Effects of oral rehydration solution-based prophylactic sodium supplementation on clinical outcomes in pediatric pneumonia: A randomized controlled trial

Abstract

BACKGROUND

Hyponatremia is a prevalent and serious electrolyte imbalance in pediatric pneumonia and is linked to increased disease severity and adverse outcomes. Oral rehydration solution (ORS) is an available, inexpensive, safe, and ready-to-use oral solution that can supplement sodium in such cases.

AIM

To assess the impact of prophylactic sodium supplementation via ORS on clinical and hospital outcomes in infants and children admitted with pneumonia.

METHODS

A randomized, interventional controlled trial was conducted on 140 infants and children admitted with pneumonia (70 per group). The primary outcome was hospital length of stay, with secondary outcomes including serum sodium and potassium levels, clinical respiratory scores, modified shock index, and nutritional/inflammatory markers. The hospital length of stay and both the laboratory and clinical parameters of the interventional and control groups were compared.

RESULTS

The hospital stay was longer in the control group than in the intervention group (P value = 0.001; effect size = 0.59). Clinical respiratory scores on day 4 were significantly lower in the intervention group than in the control group (P value = 0.001). Sodium levels were significantly lower in the control group than in the intervention group at discharge (P value = 0.002).

CONCLUSION

Prophylactic oral sodium supplementation through ORS may have a health-promoting effect on infants and children admitted with pneumonia.

Key Words: Oral rehydration solution; Hyponatremia; Pediatric pneumonia; Randomized controlled trial; Length of stay; Egypt

Core Tip: Our study outlined the possible use of oral rehydration solution (ORS) to provide prophylactic sodium supplementation in infants and children with pneumonia. Sodium and potassium supplementation may improve clinical respiratory manifestations in infants and children with pneumonia. ORS supplementation may be a prophylactic therapy for prolonged hospitalization in infants and children with pneumonia.

INTRODUCTION

The World Health Organization (WHO) reported that pneumonia is a predominant cause of mortality in children under five years of age, accounting for approximately one-fifth of all juvenile fatalities worldwide[1].

Hyponatremia is the most prevalent electrolyte imbalance encountered in clinical practice and is a common finding in children with pneumonia[2-5].

Hyponatremia linked to childhood pneumonia is usually attributed to the syndrome of inappropriate secretion of antidiuretic hormone. This condition is characterized by hyponatremia and hypoosmolality and arises from the improper and persistent release or action of antidiuretic hormone[6].

Oral rehydration solution (ORS) is a first-line treatment for compensating for volume loss due to diarrhea and vomiting among children with gastroenteritis[7]. To maximize absorption, the ORS should contain both glucose and sodium to take advantage of the sodium-glucose cotransport in the gut. ORS are widely accessible as both premixed commercial solutions and powders that may be mixed with ordinary water[8]. It is more effective, safe, easy, and cost-efficient than intravenous therapy and is recommended by the WHO and the American Academy of Pediatrics[9].

Hyponatremia is a common electrolyte imbalance in pediatric pneumonia that is associated with greater disease severity and adverse outcomes. However, existing research does not provide evidence regarding prophylactic sodium administration to these patients and its effect on their clinical outcomes. Therefore, our objectives were to evaluate the possible prophylactic use of sodium supplementation via ORS as a novel supplement in infants and children with pneumonia.

MATERIALS AND METHODS

Study setting and design

Our study was a randomized parallel controlled trial on infants and children admitted with pneumonia at Mataria Teaching Hospital conducted from April 2025 to July 2025. The flow chart of the study is shown in Figure 1.

Figure 1 Flow chart of the study according to the CONSORT checklist. ORS: Oral rehydration solution.

Children of both sexes with pneumonia whose caregivers or parents disclosed approval to participate in the study and whose ages ranged from 1 month to 5 years were enrolled. Children with comorbidities that could affect sodium or fluid balance, including renal disease, heart failure, or severe malnutrition, and children with marked electrolyte abnormalities at baseline or those on sodium or potassium medications were excluded.

