An evidence and consensus based guideline for acute diarrhoea management

Estimating utility scores in young children with acute rotavirus gastroenteritis in the UK

OBJECTIVE

To estimate utility scores for different severities of acute rotavirus gastroenteritis in children aged<5 years in the UK.

METHODS

UK general practitioners (n=25) and paediatricians (n=25) rated four different health state descriptions of acute rotavirus gastroenteritis using the EuroQol (EQ-5D) questionnaire for children aged<18 months and 18 months to 5 years. EQ-5D scores were modified to account for limited self-care and mobility, and converted into utility values using the standard algorithm using UK data.

RESULTS

General practitioners rated the mean utility for primary care cases at 0.781 (standard deviation (SD) 0.263) and 0.688 (SD 0.345) for the younger and older age groups, respectively. For hospitalised cases the corresponding scores were 0.425 (SD 0.243) and 0.200 (sd 0.386). Paediatricians rated the mean utility for hospitalised severe cases at 0.595 (SD 0.171) and 0.634 (SD 0.217) in the younger and older groups, respectively, and for hospitalised very severe cases at 0.256 (SD 0.251) and 0.077 (SD 0.340), respectively. In all cases, the utility differences between the health states were statistically significant (p<0.0001).

CONCLUSIONS

Acute rotavirus gastroenteritis substantially impairs quality of life in children aged<5 years as rated by health professionals. This study provides useful quantitative utility estimates for economic evaluations.

How has research changed my practice in the last 5 years?

You can't teach old dogs new tricks. Teaching middle-aged dogs new tricks is hard enough. They tend to stick to particular styles of attacking the postman that over the years have proved pretty reliable, often choosing to ignore new findings, or simply failing to keep up with progress in current discussions on, say, the old trouser versus postbag debate. Some unsettling papers are even asking whether dogs really need to attack postmen at all.

Urine specific gravity and other urinary indices: inaccurate tests for dehydration

OBJECTIVE

Urine output, specific gravity, and ketones (urinary indices) are commonly used as an objective means to assess for dehydration and gastroenteritis severity; however, their utility has not been established. The study was designed to evaluate the accuracy of urinary indices as diagnostic tests to identify acute dehydration.

METHODS

We completed a prospective cohort study in the Emergency Department of an urban pediatric hospital. Seventy-nine subjects ages 3 months to 36 months with gastroenteritis, clinically suspected moderate dehydration, and the need for intravenous rehydration were enrolled in the trial. Urine specific gravity and urine ketone levels were determined with bedside calorimetric (dipstick) testing, and urine output during rehydration and observation was measured by commonly used techniques. An internally validated, weight-based criterion standard for the percent dehydration on enrollment was used to identify the cohort of dehydrated subjects. Correlation statistics were calculated for urine output, specific gravity, and ketones. In addition, multilevel tables were created to determine the sensitivity, specificity, and likelihood ratio at varying test cutoff values to detect 3% and 5% dehydration.

RESULTS

Urine specific gravity (r = -0.06, P = 0.64), urine ketones (r = 0.08, P = 0.52), and urine output during rehydration (r = 0.01, P = 0.96) did not correlate with the initial degree of dehydration present. Clinically useful cutoff values for urine specific gravity and ketones to increase or decrease the likelihood of dehydration at the time of enrollment could not be identified.

CONCLUSIONS

Urinary indices are not useful diagnostic tests to identify the presence of dehydration during the initial assessment of children with gastroenteritis.

[Acute infectious diarrhea]

Acute infectious diarrhea has various causes: bacterial diarrhea with invasive or toxigenic mechanisms, especially frequent in hot regions and in travelers; viral diarrheas, frequent and cosmopolitan in children but also adults; and parasitic diarrhea, less frequent, and generally in subtropical areas. The major concerns involve the risk of complications, essentially dehydration and malnutrition, especially in vulnerable patients: young children, the elderly, and patients with immunosuppression, for whom rehydration is urgent. Diagnosis of diarrhea requires clinical assessment and history: underlying illnesses, severity of symptoms, presence and extent of dehydration and other clinical symptoms, travel history, known outbreaks, and pathogenic mechanism (invasive or toxigenic). Initial therapy should always include oral or parenteral rehydration; antimotility agents are generally not indicated; specific antibiotic treatment is not systematically indicated, except for invasive or dysenteric diarrhea and in immunosuppressed patients.

