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Marx T, Vincent-Boulay C, Marquis-Gendron L, Bareil K, Leduc S, Lefebvre G, Côté C, Mallet M, Paquette-Raynard E, Boissinot M, Bergeron MG, Berthelot S. A systematic review of tools for predicting complications in patients with acute infectious diarrhea. Am J Emerg Med 2023; 64:78-85. [PMID: 36469970 DOI: 10.1016/j.ajem.2022.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 10/31/2022] [Accepted: 11/14/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To identify tools that predict the risk of complications in patients presenting to outpatient clinics or emergency departments (ED) with acute infectious diarrhea. METHODS Medline, Embase, Cochrane Library, Web of Science and CINAHL were searched from inception to July 2021. Articles reporting on the derivation or validation of a score to stratify the risk of intravenous rehydration or hospitalization among patients with acute infectious diarrhea in the ED or outpatient clinic were retained for analysis. RESULTS Five articles reporting on two different tools were identified. Developed to assess the risk of hospitalization of children, the EsVida scale has not been externally validated. Developed originally to assess the level of dehydration in children, the Clinical Dehydration Scale (CDS) was evaluated as a risk stratification tool. For predicting intravenous rehydration, a CDS score ≥ 1 showed a sensitivity between 0.73 and 0.88 and specificity between 0.38 and 0.69, whereas a CDS score ≥ 5 showed a sensitivity between 0.06 and 0.32 and specificity between 0.94 and 0.99. For predicting hospitalization, a CDS score ≥ 1 showed a sensitivity between 0.74 and 1.00 and specificity between 0.34 and 0.38, whereas a CDS score ≥ 5 showed a sensitivity between 0.26 and 0.62 and specificity between 0.66 and 0.96. High heterogeneity among studies and unclear risk of bias precluded meta-analysis. CONCLUSION As a risk-stratification tool, the CDS has been validated only for children. Further research is needed to develop and validate a tool suitable for adults in the ED.
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Affiliation(s)
- Tania Marx
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Qc, Canada.
| | - Claudia Vincent-Boulay
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Qc, Canada
| | - Laurance Marquis-Gendron
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Qc, Canada
| | - Kathryn Bareil
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Qc, Canada
| | - Samuel Leduc
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Qc, Canada
| | - Gabrielle Lefebvre
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Qc, Canada
| | - Catherine Côté
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Qc, Canada
| | - Myriam Mallet
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Qc, Canada
| | | | - Maurice Boissinot
- Centre de Recherche en Infectiologie de l'Université Laval, Axe Maladies infectieuses et immunitaires, Centre de recherche du CHU de Québec-Université Laval, Québec, Qc, Canada
| | - Michel G Bergeron
- Centre de Recherche en Infectiologie de l'Université Laval, Axe Maladies infectieuses et immunitaires, Centre de recherche du CHU de Québec-Université Laval, Québec, Qc, Canada
| | - Simon Berthelot
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Qc, Canada; Department of Family and Emergency Medicine, Université Laval, Québec, Qc, Canada
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Vatandas NS, Yurdakok K, Yalcin SS, Celik M. Validity Analysis on the Findings of Dehydration in 2 to 24-Month-Old Children With Acute Diarrhea. Pediatr Emerg Care 2021; 37:e1227-e1232. [PMID: 31913251 DOI: 10.1097/pec.0000000000001980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The most common cause of diarrheal mortality in children is dehydration. In this study, we aimed to assess the validity (sensitivity and specificity) of history and the clinical and laboratory findings in in the diagnosis of dehydration in children younger than 2 years with acute diarrhea. METHODS One hundred twenty-six 2 to 24-month-old children with acute diarrhea, who were admitted to Hacettepe University Ihsan Dogramaci Children's Hospital's Diarrheal Diseases Treatment and Training Unit, were included. The patients were examined on admission for clinical findings of dehydration. Percent weight loss on admission was calculated by using the weight on admission and the weight after the diarrhea resolution and was used as the golden standard for analyzing the validity of clinical and laboratory findings. RESULTS Compared with the golden standard, dehydration was overestimated in 13% of the cases and underestimated in 7% when using only the World Health Organization criteria. Dehydrated children had higher diarrheal frequency and longer anuria time. Thirst, weakness, sunken fontanelle, sunken eyes, decreased tears, dry mucous membranes, and dry lip were detected in children with 2% or greater of weight loss. The most valid laboratory findings were low serum pH (<7.30), low bicarbonate (<15 mmol/L), and hyperurisemia (>5.8 mg/dL). In multivariate analysis, physical findings, such as thirst, dry mucous membranes, weakness, sunken eyes, hoarse crying, and low pH, were found to be significant for the diagnosis of dehydration. CONCLUSIONS In children with acute diarrhea, diarrheal frequency and last urination time should be asked, thirst, dry mucous membranes, weakness, sunken eyes, and hoarse crying should be examined.
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Affiliation(s)
| | - Kadriye Yurdakok
- Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children's Hospital, Department of Pediatrics, Social Pediatrics Unit, Sıhhiye, Ankara
| | - Siddika Songul Yalcin
- Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children's Hospital, Department of Pediatrics, Social Pediatrics Unit, Sıhhiye, Ankara
| | - Melda Celik
- Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children's Hospital, Department of Pediatrics, Social Pediatrics Unit, Sıhhiye, Ankara
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Del Prete C, Freccero F, Lanci A, Hallowell GD, Bullone C, Castagnetti C, Pasolini MP. Transabdominal ultrasonographic measurement of caudal vena cava to aorta derived ratios in clinically healthy neonatal foals. Vet Med Sci 2021; 7:1451-1459. [PMID: 33939323 PMCID: PMC8464261 DOI: 10.1002/vms3.506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/07/2021] [Indexed: 01/24/2023] Open
Abstract
Background Ultrasonographic measurement of the vena cava and aorta (Ao) diameters and their ratios have been suggested to be a reliable way of quantifying hypovolemia. Objective To evaluate the feasibility and reliability of an ultrasonographic technique for measurement of Ao and caudal vena cava (CVC) and derived ratios using three different acoustic windows in a population of healthy neonatal foals. Correlation between Ao and CVC measurements and ratios and foals' age or bodyweight were also investigated. Methods In 14 healthy foals aged less than 7 days, the diameters of the Ao and of the CVC in long and short axis were measured by two observers from images obtained using three different ultrasonographic imaging planes (left dorsal, left ventral and right views). The Ao and CVC cross‐sectional area and the CVC/Ao diameter and area ratios were calculated. Image quality was subjectively assessed. Intraobserver and interobserver reliabilities for image quality scores and measurements were evaluated between the two observers. Simple linear regression models were used to identify correlations between the CVC/Ao measurements and ratios and the age and bodyweight of the foals. Results The left ventral view showed the highest reliability. A correlation between bodyweight and the short axis measurement of the CVC was found (R2 = 0.385; p = 0.018). Age was positively correlated with the long axis of measurement of the CVC (R2 = 0.426; p = 0.011) and CVC/Ao diameter ratio (R2 = 0.625; p = 0.001). Conclusions The left ventral view allows the Ao and CVC cross sections to be easily visualized and measured in neonatal foals in right lateral recumbency.
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Affiliation(s)
- Chiara Del Prete
- Department of Veterinary Medicine and Animal Production, University of Naples Federico II, Naples, Italy
| | - Francesca Freccero
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Aliai Lanci
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Gayle D Hallowell
- School of Veterinary Medicine and Science, Sutton Bonington Campus, University of Nottingham, Leicestershire, UK
| | | | - Carolina Castagnetti
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy.,Health Science and Technologies Interdepartmental Center for Industrial Research (HST-ICIR), University of Bologna, Bologna, Italy
| | - Maria Pia Pasolini
- Department of Veterinary Medicine and Animal Production, University of Naples Federico II, Naples, Italy
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Weghorst AA, Holtman GA, Wolters PI, Russchen HA, Fickweiler F, Verkade HJ, Post J, Vermeulen KM, Kollen BJ, Bonvanie IJ, Berger MY. Recommendations for clinical research in children presenting to primary care out-of-hours services: a randomised controlled trial with parallel cohort study. BJGP Open 2021; 5:bjgpopen20X101154. [PMID: 33293414 DOI: 10.3399/bjgpopen20X101154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/20/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Research in primary care is essential, but recruiting children in this setting can be complex and may cause selection bias. Challenges surrounding informed consent, particularly in an acute clinical setting, can undermine feasibility. The off-protocol use of an intervention nearing implementation has become common in pragmatic randomised controlled trials (RCTs) set in primary care. AIM To describe how the informed consent procedure affects study inclusion and to assess how off-protocol medication prescribing affects participant selection in a paediatric RCT. DESIGN & SETTING A pragmatic RCT evaluating the cost-effectiveness of oral ondansetron in children diagnosed with acute gastroenteritis (AGE) in primary care out-of-hours services and a parallel cohort study. METHOD Consecutive children aged 6 months to 6 years attending primary care out-of-hours services with AGE were evaluated to assess the feasibility of obtaining informed consent, the off-protocol use of ondansetron, and other inclusion and exclusion criteria. RESULTS The RCT's feasibility was reduced by the informed consent procedure because 39.0% (n = 325/834) of children were accompanied by only one parent. GPs prescribed ondansetron off-protocol to 34 children (4.1%) of which 19 children were eligible for the RCT. RCT-eligible children included in the parallel cohort study had fewer risk factors for dehydration than children in the RCT despite similar dehydration assessments by GPs. CONCLUSION The informed consent procedure and off-protocol use of study medication affect the inclusion rate, but had little effect on selection. A parallel cohort study alongside the RCT can help evaluate selection bias, and a pilot study can reveal potential barriers to inclusion.
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Asim M, Alkadi MM, Asim H, Ghaffar A. Dehydration and volume depletion: How to handle the misconceptions. World J Nephrol 2019; 8:23-32. [PMID: 30705869 PMCID: PMC6354080 DOI: 10.5527/wjn.v8.i1.23] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 11/02/2018] [Accepted: 01/04/2019] [Indexed: 02/06/2023] Open
Abstract
Dehydration and volume depletion describe two distinct body fluid deficit disorders with differing pathophysiology, clinical manifestations and treatment approaches. However, the two are often confused or equated with each other. Here, we address a number of commonly encountered misconceptions about body-fluid deficit disorders, analyse their origins and propose approaches to overcome them.