The inclusion and exclusion criteria according to the population, intervention, comparison, and outcome framework[10] were as follows:

Population: Infants and children admitted with pneumonia at Mataria Teaching Hospital.

Intervention: Impact of ORS supplementation on clinical and hospital outcomes.

Comparison: Both groups were compared in terms of differences in hospital length of stay, clinical respiratory scores, and sodium and potassium levels.

Outcome: The primary outcome is the impact of ORS supplementation on hospital length of stay.

Data collection and intervention

Parents/Legal guardians provided informed written consent before participation in the study. When culturally or legally needed, the permission of both parents was obtained in line with institutional policy.

Demographic and clinical characteristics, including age, sex, admission diagnosis, presence of underlying disease, vital signs, anthropometric measurements, and nutritional status, were recorded.

Eligible interventional infants and children with pneumonia were supplemented with WHO-compliant ORS (Pharco Pharmaceuticals, Egypt), which contained 75 mmol/L (0.52 g/sachet) Na⁺, 20 mmol/L (0.3 g/sachet) K⁺, 75 mmol/L glucose, with an osmolarity of 245 mOsm/L. The sachet was dissolved in 200 mL of water according to the manufacturer’s instructions. Children were administered the ORS in doses adjusted to approximate age-appropriate daily sodium and potassium allowances for three consecutive days following admission. Infants aged 1-6 months received 110 mg of sodium per day, those aged 7-12 months received 370 mg/day, toddlers aged 1-3 years received 800 mg/day, and children aged 4-5 years received 1000 mg/day[11,12].

Throughout the intervention phase, adherence to ORS administration was closely monitored. Each dose was observed and documented, and vomiting or refusal events, as well as the exact amount consumed, were noted. An independent investigator reviewed daily adherence reports to ensure compliance.

Follow-up laboratory tests and clinical assessments were performed throughout hospitalization to observe and document potential adverse ORS-related effects, including feeding intolerance, overhydration, electrolyte disturbances (hypernatremia or hyperkalemia), and aspiration.

Children who were assigned to the control group received standard hospital management along with a placebo (sterile water).

In accordance with institutional protocols, all patients in both groups received standard supportive care, which included intravenous fluids, oxygen supplementation, and antibiotics.

Children were followed up until discharge or death. The primary outcome, length of hospital stay, was defined prospectively as the time from hospital admission to discharge (measured in days). Discharge criteria were standardized as follows: Stable vital signs for at least 12 hours, adequate oral intake, and oxygen saturation ≥ 92% on room air.

Secondary outcome measures included the impact of ORS supplementation on other hospital outcomes, such as the modified shock index and clinical respiratory score.

Case definition

Clinical diagnosis of pneumonia: Clinical findings of tachypnea, fever, and reduced oxygen saturation, in addition to radiological findings suggestive of pneumonia[13].

The clinical respiratory score and modified shock index were calculated as previously described[14-16].

Hyponatremia and hypokalemia: Were defined using reference ranges as previously described[11].

The length of hospital stay was prospectively defined as the interval (in days) from the time of admission to the time of discharge.

Nutritional and inflammatory markers: The prognostic nutritional index was obtained as follows: 10 × serum albumin (g/dL) + 0.005 × lymphocyte count (mm³)[17]. The neutrophil-to-lymphocyte ratio was determined as the absolute neutrophil count divided by the absolute lymphocyte count, while the platelet-to-lymphocyte ratio was calculated as the platelet count divided by the absolute lymphocyte count[18,19].

Quality improvement services: All participants who received ORS were monitored for any adverse events that emerged, such as hypernatremia, hyperkalemia, feeding intolerance, aspiration, or overhydration risk. ORS seems to be a safe adjuvant therapy, as no complications or adverse events emerged. In addition, compliance was monitored to ensure adherence. To remove any potential risk of aspiration, enteral nutrition was started using nasogastric tubes according to Consensus guidelines from the American Society for Parenteral and Enteral Nutrition, Society of Critical Care Medicine, and European Society of Pediatric and Neonatal Intensive Care[20,21].

