Evaluation and Management of Dehydration in Children

Predictors of Hospital Admissions and Return Visits in Children with Suspected Dehydration Presenting to the Emergency Department

BACKGROUND

Dehydration is a primary cause of visits to pediatric emergency departments (PED).

OBJECTIVES

1) To identify predictors of hospital admission and return visits (RV) in PED patients with all-cause dehydration. 2) To explore the association between dehydration and serum bicarbonate (HCO3) levels.

METHODS

This single-center prospective cohort study included patients under 18 years with dehydration from any cause, presenting to the PED of a tertiary center from November 2018 to March 2020. The primary outcome was hospital admission; the secondary outcome was RV to the PED. HCO3 was measured for all visits. Bivariate and multivariate analyses were conducted.

RESULTS

The study included 324 patients: most with mild dehydration (199/324, 61%). Of these, 74 (22.8%) were admitted, while 250 (77%) were discharged, 25 of which (10.8%) returned to the PED. Predictors of hospital admission included physician-estimated dehydration >5% (adjusted odds ratio [aOR] = 2.9; 95% CI: 1.5-5.8), ≥1 intravenous (IV) fluid bolus (aOR = 5.4; 95% CI: 1.2-23.8), antibiotics (aOR = 11.92; 95% CI: 3.4-35.5), and HCO3 ≤16 mmol/L (aOR = 4.4; 95% CI: 1.3-14.7). Admitted patients had lower mean HCO3 levels (19.94 ± 3.38 mmol/L vs. 20.98 ± 2.65 mmol/L, p = 0.017). Dry mucous membranes at the index visit were the only significant predictor of RV (12% vs. 35.5%, p = 0.023). Antipyretics/analgesics were associated with RV (76% vs. 51.9%, p = 0.03). Gastritis was inversely associated (4.0% vs. 22.3%, p = 0.03) with RV, but these were nonsignificant in multivariate analysis.

CONCLUSION

In this PED cohort, we found no predictors for RV to the PED. However, HCO3 ≤16 mmol/L, physician-estimated dehydration >5%, ≥1 IV fluid bolus, and PED antibiotics were associated with increase hospital admission. If replicated, these findings can help clinicians make faster disposition decisions when caring for dehydrated pediatric patients.

Overweight and Obese Children Aged 6-17 Years in China Had Lower Level of Hydration Status: A Cross-Sectional Study

PURPOSE

The aims of this study were to explore the differences in total body water and hydration status among Chinese children aged 6-17 years.

METHODS

A cross-sectional study was implemented among children aged 6-17 years in China. The total body water (TBW), intracellular water (ICW), and extracellular water (ECW) were determined by bioelectrical impedance analysis (BIA). The participants were divided according to age-age 6-8 years, age 9-11 years, age 12-14 years, age 15-17 years-and body mass index (BMI) of China-underweight, normal weight, overweight, and obese groups. The differences of variables of groups were compared using analysis of variance, Student's t-test, and Kruskal-Wallis test. Significance levels were set at 0.05 (p < 0.05).

RESULTS

A total of 59,643 participants (30,103 males and 29,540 females) completed the study. As children became older, the TBW, ICW, ECW, ICW/TBW, and TBW/FFM (TBW to fat free mass ratio) increased simultaneously (all p < 0.05); concurrently, the ECW/TBW decreased with age (all p < 0.05). Boys had higher TBW, ICW, ECW, ICW/TBW, TBW/BW, and TBW/FFM than those of girls at each age (all p < 0.05). For all BMI groups, increases in TBW, ICW, ECW were observed from the underweight group to the obese group, both in boys and girls (all p < 0.001). For the increase in BMI in all age groups, the values of TBW made a significantly lower percentage compared to BW. The higher BMI groups showed higher levels of TBW/FFM, both in girls and boys (all p < 0.001).

CONCLUSIONS

The body water contents of children aged 6-17 years varied according to their age, sex, and BMI. Overweight and obese individuals may have inferior hydration status compared to those with normal weight.