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Affiliation(s)
- Muhammad Asim
- Hamad General Hospital, Hamad Medical Corporation and Weill Cornell Medicine-Qatar, Doha 3050, Qatar
| | - Mohamad M Alkadi
- Hamad General Hospital, Hamad Medical Corporation and Weill Cornell Medicine-Qatar, Doha 3050, Qatar
| | - Hania Asim
- Birmingham City Hospital, Dudley Road, Birmingham B18 7QH, United Kingdom
| | - Adil Ghaffar
- Saint Vincent Hospital, Worcester, MA 01608, United States
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Khodashenas E, Azarfar A, Bakhtiari E, Eslami ARD, Roodi MS, Ravanshad Y. Accuracy of pediatric residents in determination of dehydration in children with gastroenteritis. Electron Physician 2018; 10:6707-6711. [PMID: 29881534 PMCID: PMC5984026 DOI: 10.19082/6707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 12/21/2017] [Indexed: 11/20/2022] Open
Abstract
Objective The aim of the present study was to determine the accuracy of pediatric residents in diagnosis of dehydration in children with gastroenteritis. Methods This was a cross-sectional study in Dr. Sheikh Hospital, affiliated with Mashhad University of Medical Sciences (Mashhad, Iran), in 2016. One hundred fifteen children aged 1 month to 14 years with gastroenteritis were included according to easy sampling. All patients were weighed. Dehydration was scored as mild, moderate and severe by pediatric residents according to Nelson standard table including pulse rate, blood pressure, blood skin supplement, skin turgor, fontanel, mucus membrane, tear respiration and urine output criteria. Patients were rehydrated and reweighed consequently. Percent loss of body weight (PLBW) was calculated and compared with dehydration score. Statistical analysis was performed using SPSS windows program version 19 (SPSS Institute, Inc., Chicago, IL, USA). Results Of the115 children, 65 patients were male (56.5%) with the median age of 14.5 months. The Kendall's tau-b and Spearman correlation coefficient for residents' estimation and PLBW were 0.18 and 0.23 respectively (p=0.01 and 0.12 respectively). The ICC between estimated dehydration and PLBW was 0.47. According to residents' estimation and gold standard, PLBW was 6.76% and 1.33%, respectively. The serum level of sodium, potassium, urea and creatinine were 141.8 mEq/L, 4.6 mEq/L, 34.45 mg/dL and 0.6 mg/dL, respectively. Conclusion There is positive but weak correlation between residents' estimation and PLBW in patients with dehydration. It is necessary to enhance the educational level of pediatric residents to increase the accuracy of physical examination and decrease medical errors.
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Affiliation(s)
- Ezzat Khodashenas
- M.D., Assistant Professor, Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Anoush Azarfar
- M.D., Associate Professor, Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Elham Bakhtiari
- Ph.D, Assistant Professor, Eye Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Reza Daneshmand Eslami
- M.D., Resident of Ophthalmology, Secretary for Education and Students Affairs, Ministry of Health and Medical Education, Tehran, Iran
| | - Masoud Shaghasi Roodi
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran
| | - Yalda Ravanshad
- M.D., Assistant Professor, Clinical Research Development Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Community Medicine, Mashhad Branch, Islamic Azad University, Mashhad, Iran
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El Amrousy D, Gamal R, Elrifaey S, Hassan S. Non-invasive Assessment of Significant Dehydration in Infants Using the Inferior Vena Cava to Aortic Ratio: Is it Useful? J Pediatr Gastroenterol Nutr 2018; 66:882-886. [PMID: 29287013 DOI: 10.1097/mpg.0000000000001865] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The aim of the study was to assess the accuracy of the inferior vena cava to aorta (IVC/Ao) diameter ratio for predicting significant dehydration in infants relative to their percentage weight change and the clinical diagnosis by a physician. METHODS A prospective observational study was performed on 200 infants presented with acute diarrhea and clinical evidence of significant dehydration whose treatment required intravenous (IV) fluids as determined by the attending physician at the pediatric emergency department of Tanta University Hospital. Weight was recorded at admission before IV fluid treatment and at hospital discharge. The percentage of dehydration was determined using the following formula: (discharge weight - admission weight)/discharge weight × 100%. Patients with a percentage weight change of <5% were considered to be nonsignificantly dehydrated, whereas patients with a percentage weight change >5% were considered significantly dehydrated. The IVC/Ao diameter ratio was measured for all patients before IV fluid rehydration and again at discharge. RESULTS Only 134 out of 200 dehydrated infants were found to be significantly dehydrated using the gold standard, percentage weight change. Receiver operating characteristics (ROC) curve analysis of the prehydration IVC/Ao ratio showed a sensitivity of 82%, a specificity of 91%, and an accuracy of 87% for predicting significant dehydration in infants at a cut-off point of less than 0.75. In contrast, physician clinical diagnosis showed a sensitivity of 70%, a specificity of 63%, and an accuracy of 73%. CONCLUSIONS The IVC/Ao diameter ratio can be used as a reliable predictor for diagnosing significant dehydration in infants.
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Affiliation(s)
- Doaa El Amrousy
- Faculty of Medicine, Tanta University Hospital, Pediatric Department, El Geish street, Tanta, Egypt
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Visser C, Kieser E, Dellimore K, van den Heever D, Smith J. Investigation of the feasibility of non-invasive optical sensors for the quantitative assessment of dehydration. Med Eng Phys 2017; 48:181-7. [PMID: 28734875 DOI: 10.1016/j.medengphy.2017.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 03/07/2017] [Accepted: 06/20/2017] [Indexed: 11/21/2022]
Abstract
This study explores the feasibility of prospectively assessing infant dehydration using four non-invasive, optical sensors based on the quantitative and objective measurement of various clinical markers of dehydration. The sensors were investigated to objectively and unobtrusively assess the hydration state of an infant based on the quantification of capillary refill time (CRT), skin recoil time (SRT), skin temperature profile (STP) and skin tissue hydration by means of infrared spectrometry (ISP). To evaluate the performance of the sensors a clinical study was conducted on a cohort of 10 infants (aged 6-36 months) with acute gastroenteritis. High sensitivity and specificity were exhibited by the sensors, in particular the STP and SRT sensors, when combined into a fusion regression model (sensitivity: 0.90, specificity: 0.78). The SRT and STP sensors and the fusion model all outperformed the commonly used "gold standard" clinical dehydration scales including the Gorelick scale (sensitivity: 0.56, specificity: 0.56), CDS scale (sensitivity: 1.0, specificity: 0.2) and WHO scale (sensitivity: 0.13, specificity: 0.79). These results suggest that objective and quantitative assessment of infant dehydration may be possible using the sensors investigated. However, further evaluation of the sensors on a larger sample population is needed before deploying them in a clinical setting.
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Levine AC, Glavis-Bloom J, Modi P, Nasrin S, Atika B, Rege S, Robertson S, Schmid CH, Alam NH. External validation of the DHAKA score and comparison with the current IMCI algorithm for the assessment of dehydration in children with diarrhoea: a prospective cohort study. Lancet Glob Health 2016; 4:e744-51. [PMID: 27567350 DOI: 10.1016/s2214-109x(16)30150-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 06/23/2016] [Accepted: 07/01/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dehydration due to diarrhoea is a leading cause of child death worldwide, yet no clinical tools for assessing dehydration have been validated in resource-limited settings. The Dehydration: Assessing Kids Accurately (DHAKA) score was derived for assessing dehydration in children with diarrhoea in a low-income country setting. In this study, we aimed to externally validate the DHAKA score in a new population of children and compare its accuracy and reliability to the current Integrated Management of Childhood Illness (IMCI) algorithm. METHODS DHAKA was a prospective cohort study done in children younger than 60 months presenting to the International Centre for Diarrhoeal Disease Research, Bangladesh, with acute diarrhoea (defined by WHO as three or more loose stools per day for less than 14 days). Local nurses assessed children and classified their dehydration status using both the DHAKA score and the IMCI algorithm. Serial weights were obtained and dehydration status was established by percentage weight change with rehydration. We did regression analyses to validate the DHAKA score and compared the accuracy and reliability of the DHAKA score and IMCI algorithm with receiver operator characteristic (ROC) curves and the weighted κ statistic. This study was registered with ClinicalTrials.gov, number NCT02007733. FINDINGS Between March 22, 2015, and May 15, 2015, 496 patients were included in our primary analyses. On the basis of our criterion standard, 242 (49%) of 496 children had no dehydration, 184 (37%) of 496 had some dehydration, and 70 (14%) of 496 had severe dehydration. In multivariable regression analyses, each 1-point increase in the DHAKA score predicted an increase of 0·6% in the percentage dehydration of the child and increased the odds of both some and severe dehydration by a factor of 1·4. Both the accuracy and reliability of the DHAKA score were significantly greater than those of the IMCI algorithm. INTERPRETATION The DHAKA score is the first clinical tool for assessing dehydration in children with acute diarrhoea to be externally validated in a low-income country. Further validation studies in a diverse range of settings and paediatric populations are warranted. FUNDING National Institutes of Health Fogarty International Center.
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Affiliation(s)
- Adam C Levine
- Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | | | - Payal Modi
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Sabiha Nasrin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Bita Atika
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Soham Rege
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Sarah Robertson
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| | - Christopher H Schmid
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| | - Nur H Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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Hubert P. Disidratazione acuta da gastroenterite nei lattanti. EMC - Urgenze 2016; 20:1-10. [DOI: 10.1016/s1286-9341(16)76183-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Il bambino sotto 1 anno e, soprattutto, di meno di 6 mesi è ad alto rischio di disidratazione, la cui causa principale è una gastroenterite acuta, soprattutto di origine virale. La gestione di una disidratazione da gastroenterite ha due componenti: la sua correzione e il rapido ripristino della normale perfusione tissutale e il mantenimento dei fabbisogni di acqua e di nutrienti, per limitare al massimo il deficit energetico. La valutazione della gravità della disidratazione è l’elemento chiave che guiderà la terapia. La perdita di peso, espressa in percentuale di peso corporeo prima dell’episodio di disidratazione, è il metodo di riferimento, ma è spesso difficile o impossibile da ottenere. Inoltre, i segni clinici, come l’alterazione dell’aspetto generale, l’allungamento del tempo di riempimento capillare, il riconoscimento di una plica cutanea persistente, gli occhi infossati, una secchezza delle mucose e la mancanza di lacrime, sono i principali elementi che permettono di valutare la gravità della disidratazione. Il trattamento si basa sulla rapida correzione del deficit del settore extracellulare. Un’espansione volemica di 20 ml/kg di una soluzione isotonica somministrata per via endovenosa o intraossea può essere necessaria nella fase iniziale nei casi più gravi (disidratazione > 10%). In tutti gli altri casi, la reidratazione per via orale per correggere il deficit di acqua in 4-6 ore è la tecnica di scelta, che si è dimostrata efficace, sicura e veloce. Essa utilizza delle soluzioni di reidratazione adattate che soddisfano criteri specifici. Il loro utilizzo precoce è la prevenzione più efficace delle forme gravi. L’allattamento al seno non deve essere interrotto e l’alimentazione artificiale deve essere ripresa da 4 a 6 ore dopo l’inizio della reidratazione. La vaccinazione contro i rotavirus prima dei 6 mesi è fortemente raccomandata.