Randomization and control of other potential biases

An independent investigator randomly allocated the enrolled children to either the intervention group or the control group at a 1:1 ratio using a computerized program (GraphPad QuickCalcs). Sequentially numbered, opaque, and sealed envelopes that were prepared and administered independently of the clinical team were used to guarantee allocation concealment. The intervention was hidden from the outcome assessor and data analysts.

Clinical trial registration: The trial was registered with Clinical Trial Registration ID: NCT06951347 in April 2025 (https://clinicaltrials.gov/study/NCT06951347). Registration preceded the first patient enrollment in accordance with CONSORT/ICMJE requirements.

Sample size

The trial was powered for the primary endpoint, which is the length of hospital stay. We opted for a medium effect size (d = 0.5) using G*Power software (version 3.1.9.2), a conservative estimate, balancing detectability and feasibility. The alpha was set as 0.05, the power (1 - β) was set as 0.80, and the case-to-control ratio was set as 1:1. Therefore, the minimum sample size needed was 64 for each group, with a total of 128 children. To compensate for possible dropouts, the sample size was rounded to 140 (70 per group).

Statistical analysis

Numerical variables are presented as the mean, standard deviation, median, and interquartile range and were analyzed using the Shapiro-Wilk and the Kolmogorov-Smirnov normality tests. Categorical variables are presented as frequencies and percentages. The normally distributed numerical variables were compared via a t test (independent). With respect to the variables that were not normally distributed, a comparison of numerical variables was carried out via the Mann-Whitney U test. Two-sided P values ≤ 0.05 were considered significant. All the statistical analyses were performed through the computer program IBM SPSS (Statistical Package for the Social Science; IBM Corp, Armonk, NY, United States), release 25 for Microsoft Windows. Mediation analysis[22] was carried out using JASP 0.19.3 software.

RESULTS

Our study was conducted on 140 infants and children with pneumonia admitted to Mataria Teaching Hospital to outline the impact of ORS supplementation on clinical and laboratory outcomes. Tables 1 and 2 illustrate the sociodemographic and clinical criteria of the enrolled study participants.

Table 1 Sociodemographic criteria of the enrolled participants, n (%).

Age (months)
Median (IQR)	4 (8.8)
Min–Max	1-59
Gender distribution
Males	74 (52.9)
Females	66 (47.1)

IQR: Interquartile range; Min: Minimum; Max: Maximum.

Table 2 Clinical criteria of the enrolled participants, n (%).

Hospital length of stay (days)
Median (IQR)	9 (7)
Min-Max	5-35
Na on admission (mmol/L)
Median (IQR)	136 (3)
Min-Max	135-144
Na on day 2 (mmol/L)
Median (IQR)	135 (3)
Min-Max	127-150
Na on day 4 (mmol/L)
Median (IQR)	135 (3)
Min-Max	127-148
Na on discharge (mmol/L)
Median (IQR)	136 (3)
Min-Max	128-148
K on admission (mmol/L)
Median (IQR)	4.9 (1.0)
Min-Max	3.0-6.3
K on day 2 (mmol/L)
Median (IQR)	4.8 (1.2)
Min-Max	3.1-6.5
K on day 4 (mmol/L)
Median (IQR)	5 (1.2)
Min-Max	3.2-6.4
K on discharge (mmol/L)
Median (IQR)	4.8 (1)
Min-Max	2.5-6.1
Modified shock index on admission
Median (IQR)	2 (0.3)
Min-Max	1.4-2.4
Modified shock index on day 4
Median (IQR)	1.8 (0.3)
Min-Max	1.2-2.5
Modified shock index on discharge
Median (IQR)	1.7 (0.4)
Min-Max	1.2-2.7
Respiratory score on admission
Median (IQR)	8 (2)
Min-Max	5-12
Respiratory score on day 4
Median (IQR)	5 (4)
Min-Max	2-12
Fasting time in hours
Median (IQR)	24 (18)
Min-Max	6-48
Weight Z score
Median (IQR)	-1.1 (2.4)
Min-Max	-3.0:2.0
Height Z score
Median (IQR)	-1.1 (1.2)
Min-Max	-3.0:0.8
BMI Z score
Median (IQR)	-0.7 (2.7)
Min-Max	-3.0:3.0
NLR on admission
Median (IQR)	1.3 (1.4)
Min-Max	0.03-27.2
NLR on discharge
Median (IQR)	1.0 (0.9)
Min-Max	0.09-12
PNI on admission
Median (IQR)	62.0 (23.3)
Min-Max	27.5-248
PNI on discharge
Median (IQR)	58.0 (14.7)
Min-Max	29.5-102
PLR on admission
Median (IQR)	81.5 (85.1)
Min-Max	13.3-419
PLR on discharge
Median (IQR)	88.2 (75.2)
Min-Max	11.9-548

BMI: Body mass index; IQR: Interquartile range; K: Potassium; Min: Minimum; Max: Maximum; Na: Sodium; NLR: Neutrophil-lymphocyte ratio; PLR: Platelet-to-lymphocyte ratio; PNI: Prognostic Nutritional Index.

To remove any potential bias, matching between cases and controls was carried out. There were no significant differences except for the potassium levels at admission, which were lower in the intervention group than in the control group, as shown in Table 3. However, this difference may underscore the value of ORS supplementation, as no further significant differences were detected at days 2 or 4 or at discharge, as shown in Table 4. Sodium levels at discharge were significantly lower in the control group. In addition, the fasting time was shortened, and the clinical respiratory score was significantly lower on day 4 in the intervention group, as shown in Table 4.

Table 3 Matching between the intervention and control groups, n (%).

	Interventional (n = 70)	Control (n = 70)	P value
Age in months
Median (IQR)	5 (9.5)	4 (4.6)	0.1461
Min-Max	1.3-4.8	1-59
Modified shock index on admission
Median (IQR)	1.9 (0.3)	2.0 (0.3)	0.0511
Min-Max	1.4-2.4	1.5-2.4
Respiratory score on admission
Median (IQR)	8 (2)	8 (2)	0.9511
Min-Max	5-12	5-12
Sodium on admission (mmol/L)
Median (IQR)	136 (2)	137 (3)	0.0611
Min-Max	135-142	135-144
Potassium on admission (mmol/L)
Mean (SD)	4.6 (0.7)	4.9 (0.7)	0.0382,a
Min-Max	3.0-6.0	3.3-6.3
Weight Z score
Median (IQR)	-1.0 (2.16)	-1.2 (2.4)	0.1631
Min-Max	-3.0:2.0	-3.0:1.8
Height Z score
Mean (SD)	-1 (0.7)	-1.1 (0.9)	0.4942
Min-Max	-3.0:0.6	-3.0:0.8
BMI Z score
Median (IQR)	-0.7 (2.5)	-1.1 (2.7)	0.2581
Min-Max	-3.0:3.0	-3.0:2.0
NLR
Median (IQR)	1.0 (1.4)	1.0 (1.8)	0.1981
Min-Max	0.1-27.2	0.03-24
PNI
Median (IQR)	60.0 (20.6)	64.7 (24.0)	0.6941
Min-Max	45-126	27.5-248
PLR
Median (IQR)	84.4 (87.1)	74.8 (84.4)	0.4261
Min-Max	26.6-419	13.3-375.3

¹Mann-Whitney U test.

²Independent t test.

^aP values less than 0.05 were considered significant.

BMI: Body mass index; IQR: Interquartile range; Min: Minimum; Max: Maximum; NLR: Neutrophil-lymphocyte ratio; PLR: Platelet-to-lymphocyte ratio; PNI: Prognostic Nutritional Index.

Table 4 Impact of oral rehydration solution supplementation on hospital outcomes in both groups, n (%).

