe sepsis and severe malaria, with reassessment after each bolus 6, 7. The 2025 AHA/AAP guidelines state that either isotonic crystalloids or colloids can be effective as initial fluid choice 7.

Maintenance Fluid Guidelines

The 2022 ESPNIC guidelines strongly recommend isotonic maintenance fluids in acutely and critically ill children to reduce hyponatremia risk 8. They also recommend:

• Glucose provision in sufficient amounts guided by blood glucose monitoring (at least daily) to prevent hypoglycemia
• Balanced solutions to slightly reduce length of stay

Clinical Algorithm for SAM Resuscitation

Step 1: Assess Dehydration Severity and Shock

• Severe dehydration or shock present: Proceed with fluid resuscitation
• Mild-moderate dehydration, no shock: Consider oral/nasogastric route first 2, 1

Step 2: Choose Fluid Type

Use isotonic balanced crystalloid solutions (e.g., lactated Ringer's) with glucose supplementation:

• Balanced crystalloids preferred over 0.9% saline 5, 7, 8
• Include glucose to prevent hypoglycemia—this is critical in SAM 4, 3
• Monitor blood glucose at least daily 8

Step 3: Fluid Administration Strategy

For settings WITH intensive care availability:

• Administer 10-20 mL/kg boluses up to 40-60 mL/kg in first hour 5
• Reassess after each bolus for:
  • Clinical markers of cardiac output (heart rate, blood pressure, capillary refill, mental status, urine output)
  • Signs of fluid overload (pulmonary edema, hepatomegaly)

For settings WITHOUT intensive care:

• If hypotensive: up to 40 mL/kg in 10-20 mL/kg boluses over first hour 5
• If not hypotensive: start maintenance fluids, avoid boluses 5

Step 4: Monitor Closely

• Reassess frequently after each intervention
• Monitor for fluid overload signs (though rare per recent evidence 1)
• Check blood glucose regularly
• Monitor electrolytes, particularly sodium

Critical Nuances and Pitfalls

The Fluid Overload Myth

Traditional teaching overestimated fluid overload risk in SAM. The GASTROSAM trial found zero cases of pulmonary edema or cardiac overload despite using standard volumes 1. The systematic review of three RCTs (484 participants) similarly reported no fluid overload events 9.

Hypoglycemia vs. Hypernatremia Trade-off

While dextrose-free fluids theoretically reduce hypernatremia risk, hypoglycemia poses a far greater immediate mortality threat in SAM 3. The GASTROSAM trial showed no difference in severe hypernatremia rates between groups 2.

Don't Confuse Cardiac Arrest Data

One 1986 animal study showed worse neurologic outcomes with 5% dextrose during cardiac arrest resuscitation 10. This is NOT applicable to SAM resuscitation, which involves different pathophysiology and clinical context.

ReSoMal Is No Longer Necessary

The GASTROSAM trial demonstrated that standard WHO-ORS performs equivalently to ReSoMal 2. This simplifies management—standard isotonic solutions with appropriate glucose content are sufficient.

Bottom Line Recommendation

Use isotonic balanced crystalloid solutions WITH glucose supplementation for SAM resuscitation. The evidence no longer supports avoiding dextrose-containing fluids. The real priorities are:

1. Prevent hypoglycemia (major mortality risk)
2. Use isotonic balanced solutions
3. Give appropriate volumes with frequent reassessment
4. Monitor for fluid overload (though risk is lower than historically believed)

The 2026 GASTROSAM trial provides the highest quality, most recent evidence specifically addressing SAM populations and should guide current practice 1.