Exploring the clinical utility of blood ketone levels in the emergency department assessment of paediatric patients

BACKGROUND

Ketonuria (on standard urine testing) is a frequent finding in children presenting to emergency departments. With the advent of hand-held ketone meters, blood ketone levels can now be rapidly quantified.

HYPOTHESIS

Point of care testing (POCT) of blood ketone levels could provide clinically useful information on severity of illness in children and risk of hospital admission.

METHODS

A prospective study using POCT of blood ketone levels in a convenience sample of children <13 years old, with a typical case mix of medical problems.

FINDINGS

186 children were studied. The range of ketone levels varied widely among this study population depending on the presenting complaint. Higher levels were noted in those presenting with anorexia or vomiting and fever. The median ketone level of the total study population was 0.2 (range 0-6.0, interquartile range 0.1-0.9) mmol/l. Ketone levels correlated poorly with discharge destination and duration of admission. However, receiver-operator characteristics for ketones as a predictor of admission were comparable to Pediatric Risk of Admission scores (area under the curve 0.64 and 0.72, respectively) and may represent an independent risk factor for admission. A ketone level >1.2 mmol/l has a positive predictive value of 66.7% for admission. Ketone levels correlated well with decreased oral intake (R2 = 0.25; p<0.001).

CONCLUSIONS

A strong association was found between ketone levels, decreased oral intake and fever. Although ketone levels do not correlate well with more traditional markers of illness severity, they can help to predict the requirement for admission to hospital when interpreted in the context of the presenting illness. They may have applications in both the emergency department and primary care settings. Further prospective testing is required to validate these findings.

Best practice in primary care pathology: review 6

This sixth best practice review examines four series of common primary care questions in laboratory medicine: (1) laboratory monitoring in hypertension and heart failure abnormalities; (2) markers of inflammatory joint disease; (3) laboratory investigation of chronic diarrhoea; and (4) mumps and chickenpox. The review is presented in question-answer format, referenced for each question series. The recommendations represent a precis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus based rather than evidence based. They will be updated periodically to take account of new information.

Meta-analysis: ondansetron for vomiting in acute gastroenteritis in children

BACKGROUND

Vomiting is a common sympton in children with gastroenteritis, but its treatment remains controversial.

AIM

To investigate potential beneficial effects of ondansetron, compared with placebo or no intervention, in treating vomiting during acute gastroenteritis in children.

METHODS

The following electronic databases were searched through August 2006: MEDLINE, EMBASE, CINAHL and The Cochrane Library; additional references were obtained from reviewed articles. Only randomized-controlled trials (RCTs) were included.

RESULTS

Four RCTs involving 490 patients with vomiting during acute gastroenteritis were included. Combined data from three RCTs (n = 466) showed that ondansetron compared with the control significantly increased the chance for vomiting cessation soon after drug administration [relative risk (RR): 1.3, 95% confidence interval (CI): 1.2-1.5, number needed to treat (NNT): 5, 95% CI: 4-8], but this effect was not observed at 24 h (three RCTs, n = 144, RR 1.2, 95% CI: 0.9-1.7). Ondansetron significantly reduced the risk of intravenous rehydration (two RCTs, n = 359, RR 0.4, 95% CI: 0.3-0.7, NNT 7, 95% CI: 5-14). Outcome measures not significantly different after ondansetron treatment were the need for hospitalization and return emergency department visits.

CONCLUSIONS

Despite some clinical benefits, there is insufficient evidence to recommend the routine use of ondansetron for vomiting during acute gastroenteritis in children.