	Interventional (n = 70)	Control (n = 70)	P value
Na on day 2 (mmol/L)
Median (IQR)	135 (3)	136 (5)	0.7951
Min-Max	131-150	127-143
Na on day 4 (mmol/L)
Median (IQR)	135 (3)	135 (5)	0.4131
Min-Max	129-145	127-148
Na on discharge (mmol/L)
Median (IQR)	137 (3)	135 (4)	0.0021,a
Min-Max	132-141	128-148
K on day 2 (mmol/L)
Mean (SD)	4.7 (0.7)	4.8 (0.7)	0.3722
Min-Max	3.1-6.5	3.4-6.2
K on day 4 (mmol/L)
Median (IQR)	4.9 (1.2)	5.0 (1.2)	0.4691
Min-Max	3.3-6.0	3.2-6.4
K on discharge (mmol/L)
Median (IQR)	4.9 (0.8)	4.8 (1.0)	0.7371
Min-Max	3.5-6.1	2.5-6.0
Modified shock index on day 4
Median (IQR)	1.8 (0.3)	1.8 (0.3)	0.6911
Min-Max	1.2-2.5	1.3-2.4
Respiratory score on day 4
Median (IQR)	4 (2)	6 (4)	0.0011,a
Min-Max	2-12	2-12
Modified shock index on discharge
Median (IQR)	1.8 (0.4)	1.6 (0.4)	0.2951
Min-Max	1.2-2.7	1.2-2.5
Fasting time (hours)
Mean (SD)	23.1 (11.5)	28.2 (12.2)	0.0122,a
Min-Max	6-48	6-48
NLR
Median (IQR)	1.0 (0.5)	0.9 (1.2)	0.9951
Min-Max	0.1- 3.7	0.1- 12
PNI
Median (IQR)	58.7 (17.9)	58 (12.6)	0.6861
Min-Max	29.5-102	39.5-96
PLR
Median (IQR)	92.0 (79.7)	84.4 (69.8)	0.2451
Min-Max	18-548	11.9-301.7

¹Mann-Whitney U test.

²Independent t test.

^aP values less than 0.05 were considered significant.

IQR: Interquartile range; K: Potassium; Min: Minimum; Max: Maximum; Na: Sodium; NLR: Neutrophil-lymphocyte ratio; PLR: Platelet-to-lymphocyte ratio; PNI: Prognostic Nutritional Index.

We were interested in determining the effect of ORS supplementation on hospital outcomes, as illustrated in Table 5. The hospital stay was significantly shorter in the intervention group. A Kaplan-Meier curve for the length of hospital stay illustrates a significantly shorter time to discharge in the interventional group compared to the control group; P value < 0.001, as shown in Figure 2.

Figure 2 Kaplan-Meier curve for time to discharge in the intervention and control groups. Children in the intervention group had a significantly shorter time to discharge than those in the control group did.

Table 5 Impact of oral rehydration solution on hospital length of stay, n (%).

	Interventional (n = 70)	Control (n = 70)		P value
Hospital length of stay (days)
Median (IQR)	7 (3)	11 (9)		0.0011,a
Min-Max	5-20	5-35
Hodges-Lehmann median difference
Estimate	Confidence interval
	Upper level		Lower level
4	3		5
Effect size = 0.596

¹Mann-Whitney U test.

^aP values less than 0.05 were considered significant.

IQR: Interquartile range; Min: Minimum; Max: Maximum.

Similarly, we were interested in determining the differences in sodium and potassium levels as “on discharge – on admission”, as shown in Table 6. Furthermore, the direct effect of ORS supplementation on hospital stay was tested via a median analysis in the presence of mediators. The direct and total effects of ORS supplementation were significant, as shown in Table 7. The path diagram is shown in Figure 3. As illustrated, the total effect was the sum of the direct effect of ORS and the indirect effect of the mediators. As shown, the direct effect was significant, and the total effect was still significant and not affected by the mediators.

Figure 3 Path diagram for oral rehydration solution supplementation showing the direct effect of oral rehydration solution and the indirect effects of mediators and the total effect. a and b: Indirect effect of the mediators; c: Direct effect of oral rehydration solution. ORS: Oral rehydration solution.

Table 6 Differences in sodium and potassium levels (on discharge–on admission) in the intervention and control groups, n (%).

