Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis

Water Versus Electrolyte Rehydration on Vocal Fold Osmotic and Oxidative Stress Gene Expression

OBJECTIVES

Systemic dehydration may induce osmotic and oxidative stress in the vocal folds, but our knowledge of the biology and mitigation with rehydration is limited. The purpose of this experiment was to evaluate whether systemic dehydration induces vocal fold oxidative and osmotic stress and to compare the impact of rehydration by water intake versus electrolyte intake on osmotic and oxidative stress-related gene expression.

METHODS

Four-month-old male Sprague-Dawley rats (N = 32) underwent water restriction. Rehydration was achieved with ad libitum access to water or electrolytes for 24 hours. Rats were divided into four groups: euhydration control, dehydration-only, dehydration followed by either water or electrolyte rehydration (n = 8/group). Gene expression was assessed via RT2 Gene Expression Profiler arrays.

RESULTS

With respect to oxidative stress, 10 genes were upregulated and 2 were downregulated after vocal fold dehydration compared with the euhydrated control. Concerning osmotic stress, six genes were upregulated with dehydration only, six genes were upregulated following rehydration with water, whereas a single gene was upregulated with electrolyte rehydration. All genes with significantly different expression between the rehydration groups showed lower expression with electrolytes compared with water.

CONCLUSIONS

The results support a potential role of oxidative and osmotic stresses in vocal folds related to systemic dehydration. The differences in stress-related gene expression in vocal fold tissue between rehydration with electrolytes or water, albeit modest, suggest that both rehydration options offer clinical utility to subjects experiencing vocal fold dehydration with preliminary evidence that electrolytes may be more effective than water in resolving osmotic stress.

LEVELS OF EVIDENCE

NA (prospective animal study) Laryngoscope, 2024.

Emergency department assessment and management of children with gastroenteritis

BACKGROUND

Acute gastroenteritis is a major cause of morbidity and mortality in children. The aim of this study was to explore assessment and management of children aged between 6 and 48 months presenting to the emergency department (ED) with acute gastroenteritis.

METHODS

This retrospective cohort study included 340 children aged 6-48 months. Data were collected by medical record audit for children presenting between 1 January and 31 December 2019.

RESULTS

General assessments were appropriate, specific dehydration assessment, blood pressure measurement and fluid balance chart documentation could be improved. Management of children with severe or no/mild dehydration was largely compliant with current recommendations: there was variability in management of children with moderate dehydration. There were no significant differences between Australian Aboriginal and non-Aboriginal children in terms of dehydration severity and pathology abnormalities, however there were differences in management strategies.

CONCLUSIONS

ED management of children with gastroenteritis was largely consistent with, or superior to, evidence-based recommendations. There was variability in the management of children with moderate dehydration and Australian Aboriginal children but it is unclear whether this is suboptimal or patient specific care. This study has highlighted areas for further research in this unique context.

Point-of-care ultrasound to assess degree of dehydration in children: a systematic review with meta-analysis

BACKGROUND

There is no perfect method to assess level of dehydration in children. There are studies with conflicting results, where point-of-care ultrasound (POCUS) measurement of diameter ratio of the inferior vena cava to the aorta (IVC/Ao) was used to predict degree of dehydration.

OBJECTIVE

To systematically review the diagnostic accuracy of POCUS measurement of IVC/Ao ratio in predicting dehydration in children.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched. The primary outcome was the diagnostic accuracy of IVC/Ao ratio. The pooled sensitivity and specificity were calculated. Quality analysis was conducted using Quality Assessment of Diagnostic Accuracy Studies-2.

RESULTS

Eleven studies (2679 patients) were included. The most numerous group (five studies) used percentage weight change as a reference standard; the pooled sensitivity, specificity of POCUS in this group were: 0.7 (95% CI: 0.67 to 0.73), I2: 82%; 0.53 (95% CI: 0.5 to 0.53), I2: 84%. In the remaining studies, different comparator tests were used: Clinical Dehydration Scale (two studies, 0.8 (95% CI: 0.72 to 0.86), I2: 0%; 0.56 (95% CI: 0.48 to 0.65), I2: 0%; clinical judgement (three studies, 0.78 (95% CI: 0.73 to 0.83), I2: 95%; 0.82 (95% CI: 0.77 to 0.86), I2: 93% and one study used the Dehydration: Assessing Kids Accurately score model.