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Levine AC, Glavis-Bloom J, Modi P, Nasrin S, Rege S, Chu C, Schmid CH, Alam NH. Empirically Derived Dehydration Scoring and Decision Tree Models for Children With Diarrhea: Assessment and Internal Validation in a Prospective Cohort Study in Dhaka, Bangladesh. Glob Health Sci Pract 2015; 3:405-18. [PMID: 26374802 PMCID: PMC4570015 DOI: 10.9745/ghsp-d-15-00097] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 07/10/2015] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Diarrhea remains one of the most common and most deadly conditions affecting children worldwide. Accurately assessing dehydration status is critical to determining treatment course, yet no clinical diagnostic models for dehydration have been empirically derived and validated for use in resource-limited settings. METHODS In the Dehydration: Assessing Kids Accurately (DHAKA) prospective cohort study, a random sample of children under 5 with acute diarrhea was enrolled between February and June 2014 in Bangladesh. Local nurses assessed children for clinical signs of dehydration on arrival, and then serial weights were obtained as subjects were rehydrated. For each child, the percent weight change with rehydration was used to classify subjects with severe dehydration (>9% weight change), some dehydration (3-9%), or no dehydration (<3%). Clinical variables were then entered into logistic regression and recursive partitioning models to develop the DHAKA Dehydration Score and DHAKA Dehydration Tree, respectively. Models were assessed for their accuracy using the area under their receiver operating characteristic curve (AUC) and for their reliability through repeat clinical exams. Bootstrapping was used to internally validate the models. RESULTS A total of 850 children were enrolled, with 771 included in the final analysis. Of the 771 children included in the analysis, 11% were classified with severe dehydration, 45% with some dehydration, and 44% with no dehydration. Both the DHAKA Dehydration Score and DHAKA Dehydration Tree had significant AUCs of 0.79 (95% CI = 0.74, 0.84) and 0.76 (95% CI = 0.71, 0.80), respectively, for the diagnosis of severe dehydration. Additionally, the DHAKA Dehydration Score and DHAKA Dehydration Tree had significant positive likelihood ratios of 2.0 (95% CI = 1.8, 2.3) and 2.5 (95% CI = 2.1, 2.8), respectively, and significant negative likelihood ratios of 0.23 (95% CI = 0.13, 0.40) and 0.28 (95% CI = 0.18, 0.44), respectively, for the diagnosis of severe dehydration. Both models demonstrated 90% agreement between independent raters and good reproducibility using bootstrapping. CONCLUSION This study is the first to empirically derive and internally validate accurate and reliable clinical diagnostic models for dehydration in a resource-limited setting. After external validation, frontline providers may use these new tools to better manage acute diarrhea in children.
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Affiliation(s)
- Adam C Levine
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Payal Modi
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Sabiha Nasrin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Soham Rege
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Chieh Chu
- Brown University School of Public Health, Department of Biostatistics, Providence, RI, USA
| | - Christopher H Schmid
- Brown University School of Public Health, Department of Biostatistics, Providence, RI, USA
| | - Nur H Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Hoxha T, Xhelili L, Azemi M, Avdiu M, Ismaili-Jaha V, Efendija-Beqa U, Grajcevci-Uka V. Performance of clinical signs in the diagnosis of dehydration in children with acute gastroenteritis. Med Arch 2015; 69:10-2. [PMID: 25870468 PMCID: PMC4384849 DOI: 10.5455/medarh.2015.69.10-12] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/11/2014] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Acute evaluation and treatment of children presenting with dehydration represent one of the most common situation in the pediatric emergency department. To identify dehydration in infants and children before treatment, a number of symptoms and clinical signs have been evaluated. The aim of the study was to describe the performance of clinical signs in detecting dehydration in children. METHODS Two hundred children aged 1 month to 5 year were involved in our prospective study. The clinical assessment consisted of the ten clinical signs of dehydration, including those recommended by WHO (World Health Organization), heart rate, and capillary refill time. RESULTS Two hundred patients with diarrhea were enrolled in the study. The mean age was 15.62±9.03 months and 57.5% were male. Of these 121 had a fluid deficit of < 5%, 68 had a deficit of 5 to 9% and 11(5.5%) had a deficit of 10% or more. Patients classified as having no or mild, moderate, and severe dehydration were found to have the following respective gains in percent weight at the end of illness: 2.44±0.3, 6.05± 1.01 and, 10.66± 0.28, respectively. All clinical signs were found more frequently with increasing amounts of dehydration(p<0.001, One-way ANOVA). The median number of findings among subjects with no or mild dehydration (deficit <5%) was 3; among those with moderate dehydration (deficit 5% to 9%) was 6.5 and among those with severe dehydration (deficit >10%) the median was 9 (p<0.0001, Kruskal-Wallis test). Using stepwise linear regression and a p value of <0.05 for entry into the model, a four-variable model including sunken eyes, skin elasticity, week radial pulse, and general appearance was derived. CONCLUSION None of the 10 findings studied, is sufficiently accurate to be used in isolation. When considered together, sunken eyes, decreased skin turgor, weak pulse and general appearance provide the best explanatory power of the physical signs considered.
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Affiliation(s)
- Teuta Hoxha
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo
| | - Luan Xhelili
- Department of Pediatrics, University Hospital Centre "Mother Teresa", Tirana, Albania
| | - Mehmedali Azemi
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo
| | - Muharrem Avdiu
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo
| | - Vlora Ismaili-Jaha
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo
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Jauregui J, Nelson D, Choo E, Stearns B, Levine AC, Liebmann O, Shah SP. The BUDDY (Bedside Ultrasound to Detect Dehydration in Youth) study. Crit Ultrasound J 2014; 6:15. [PMID: 25411590 PMCID: PMC4233328 DOI: 10.1186/s13089-014-0015-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 08/15/2014] [Indexed: 12/19/2022] Open
Abstract
Background Prior research suggests that the ratio of the ultrasound-measured diameter of the inferior vena cava to the aorta correlates with the level of dehydration in children. This study was designed to externally validate this and to access the accuracy of the ultrasound measured inspiratory IVC collapse and physician gestalt to predict significant dehydration in children in the emergency department. Methods We prospectively enrolled a non-consecutive cohort of children ≤18 years old. Patient weight, ultrasound measurements of the IVC and Ao, and physician gestalt were recorded. The percent weight change from presentation to discharge was used to calculate the degree of dehydration. A weight change of ≥5% was considered clinically significant dehydration. Receiver operating characteristic (ROC) curves were constructed for each of the ultrasound measurements and physician gestalt. Sensitivity (SN) and specificity (SP) were calculated based on previously established cutoff points of the IVC/Ao ratio (0.8), the IVC collapsibility index of 50%, and a new cut off point of IVC collapsibility index of 80% or greater. Intra-class correlation coefficients were calculated to assess the degree of inter-rater reliability between ultrasound observers. Results Of 113 patients, 10.6% had significant dehydration. The IVC/Ao ratio had an area under the ROC curve (AUC) of 0.72 (95% CI 0.53 to 0.91) and, with a cutoff of 0.8, produced a SN of 67% and a SP of 71% for the diagnosis of significant dehydration. The IVC collapsibility index of 50% had an AUC of 0.58 (95% CI 0.44 to 0.72) and, with a cutoff of 80% collapsibility, produced a SN of 83% and a SP of 42%. The intra-class correlation coefficient was 0.83 for the IVC/Ao ratio and 0.70 for the IVC collapsibility. Physician gestalt had an AUC of 0.61 (95% CI 0.44 to 0.78) and, with a cutoff point of 5, produced a SN of 42% and a SP of 65%. Conclusions The ultrasound-measured IVC/Ao ratio is a modest predictor of significant dehydration in children. The inspiratory IVC collapse and physician gestalt were poor predictors of the actual level of dehydration in this study.
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Affiliation(s)
- Joshua Jauregui
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence 02912, RI, USA ; Division of Emergency Medicine, Harborview Medical Center, University of Washington, M/S 325 9th Avenue, Seattle 98104, WA, USA
| | - Daniel Nelson
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence 02912, RI, USA
| | - Esther Choo
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence 02912, RI, USA
| | | | - Adam C Levine
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence 02912, RI, USA
| | - Otto Liebmann
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence 02912, RI, USA
| | - Sachita P Shah
- Division of Emergency Medicine, Harborview Medical Center, University of Washington, M/S 325 9th Avenue, Seattle 98104, WA, USA
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Jauregui J, Nelson D, Choo E, Stearns B, Levine AC, Liebmann O, Shah SP. External validation and comparison of three pediatric clinical dehydration scales. PLoS One 2014; 9:e95739. [PMID: 24788134 PMCID: PMC4008432 DOI: 10.1371/journal.pone.0095739] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 03/28/2014] [Indexed: 11/23/2022] Open
Abstract
Objective To prospectively validate three popular clinical dehydration scales and overall physician gestalt in children with vomiting or diarrhea relative to the criterion standard of percent weight change with rehydration. Methods We prospectively enrolled a non-consecutive cohort of children ≤ 18 years of age with an acute episode of diarrhea or vomiting. Patient weight, clinical scale variables and physician clinical impression, or gestalt, were recorded before and after fluid resuscitation in the emergency department and upon hospital discharge. The percent weight change from presentation to discharge was used to calculate the degree of dehydration, with a weight change of ≥ 5% considered significant dehydration. Receiver operating characteristics (ROC) curves were constructed for each of the three clinical scales and physician gestalt. Sensitivity and specificity were calculated based on the best cut-points of the ROC curve. Results We approached 209 patients, and of those, 148 were enrolled and 113 patients had complete data for analysis. Of these, 10.6% had significant dehydration based on our criterion standard. The Clinical Dehydration Scale (CDS) and Gorelick scales both had an area under the ROC curve (AUC) statistically different from the reference line with AUCs of 0.72 (95% CI 0.60, 0.84) and 0.71 (95% CI 0.57, 0.85) respectively. The World Health Organization (WHO) scale and physician gestalt had AUCs of 0.61 (95% CI 0.45, 0.77) and 0.61 (0.44, 0.78) respectively, which were not statistically significant. Conclusion The Gorelick scale and Clinical Dehydration Scale were fair predictors of dehydration in children with diarrhea or vomiting. The World Health Organization scale and physician gestalt were not helpful predictors of dehydration in our cohort.