Disidratazione acuta nel lattante

Il lattante al di sotto di un anno, e soprattutto al di sotto di sei mesi, è ad alto rischio di disidratazione, di cui la prima causa è la diarrea. Questa è principalmente di origine virale. La gestione di una disidratazione comporta la correzione di questa e il soddisfacimento delle richieste idriche e nutrizionali. La valutazione della gravità della disidratazione è l’elemento chiave che guiderà la terapia. La perdita di peso, espressa in percentuale del peso corporeo prima dell’episodio di disidratazione, rappresenta il metodo di riferimento, ma è spesso difficile o impossibile da rilevare. Così, i segni clinici come l’alterazione dell’aspetto generale, il prolungamento del tempo di rivascolarizzazione cutanea, la constatazione di una plica cutanea persistente, occhi infossati, una secchezza delle mucose, un’assenza di lacrime sono i principali elementi che, insieme a tachicardia, pressione arteriosa e diuresi, permettono di valutare la gravità della disidratazione. La terapia si basa sulla correzione rapida del deficit del settore extracellulare. Può essere necessaria un’espansione volemica con 20 ml/kg di una soluzione cristalloide isotonica somministrata per via endovenosa o intraossea nella fase iniziale nei casi più gravi (disidratazione >10%). In tutti gli altri cas, la reidratazione per via orale volta a correggere il deficit idrico in quattro ore è la tecnica di elezione, che si è dimostrata efficace, sicura e rapida. Essa utilizza delle soluzioni per reidratazione adattate, che rispondono a criteri specifici. Il loro uso precoce rappresenta la prevenzione più efficace delle forme gravi e deve essere diffuso più ampiamente.

Evidence-based guidelines for pediatric emergencies

An increasing number of clinical guidelines are being developed to provide high-quality and consistent standards of care, most of which are based on a specific diagnosis. In a pediatric emergency department, the diagnosis may not be known on presentation and the junior doctors are usually the first to assess a patient and will need to establish the diagnosis and execute a management plan. In these circumstances, problem-based guidelines are useful to clinicians and provide a decision pathway by which a clinician can develop a working diagnosis and then follow a guideline for the particular disease. More experienced clinicians may find guidelines for individual diseases or conditions to be of more use. High-quality evidence for either of these styles of guidelines is not readily available and may require extrapolation from the literature focusing on adults or a consensus approach to inform discussions and the development of the recommendations. Due to the complexity of the process it must be systematic, transparent and open to scrutiny. The cost of developing a guideline in a systematic transparent process is high and it is, therefore, essential to ensure the implementation of the guidelines with as much rigor as the development itself. This review discusses the challenges encountered while developing and implementing pediatric emergency guidelines and concludes with the authors' suggestions for future research in this area.

Critères de gravité d'une diarrhée aiguë

Clinician should recognize any life-threatening causes of diarrhoea, such as intussusceptions, surgical abdomen, and haemolytic uraemic syndrome. The following clinical features should alert: abdominal pain with tenderness, with or without guarding, pallor, jaundice, oligo-anuria, bloody diarrhoea, systemically unwell out of proportion to the level of dehydration, shock. The risk of dehydration is related to age (highest in young infants<6 months), and frequency of watery stools (>8/day) and vomiting (>2/day before 1 year and >4/day after 1 year), but these historical points have a moderate sensitivity. The severity of dehydration is rarely estimated with accuracy in terms of weight loss (third sector with full colon, absence of accurate baseline pre-dehydration weight). Combinations of examination signs perform markedly better than any individual sign in predicting dehydration (poor rate agreement, clinically unhelpful likelihood ratio). The presence of at least three signs better correlate with dehydration. Laboratory tests are not helpful. New studies are mandatory to validate severity scoring systems.

Dysfunctional Tear Syndrome

PURPOSE

To develop current treatment recommendations for dry eye disease from consensus of expert advice.

METHODS

Of 25 preselected international specialists on dry eye, 17 agreed to participate in a modified, 2-round Delphi panel approach. Based on available literature and standards of care, a survey was presented to each panelist. A two-thirds majority was used for consensus building from responses obtained. Treatment algorithms were created. Treatment recommendations for different types and severity levels of dry eye disease were the main outcome.

RESULTS

A new term for dry eye disease was proposed: dysfunctional tear syndrome (DTS). Treatment recommendations were based primarily on patient symptoms and signs. Available diagnostic tests were considered of secondary importance in guiding therapy. Development of algorithms was based on the presence or absence of lid margin disease and disturbances of tear distribution and clearance. Disease severity was considered the most important factor for treatment decision-making and was categorized into 4 levels. Severity was assessed on the basis of tear substitute requirements, symptoms of ocular discomfort, and visual disturbance. Clinical signs present in lids, tear film, conjunctiva, and cornea were also used for categorization of severity. Consensus was reached on treatment algorithms for DTS with and without concurrent lid disease.

CONCLUSION

Panelist opinion relied on symptoms and signs (not tests) for selection of treatment strategies. Therapy is chosen to match disease severity and presence versus absence of lid margin disease or tear distribution and clearance disturbances.

Isotonic is better than hypotonic saline for intravenous rehydration of children with gastroenteritis: a prospective randomised study

AIMS

To determine whether the risk of hyponatraemia in children with gastroenteritis receiving intravenous (IV) fluids is decreased by the use of 0.9% saline.

METHODS

A prospective randomised study was carried out in a tertiary paediatric hospital. A total of 102 children with gastroenteritis were randomised to receive either 0.9% saline + 2.5% dextrose (NS) or 0.45% saline + 2.5% dextrose (N/2) at a rate determined by their treating physician according to hospital guidelines and clinical judgement. Plasma electrolytes, osmolality, and plasma glucose were measured before (T(0)) and 4 hours after (T(4)) starting IV fluids, and subsequently if clinically indicated. Electrolytes and osmolality were measured in urine samples. Results were analysed according to whether children were hyponatraemic (plasma sodium <135 mmol/l) or normonatraemic at T(0).

RESULTS

At T(0), mean (SD) plasma sodium was 135 (3.3) mmol/l (range 124-142), with 37/102 (36%) hyponatraemic. At T(4), mean plasma sodium in children receiving N/2 remained unchanged in those initially hyponatraemic (n = 16), but fell 2.3 (2.2) mmol/l in the normonatraemic group. In contrast, among children receiving NS, mean plasma sodium was 2.4 (2.0) mmol/l higher in those hyponatraemic at baseline (n = 21) and unchanged in the initially normonatraemic children. In 16 children who were still receiving IV fluids at 24 hours, 3/8 receiving N/2 were hyponatraemic compared with 0/8 receiving NS. No child became hypernatraemic.

CONCLUSIONS

In gastroenteritis treated with intravenous fluids, normal saline is preferable to hypotonic saline because it protects against hyponatraemia without causing hypernatraemia.

High antidiuretic hormone levels and hyponatremia in children with gastroenteritis

OBJECTIVES

Nonosmotic antidiuretic hormone (ADH) activity can cause severe hyponatremia during involuntary fluid administration. We looked for evidence of this before and during intravenous (IV) fluid administration in children treated for gastroenteritis.

METHODOLOGY

In this prospective observational study, plasma ADH, electrolytes, osmolality, and glucose were measured in 52 subjects before (T0) and 4 hours after (T4) starting 0.45% saline + 2.5% dextrose and subsequently when indicated. Hormonal markers of stress were measured at T0. Urine samples were collected to measure electrolytes and osmolality.

RESULTS

The nonosmotic stimuli of ADH secretion that we identified were vomiting (50 of 52), dehydration (median: 5%; range: 3-8%), hypoglycemia (2 of 52), and raised hormonal markers of stress (mean +/- SD: cortisol, 1094 +/- 589 nmol/L; reverse triiodothyronine, 792 +/- 293 pmol/L). At T0, half the children were hyponatremic (plasma sodium concentration of < 135 mmol/L; n = 27). The median plasma ADH concentration at T0 was significantly elevated (median: 7.4 pg/mL; range: < 1.9-85.6 pg/mL). ADH was high in both hyponatremic and normonatremic children and remained high at T4 in 33 of the 52 children, 22 of whom were concurrently hyponatremic. At T4, mean plasma sodium concentration was unchanged in the hyponatremic children but was 2.6 mmol/L (+/-2.0) lower in those who were initially normonatremic. Urine tonicity was high compared with 0.45% saline in 16 of 19 children at baseline and in 20 of 37 children after 3 to 12 hours of IV fluids.

CONCLUSIONS

Nonosmotic stimuli of ADH secretion are frequent in children with gastroenteritis. Their persistence during IV-fluid administration predisposes to dilutional hyponatremia. The use of hypotonic saline for deficit replacement needs to be reassessed.

A prospective cohort study comparing hospital admission for gastro-enteritis with home management

OBJECTIVES

To compare physical and psychological outcomes in children presenting at Accident and Emergency Departments (A&E), diagnosed with gastro-enteritis and admitted to hospital with those of a similar age, sex and severity of illness discharged home. The physical and psychological well-being of children in these two groups, in the month after the episode, were compared as was further use of health care services.