Serum Lipid Profile and Electrolytes Reference Intervals for Apparently Healthy Children and Adolescents in Addis Ababa, Ethiopia

BACKGROUND

Accurate reference intervals generated from an apparently healthy population and stratified by crucial variables such as age and gender are required to guarantee appropriate interpretation of test results. Since there were no local reference intervals in the study area, the present study aimed to establish reference intervals on serum lipid profiles and electrolytes for children and adolescents in Addis Ababa.

METHODS

This community-based cross-sectional study was conducted from April to October 2019. Laboratory analysis was performed using the automatic biochemical analyzer Cobas 6000 (c501) from Roche. According to Clinical and Laboratory Standards Institute (CLSI) guidelines, reference intervals for lipid profile and electrolyte tests for apparently healthy children and adolescents were established. We used a non-parametric method to calculate the 2.5th and 97.5th percentiles with a 90% confidence interval.

RESULTS

In children, the reference intervals for serum potassium, sodium, chloride, calcium, magnesium, and phosphate in mmol/L were 4.37-5.20, 137-145.50, 101.90-107.90, 2.34-2.70, 0.74-0.97, and 1.42-1.85, respectively; and for total cholesterol, triglycerides, low-density lipoprotein, and high-density lipoprotein, the respective values were 100.76-171.70, 44.16-126.36, 60.60-105.60, and 31.60-53.70 in mg/dL, for both genders. For adolescents, the reference intervals were 4.03-5.58, 137-146, 98.90-120.90, 2.39-2.70, 0.73-0.96, and 0.96-1.80 for serum potassium, sodium, chloride, calcium, magnesium, and phosphate in mmol/L, respectively; and 97.20-189.10, 40.50-143.60, 41.70-120.90, and 21.30-57.0 in mg/dL for total cholesterol, triglycerides, low-density lipoprotein, and high-density lipoprotein, respectively, for both genders.

CONCLUSION

The established reference intervals in the current study revealed that both the lower and upper limits contradicted the manufacturer values as well as the available literature. The study also discovered significant gender differences in reference values for TC, TG, LDL-C, potassium, phosphate, and chloride in the adolescent age groups.

Mild Dehydration Triggered by Exercise Reduces Cognitive Performance in Children, But Does Not Affect Their Motor Skills

OBJECTIVE

Children face the risk of dehydration in varying amounts during the day due to reasons such as physical activity, sweating, eating salty foods and drinking carbonated beverages. It is assumed that dehydration can lead to impaired motor skills and cognitive performance since it affects brain function. However, inconsistencies in study results, test times and problems caused by heat stress make new research mandatory. In our research, we examined the effects of exercise-induced mild dehydration on motor skills and cognitive performance in active/sedentary boys who do/do not do regular physical activities in their daily lives.

METHODS

The study included 112 boys who do regular physical activity (n:57; 12.40 ± 0.49age) and sedentary (n:55; 12.49 ± 0.50age). The children were given a 12-h hydration program. Mild dehydration was created by giving exercises after hydration measurements. In case of hydration and mild dehydration, Bruininks-Oseretsky Motor Proficiency and d2 attention test were applied to the children. For comparison, Repeated Measures ANOVA and Bonferroni post-hoc test was performed at the second level.

RESULTS

According to the hydration and mild dehydration comparison results, there was no difference in total score of Fine Motor Skill Sensitivity, Fine Motor Skill Integration, Hand Dexterity and Bidirectional Coordination, Balance, Running Speed and Agility, Hand-Arm Coordination, Strength, and BOT-2 in children. There was a decrease in both groups in terms of Focused Attention, Processing Speed, Accuracy, Concentration Performance and Attention Span.

CONCLUSION

As a result, mild dehydration is associated with daily physical activity in children (physical education classes, etc.) or it can easily occur due to food/beverage preferences. It may affect children's performance of school curriculum and extracurricular activities. It shows that maintaining optimal hydration is important.