CONCLUSION

This systematic review and meta-analysis showed that POCUS has a moderate sensitivity and specificity for identifying dehydration in children. Its use as a complementary diagnostic tool could be promising but needs to be validated in randomised controlled trials.

PROSPERO REGISTRATION NUMBER

CRD42022346166.

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

BACKGROUNDS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Point-of-Care Ultrasonography for the Assessment of Dehydration in Children: A Systematic Review

OBJECTIVES

Accurate estimation of the degree of dehydration remains a diagnostic challenge. The primary objective was to systematically review the literature on the role of ultrasound in assessment of the degree of dehydration in children.

METHODS

Data sources included Ovid MEDLINE, Web of Science Core Collection, Current Index to Nursing and Allied Health Literature, Cochrane Library, ClinicalTrials.gov , and Trip Pro Database. Two independent reviewers used screening protocol to include articles on assessment of dehydration in children with the use of point-of-care ultrasonography (POCUS). The level of evidence was assessed in accordance with the "The Oxford 2011 Levels of Evidence." The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to evaluate risk of bias.

RESULTS

We identified 108 studies, and 8 studies met our inclusion criteria. All studies were prospective cohort studies (level of evidence, 3-4). The authors of 5 studies used difference between ill weight and weight after rehydration as the reference standard for dehydration, and the authors of 3 studies used clinical dehydration scale. Two studies from the United States showed acceptable areas under the curve for inferior vena cava to aorta (IVC/Ao) diameter ratio at 0.72 and 0.73 for prediction of significant dehydration (>5% weight loss). The IVC/Ao ratio with cut-off at 0.8 had sensitivity of 67% and 86% and specificity of 71% and 56% for prediction of significant dehydration. Studies from the resource-limited settings were more heterogeneous. One study with acceptable risk of biases reported poor sensitivity (67%) and specificity (49%) of Ao/IVC ratio with cut-off of 2.0 for predicting severe dehydration (>9% weight loss) with area under the curve at 0.6. Three studies showed increase in IVC diameter with fluid resuscitation with mean change in IVC diameter by 30% in children with significant dehydration (>5% weight loss) and by 22% without significant dehydration (<5% weight loss). Metaanalysis was not completed due to high heterogeneity.

CONCLUSIONS

This study showed that the quantity and quality of research on the application of POCUS for the assessment of dehydration in children is limited. There is no criterion standard for assessing the degree of dehydration and no universal definition of the degree of dehydration. Thus, more methodologically rigorous studies are required. Current systematic review does not support the routine use of US to determine the severity of dehydration in children. Despite these limitations, the use of POCUS in children with dehydration demonstrates potential. Given the clear increase in IVC size with rehydration, repeated IVC US scans may be helpful in guiding fluid resuscitation in children with dehydration. From different proposed US parameters, IVC/Ao ratio has better diagnostic accuracy in detecting significant dehydration than Ao/IVC ratio and IVC collapsibility index. Despite low to moderate diagnostic performance, US still showed better assessment of dehydration than physician gestalt and World Health Organization score.

Comparative proteomic changes in rabbit vocal folds undergoing systemic dehydration and systemic rehydration

BACKGROUND

A considerable body of clinical evidence suggests that systemic dehydration can negatively affect voice production, leading to the common recommendation to rehydrate. Evidence for the corrective benefits of rehydration, however, is limited with mixed conclusions, and biological data on the underlying tissue changes with rehydration is lacking. In this study, we used a rabbit model (n = 24) of acute (5 days) water restriction-induced systemic dehydration with subsequent rehydration (3 days) to explore the protein-level changes underlying the molecular transition from euhydration to dehydration and following rehydration using LC-MS/MS protein quantification in the vocal folds. We show that 5-day water restriction led to an average 4.3% decrease in body weight with relative increases in anion gap, Cl-, creatinine, Na+, and relative decreases in BUN, iCa2+, K+, and tCO2 compared to control (euhydrated) animals. A total of 309 differentially regulated (p < 0.05) proteins were identified between the Control and Dehydration groups. We observed a noteworthy similarity between the Dehydration and Rehydration groups, both well differentiated from the Control group, highlighting the distinct timelines of resolution of the clinical symptoms of systemic dehydration and the underlying molecular changes.

