Box 1. Management of cholera in children with severe acute malnutrition.

WHO Guidelines (2013) 3	The only indication for intravenous infusion in a child with SAM is shock OR a child with severe dehydration and who cannot be rehydrated orally or by nasogastric tube. These children should receive 15ml/Kg/hour of either ½ strength Darrow’s + 5% dextrose OR Ringers lactate +5% dextrose. Children should be monitored every 5–10minutes for signs of over-hydration and congestive heart failure. If there is no improvement, a blood transfusion (10ml/Kg over at least 3hours) should be given.
Evidence for intravenous rehydration	This review includes 266 children with cholera out of a possible total of 802 (33%) from two studies that identified children with cholera (Alam et al. and Ahmed et al.) 9, 10. Ahmed did not perform any sub-analyses on children with cholera. Relevant findings from Alam 2009: 149 (85%) children presented with severe dehydration and required IV rehydration (mean amount of IV fluid required was 103 ml/Kg (95%CI 96-109)) No significant difference in baseline electrolyte abnormalities No children died in this study and no children developed signs of fluid overload No child developed signs of hyponatraemia (not specified) All children were clinically rehydrated within 6 hours although 31% did not pass urine within this period Rice-ORS group had significantly less stool output
Implications in practice	There is just one study evaluating safety of intravenous rehydration in children with SAM and cholera. This study rehydrated 149 children with a mean amount of 103ml/Kg of ‘cholera saline’ (sodium 133 mmol/L, potassium 13 mmol/L, chloride 98 mmol/L) and did not report any adverse outcome from this treatment i.e. no fluid overload, no significant difference in dysnatraemia, mortality or fluid related adverse effects. Guidelines for cholera in children with SAM remain extremely conservative and are at risk of undertreating children.