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Affiliation(s)
- Joshua Jauregui
- Warren Alpert Medical School Department of Emergency Medicine, Brown University, Providence, Rhode Island, United States of America
- Division of Emergency Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - Daniel Nelson
- Warren Alpert Medical School Department of Emergency Medicine, Brown University, Providence, Rhode Island, United States of America
| | - Esther Choo
- Warren Alpert Medical School Department of Emergency Medicine, Brown University, Providence, Rhode Island, United States of America
| | - Branden Stearns
- Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Adam C. Levine
- Warren Alpert Medical School Department of Emergency Medicine, Brown University, Providence, Rhode Island, United States of America
| | - Otto Liebmann
- Warren Alpert Medical School Department of Emergency Medicine, Brown University, Providence, Rhode Island, United States of America
| | - Sachita P. Shah
- Rhode Island Hospital, Providence, Rhode Island, United States of America
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Yalda Lucero A. Etiología y manejo de la gastroenteritis aguda infecciosa en niños y adultos. Revista Médica Clínica Las Condes 2014. [DOI: 10.1016/s0716-8640(14)70063-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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16
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Levine AC, Munyaneza RM, Glavis-Bloom J, Redditt V, Cockrell HC, Kalimba B, Kabemba V, Musavuli J, Gakwerere M, Umurungi JPDC, Shah SP, Drobac PC. Prediction of severe disease in children with diarrhea in a resource-limited setting. PLoS One 2013; 8:e82386. [PMID: 24349271 PMCID: PMC3857792 DOI: 10.1371/journal.pone.0082386] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 10/29/2013] [Indexed: 12/04/2022] Open
Abstract
Objective To investigate the accuracy of three clinical scales for predicting severe disease (severe dehydration or death) in children with diarrhea in a resource-limited setting. Methods Participants included 178 children admitted to three Rwandan hospitals with diarrhea. A local physician or nurse assessed each child on arrival using the World Health Organization (WHO) severe dehydration scale and the Centers for Disease Control (CDC) scale. Children were weighed on arrival and daily until they achieved a stable weight, with a 10% increase between admission weight and stable weight considered severe dehydration. The Clinical Dehydration Scale was then constructed post-hoc using the data collected for the other two scales. Receiver Operator Characteristic (ROC) curves were constructed for each scale compared to the composite outcome of severe dehydration or death. Results The WHO severe dehydration scale, CDC scale, and Clinical Dehydration Scale had areas under the ROC curves (AUCs) of 0.72 (95% CI 0.60, 0.85), 0.73 (95% CI 0.62, 0.84), and 0.80 (95% CI 0.71, 0.89), respectively, in the full cohort. Only the Clinical Dehydration Scale was a significant predictor of severe disease when used in infants, with an AUC of 0.77 (95% CI 0.61, 0.93), and when used by nurses, with an AUC of 0.78 (95% CI 0.63, 0.93). Conclusions While all three scales were moderate predictors of severe disease in children with diarrhea, scale accuracy varied based on provider training and age of the child. Future research should focus on developing or validating clinical tools that can be used accurately by nurses and other less-skilled providers to assess all children with diarrhea in resource-limited settings.
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Affiliation(s)
- Adam C. Levine
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
- * E-mail:
| | - Richard M. Munyaneza
- Department of Community Health, Rwanda Ministry of Health, Kigali, Kigali Province, Rwanda
| | - Justin Glavis-Bloom
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
| | - Vanessa Redditt
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hannah C. Cockrell
- Watson Institute for International Studies, Brown University, Providence, Rhode Island, United States of America
| | - Bantu Kalimba
- Department of Medicine, Kirehe Hospital, Kirehe, Eastern Province, Rwanda
| | - Valentin Kabemba
- Department of Medicine, Kirehe Hospital, Kirehe, Eastern Province, Rwanda
| | - Juvenal Musavuli
- Department of Medicine, Butaro Hospital, Butaro, Northern Province, Rwanda
| | - Mathias Gakwerere
- Department of Medicine, Butaro Hospital, Butaro, Northern Province, Rwanda
| | | | - Sachita P. Shah
- Division of Emergency Medicine, University of Washington Medical Center, Seattle, Washington, United States of America
| | - Peter C. Drobac
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Research Department, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Eastern Province, Rwanda
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Jucá CA, Rey LC, Martins CV. Comparison between normal saline and a polyelectrolyte solution for fluid resuscitation in severely dehydrated infants with acute diarrhoea. ACTA ACUST UNITED AC 2013; 25:253-60. [PMID: 16297299 DOI: 10.1179/146532805x72395] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
UNLABELLED The optimal intravenous solution for rehydration of infants and children with severe dehydration is debated. AIM The aim was to compare the efficacy of a polyelectrolyte solution (group PS) with sodium chloride 0.9% solution (group NS) in rapid parenteral rehydration of severely dehydrated infants with acute diarrhoea. METHODS Primary outcomes were volume and time to hydration. Secondary outcomes were urea, creatinine, electrolytes, glucose, arterial pH and bicarbonate levels. Patients were assigned randomly and openly to one of the two treatment groups. Severe dehydration was defined as one or more of the following associated with any other sign of dehydration: depressed consciousness, a weak or absent pulse or capillary refill time > 10 sec. Peripheral blood samples for chemical pathology were collected before and after rapid fluid therapy. The mean age of the 36 enrolled infants was 9.1 mths. All had depressed consciousness or severe hypotension/shock. The fluid infusion rate was 50 ml/kg/hr until haemodynamic stability was restored (absence of severe hypotension and two urine emissions). Fluid volume, time to rehydration and weight before and after rehydration were recorded. RESULTS All infants recovered full pulse within 1 hr; most had a better level of consciousness or capillary refill <3 sec. Group NS (15 infants) showed (before and after treatment, respectively) a decrease of plasma potassium (3.4 to 3.1 mmol/L, p=0.07), bicarbonate (13.3 to 12.2 mmol/L, p=0.01) and glucose (8.2 to 5.8 mmol/L, p<0.01). Group PS (21 infants) showed a decrease of potassium (4.4 to 3.2 mmol/L, p<0.01) but an increase in bicarbonate (11.6 to 13.3 mmol/L, p<0.01) and glucose (11.4 to 14.8 mmol/L, p=0.08). CONCLUSION Polyelectrolyte solution was as effective as normal saline on volume expansion and better for correcting acidosis.
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Affiliation(s)
- Conceição A Jucá
- Emergency Unit, Hospital Infantil Albert Sabin, Fortaleza, Brazil
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Pruvost I, Dubos F, Chazard E, Hue V, Duhamel A, Martinot A. The value of body weight measurement to assess dehydration in children. PLoS One 2013; 8:e55063. [PMID: 23383058 PMCID: PMC3558475 DOI: 10.1371/journal.pone.0055063] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 12/21/2012] [Indexed: 11/18/2022] Open
Abstract
Dehydration secondary to gastroenteritis is one of the most common reasons for office visits and hospital admissions. The indicator most commonly used to estimate dehydration status is acute weight loss. Post-illness weight gain is considered as the gold-standard to determine the true level of dehydration and is widely used to estimate weight loss in research. To determine the value of post-illness weight gain as a gold standard for acute dehydration, we conducted a prospective cohort study in which 293 children, aged 1 month to 2 years, with acute diarrhea were followed for 7 days during a 3-year period. The main outcome measures were an accurate pre-illness weight (if available within 8 days before the diarrhea), post-illness weight, and theoretical weight (predicted from the child's individual growth chart). Post-illness weight was measured for 231 (79%) and both theoretical and post-illness weights were obtained for 111 (39%). Only 62 (21%) had an accurate pre-illness weight. The correlation between post-illness and theoretical weight was excellent (0.978), but bootstrapped linear regression analysis showed that post-illness weight underestimated theoretical weight by 0.48 kg (95% CI: 0.06-0.79, p<0.02). The mean difference in the fluid deficit calculated was 4.0% of body weight (95% CI: 3.2-4.7, p<0.0001). Theoretical weight overestimated accurate pre-illness weight by 0.21 kg (95% CI: 0.08-0.34, p = 0.002). Post-illness weight underestimated pre-illness weight by 0.19 kg (95% CI: 0.03-0.36, p = 0.02). The prevalence of 5% dehydration according to post-illness weight (21%) was significantly lower than the prevalence estimated by either theoretical weight (60%) or clinical assessment (66%, p<0.0001).These data suggest that post-illness weight is of little value as a gold standard to determine the true level of dehydration. The performance of dehydration signs or scales determined by using post-illness weight as a gold standard has to be reconsidered.
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Affiliation(s)
- Isabelle Pruvost
- Univ Lille Nord de France, UDSL, Lille, France
- Paediatric Emergency and Infectious Diseases Unit, CHU Lille, Lille, France
| | - François Dubos
- Univ Lille Nord de France, UDSL, Lille, France
- EA2694, Public Health, Epidemiology and Quality of Care, Lille, France
- Paediatric Emergency and Infectious Diseases Unit, CHU Lille, Lille, France
| | | | - Valérie Hue
- Paediatric Emergency and Infectious Diseases Unit, CHU Lille, Lille, France
| | - Alain Duhamel
- Univ Lille Nord de France, UDSL, Lille, France
- EA2694, Public Health, Epidemiology and Quality of Care, Lille, France
- Department of Biostatistics, CHU Lille, Lille, France
| | - Alain Martinot
- Univ Lille Nord de France, UDSL, Lille, France
- EA2694, Public Health, Epidemiology and Quality of Care, Lille, France
- Paediatric Emergency and Infectious Diseases Unit, CHU Lille, Lille, France
- * E-mail:
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van den Berg J, Berger MY. Guidelines on acute gastroenteritis in children: a critical appraisal of their quality and applicability in primary care. BMC Fam Pract 2011; 12:134. [PMID: 22136388 PMCID: PMC3331832 DOI: 10.1186/1471-2296-12-134] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 12/02/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Reasons for poor guideline adherence in acute gastroenteritis (AGE) in children in high-income countries are unclear, but may be due to inconsistency between guideline recommendations, lack of evidence, and lack of generalizability of the recommendations to general practice. The aim of this study was to assess the quality of international guidelines on AGE in children and investigate the generalizability of the recommendations to general practice. METHODS Guidelines were retrieved from websites of professional medical organisations and websites of institutes involved in guideline development. In addition, a systematic search of the literature was performed. Articles were selected if they were a guideline, consensus statement or care protocol. RESULTS Eight guidelines met the inclusion criteria, the quality of the guidelines varied. 242 recommendations on diagnosis and management were found, of which 138 (57%) were based on evidence.There is a large variety in the classification of symptoms to different categories of dehydration. No signs are generalizable to general practice.It is consistently recommended to use hypo-osmolar ORS, however, the recommendations on ORS-dosage are not evidence based and are inconsistent. One of 14 evidence based recommendations on therapy of AGE is based on outpatient research and is therefore generalizable to general practice. CONCLUSIONS The present study shows considerable variation in the quality of guidelines on AGE in children, as well as inconsistencies between the recommendations. It remains unclear how to asses the extent of dehydration and determine the preferred treatment or referral of a young child with AGE presenting in general practice.
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Affiliation(s)
- José van den Berg
- Department of General Practice, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
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Gravel J, Manzano S, Guimont C, Lacroix L, Gervaix A, Bailey B. [Multicenter validation of the clinical dehydration scale for children]. Arch Pediatr 2010; 17:1645-51. [PMID: 20951010 DOI: 10.1016/j.arcped.2010.09.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 08/05/2010] [Accepted: 09/10/2010] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Dehydration is an important complication for sick children. The Clinical Dehydration Scale for children (CDS) measures dehydration based on 4 clinical signs: general appearance, eyes, saliva, and tears. OBJECTIVE To validate the association between the CDS and markers of dehydration in children aged 1 month to 5 years visiting emergency departments (EDs) for vomiting and/or diarrhea. METHOD An international prospective cohort study conducted in 3 university-affiliated EDs in 2009. Participants were a convenience sample of children aged 1-60 months presenting to the ED for acute vomiting and/or diarrhea. Following triage, a research nurse obtained informed consent and evaluated dehydration using the CDS. A few days after recovery, another research assistant weighed participants at home. The primary outcome was the percentage of dehydration calculated by the difference in weight at first evaluation and after recovery. Secondary outcomes included proportion of blood test measurements, intravenous use, hospitalization, and inter-rater agreement. RESULTS During the study period, 264 children were recruited and data regarding weight and dehydration scores were complete for 219 (83%). According to the CDS, 88 had no dehydration, 159 some dehydration, and 15 moderate or severe dehydration. A Chi-square test showed a statistical association between CDS and weight gain, the occurrence of blood tests, intravenous rehydration, hospitalization, and abnormal plasmatic bicarbonate. Good inter-rater correlation was found among participants (linear weighted Kappa score of 0.65; (95% CI, 0.43-0.87). CONCLUSION CDS categories correlate with markers of dehydration for young children complaining of vomiting and/or diarrhea in the ED.
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Levine AC, Shah SP, Umulisa I, Munyaneza RBM, Dushimiyimana JM, Stegmann K, Musavuli J, Ngabitsinze P, Stulac S, Epino HM, Noble VE. Ultrasound assessment of severe dehydration in children with diarrhea and vomiting. Acad Emerg Med 2010; 17:1035-41. [PMID: 21040103 DOI: 10.1111/j.1553-2712.2010.00830.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective of this study was to determine the test characteristics for two different ultrasound (US) measures of severe dehydration in children (aorta to inferior vena cava [IVC] ratio and IVC inspiratory collapse) and one clinical measure of severe dehydration (the World Health Organization [WHO] dehydration scale). METHODS The authors enrolled a prospective cohort of children presenting with diarrhea and/or vomiting to three rural Rwandan hospitals. Children were assessed clinically using the WHO scale and then underwent US of the IVC by a second clinician. All children were weighed on admission and then fluid-resuscitated according to standard hospital protocols. A percent weight change between admission and discharge of greater than 10% was considered the criterion standard for severe dehydration. Receiver operating characteristic (ROC) curves were created for each of the three tests of severe dehydration compared to the criterion standard. RESULTS Children ranged in age from 1 month to 10 years; 29% of the children had severe dehydration according to the criterion standard. Of the three different measures of dehydration tested, only US assessment of the aorta/IVC ratio had an area under the ROC curve statistically different from the reference line. At its best cut-point, the aorta/IVC ratio had a sensitivity of 93% and specificity of 59%, compared with 93% and 35% for IVC inspiratory collapse and 73% and 43% for the WHO scale. CONCLUSIONS Ultrasound of the aorta/IVC ratio can be used to identify severe dehydration in children presenting with acute diarrhea and may be helpful in guiding clinical management.
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Affiliation(s)
- Adam C Levine
- Department of Emergency Medicine, Brown University Alpert Medical School, Providence, RI, USA.
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O'Ryan M, Lucero Y, O'Ryan-Soriano MA, Ashkenazi S. An update on management of severe acute infectious gastroenteritis in children. Expert Rev Anti Infect Ther 2010; 8:671-82. [PMID: 20521895 DOI: 10.1586/eri.10.40] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
This article focuses on clinical and diagnostic aspects relevant to severe acute infectious gastroenteritis in children and will update treatment strategies focused on, although not limited to, anti-infective therapy. For the purposes of this article we will consider severe acute infectious gastroenteritis as follows: watery diarrhea accompanied by, or at high risk for, moderate to severe dehydration due to abrupt onset of vomiting that reduces oral intake, and/or frequent emission of liquid stools, or moderate to severe dysenteric/bloody diarrhea with moderate to high-grade fever. The article will not include food poisoning associated with bacterial toxins and will only briefly discuss oral rehydration strategies and intravenous solutions. The article will also briefly discuss current preventive measures against rotavirus gastroenteritis through vaccination, a topic that has been extensively discussed elsewhere.
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Affiliation(s)
- Miguel O'Ryan
- Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago, Chile.
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Abstract
OBJECTIVES The objective was to validate the clinical dehydration scale (CDS) for children with gastroenteritis in a different pediatric emergency department (ED) from where it was initially derived and validated. METHODS A prospective cohort study was performed in a tertiary care pediatric ED over a 1-year period. A sample of triage nurses were trained in applying the CDS. The CDS consists of four clinical characteristics (general appearance, eyes, mucous membranes, and tears), each of which are scored 0, 1, or 2 for a total score of 0 to 8, with 0 representing no dehydration; 1 to 4, some dehydration; and 5 to 8, moderate/severe dehydration. Children 1 month to 5 years of age with vomiting and/or diarrhea who had the CDS documented at triage and a final diagnosis of gastroenteritis, gastritis, or enteritis were enrolled. Exclusion criteria included a chronic disease, treatment with intravenous (IV) rehydration within the previous 24 hours, visit to the ED for the same illness in the 7 days prior to arrival, and diarrhea of more than 10 days' duration. The primary outcome was the length of stay (LOS) in the ED from the time of seeing a physician to discharge, analyzed with a Kruskal-Wallis test. RESULTS From April 2008 to March 2009, 150 patients with a mean (+/-SD) age of 22 (+/-14) months (range = 4 months to 4 years) were enrolled. Fifty-six patients had no dehydration, 74 had some dehydration, and 20 had moderate/severe dehydration. The median LOS in the ED after being seen by a physician was significantly longer as children appeared more dehydrated according to the CDS: 54 minutes (interquartile range [IQR] = 26-175 minutes), 128 minutes (IQR = 25-334 minutes), and 425 minutes (IQR = 218-673 minutes) for the no, some, and moderate/severe dehydration groups, respectively (p < 0.001). CONCLUSIONS The CDS has been further validated in children with gastroenteritis in a different pediatric center than the original one where it was developed. It is a good predictor of LOS in the ED after being seen by a physician.
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Affiliation(s)
- Benoit Bailey
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montréal, Quebec, Canada.
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Abdulrhman MA, Mekawy MA, Awadalla MM, Mohamed AH. Bee Honey Added to the Oral Rehydration Solution in Treatment of Gastroenteritis in Infants and Children. J Med Food 2010; 13:605-9. [DOI: 10.1089/jmf.2009.0075] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
OBJECTIVES Oral rehydration therapy is underused by physicians treating children with acute infectious enteritis. To guide management, we hypothesized that clinical variables available at the initial assessment could be identified that will predict the need for intravenous fluid administration. PATIENTS AND METHODS Clinical data were prospectively collected on a cohort of 214 children, aged 6 months to 10 years, treated in an emergency department for dehydration secondary to acute enteritis. All of the children performed supervised oral rehydration therapy for a minimum of 60 minutes according to protocol.Outcomes assessed were intravenous rehydration, return visits after discharge, and successful oral rehydration therapy. The latter variable was defined as the consumption of > or = 12.5 mL/kg per hour of oral rehydration solution. Variables individually associated with outcomes of interest were evaluated by using multiple logistic regression analysis. RESULTS Forty-eight (22%) of 214 children received intravenous rehydration. In multivariate analysis, the 2 clinical predictors of intravenous rehydration were large urinary ketones and altered mental status. Significant predictors of repeat emergency department visits within 3 days included > or = 10 episodes of vomiting over the 24 hours before presentation and a higher heart rate at discharge from the emergency department. CONCLUSIONS Among children with enteritis and mild-to-moderate dehydration, the presence of large urine ketones or an altered mental status is associated with intravenous rehydration after a 60-minute oral rehydration therapy period. Caution should be exercised before discharging children with either tachycardia or a history of significant vomiting before presentation, because they are more likely to require future emergency department care.
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Affiliation(s)
- Stephen B Freedman
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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Roland D, Clarke C, Borland ML, Pascoe EM. Does a standardised scoring system of clinical signs reduce variability between doctors' assessments of the potentially dehydrated child? J Paediatr Child Health 2010; 46:103-7. [PMID: 20105256 DOI: 10.1111/j.1440-1754.2009.01646.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS Clinical assessment of dehydration in children is often inaccurate. We aimed to determine if a scoring system based on standardised clinical signs would reduce the variability between doctors' assessment of dehydration. METHODS A clinical scoring system was developed using seven physiological variables based on previously published research. Estimated percentage dehydration and severity scores were recorded for 100 children presenting to a Paediatric Emergency Department with symptoms of gastroenteritis and dehydration by three doctors of different seniority (resident medical officer, registrar and consultant). Agreement was measured using intra-class correlation coefficient (ICC) for percentage ratings and total clinical scores and kappa for individual characteristics. RESULTS Estimated percentage dehydration ranged from 0-9%, mean 2.96%, across the three groups. Total clinical scores from 0-10, mean 2.20. There was moderate agreement amongst clinicians for the percentage dehydration (ICC 0.40). The level of agreement on the clinical scoring system was identical (ICC 0.40). Consultants gave statistically lower scores than the other two groups (Consultant (Con) vs. Resident P = 0.001, Con vs. Registrar P = 0.013). There was a marked difference in agreement across characteristics comprising the scoring system, from kappa 0.02 for capillary refill time to 0.42 for neurological status. CONCLUSION The clinical scoring system used did not reduce the variability of assessment of dehydration compared to doctors' conventional methods. In order to reduce variability improving education may be more important than production of a scoring system as experience appears to be a key determinant in the assessment of a potentially dehydrated child.
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Affiliation(s)
- Damian Roland
- Emergency Department, Leicester Royal Infirmary, Leicester, UK.
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Colletti JE, Brown KM, Sharieff GQ, Barata IA, Ishimine P. The management of children with gastroenteritis and dehydration in the emergency department. J Emerg Med 2009; 38:686-98. [PMID: 19345549 DOI: 10.1016/j.jemermed.2008.06.015] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2008] [Revised: 05/12/2008] [Accepted: 06/04/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute gastroenteritis is characterized by diarrhea, which may be accompanied by nausea, vomiting, fever, and abdominal pain. OBJECTIVE To review the evidence on the assessment of dehydration, methods of rehydration, and the utility of antiemetics in the child presenting with acute gastroenteritis. DISCUSSION The evidence suggests that the three most useful predictors of 5% or more dehydration are abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern. Studies are conflicting on whether blood urea nitrogen (BUN) or BUN/creatinine ratio correlates with dehydration, but several studies found that low serum bicarbonate combined with certain clinical parameters predicts dehydration. In most studies, oral or nasogastric rehydration with an oral rehydration solution was equally efficacious as intravenous (i.v.) rehydration. Many experts discourage the routine use of antiemetics in young children. However, children receiving ondensetron are less likely to vomit, have greater oral intake, and are less likely to be treated by intravenous rehydration. Mean length of Emergency Department (ED) stay is also less, and very few serious side effects have been reported. CONCLUSIONS In the ED, dehydration is evaluated by synthesizing the historical and physical examination, and obtaining laboratory data points in select patients. No single laboratory value has been found to be accurate in predicting the degree of dehydration and this is not routinely recommended. The evidence suggests that the majority of children with mild to moderate dehydration can be treated successfully with oral rehydration therapy. Ondansetron (orally or intravenously) may be effective in decreasing the rate of vomiting, improving the success rate of oral hydration, preventing the need for i.v. hydration, and preventing the need for hospital admission in those receiving i.v. hydration.
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Affiliation(s)
- James E Colletti
- Department of Emergency Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Abstract
OBJECTIVE We previously created a clinical dehydration scale. Our objective was to validate the clinical dehydration scale with a new cohort of patients with acute gastroenteritis who were assessed in a tertiary emergency department in a developed country. METHODS A prospective observational study was performed in an emergency department at a large pediatric tertiary center in Canada. Children 1 month to 5 years of age with symptoms of acute gastroenteritis who were assessed in the emergency department were enrolled consecutively during a 4-month period. The main outcome measures were length of stay, proportion of children receiving intravenous fluid rehydration, and proportions of children with abnormal serum pH values or bicarbonate levels. RESULTS A total of 205 children were enrolled, with a mean age of 22.4 +/- 14.9 months; 103 (50%) were male. The distribution of severity categories was as follows: no dehydration (score of 0), n = 117 (57%); some dehydration (score of 1-4), n = 83 (41%); moderate/severe dehydration (score of 5-8), n = 5 (2%). The 3 dehydration categories were significantly different with respect to the validation hypotheses (length of stay, mean +/- SD: none, 245 +/- 181 minutes; some, 397 +/- 302 minutes; moderate/severe, 501 +/- 389 minutes; treatment with intravenous fluids: none, n =17, 15%; some, n = 41, 49%; moderate/severe, n = 4, 80%; number of vomiting episodes in the 7 days before the emergency department visit: none, 8.4 +/- 7.7 episodes; some, 13 +/- 10.7 episodes; moderate/severe, 30.2 +/- 14.8 episodes). CONCLUSION The clinical dehydration scale and the 3 severity categories were valid for a prospectively enrolled cohort of patients who were assessed in our tertiary emergency department. The scoring system was valuable in predicting a longer length of stay and the need for intravenous fluid rehydration for children with symptoms of acute gastroenteritis.
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Affiliation(s)
- Ran D Goldman
- Division of Pediatric Emergency Medicine, BC Children's Hospital, 4480 Oak St, Vancouver, BC V6H 3V4, Canada.
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Pruvost I, Dubos F, Aurel M, Hue V, Martinot A. Valeur des données anamnestiques, cliniques et biologiques pour le diagnostic de déshydratation par diarrhée aiguë chez l’enfant de moins de 5 ans. Presse Med 2008; 37:600-9. [DOI: 10.1016/j.lpm.2007.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Revised: 10/17/2007] [Accepted: 10/24/2007] [Indexed: 11/30/2022] Open
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Abstract
Acute gastroenteritis remains a common and often severe illness among infants and children throughout the world. The management of a child with acute diarrhea includes rehydration and maintenance fluids with oral rehydration solutions (ORS), combined with continued age-appropriate nutrition. However, although substantial data support the role of continued nutrition in improving gastrointestinal function and anthropometric, biochemical, and clinical outcomes, the practice of continued feeding during diarrheal episodes has been difficult to establish as accepted standard of care. Recommendations for maintenance dietary therapy depend on the age and diet history of the patient. It has been clear for many years that, when affected by gastroenteritis, breastfed infants should be continued on breast milk without any need for interruption and, by that way, will get faster recovery and improved nutrition. Moreover, many well-conducted studies have provided evidence that in formula-fed children not severely dehydrated, a rapid return to full feeding is well tolerated. Lactose intolerance and/or secondary cow's milk allergy are not a clinical concern for the vast majority of patients. In fact early refeeding i.e resumption of normal diet, in amounts sufficient to satisfy energy and nutrient requirements, should be the rule. However, in children younger than 6 months of age, the lack of suitable studies must lead to caution and use of specific lactose-free or extensively hydrolysate formulae, especially in case of severe and/or prolonged diarrhea. Several studies support the use of zinc supplementation or probiotics for acute diarrhea but some doubts persist in infant in developed countries.
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Affiliation(s)
- J-P Chouraqui
- Unité de Gastro-entérologie, Hépatologie et Nutrition, et unité d'urgences Pédiatriques, Pôle Couple-Enfant. CHU de Grenoble-38043 Grenoble-cedex 07, France.
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Abstract
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.
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Affiliation(s)
- Michael J Steiner
- Department of Pediatrics, Childrens Hospital Los Angeles, Los Angeles, CA, USA.
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Abstract
BACKGROUND Rapid intravenous (IV) rehydration in the emergency department (ED) is required for certain children with acute gastroenteritis (AGE). OBJECTIVES To determine whether the amount of IV dextrose administered is related to a return visit with admission (RVA) in children with AGE and dehydration, and to determine which clinical, laboratory, and treatment parameters are associated with an RVA. METHODS The investigators performed a case control study of children aged 6 months to 6 years who presented to an urban ED with AGE and dehydration and who received IV rehydration before discharge from the ED. Dehydration was defined a priori on the basis of parameters used in prior studies. Cases were defined as those patients who had an RVA within 72 hours of an original visit for ongoing symptoms. Controls were defined as those patients who met inclusion criteria who did not have an RVA. The authors studied whether the amount of IV dextrose administered at the initial visit was related to an RVA as well as which other clinical and treatment parameters were associated with an RVA. RESULTS A total of 56 cases and 112 controls were studied. Patients who had an RVA received significantly less IV dextrose (mean: 399 mg/kg vs. 747 mg/kg, p < 0.001) than those who did not have an RVA. Patients who received no IV dextrose had 3.9 times greater odds of having a return visit with admission than those who received some dextrose. Controlling for fluid volume, the amount of dextrose administered remained statistically significant by logistic regression; for every 500 mg/kg of IV dextrose administered, the patient was 1.9 times less likely to have an RVA. Patients with length of symptoms less than or equal to one day were more likely to have an RVA than were those with symptom length of two or more days. No other historical or physical exam findings or laboratory parameters (including mean serum bicarbonate) were associated with a return visit requiring admission. CONCLUSIONS Administration of larger amounts of IV dextrose is associated with reduced return visits requiring admission in children with gastroenteritis and dehydration.
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Affiliation(s)
- Jason A Levy
- Division of Emergency Medicine, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA.
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Abstract
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.
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Affiliation(s)
- A Martinot
- Clinique de pédiatrie et université de Lille II, hôpital Jeanne-de-Flandre, avenue E.-Avinée, 59037 Lille cedex, France.
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Jarvis JN, Planche T, Bicanic T, Dzeing-Ella A, Kombila M, Issifou S, Borrmann S, Kremsner PG, Krishna S. Lactic Acidosis in Gabonese Children with Severe Malaria Is Unrelated to Dehydration. Clin Infect Dis 2006; 42:1719-25. [PMID: 16705578 DOI: 10.1086/504329] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2005] [Accepted: 02/18/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Hyperlactatemia is an important and common complication of severe malaria. We investigated changes in fluid compartment volumes in patients with severe malaria and control patients with the use of bioimpedence analysis. METHODS We estimated extracellular water and total body water volumes in a total of 180 children: 56 with severe malaria, 94 with moderate malaria, 24 with respiratory tract infection, and 6 with severe diarrhea. RESULTS There was a mean (+/-SD) decrease in total body water volume of 17+/-24 mL/kg (or 3% of total body water volume) in patients with severe malaria. This compares with a mean (+/-SD) decrease in total body water volume of 33+/-28 mL/kg (or 6% of total body water volume) in patients with severe diarrhea. There was no increase in extracellular water volume in patients with severe malaria, suggesting no significant intravascular volume depletion in patients with severe malaria. There was no relationship between lactatemia and any changes in fluid compartment volumes. CONCLUSIONS The changes in fluid volumes that were observed are unlikely to be of physiological significance in the pathophysiology of severe malaria.
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Affiliation(s)
- J N Jarvis
- Department of Cellular and Molecular Medicine, Infectious Diseases, St. George's Hospital Medical School, London, United Kingdom
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Abstract
BACKGROUND Vomiting limits the success of oral rehydration in children with gastroenteritis. We conducted a double-blind trial to determine whether a single oral dose of ondansetron, an antiemetic, would improve outcomes in children with gastroenteritis. METHODS We enrolled 215 children 6 months through 10 years of age who were treated in a pediatric emergency department for gastroenteritis and dehydration. After being randomly assigned to treatment with orally disintegrating ondansetron tablets or placebo, the children received oral-rehydration therapy according to a standardized protocol. The primary outcome was the proportion who vomited while receiving oral rehydration. The secondary outcomes were the number of episodes of vomiting and the proportions who were treated with intravenous rehydration or hospitalized. RESULTS As compared with children who received placebo, children who received ondansetron were less likely to vomit (14 percent vs. 35 percent; relative risk, 0.40; 95 percent confidence interval, 0.26 to 0.61), vomited less often (mean number of episodes per child, 0.18 vs. 0.65; P<0.001), had greater oral intake (239 ml vs. 196 ml, P=0.001), and were less likely to be treated by intravenous rehydration (14 percent vs. 31 percent; relative risk, 0.46; 95 percent confidence interval, 0.26 to 0.79). Although the mean length of stay in the emergency department was reduced by 12 percent in the ondansetron group, as compared with the placebo group (P=0.02), the rates of hospitalization (4 percent and 5 percent, respectively; P=1.00) and of return visits to the emergency department (19 percent and 22 percent, P=0.73) did not differ significantly between groups. CONCLUSIONS In children with gastroenteritis and dehydration, a single dose of oral ondansetron reduces vomiting and facilitates oral rehydration and may thus be well suited for use in the emergency department.
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Affiliation(s)
- Stephen B Freedman
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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Abstract
Abdominal pain and gastrointestinal symptoms such as vomiting or diarrhea are common chief complaints in young children who present in emergency departments. It is the emergency physician's role to differentiate between a self-limited process such as viral gastroenteritis or constipation and more life-threatening surgical emergencies. Considering the difficulties inherent in the pediatric examination, it is not surprising that appendicitis, intussusception, and malrotation with volvulus continue to be among the most elusive diagnoses. This article reviews both the self-limited and more life-threatening gastrointestinal conditions that may present in the emergency department.
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Affiliation(s)
- Maureen McCollough
- Pediatric Emergency Medicine, Keck USC School of Medicine, University of Southern California, 755 Woodward Boulevard, Pasadena, CA 91107, USA.
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Mehta S, Kumar P, Narang A. A randomized controlled trial of fluid supplementation in term neonates with severe hyperbilirubinemia. J Pediatr 2005; 147:781-5. [PMID: 16356431 DOI: 10.1016/j.jpeds.2005.07.026] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2005] [Revised: 05/26/2005] [Accepted: 07/18/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of fluid supplementation in decreasing the rate of exchange transfusion and the duration of phototherapy in term neonates with severe nonhemolytic hyperbilirubinemia. STUDY DESIGN This was a randomized controlled trial conducted in a tertiary care referral unit in northern India. Seventy-four term neonates with severe nonhemolytic hyperbilirubinemia (total serum bilirubin > 18 mg/dL [308 micromol/L] to < 25 mg/dL [427 micromol/L]). The subjects were randomized to an "extra fluids" group (intravenous fluid supplementation for 8 hours and oral supplementation for the duration of phototherapy; n = 37) or a control group (n = 37). RESULTS At inclusion, 54 infants (73%) had high serum osmolality, including 28 (75%) in the extra fluids group and 26 (70%) in the control group. The proportion of infants who underwent exchange transfusion was lower in the extra fluids group than in the control group: 6 (16%) versus 20 (54%)(P = .001; relative risk = 0.30; 95% confidence interval = 0.14 to 0.66). The duration of phototherapy was also shorter in the extra fluids group: 52 +/- 18 hours versus 73 +/- 31 hours (P = .004). CONCLUSION Fluid supplementation in term neonates presenting with severe hyperbilirubinemia decreased the rate of exchange transfusion and duration of phototherapy.
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Affiliation(s)
- Shailender Mehta
- Department of Pediatrics, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Walsh P, Rothenberg SJ, O'Doherty S, Hoey H, Healy R. A validated clinical model to predict the need for admission and length of stay in children with acute bronchiolitis. Eur J Emerg Med 2005; 11:265-72. [PMID: 15359199 DOI: 10.1097/00063110-200410000-00005] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To develop and validate a logistic regression model to predict need for admission and length of hospital stay in children presenting to the Emergency Department with bronchiolitis. SETTING Two children's hospitals in Dublin, Ireland. METHODS We reviewed 118 episodes of bronchiolitis in 99 children admitted from the Emergency Department. Those discharged within 24 h by a consultant/attending paediatrician were retrospectively categorized as suitable for discharge. We then validated the model using a cohort of 182 affected infants from another paediatric Emergency Department in a bronchiolitis season 2 years later. In the validation phase actual admission, failed discharge, and age less than 2 months defined the need for admission. RESULTS The model predicted admission with 91% sensitivity and 83% specificity in the validation cohort. Age [odds ratio (OR) 0.86, 95% confidence interval (CI) 0.76-0.97], dehydration (OR 2.54, 95% CI 1.34-4.82), increased work of breathing (OR 3.39, 95% CI 1.29-8.92) and initial heart rate above the 97th centile (OR 3.78, 95% CI 1.05-13.57) predicted the need for admission and a longer hospital stay. CONCLUSION We derived and validated a severity of illness model for bronchiolitis. This can be used for outcome prediction in decision support tools or severity of illness stratification in research/audit.
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Affiliation(s)
- Paul Walsh
- Department of Emergency Medicine, Kern Medical Centre, Bakersfield, CA, USA.
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Abstract
OBJECTIVE To develop a clinical dehydration scale for use in children <3 years of age. STUDY DESIGN Prospective cohort study of children between 1 and 36 months of age who presented to a tertiary pediatric emergency department (ED) with gastroenteritis. Children were weighed and scored for 12 clinical signs, were rehydrated, and then were reweighed and rescored when rehydration was completed. Weight change from pre- to post-rehydration was used to assess criterion validity with independent global assessments of dehydration severity by attending physicians and nurses as measures of construct validity. Formal approaches to item selection and reduction, reliability, discriminatory power, validity, and responsiveness were used. RESULTS 137 children (median age: 18 months) with gastroenteritis were studied. The final dehydration scale consisted of four clinical characteristics: general appearance, eyes, mucous membranes, and tears. The measurement properties were as follows: validity as assessed by Pearson's correlation coefficient was 0.36 to 0.57; reliability as assessed by the intra-class correlation coefficient was 0.77; discriminatory power as assessed by Ferguson's delta was 0.83; and responsiveness to change as assessed by Wilcoxon signed rank test was significant at P <.01. CONCLUSION Clinicians and researchers may consider this four-item, 8-point rating scale, developed using formal measurement methodology, as an alternative to scales developed ad hoc.
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Affiliation(s)
- Jeremy N Friedman
- Division of Pediatric Medicine, Department of Pediatrics, University of Toronto Faculty of Medicine and the Hospital for Sick Children, Toronto, Ontario, Canada
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Abstract
OBJECTIVE The purpose of this study was to establish the usefulness of capillary refill time when measured during the initial assessment of children. METHODS All children with spontaneous illness attending a paediatric accident and emergency department over a 7-month period were eligible for entry into the study. Capillary refill time was measured at the fingertip, using a standard technique, as part of the initial assessment. Each child was then followed up to ascertain clinical progress, including the need for admission, intravenous fluids, length of stay and diagnosis, as well as the white cell count when this was available. The value of capillary refill time as a predictor of the markers of illness severity was then assessed. RESULTS Capillary refill time measurements were recorded on 4878 children. There was no significant association of capillary refill time with meningococcal disease, other significant bacterial illness or the white cell count. A prolonged capillary refill time was associated with a more urgent triage category, the administration of a fluid bolus and the length of hospital stay (P<0.0001). The best performance was obtained when a capillary refill time of 3s or more is taken to be 'prolonged'. However, this gave positive predictive values of only 9% for a triage category of 1 or 2 (negative predictive value 97%), 11% for requiring a fluid bolus (negative predictive value 99%), 55% for hospital admission (negative predictive value 65%) and 22% for stay over 2 days/death (negative predictive value 91%). CONCLUSION The prolongation of capillary refill time is a poor predictor of the need for intravenous fluid bolus or hospital admission.
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Affiliation(s)
- Paul A Leonard
- Department of Accident and Emergency Medicine, Royal Hospital for Sick Children, Edinburgh, Scotland, UK.
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Porter SC, Fleisher GR, Kohane IS, Mandl KD. The value of parental report for diagnosis and management of dehydration in the emergency department. Ann Emerg Med 2003; 41:196-205. [PMID: 12548269 DOI: 10.1067/mem.2003.5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVES We define the predictive value of parents' computer-based report for history and physical signs of dehydration for a primary outcome of percentage of dehydration (fluid deficit) and 2 secondary outcomes: clinically important acidosis and hospital admission. We also sought to compare the reports of physical signs related to dehydration made by parents and nurses. METHODS We performed a prospective observational trial in an urban pediatric emergency department. A convenience sample of parents completed a computer-based interview covering historical details and physical signs (ill appearance, sunken fontanelle, sunken eyes, decreased tears, dry mouth, cool extremities, and weak cry) related to dehydration. Nurses independently completed an assessment of physical signs for enrolled children. The primary outcome was the degree of dehydration (fluid deficit), which was defined as the percentage difference between initial ED weight and stable final weight after the illness. Secondary outcomes included clinically important acidosis (defined as a serum CO(2) value of </=15 mEq/L) and hospital admission. RESULTS One hundred thirty-two parent-child dyads comprised the final sample. Parent-reported data manifested higher sensitivity (range 73% to 100%) than specificity (range 0% to 49%) for the prediction of dehydration of 5% or greater. Likelihood ratios (LRs) near zero (<0.1) suggest that a normal history of fluid intake and urine output reduced the likelihood of significant dehydration. Parental report of a normal tearing state reduced the likelihood of significant dehydration and clinically important acidosis (negative LRs of 0.4 and 0.1, respectively). Two physical signs reported by parents, sunken fontanelle and decreased tears, were associated with hospital admission (positive LR of 3.4 and 4.0, respectively). CONCLUSION Parents' report of history and observations for children captured through computer-based interview demonstrates predictive value for relevant outcomes in dehydration.