SIGNIFICANCE

Voice disorders are a ubiquitous problem with considerable economic and psychological impact. Maintenance of proper hydration is commonly prescribed as a general vocal hygiene practice. There is evidence that dehydration negatively impacts phonation, but our understanding of the state of vocal folds in the context of systemic dehydration are limited, particular from a molecular perspective. Further, ours is a novel molecular study of the short-term impact of rehydration on the tissue. Given the relatively minimal difference in vocal fold proteomic profiles between the Dehydration and Rehydration groups, our data demonstrate a complex physiological response to acute systemic dehydration, and highlight the importance of considering persistent underlying molecular pathology despite the rapid resolution of clinical measures. This study sets a foundation for future research to confirm the nature of potential beneficial outcomes of clinical recommendations related to hydration.

Point-of-Care Noninvasive Technology for Pediatric Dehydration Assessment

OBJECTIVE

Dehydration is a commonly encountered problem worldwide. Current clinical assessment is limited by subjectivity and limited provider training with children. The objective of this study is to investigate a new noninvasive, point-of-care technology that measures capillary refill combined with patient factors to accurately diagnose dehydration.

METHODS

This is a prospective observational study at a tertiary care children's hospital in Buenos Aires, Argentina. Patients were eligible if younger than 10 years who presented to the emergency department with vomiting and/or diarrhea whom the triage nurse deems to be potentially dehydrated. Patients had the digital capillary refill device done on presentation in addition to standard of care vital signs and weight. Patients had serial weights measured on hospital scales throughout their stay. The primary outcome was dehydration, which was calculated as a percent change in weight from admission to discharge.

RESULTS

Seventy-six children were enrolled in the study with 56 included in the final analysis. A stepwise forward method selection chose malnutrition, temperature, and systolic blood pressure for the multivariable model. The area under the curve for the final model was fair (0.7431). To further look into the utility of such a device in the home setting where blood pressure is not available often, we reran the model without systolic blood pressure. The area under the curve for the final model was 0.7269.

CONCLUSIONS

The digital capillary refill point-of-care device combined with readily available patient-specific factors may improve the ability to detect pediatric dehydration and facilitate earlier treatment or transfer to higher levels of care.

Understanding the use of oral rehydration therapy: A narrative review from clinical practice to main recommendations

Background and Aims

Fluid loss due to diarrhea remains a significant cause of mortality among children under the age of 5.

Methods

Oral rehydration therapy (ORT) is a first‐line therapeutic measure to compensate the volume loss due to diarrhea and vomiting among gastroenteritis patients. Despite adequate knowledge, the practice of ORT is limited, particularly in developing countries.

Results

Several recommendations are provided regarding the use of ORT to treat hypovolemia, however, the information regarding its adequate usage is restricted within the healthcare centers and professionals.

Conclusion

This review highlights the importance of providing recommendations regarding the use of ORT. We also discuss the barriers and alternatives that might limit its use.