Management of Pediatric Parenteral Fluids

Parenteral fluid therapy in children requires careful consideration of patient-specific factors such as weight, hydration status, and concomitant disease states. Recent literature has changed the standard of care for maintenance fluids for children in the past decade and brought to light more questions. Concentrations of electrolytes in fluids and the use of balanced fluids are still controversial. This article will review the use of parenteral fluids in children, including fluid content, maintenance fluid rate, treatment of dehydration, and the basics of parenteral fluid ingredients. All pediatric patients should have a plan for fluid therapy that includes careful consideration of hydration status and individual response to therapy.

Hydration status in adults with metabolic disorders in relation to socioeconomic, lifestyle and health factors

INTRODUCTION

Adequate hydration is essential for maintaining the health and functionality of the human body. This study aimed to examine the association between selected socioeconomic, lifestyle, and health factors and the hydration status of adults with metabolic disorders by analyzing their urine osmolality.

METHODS

The study involved 290 adults aged 18-70 years with metabolic disorders. Separate multivariate logistic regression models were conducted to evaluate the factors associated with urine osmolality in tertiles for women and men. Odds Ratios (OR) and 95% Confidence Intervals (95% CI) were calculated.

RESULTS

In women, the following factors of urine osmolality were identified in 1st tertile: age (OR:1.04), physical activity (moderate/high vs. no/low; OR:0.38), and headaches (no vs. yes; OR:1.55), in 2nd tertile: physical activity (moderate/high vs. no/low; OR:2.46) and fatigue during the day (sometimes vs. never/very rarely; OR:0.45), and in 3rd tertile: age (OR:0.94), professional status ('I work part-time/I study and I work' vs. 'I do not work/I study'; OR:0.27), fatigue during the day (very often vs. never/very rarely; OR:2.55), and headaches (no vs. yes; OR:0.44). In men, the following factors of urine osmolality were identified in 1st tertile: place of residence (city vs. village; OR:2.72) and health assessment (average vs. poor; OR:0.32).

CONCLUSION

Different factors affecting urine osmolality have been identified in women and men. These results highlight the need to implement studies to clarify the relationship between socioeconomic, lifestyle and health factors, and hydration status in adults with metabolic disorders.

Acute kidney injury and risk factors in pediatric patients undergoing hematopoietic stem cell transplantation

BACKGROUND

Acute kidney injury (AKI) is a common complication of hematopoietic stem cell transplantation (HSCT) with increased mortality and morbidity. Understanding the risk factors for AKI is essential. This study aimed to identify AKI incidence, risk factors, and prognosis in pediatric patients post-HSCT.

METHODS

We conducted a retrospective case-control study of 278 patients who were divided into two groups: those with AKI and those without AKI (non-AKI). The groups were compared based on the characteristics and clinical symptoms of patients, as well as post-HSCT complications and the use of nephrotoxic drugs. Logistic regression analysis was employed to identify the risk factors for AKI.

RESULTS

A total of 16.9% of patients had AKI, with 8.5% requiring kidney replacement therapy. Older age (OR 1.129, 95% CI 1.061-1.200, p < 0.001), sinusoidal obstruction syndrome (OR 2.562, 95% CI 1.216-5.398, p = 0.011), hemorrhagic cystitis (OR 2.703, 95% CI 1.178-6.199, p = 0.016), and nephrotoxic drugs, including calcineurin inhibitors, amikacin, and vancomycin (OR 17.250, 95% CI 2.329-127.742, p < 0.001), were identified as significant independent risk factors for AKI following HSCT. Mortality rate and mortality due to AKI were higher in stage 3 patients than those in stage 1 and 2 AKI (p = 0.019, p = 0.007, respectively). Chronic kidney disease developed in 1 patient (0.4%), who was in stage 1 AKI (2.1%).