DESIGN

A prospective cohort study.

METHODS

A comparison of 116 children aged 1-6 years with gastro-enteritis, presenting at A&E over a 6 months period. Admitted children were compared with children discharged, of a similar age, sex and illness severity (triage score) with follow-up at 1 week and 1 month. Clinical history, psychosocial factors, investigations and outcomes were recorded at presentation and physical, psychological and family outcomes at 1 week and 1 month.

RESULTS

Of 116 children, 112 (97%) completed the study (56 in each group). No differences were detected in psychosocial factors, socio-economic status, family factors, time of arrival at A&E or waiting times. Parental perception of illness was greater in the admitted group (P < 0.005), but was recorded after the decision on admission was made. At 1 week follow-up admitted children had increased separation anxiety compared with children who were discharged (P < 0.05), but this difference disappeared at 1 month. Clinical outcomes were the same for both groups, although admitted children had more investigations (91% vs. 39%). Parents were equally satisfied with their child's treatment, but one-third of children in both groups sought further consultation with a health professional in the following week.

CONCLUSIONS

There is no statistically significant difference in socio-demographic data, time of arrival at A&E, waiting times, clinical and psychosocial outcomes in children with acute gastro-enteritis admitted to hospital compared with a group of children of similar age, gender and severity of illness managed at home. However, parents seek reassurance and follow-up of acutely ill children, even if the child is admitted to hospital, which has service and resource implications.

Pilot study of a paediatric emergency department oral rehydration protocol

OBJECTIVE

To ascertain if the use of a paediatric oral rehydration protocol in the emergency department changed rates of admission, total time spent in hospital, total time spent in the emergency department, or number of unscheduled returns to the emergency department.

METHODS

A two month time period was analysed before and then after the adoption of an oral rehydration protocol for children presenting to the emergency department with symptoms suggestive of gastroenteritis. The rates of admission, total time spent in hospital, total time spent in the emergency department, and the rate of unscheduled returns were analysed using Fisher's exact and Wilcoxon testing for non-parametric data.

RESULTS

The adoption of a paediatric rehydration protocol was associated with a significant reduction in admission rates (before = 22.5%, after 5.1%; p = 0.048) and mean total hospital time (before = 7 hours 54 minutes, after = 2 hours 17 minutes; p = 0.017). There was no significant difference in time spent in the emergency department (before = 1 hour 25 minutes, after 1 hour 35 minutes, p = 0.3). The number of unscheduled returns did not change significantly (p = 0.3).

CONCLUSION

Adoption of a paediatric rehydration protocol significantly reduces admission rates and total time spent in hospital for children presenting to the emergency department with symptoms of gastroenteritis. The mean time spent in the actual emergency department does not significantly increase. The rate of unscheduled returns does not change.

The role of a clinical pathway in curtailing unnecessary investigations in children with gastroenteritis

Clinical pathways are useful tools in improving the quality of care of patients treated in hospitals. Gastroenteritis is a short, self-limiting, but common illness of childhood associated with significant costs to the community. The authors assessed the impact of a clinical pathway on investigation ordering in children with gastroenteritis. A retrospective analysis of 2 cohorts of children was performed before (n=1498) and after (n=1252) the introduction of a clinical pathway. Children admitted to hospital with a diagnosis of gastroenteritis were assessed as to the type of pathology tests ordered. Further outcomes measured were rates of admission, emergency department presentations, average length of stay, and direct costs. Subset analysis was undertaken on the initial cohort of patients who had a full blood count as part of their initial assessment. Full blood count was more likely to be performed prior to the introduction of the pathway(77.1%) than after pathway introduction (66.8%; P<.004). Urine microscopy and culture also was significantly decreased from 56.3% to 40.4% (P<.0005). Median patient costs were reduced from $1228 to $752 following pathway introduction (P<.0001); however, rates of admission were increased from 18.6% to 28.8% (P<.0001). Length of stay decreased but was not statistically significant. Full blood count results in the subset analysis revealed that the measurement of a full blood count had no impact on management. Thus, a clinical pathway contributed to more rational ordering of pathology tests and lowered the costs to a hospital of caring for patients with this common illness.

2. Acute infectious diarrhoea and dehydration in children

Gastroenteritis in children is still a common reason for consulting a general practitioner and for hospital admission. Rotavirus is the most common cause of gastroenteritis in children and accounts for half of all hospital admissions for severe acute infectious diarrhoea. Most children with gastroenteritis do not develop dehydration and can be treated at home. Children with mild to moderate dehydration should be treated with low osmolarity oral rehydration solutions, and those with severe dehydration or shock need to be admitted for administration of intravenous fluids. Lactose-free feeds should not be routinely used after acute gastroenteritis, but there is some evidence that a lactose-free diet may reduce the duration of diarrhoea. Antimotility drugs are rarely indicated in children with gastroenteritis, as the potential risks outweigh the benefits. The development of a rotavirus vaccine would provide huge public health benefits and cost savings. Other preventive strategies include educating people about personal and food hygiene and encouraging breastfeeding.

Audit of therapeutic interventions in inpatient children using two scores: are they evidence-based in developing countries?

Background

The evidence base of clinical interventions in paediatric hospitals of developing countries has not been formally assessed. We performed this study to determine the proportion of evidence-based therapeutic interventions in a paediatric referral hospital of a developing country

Methods

The medical records of 167 patients admitted in one-month period were revised. Primary diagnosis and primary therapeutic interventions were determined for each patient. A systematic search was performed to assess the level of evidence for each intervention. Therapeutic interventions were classified using the Ellis score and the Oxford Centre for Evidence Based Medicine Levels of Evidence

Results

Any dehydration due to diarrhoea (59 cases) and pneumonia (42 cases) were the most frequent diagnoses. Based on Ellis score, level I evidence supported the primary therapeutic intervention in 21%, level II in 73% and level III in 6% cases. Using the Oxford classification 16%, 8%, 1% and 75% therapeutic interventions corresponded to grades A, B, C, and D recommendations, respectively. Overall, according to Ellis score, 94% interventions were evidence based. However, out of the total, 75% interventions were based on expert opinion or basic sciences. Most children with mild to moderate dehydration (52 cases) were inappropriately treated with slow intravenous fluids, and most children with non-complicated community acquired pneumonia (42 cases) received intravenous antibiotics

Conclusions

Most interventions were inappropriate, despite the availability of effective therapy for several of them. Diarrhoeal dehydration and community acquired pneumonia were the most common diagnoses and were inappropriately managed. Existing effective interventions for dehydration and pneumonia need to be put into practice at referral hospitals of developing countries. For the remaining problems, there is the need to conduct appropriate clinical studies. Caution must be taken when assigning the level of evidence supporting therapeutic interventions, as commonly used classifications may be misleading

The effect of flavoring oral rehydration solution on its composition and palatability

OBJECTIVE

As a number of mild to moderately dehydrated children refuse to drink oral rehydration solution (ORS) because of its strong salty taste, many parents and health workers flavor ORS with the childs favorite juice. The effects of flavoring ORS on electrolyte content and osmolality were assessed and the palatability of various solutions were compared with commercially flavored ORS.

METHODS

Osmolality, sodium, potassium, chloride and glucose content after flavoring with varying concentrations of apple juice, orange juice or orangeade was determined. Two of the solutions were offered to 30 children and adults to assess palatability.

RESULTS

All additions to ORS (apple juice, orange juice or orangeade) caused a decrease of sodium (-30 to -53 mmol/L) and chloride (-27 to -47 mmol/L) content, whereas osmolality increased to greater than 311 mOsm/kg. These homemade oral rehydration solutions did not fulfill ESPGAN criteria for ORS, and rehydration will therefore be less effective. The majority of subjects also preferred the commercially flavored ORS.

CONCLUSION

Only very small amounts of apple juice or orange juice can be added to the ORS without significantly altering electrolyte composition and osmolality. Palatability, however, does not improve compared with commercially flavored ORS. We therefore recommend using commercially flavored ORS, the composition of which fulfills ESPGAN criteria.

[Oral rehydration in pediatric emergencies. A Spanish survey]

OBJECTIVES

To analyze the approach of emergency pediatricians to acute dehydration and their theoretical knowledge of oral rehydration, to identify the situations in which they believe oral rehydration to be indicated and its use in daily practice, as well as to determine the disadvantages of oral solutions in emergencies.