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Affiliation(s)
- Stephen C Porter
- Division of Emergency Medicine, Children's Hospital, Boston, MA 02115, USA.
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Abstract
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.
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Affiliation(s)
- Susan Jones
- University of Oklahoma, College of Nursing, USA
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Hansen B, DeFrancesco T. Relationship between hydration estimate and body weight change after fluid therapy in critically ill dogs and cats. J Vet Emerg Crit Care (San Antonio) 2002. [DOI: 10.1046/j.1435-6935.2002.t01-1-00050.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Bocquet A, Bresson JL, Briend A, Chouraqui JP, Darmaun D, Dupont C, Frelut ML, Ghisolfi J, Goulet O, Putet G, Rieu D, Turck D, Vidailhet M. [Nutritional treatment of acute diarrhea in an infant and young child]. Arch Pediatr 2002; 9:610-9. [PMID: 12108317 DOI: 10.1016/s0929-693x(01)00933-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This paper written by the Comité de nutrition de la Société française de pédiatrie is specially devoted to the nutritional treatment of infant and child acute diarrhea, i.e. oral rehydration with salts solution and feeding. It complements an article on drug therapy of child acute diarrhea written by the Groupe francophone d'hépatologie, gastroentérologie et nutrition pédiatriques, and published in this same issue of the Archives de pédiatrie.
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Affiliation(s)
- A Bocquet
- Unité de gastroentérologie, hépatologie et nutrition, clinique de pédiatrie, hôpital Jeanne-de-Flandre et Faculté de médecine, 2, avenue Oscar-Lambret, 59037 Lille, France
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Duke T, Mokela D, Frank D, Michael A, Paulo T, Mgone J, Kurubi J. Management of meningitis in children with oral fluid restriction or intravenous fluid at maintenance volumes: a randomised trial. Ann Trop Paediatr 2002; 22:145-57. [PMID: 12070950 DOI: 10.1179/027249302125000878] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
A multi-centre randomised open trial was done to determine whether moderate oral fluid restriction or intravenous fluid at full maintenance volumes would result in a better outcome for children with bacterial meningitis in Papua New Guinea, and what clinical signs could guide fluid management. Children with clinical signs and cerebrospinal fluid suggestive of bacterial meningitis received either breast milk by nasogastric tube at 60% of normal maintenance volumes (n = 172) or intravenous half-normal saline and 5% dextrose at 100% of normal maintenance volumes (n = 174) for the 1st 48 hrs of treatment. An adverse outcome was death or severe neurological sequelae, and a good outcome was defined as intact survival or survival with at worst mild-to-moderate neurological sequelae. The probability of an adverse outcome was 24.7% in the intravenous group and 33.1% in the oral-restricted group, but the difference was not statistically significant (RR 0.75, 0.53-1.04, p = 0.08). Sunken eyes or reduced skin turgor at presentation were risk factors for an adverse outcome (OR 5.70, 95% CI 2.87-11.29) and were most strongly associated with adverse outcome in the fluid-restricted group. Eyelid oedema during treatment was also a risk factor for an adverse outcome (OR 2.54, 95% CI 1.36-4.75) and eyelid oedema was much more common in the intravenous group (26%) than in the restricted group (5%). For many children with bacterial meningitis in less developed countries, moderate fluid restriction is unnecessary and will be harmful; a normal state of hydration should be achieved but over-hydration should be avoided. Giving 100% of normal maintenance fluids, especially with intravenous hypotonic fluid, will lead to oedema in up to one quarter of children with bacterial meningitis. If additional intravenous fluids are required for children with meningitis, an isotonic solution should be used.
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Perlstein PH, Lichtenstein P, Cohen MB, Ruddy R, Schoettker PJ, Atherton HD, Kotagal U. Implementing an evidence-based acute gastroenteritis guideline at a children's hospital. Jt Comm J Qual Improv 2002; 28:20-30. [PMID: 11787237 DOI: 10.1016/s1070-3241(02)28003-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Guidelines for preventing and treating acute gastroenteritis (AGE) have generally not been incorporated into medical practice. An evidence-based clinical practice guideline was adapted from national guidelines to meet the practice styles characterizing care in southwestern Ohio and implemented at the Children's Hospital Medical Center (Cincinnati). Its efficacy was assessed in terms of emergency department (ED) encounters and admissions, mean and total hospital costs, and mean length of hospitalization. METHODS Comparisons were made between patients seen during peak gastroenteritis months (December-May) before (fiscal year [FYs] 1994-1997) and after (FYs 1998 and 1999) guideline implementation. Data were extracted from hospital charts, clinical databases, and billing records. RESULTS Following implementation, mean yearly ED encounters for AGE decreased 22% and mean yearly admissions decreased 33%. The percentage of admitted children with minor illness decreased (p = 0.002). Mean length of stay decreased 21% for children with minor illness (p = 0.0001) and 5% for others. Hydration status was noted in only 15% of ED charts examined but increased to 63% in FY 1998 and 86% in FY 1999 (p < 0.001). The proportion of admitted patients who advanced to a regular diet by discharge increased from 4.9% (FY 1997) to 23% (FY 1998) and 76% (FY 1999; p < 0.0001). Total inpatient days/year decreased by 43%. Mean hospital costs did not change significantly. DISCUSSION Following implementation, fewer patients with AGE were seen in the ED and fewer were admitted to the hospital for care. Hospital stays were shorter, and children were more likely to resume their diets before discharge.
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MESH Headings
- Acute Disease
- Child, Preschool
- Dehydration/etiology
- Dehydration/prevention & control
- Diarrhea, Infantile/complications
- Diarrhea, Infantile/economics
- Diarrhea, Infantile/etiology
- Diarrhea, Infantile/therapy
- Emergency Service, Hospital/statistics & numerical data
- Evidence-Based Medicine
- Fluid Therapy/standards
- Gastroenteritis/complications
- Gastroenteritis/economics
- Gastroenteritis/therapy
- Guideline Adherence
- Hospitals, Pediatric/economics
- Hospitals, Pediatric/standards
- Hospitals, Pediatric/statistics & numerical data
- Humans
- Infant
- Length of Stay/statistics & numerical data
- Ohio
- Patient Admission/statistics & numerical data
- Practice Guidelines as Topic
- Societies, Medical
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Affiliation(s)
- Paul H Perlstein
- Division of Health Policy and Clinical Effectiveness, Department of Neonatology, Children's Hospital Medical Center (CHMC), Cincinnati, Ohio, USA
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Abstract
OBJECTIVE To develop an evidence and consensus based guideline for the management of the child who presents to hospital with diarrhoea (with or without vomiting), a common problem representing 16% of all paediatric medical attenders at an accident and emergency department. Clinical assessment, investigations (biochemistry and stool culture in particular), admission, and treatment are addressed. The guideline aims to aid junior doctors in recognising children who need admission for observation and treatment and those who may safely go home. EVIDENCE A systematic review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendation were generated. CONSENSUS An anonymous, postal Delphi consensus process was used. A panel of 39 selected medical and nursing staff were asked to grade their agreement with the generated statements. They were sent the papers, appraisals, and literature review. On the second and third rounds they were asked to re-grade their agreement in the light of other panelists' responses. Consensus was predefined as 83% of panelists agreeing with the statement. RECOMMENDATIONS Clinical signs useful in assessment of level of dehydration were agreed. Admission to a paediatric facility is advised for children who show signs of dehydration. For those with mild to moderate dehydration, estimated deficit is replaced over four hours with oral rehydration solution (glucose based, 200-250 mOsm/l) given "little and often". A nasogastric tube should be used if fluid is refused and normal feeds started following rehydration. Children at high risk of dehydration should be observed to ensure at least maintenance fluid is tolerated. Management of more severe dehydration is detailed. Antidiarrhoeal medication is not indicated. VALIDATION The guideline has been successfully implemented and evaluated in a paediatric accident and emergency department.
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Affiliation(s)
- K Armon
- Academic Division of Child Health, School of Human Development, University of Nottingham, Nottingham NG7 2UH, UK.
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Tibby SM, Hatherill M, Murdoch IA. Capillary refill and core-peripheral temperature gap as indicators of haemodynamic status in paediatric intensive care patients. Arch Dis Child 1999; 80:163-6. [PMID: 10325733 PMCID: PMC1717816 DOI: 10.1136/adc.80.2.163] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Capillary refill time is an important diagnostic adjunct in the acute resuscitation phase of the shocked child. This study assesses its relation to commonly measured haemodynamic parameters in the postresuscitation phase when the child has reached the intensive care unit, and compares this with core-peripheral temperature gap. METHODS Ninety standardised measurements of capillary refill time were made on 55 patients, who were divided into postcardiac surgery (n = 27), and general (n = 28), most of whom had septic shock (n = 24). A normal capillary refill time was defined as < or = 2 seconds. Measured haemodynamic variables included: cardiac index, central venous pressure, systemic vascular resistance index, stroke volume index (SVI), and blood lactate. Seventy measurements were made on patients while being treated with inotropes or vasodilators. RESULTS Capillary refill time and temperature gap both correlated poorly with all haemodynamic variables among post-cardiac surgery children. For general patients, capillary refill time was related to SVI and lactate; temperature gap correlated poorly with all variables. General patients with a prolonged capillary refill time had a lower median SVI (28 v 38 ml/m2) but not a higher lactate (1.7 v 1.1 mmol/l). A capillary refill time of > or = 6 seconds had the best predictive value for a reduced SVI. CONCLUSION Among ventilated, general intensive care patients, capillary refill time is related weakly to blood lactate and SVI. A normal value for capillary refill time of < or = 2 seconds has little predictive value and might be too conservative for this population; septic shock.
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Affiliation(s)
- S M Tibby
- Department of Paediatric Intensive Care, Guy's Hospital, London, UK
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