CONCLUSIONS

AKI poses a serious threat to children post-HSCT, leading to alarming rates of mortality and morbidity. To enhance outcomes and mitigate these risks, it is vital to identify AKI risk factors, adopt early preventive strategies, and closely monitor this patient group.

The usefulness of point-of-care ultrasound in dehydrated patients in a pediatric emergency department

BACKGROUNDS

Dehydration is among the most common causes of Pediatric Emergency Department admission; however, no clinical signs, symptoms, or biomarkers have demonstrated sufficient sensitivity, specificity, or reliability to predict dehydration.

METHODS

We conducted a prospective, monocentric, observational study at Giannina Gaslini Hospital, a tertiary care pediatric hospital. Our study aimed to compare inferior vena cava ultrasound measurement with volume depletion biomarkers to understand if point-of-care ultrasound could help grade, evaluate, and better manage dehydration in children presenting to the pediatric emergency department. We enrolled patients under the age of 14 who required blood tests in the suspect of dehydration; for each patient, we collected values of venous pH, natremia, bicarbonatemia, uric acid, chloremia, and blood urea nitrogen. For each patient, we performed two ultrasound scans to calculate the Inferior Vena Cava/Aorta area ratio and to assess the IVC collapsibility index; moreover, we described the presence of the "kiss sign" (100% IVC walls collapsing during the inspiratory phase).

RESULTS

Patients with the "kiss sign" (25/65 patients, 38.5% of the total) showed worse blood tests, in particular, uric acid levels (p = 0.0003), bicarbonatemia (p = 0.001) and natriemia (p = 0.0003). Moreover, patients with the "kiss sign" showed a high frequency of ≥ 2 pathological blood tests (p = 0.0002). We found no statistical significant difference when comparing the IVC/Ao ratio and IVC-CI with the considered blood tests.

CONCLUSIONS

The "kiss sign" seems to be related to worse hydration state, whereas IVC/Ao and IVC-CI are not. In an emergency setting, where physicians must take diagnostic-therapeutic decisions quickly, the presence of the "kiss sign" in patients suspected to be dehydrated can be a helpful tool in their management.

Knowledge and practice towards intravenous fluid therapy in children among nurses in the pediatrics emergency department of selected public hospitals

Morbidity and mortality in hospitalized patients can be increased due to errors that are caused by inadequate knowledge and unsatisfactory practice of intravenous (IV) fluid therapy among healthcare workers. The knowledge and practice of nurses are very critical to IV fluid therapy because they are the cornerstone of a subject. This study assessed nurse's knowledge and practice of IV fluid therapy. A cross-sectional study design was employed at four selected public hospitals in Addis Ababa, Ethiopia. Data were collected from 112 nurses using a structured questionnaire for knowledge and using an observational checklist for practice. Data were analyzed using SPSS version 26 computer programs. Most respondents (67%) were males; the mean age of respondents was 31.2 ± 4.3. Among participated nurses, 42% (95% CI 32.8, 51.2) and 56.3% (95% CI 47.1, 65.6) had inadequate knowledge and satisfactory practice regarding IV fluid therapy in children, respectively. A significant association was observed between nurses' intravenous fluid therapy knowledge and in-service training that nurses who had training on fluid therapy in children had 4 times adequate knowledge than those who had no training (P = 0.01), an educational qualification that master degree holders had 4.8 times adequate knowledge than first-degree holders (P = 0.04) and training institution that nurse who had taken training in governmental teaching institution had 4 times adequate knowledge than who had taken training in private teaching institution (P = 0.011). No statistically significant association was found between practice level and independent variables regarding IV fluid therapy. Nurses' knowledge of IV fluid therapy was inadequate and practice was relatively satisfactory. Continuous education and training of nurses on IV fluid therapy should be conducted regularly to improve their knowledge and practice. Further research should be employed involving other hospitals and focusing on risk factors for knowledge and practice inadequacy that are not discussed in this study.