National Consensus for the Management of Acute Gastroenteritis in Jordanian Children: Consensus Recommendations Endorsed by the Jordanian Paediatric Society

Diarrhoeal diseases are one of the leading worldwide preventable causes of death among children under 5 years of age. Almost half of children do not receive optimal acute gastroenteritis (AGE) treatment in Jordan. With neither regional nor local guidelines available for AGE, consensus recommendations on the management of paediatric AGE in Jordan were developed by a panel of senior paediatricians and paediatric gastroenterologists and are endorsed by the Jordanian Paediatric Society. Recommendations are based on international guidelines and available relevant literature in relation to the AGE landscape and the healthcare system in Jordan. The prevention of diarrhoeal diseases should focus on the improvement of nutrition, hygiene, and sanitation, the introduction of routine vaccination against rotavirus, and the adoption of a standardised approach for AGE management (oral rehydration solution (ORS) use±adjunct therapies, continued feeding, and avoiding routine antibiotic use). Ondansetron, diosmectite, racecadotril, probiotics, and zinc can be considered adjunct to ORS, if needed. Local data gaps should be addressed. The clinical algorithm for the management of paediatric AGE could promote adherence to practice recommendations and by extension improve health outcomes in children.

Comparison of End-Tidal Carbon Dioxide (ETCO2) Gradient and Vena Cava Collapsibility Index (VCCI) in Response to Intravenous Fluid Therapy in Patients with Moderate and Severe Dehydration and Acute Gastroenteritis

INTRODUCTION AND OBJECTIVE

Acute gastroenteritis (AGE) is one of the most common clinical diagnoses globally, and dehydration in severe AGE cases can cause severe morbidity and mortality. Depending on the metabolic acidosis that occurs in dehydration, the respiratory rate per minute is increased, and the carbon dioxide pressure in the arterial blood is decreased. This condition correlates with end-tidal carbon dioxide (ETCO2). Therefore, this study primarily aims to evaluate whether ETCO2 measurement has a role in detecting metabolic fluid deficit, dehydration level, and regression in dehydration level after fluid replacement and its correlation with Vena Cava Collapsibility Index (VCCI).

MATERIAL AND METHOD

This study included spontaneously breathing patients admitted to the emergency department of a tertiary training and research hospital with symptoms of AGE and were thought to be moderately (6.0%-9.0%) and severely (>10.0%) dehydrated according to the Primary Options of Acute Care (POAC) Clinical Dehydration Scale. After the first evaluation, the patients' vital signs, ETCO2 values, diameters of the inferior vena cava (IVC) in inspiration and expiration, and VCCI were measured and recorded. These measurements were repeated after intravenous (IV) fluid replacement, and finally, a comparison was made between the measurements.

RESULTS

A total of 49 patients, as 16 male (32.7%) and 33 female (67.3%), were included in the study. The mean fluid replacement value was calculated as 664.29 (SD = 259.41) ml. The mean increase in ETCO2 was 3.653 (SD = 2.554) mmHg (P <.001). The mean increase in inferior vena cava expirium (IVCexp) was calculated as 0.402 (SD = 0.280) cm (P <.001) and the mean increase in inferior vena cava inspirium (IVCinsp) as 0.476 (SD = 0.306) cm (P <.001). The VCCI (%) decreased by 12.556 (SD = 13.683) (P <.001). Post-replacement vital signs, ETCO2, and VCCI correlations of the patients were examined and no significant correlation was found between ETCO2 and VCCI (%). As a result of this study, a receiver operating characteristic (ROC) curve was established for the ETCO2 values predicting the level of dehydration and fluid response, and the area under the curve was calculated as 0.748. However, to classify the patient as moderately dehydrated, the ETCO2 cutoff value was determined as 28.5mmHg.

CONCLUSION

The sensitivity and specificity of ETCO2 levels were 71.43% and 74.29% in evaluating the level of dehydration, and no correlation was found with VCCI, which is known to have high sensitivity and specificity in previous studies in determining the level of dehydration and fluid response. Hence, VCCI measurement made through ultrasonography (USG) is a method that should be preferred more in determining the level of dehydration. Nevertheless, as per the results of this study, swift ETCO2 measurements may be helpful in monitoring the change in the degree of dehydration with treatment in patients who were admitted to the emergency department with dehydration findings and were administered IV fluid replacement therapy.

Hematochezia in children with acute diarrhea seeking emergency department care - a prospective cohort study

OBJECTIVES

Although the passage of blood in stools in children represents a medical emergency, children seeking emergency department (ED) care remain poorly characterized. Our primary objective was to compare clinical characteristics and etiologic pathogens in children with acute diarrhea with and without caregiver-reported hematochezia. Secondary objectives were to characterize interventions and resource utilization.