	Interventional (n = 70)	Control (n = 70)	P value
Differences in sodium and potassium levels (on discharge–on admission)
Difference of Na
Median (IQR)	0 (3.0)	-1.5 (3.2)	< 0.0011,a
Min-Max	-7:5	-12:9
Difference of K
Mean (SD)	0.1 (0.7)	-0.2 (0.8)	0.0132,a
Min-Max	-1.2:1.8	-2.2:1.7
Differences in sodium and potassium levels (on day 4–on admission)
Difference of Na
Median (IQR)	-0.5 (3.2)	-2.0 (5.0)	0.0331,a
Min-Max	-8:10	-12:12
Difference of K
Mean (SD)	0.1 (0.77)	-0.01 (0.78)	0.1182
Min-Max	-2.3:2.5	-1.7:2.3
Differences in sodium and potassium levels (on day 2–on admission)
Difference of Na
Median (IQR)	-1 (2)	-1 (4)	0.0861
Min-Max	-10:14	-11:5
Difference of K
Median (IQR)	0.05 (1)	0 (0.7)	0.4961
Min-Max	-1.4:2.2	-2:1.4

¹Mann-Whitney U test.

²Independent t test.

^aP values less than 0.05 were considered significant.

IQR: Interquartile range; K: Potassium; Min: Minimum; Max: Maximum; Na: Sodium.

Table 7 Mediation analysis for hospital stay to assess the direct effect of oral rehydration solution.

The outcome is an improvement in hospital length of stay
Estimate	Std. Error	Z value	aP value	95%CI lower level	95%CI upper level
A: Direct effect of Na supplementation
-3.3	0.54	-6	< 0.001a	-4.4	-2.2
B: Indirect effect: In the presence of mediators
Mediator 1: Respiratory score on day 4
0.423	0.224	-1.8	0.059	-0.86	0.015
Mediator 2: Fasting time
-1.2	0.516	-2.4	0.014a	-2.28	0.26
C: Total effect: Direct + indirect
-5.02	0.792	-6.3	< 0.001a	-6.5	-3.4

^aP values less than 0.05 were considered significant.

To exclude any potential bias, we carried out a regression analysis to check whether the baseline potassium level was a significant covariate as it was significantly lower in the intervention group at the start of the study. The results indicated that baseline potassium level was not a significant covariate, as shown in Table 8.

Table 8 Regression analysis for hospital length of stay.

Hospital length of stay in days
Variable	Univariate analysis			Multivariate analysis
	B	CI	P value	CI	P value
Interventional (ORS) vs control1	-5.09	-6.6:-3.4	< 0.001a	-6.37:-3.4	< 0.001a
Respiratory scores on admission	1.3	0.86:1.9	< 0.001a	0.88:1.84	< 0.001a
Modified shock index on admission	4.5	0.73:8.4	0.02a	-3.9:3.2	0.859
Age in months	-0.18	-0.096:0.06	0.652
Sex2	0.71	-1.07:2.5	0.43
Na on admission	0.032	-0.4:0.4	0.88
K on admission	0.947	-0.28:2.1	0.131	-0.09:1.2	0.786
Weight Z scores	-0.73	-1.4:-0.07	0.03	-5.4:1.9	0.356
Height Z scores	-1.06	-2:-0.04	0.04	-1.87:2.1	0.88
BMI Z scores	-0.4	-1:0.08	0.096	-1.43:3.6	0.387

¹The control group is the reference.

²Female sex is the reference.

^aP values less than 0.05 were considered significant.

BMI: Body mass index; K: Potassium; Na: Sodium; ORS: Oral rehydration solution.

For more clarity, we compared Na levels as hyponatremia, normal, or hypernatremia on admission, day 2, day 4, and at discharge, as shown in Table 9. There were more children in the control group with hyponatremia at discharge (P value = 0.02).

Table 9 Cross-tabulation of Na levels between the studied groups, n (%).