The incidence and factors associated with dysnatremia in children with acute gastritis/gastroenteritis

BACKGROUND

The incidence of dysnatremia in children with acute gastritis/gastroenteritis varies, and factors associated with either dysnatremia or hyponatremia at presentation have not been identified clearly.

METHODS

This retrospective study included patients aged 1 month to 18 years hospitalized for community-acquired acute gastritis/gastroenteritis from January to October 2016. Factors associated with dysnatremia at presentation were identified using multivariable analysis.

RESULTS

Among the 304 children included, the median age was 2.2 (1.0, 4.2) years. The incidence of dysnatremia at presentation was 17.1% (hyponatremia 15.8%; hypernatremia 1.3%). Patients who had moderate (p = 0.03) and severe dehydration (p = 0.04) and presented with vomiting and diarrhea simultaneously (p = 0.03) were associated with dysnatremia at presentation. Patients presented with vomiting and diarrhea simultaneously was associated with hyponatremia at presentation (p = 0.02).

CONCLUSIONS

Dysnatremia was common in children with acute gastritis/gastroenteritis. Moderate to severe dehydration and the presence of vomiting and diarrhea simultanously were significantly associated with dysnatremia at presentation. Furthermore, presenting with vomiting and diarrhea silmutaneously was associated with hyponatremia at presentation. Serum electrolytes should be monitored in patients with those conditions.

Noninvasive Monitoring to Detect Dehydration: Are We There Yet?

The need for hydration monitoring is significant, especially for the very young and elderly populations who are more vulnerable to becoming dehydrated and suffering from the effects that dehydration brings. This need has been among the drivers of considerable effort in the academic and commercial sectors to provide a means for monitoring hydration status, with a special interest in doing so outside the hospital or clinical setting. This review of emerging technologies provides an overview of many technology approaches that, on a theoretical basis, have sensitivity to water and are feasible as a routine measurement. We review the evidence of technical validation and of their use in humans. Finally, we highlight the essential need for these technologies to be rigorously evaluated for their diagnostic potential, as a necessary step to meet the need for hydration monitoring outside of the clinical environment.

Crystalloid Solutions in Hospital: A Review of Existing Literature

Intravenous fluids (IVF) like normal saline (NS) and Ringer's lactate (RL) are often crucial in the management of hospitalized patients. Mishandling these fluids can lead to complications in about 20% of patients receiving them. In this review, we present the current evidence through the identification of observational studies and randomized trials that observed the optimal use of IVF. We found that NS may cause hyperchloremic metabolic acidosis in surgical patients, but there is no clear difference in mortality and long-term outcomes between NS and balanced crystalloids. Critically ill patients, particularly those in sepsis, benefit from balanced crystalloids, as high chloride content fluids like NS increase the risk of complications and mortality. In pancreatitis, NS has been shown to increase the risk of ICU admission when compared to RL; however, there is no significant difference in long-term outcomes and mortality between the fluids. RL is preferred for burns due to its isotonicity and lack of protein, preventing edema formation in an already dehydrated state. Plasma-lyte may resolve diabetic ketoacidosis faster, while prolonged NS use can lead to metabolic acidosis, acute kidney injury, and cerebral edema. In conclusion, NS, RL, and plasma-lyte are the most commonly used isotonic IVF in the hospital population. Incorrect choice of fluids in a different clinical scenario can lead to worse outcomes.

Recommendation document on rapid intravenous rehydration in acute gastroenteritis

INTRODUCTION

The efficacy and safety of the Rapid Intravenous Rehydration (RIR) guidelines in children affected by dehydration secondary to acute gastroenteritis is supported by current scientific evidence, but there is also great variability in its use in clinical practice.

OBJECTIVE

To prepare a document with evidence-based recommendations about RIR in paediatric population.

METHODS

The project was developed based on GRADE methodology, according to the following work schedule: Working Group training; creation of a catalogue of questions about research and definition of "relevant outcomes"; score and selection criteria for each item; bibliographic review; scientific evidence evaluation and synthesis (GRADE); review, discussion and creation of recommendations. 10 clinical questions and 15 relevant outcomes were created (7 about efficacy and 8 about security).