METHODS

We conducted a secondary analysis of the Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE) database. Children <18 years presenting to two pediatric EDs within a 24-hour period and <7 days of symptoms were consecutively recruited.

RESULTS

Of 1,061 participants, 115 (10.8%) reported hematochezia at the enrollment visit at which time those with hematochezia, compared to those without, had more diarrheal episodes/24-hour period (9 vs. 6; difference: 2; 95% confidence interval [CI]: 2.0, 4.0; p < 0.001), and were less likely to have experienced vomiting (54.8% vs. 80.2%; difference: -25.4; 95% CI: -34.9, -16.0; p < 0.001). They were more likely to receive intravenous fluids (33.0% vs. 17.9%; difference: 15.2; 95% CI: 6.2, 24.1; p < 0.001) and require repeat health care visits (45.5% vs. 34.7%; difference: 10.7; 95% CI: 0.9, 20.6; p = 0.03). A bacterial pathogen was identified in 33.0% of children with hematochezia versus 7.9% without (difference: 25.1; 95% CI: 16.3, 33.9; p < 0.001); viruses were detected in 31.3% of children with hematochezia compared to 72.3% in those without (difference: -41.0%, 95% CI: -49.9, -32.1; p < 0.001).

CONCLUSION

In children with acute diarrhea, caregiver report of hematochezia, compared to the absence of hematochezia, was associated with more diarrheal but fewer vomiting episodes, and greater resource consumption. The former group of children was also more likely to have bacteria detected in their stool.

Water - A life-giving toxin - A nephrological oxymoron. Health consequences of water and sodium balance disorders. A review article

BACKGROUND

This article aims to reveal misconceptions about methods of assessment of hydration status and impact of the water disorders on the progression of kidney disease or renal dysfunction.

MATERIALS AND METHODS

The PubMed database was searched for reviews, meta-analyses and original articles on hydration, volume depletion, fluid overload and diagnostic methods of hydration status, which were published in English.

RESULTS

Based on the results of available literature the relationship between the amount of fluid consumed, and the rate of progression of chronic kidney disease, autosomal dominant polycystic kidney disease, and kidney stones disease was discussed. Selected aspects of the assessment of the hydration level in clinical practice based on physical examination, laboratory tests, and imaging are presented. The subject of in-hospital fluid therapy is discussed. Based on available randomized studies, an attempt was made to assess, which fluids should be selected for intravenous treatment.

CONCLUSIONS

There is some evidence for the beneficial effect of increased water intake in preventing recurrent cystitis and kidney stones, but there are still no convincing data for chronic kidney disease and autosomal dominant polycystic kidney disease. Further studies are needed to clarify the aforementioned issues and establish a reliable way to assess the volemia and perform suitable fluid therapy.

Furosemide-induced systemic dehydration alters the proteome of rabbit vocal folds

Whole-body dehydration (i.e., systemic dehydration) leads to vocal fold tissue dehydration. Furosemide, a common diuretic prescribed to treat hypertension and edema-associated conditions, induces systemic dehydration. Furosemide also causes voice changes in human speakers, making this method of systemic dehydration particularly interesting for vocal fold dehydration studies. Our objective was to obtain a comprehensive proteome of vocal folds following furosemide-induced systemic dehydration. New Zealand White rabbits were used as the animal model and randomly assigned to euhydrated (control) or furosemide-dehydrated groups. Systemic dehydration, induced by injectable furosemide, was verified by an average body weight loss of -5.5% and significant percentage changes in blood analytes in the dehydrated rabbits compared to controls. Vocal fold specimens, including mucosa and muscle, were processed for proteomic analysis using label-free quantitation LC-MS/MS. Over 1600 proteins were successfully identified across all vocal fold samples; and associated with a variety of cellular components and ubiquitous cell functions. Protein levels were compared between groups showing 32 proteins differentially regulated (p ