Journal Jam 8 – Dilute Apple Juice for Pediatric Gastroenteritis

This is EM Cases Journal Jam podcast on a randomized control trial of dilute apple juice vs PediaLyte for mild pediatric gastroenteritis.

While IV rehydration is required in cases of severe gastroenteritis (which we rarely see in North America) and oral rehydration with electrolyte maintenance solutions is still the mainstay in treating moderate gastroenteritis, could better-tasting, more cost-effective fluids such as diluted apple juice be just as effective as traditional electrolyte solutions in milder cases? Listen to Dr. Justin Morgenstern (@First10EM) interviewing Dr. Stephen Freedman, the world-renowned pediatric EM researcher who put ondansetron for pediatric gastroenteritis on the map and who was one of our guest experts on our main episode on Pediatric Gastroenteritis, Constipation and Bowel Obstruction, about this practice-changing paper. This is followed by a hilarious rant on the topic from Dr. Anthony Crocco (“Ranthony”), the Division head and medical director of pediatric EM at Hamilton Health Sciences.

Produced by Anton Helman (@EMCases), Justin Morgenstern (@First10EM), and Anthony Crocco (@croccoag) November 2016

Cite this podcast as: Morgenstern, J, Freedman, S, Crocco, A, Helman, A. Dilute Apple Juice for Pediatric Gastroenteritis. Emergency Medicine Cases. November, 2016. Accessed [date].

Inclusion and Exclusion Criteria for Dilute Apple Juice in Pediatric Mild Gastroenteritis

Before diving in and using dilute apple juice for all your pediatric patients with gastroenteritis be sure to review the inclusion and exclusion criteria of this study to help you decide whether or not to apply the evidence to your patient in the ED.

Inclusion Criteria

  • 6 months-60 months
  • 3 + episodes diarrhea or vomiting in preceding 24hrs
  • < 96hrs of symptoms
  • none to minimal dehydration

Exclusion Criteria

  • clinical dehydration scale score 5+ (see clinical dehydration score below)
  • <8kg
  • < 6 months
  • > 2sec cap refill
  • significant GI disease (eg: short gut syndrome)
  • significant co-morbidities (eg: diabetes)
  • premature
  • bilious vomiting
  • hematochezia or hemato-emesis
  • requiring immediate IV access for any reason

Dr. Freedman recommends using the validated Clinical Dehydration Scale to assess for hypovolemia in children suspected of gastroenteritis.

dilute apple juice for pediatric gastroenteritis

Clinical Dehydration Scale


If you do use dilute apple juice for hydration in children with mild gastroenteritis give 5ml q2-5min in the ED plus 10ml/kg for each episode of diarrhea or 2ml/kg for each emesis.


Dr. Helman, Dr. Morgenstern, Dr. Freedman and Dr. Crocco have no conflicts of interest to declare.

References for Dilute Apple Juice in Pediatric Gastroenteritis

Freedman SB, Willan AR, Boutis K, Schuh S. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. JAMA. 2016;315(18):1966-74. Abstract

Kinlin LM, Freedman SB. Evaluation of a clinical dehydration scale in children requiring intravenous rehydration. Pediatrics. 2012;129(5):e1211-9. Full PDF


Other FOAMed Resources on Pediatric Gastroenteritis and Dilute Apple Juice

The EM Cases main episode on gastroenteritis with Dr. Stephen Freedman and Dr. Anna Jarvis

RebelEM does Forget the PediLyte

Ken Milne dissects the paper on The SGEM

Don’t Forget the Bubbles covers An Apple Juice a Day


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About the Author:

Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.

One Comment

  1. Dr Ian Light August 6, 2018 at 8:06 am - Reply

    Interestingly the Melbourne Australia Royal Children’s Hospital Guidelines for GastroEnteritis Treatments says No to Lemonade or Juices or Sports Drinks but does not mention dilutions of these if the Pharmaceutical Electrolyte Solutions are intolerable .
    However as a GP practicing 1980-2010 juices or cordial or flat lemonade diluted 1 in 4 was OK according to RCH admitting officers or consultants if dehydration definetly less than 3% .
    3% or less dehydration meant No a normals on Exam : Normal Skin Turgor Normal capillary refill normal respiration mental state alert ,well mental state normal and full pulse normal eyes and fontanelles moist mouth and tongue warm peripheries .Only might be reduced is urine output .
    Beyond 3% dehydration so signs tachycardia tachypnoe dry – send to emergency ASOP.
    Australian Therapeutic Guidelines 5th Edition 2011 on page 108 states ” Soft drinks sports and energy drinks cordials and fruit juice are not optimal for use and may cause Futher deterioration ……IF NOT PROPERLY DILUTED ”
    So Evidence Based diluted Apple Juice ought be OK.

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