MATERIAL AND METHOD

We designed a survey, adapted from several similar studies, to evaluate theoretical and practical features of rehydration. The survey was applied in 23 emergency facilities in Spain.

RESULTS

Two-hundred ninety questionnaires were included. A total of 59.3 % of the emergency pediatricians surveyed frequently used oral rehydration in acute dehydration and 10.3 % never used it. All (100 %) used it in mild dehydration (79.3 % if it was associated with vomiting), 70.3 % used it in moderate dehydration with vomiting and 22.8 % used it if it was associated with moderate diarrhea. The main disadvantages of oral rehydration were the number of visits (34.2 %), lack of space (16.6 %) and family distrust (16.2 %). Oral rehydration was used by 64.1 % of emergency pediatricians in children of all age groups and by 17.44 % only in children older than 3 months. A few (3.8 %) believed vomiting to be a contraindication; 26.9 % sometimes used an antiemetic drug and 73.8 % used a nasogastric tube to improve tolerance in the case of vomiting.

CONCLUSIONS

Oral rehydration is widely accepted, but knowledge of its indications and techniques for application could be improved. Its main contraindications are vomiting and/or moderate dehydration; in the case of the emergency infrastructure, its main disadvantage is lack of time and workload. A nasogastric tube is a useful option to avoid an intravenous line. Guidelines for the use of oral rehydration that would reduce obstacles such as lack of time and family distrust should be developed.

The impact of presenting problem based guidelines for children with medical problems in an accident and emergency department

AIMS

To evaluate the impact of presenting problem based guidelines in managing children with either diarrhoea (with or without vomiting) or seizure (with or without fever).

METHODS

This prospective observational study with an intervention was based on a paediatric accident and emergency (A&E) department in Nottingham. All patients (either GP or self referred) were acute attenders aged 0-15 years, with a medical presenting problem during 4 months in the spring of 1997 and 1999. Five hundred and thirty-one diarrhoea attendances (292 before guideline implementation and 239 after) and 411 seizure attendances (212 before guideline implementation and 199 after) were recorded. Evidence based and consensus ratified guidelines developed for the study were implemented using care pathway documentation. Process (documentation, time in the department, investigations, treatment) and outcome (admission to hospital, returns to A&E) data were collected from case notes.

RESULTS

The percentage of children investigated with blood tests fell significantly (haematology requests in diarrhoea presentations from 11% to 4%, biochemistry in seizure presentations from 29% to 17%). Intravenous infusions in diarrhoea presenters fell (9% to 1%), and more appropriate oral fluids were used. Management time in A&E was reduced (diarrhoea presenters: median of 55-40 minutes, seizure presenters: 80-55 minutes, but remained static for other presenting problems). Marked improvements in documentation were seen. Admission rates for diarrhoea attenders increased (27% to 34%) but remained the same for seizure (69% v 73%).

CONCLUSIONS

The implementation of a presenting problem based guideline as a care pathway was associated with improvements in the quality of care by: improved documentation; reduced invasive investigations; more appropriate treatment, and reduced time spent in A&E.

Acute gastroenteritis in children : what role for antibacterials?

The aim of this article is to define the currently accepted role of antibacterials in the treatment of acute gastroenteritis in children. Most cases of acute gastroenteritis in children are viral, self-limited, and need only supportive treatment. Appropriate fluid and electrolyte therapy, with close attention to nutrition, remain central to therapy.Antibacterial therapy serves as an adjunct, to shorten the clinical course, eradicate causative organisms, reduce transmission, and prevent invasive complications. Selection of antibacterials to use in acute bacterial gastroenteritis is based on clinical diagnosis of the likely pathogen prior to definitive laboratory results. Antibacterial therapy should be restricted to specific bacterial pathogens and disease presentations. In general, infections with Shigella spp. and Vibrio cholera should usually be treated with antibacterials, while antibacterials are only used in severe unresponsive infections with Salmonella, Yersinia, Aeromonas, Campylobacter, Plesiomonas spp., and Clostridium difficile. Antibacterials should be avoided in enterohemorrhagic Escherichia coli infection. However, empiric therapy may be appropriate in the presence of a severe illness with bloody diarrhea and stool leucocytes, particularly in infancy and the immunocompromised. The benefits and risks of adverse drug reactions should be weighed before prescribing antibacterials. Moreover, a major concern is the emergence of antibacterial-resistant strains due to the widespread use of antibacterial agents.