RESULTS

16 recommendations were set up, from which we can highlight as the main ones: 1) RIR is safe for children affected by mild-moderate dehydration secondary to acute gastroenteritis, unless expressly contraindicated or acute severe comorbidity (strong recommendation, moderate evidence). 2) Its use is recommended in this situation when oral rehydration has failed or due to contraindication (strong, high). 3) Isotonic fluids are recommended (strong, high), suggesting saline fluid as the first option (light, low), supplemented by glucose (2.5%) in those patients showing normoglycemia and ketosis (strong, moderate). 4) A rhythm of 20cc/kg/h is recommended (strong, high) during 1-4 h (strong, moderate).

CONCLUSIONS

This document establishes consensus recommendations, based on the available scientific evidence, which could contribute to the standardisation of the use of RIR in our setting.

[Recommendation document on rapid intravenous rehydration in acute gastroenteritis]

INTRODUCTION

The efficacy and safety of the rapid intravenous rehydration (RIR) guidelines in children affected by dehydration secondary to acute gastroenteritis is supported by current scientific evidence, but there is also great variability in its use in clinical practice.

OBJECTIVE

To prepare a document with evidence-based recommendations about RIR in paediatric population.

METHODS

The project was developed based on GRADE methodology, according to the following work schedule: Working Group training; creation of a catalogue of questions about research and definition of «relevant outcomes»; score and selection criteria for each item; bibliographic review; scientific evidence evaluation and synthesis (GRADE); review, discussion and creation of recommendations. 10 clinical questions and 15 relevant outcomes were created (7 about efficacy and 8 about security).

RESULTS

Sixteen recommendations were set up, from which we can highlight as the main ones: (1) RIR is safe for children affected by mild-moderate dehydration secondary to acute gastroenteritis, unless expressly contraindicated or acute severe comorbidity (strong recommendation and moderate evidence). (2) Its use is recommended in this situation when oral rehydration has failed or due to contraindication (strong and high). (3) Isotonic fluids are recommended (strong and high), suggesting saline fluid as the first option (light and low), supplemented by glucose (2.5%) in those patients showing normoglycemia and ketosis (strong and moderate). (4) A rhythm of 20 cc/kg/h is recommended (strong and high) during 1-4 h (strong and moderate).

CONCLUSIONS

This document establishes consensus recommendations, based on the available scientific evidence, which could contribute to the standardisation of the use of RIR in our setting.

Integrating Population Variants and Protein Structural Analysis to Improve Clinical Genetic Diagnosis and Treatment in Nephrogenic Diabetes Insipidus

Congenital nephrogenic diabetes insipidus (NDI) is a rare genetic disorder characterized by renal inability to concentrate urine. We utilized a multicenter strategy to investigate the genotype and phenotype in a cohort of Chinese children clinically diagnosed with NDI from 2014 to 2019. Ten boys from nine families were identified with mutations in AVPR2 or AQP2 along with dehydration, polyuria-polydipsia, and severe hypernatremia. Genetic screening confirmed the diagnosis of seven additional relatives with partial or subclinical NDI. Protein structural analysis revealed a notable clustering of diagnostic mutations in the transmembrane region of AVPR2 and an enrichment of diagnostic mutations in the C-terminal region of AQP2. The pathogenic variants are significantly more likely to be located inside the domain compared with population variants. Through the structural analysis and in silico prediction, the eight mutations identified in this study were presumed to be disease-causing. The most common treatments were thiazide diuretics and non-steroidal anti-inflammatory drugs (NSAIDs). Emergency treatment for hypernatremia dehydration in neonates should not use isotonic saline as a rehydration fluid. Genetic analysis presumably confirmed the diagnosis of NDI in each patient in our study. We outlined methods for the early identification of NDI through phenotype and genotype, and outlined optimized treatment strategies.