	Interventional (n = 70)	Control (n = 70)	P value
On day 2
Hyponatremia on day 2	38 (54.3)	34 (48.5)	0.491
Normal natremia on day 2	32 (45.7)	36 (51.4)
On day 4
Hyponatremia on day 4	37 (52.8)	35 (50)	0.731
Normal natremia on day 4	33 (47.2)	35 (50)
On discharge
Hyponatremia on discharge	21 (30)	39 (55.7)	0.021,a
Normal natremia on discharge	49 (70)	31 (44.3)

¹χ² test.

^aP values less than 0.05 were considered significant.

Hyponatremia was defined as a serum sodium concentration < 135 mmol/L, and normal natremia was defined as a serum sodium concentration of 135–145 mmol/L.

The ORS was well tolerated, with good adherence observed among participants throughout the study period. No adverse events related to ORS supplementation were reported.

DISCUSSION

Pneumonia is a leading cause of pediatric death and morbidity worldwide. Accurate diagnosis and identification of the causes of pneumonia are critical for evaluating the burden of illness, implementing appropriate prevention or treatment methods, and developing more effective therapies[23]. Electrolyte disturbances have been linked to a wide range of acute infections, including pneumonia, predominantly hyponatremia, and are present in the vast majority of community-acquired pneumonia cases. Hyper and hypokalemia are less common electrolyte disturbances[3].

Electrolyte disturbances, notably hyponatremia, are prevalent in children hospitalized with lower respiratory tract infections, particularly pneumonia, with estimated rates reaching 40% in some cohorts. Recent studies have shown that reduced serum sodium levels are independently associated with greater disease severity, longer hospital stays, increased requirements for mechanical ventilation or intensive care, hemodynamic instability, and higher fatality rates[24-26]. These findings emphasize the importance of electrolyte monitoring in pediatric patients with pneumonia and underscore the need for additional research evaluating preventive or prophylactic strategies to increase sodium and potassium levels and thus improve clinical outcomes. Therefore, we were encouraged to study the impact of prophylactic ORS supplementation on clinical outcomes and length of hospital stay in pediatric pneumonia.

Hyponatremia is common in infants and children hospitalized with pneumonia and is linked to increased disease severity. The underlying process is incompletely understood, yet the syndrome of inappropriate antidiuretic hormone secretion is thought to play an important role. Traditional choices for managing hyponatremia in such children are challenging[27].

Hyponatremia is a common finding in children with lower respiratory tract infections and seems to be linked to disease severity and hospitalization duration[28]. This may have been the case in our study, as the interventional group experienced lower respiratory scores and shorter hospital stays. Hyponatremia was associated with an increased length of hospital stay in another study[29].

Low sodium levels can affect gastrointestinal tract functional capacity[30]. This was found in our study, in which the fasting time was significantly shorter in the intervention group (P value = 0.012). This may add to the possible value of supplementation with ORS in hospitalized patients.

ORS are formulated to have a greater effect on sodium levels than on potassium levels[31]. This may be the basis for our results, as potassium levels at discharge did not differ significantly between the interventional and control groups. This may underscore the fact that hyponatremia is more prevalent than hypokalemia in children hospitalized with pneumonia[32]. However, compared with those in the interventional group, potassium levels in the control group shifted to lower levels. This finding may further reveal the importance of ORS supplementation in vulnerable children.

Strength of the study

To the best of our knowledge, our study is the first to outline the possible effect of ORS as an adjuvant therapy in infants and children hospitalized with pneumonia and its effect on hospital length of stay.

Limitations

The observed reduction in hospital stay is encouraging but should be considered in light of our single-center design and relatively small sample size. Larger, multicenter trials are needed before generalizations can be made or routine preventive ORS usage in all pediatric pneumonia cases can be suggested. Furthermore, studies with longer follow-up periods are needed to outline the long-term safety of ORS in such vulnerable age groups.

Recommendation: Further studies are needed to clarify the possible use of ORS as a routine supplement in children with pneumonia.

CONCLUSION

This study may increase the awareness of health care providers regarding the possible use of ORS as an adjuvant prophylactic therapy in infants and children admitted with pneumonia. In this single-center trial, ORS supplementation was associated with shorter hospitalization. Larger trials are needed to confirm these findings.