A clinical pathway for pediatric gastroenteritis

Gastroenteritis is one of the most common reasons for hospitalization in the United States for children under the age of 5 years. Second only to respiratory problems, the cost of providing care for these children is estimated to exceed $2 billion dollars annually ( Burkhart, 1999; Prescilla, 2002). This article reviews the causes of gastroenteritis as well as the 1996 American Academy of Pediatrics Guidelines for treatment of gastroenteritis. These guidelines and more recently published literature were used to develop a clinical pathway to improve the care of pediatric patients admitted to the hospital with gastroenteritis. The article discusses the importance of clinical pathways and the process of implementation of a pathway for pediatric gastroenteritis. Additionally, the article provides a parent teaching tool to address recurrent questions parents have related to home management of a child with gastroenteritis. Useful web sites for resource information related to gastroenteritis are provided as well.

Investigation of daytime wetting: when is spinal cord imaging indicated?

BACKGROUND

Most children with daytime wetting have detrusor instability. A minority have neuropathic vesicourethral dysfunction. The commonest cause is spina bifida, which may be closed. Clinical features suggestive of closed spina bifida include cutaneous, neuro-orthopaedic or lumbosacral spine x ray abnormalities, impaired bladder sensation, and incomplete bladder emptying. MRI is the ideal method for detecting spinal cord abnormality. It has been suggested that MRI spine is an unnecessary investigation in children with daytime wetting in the absence of cutaneous, neuro-orthopaedic, or lumbosacral spine x ray abnormalities.

AIM

To clarify indications for magnetic resonance imaging (MRI) of the spine in children with voiding dysfunction.

METHODS

Retrospective study of children with voiding dysfunction referred from the Guy's Hospital neurourology clinic for MRI spine between April 1998 and April 2000. Clinical notes and results of investigations, including urodynamic studies and MRI spine were reviewed.

RESULTS

There were 48 children (median age 9.1 years). Closed spina bifida was detected in five, of whom four had neuropathic vesicourethral dysfunction confirmed by urodynamic studies. Impaired bladder sensation and incomplete bladder emptying were more frequent in these children than in those with normal MRI spine. One child with spinal cord abnormality had no cutaneous, neuro-orthopaedic, or lumbosacral spine x ray abnormalities.

CONCLUSION

Spinal cord imaging should be considered in children with daytime wetting when this is associated with impaired bladder sensation or poor bladder emptying, even in the absence of neuro-orthopaedic, cutaneous, or lumbosacral spine x ray abnormalities.

Retrospective comparison of management of gastro-enteritis in hospitalised children

In Hong Kong, bacterial pathogens, the majority of them Salmonellae, cause approximately one-third of paediatric admissions for diarrhoea. This study retrospectively reviewed inpatient gastro-enteritis management, with particular focus on antibiotic use. Antibiotics are generally recommended for Salmonella gastro-enteritis in infants under 3 months of age but not for older infants and children unless they are so toxic that bacteraemia is suspected. Three groups of children admitted with acute gastro-enteritis were randomly identified from a computerised discharge database. Based on pathological reports held in the case records department, the final groups for analysis were Salmonella (n = 86), rotavirus (n = 55) and non-specified (n = 126). Epi Info version 6 (CDC, Atlanta) was used for data entry and analysis. Compared with a combined rotavirus/non-specified group, the Salmonella group were significantly more likely to have blood (OR 6.1, 95% CI 3.2-11.7, p < 0.0001) and mucus (OR 4.8, 95% CI 2.6-8.9, p < 0.0001) in the stool, fever during admission (OR 3.6, 95% CI 1.6-8.4, p = 0.001), more stools per day (median 6.2 vs 4.2, p < 0.0001), a longer stay in hospital (median 3.4 vs 2 days, p < 0.0001) and to be younger (median 7.1 vs 14.6 mths, p < 0.0001). The Salmonella group were more likely to have been given antibiotics (38% vs 15%, OR 3.6, 95% CI 1.9-6.9, p < 0.0001) but age did not influence the likelihood that antibiotics would be given.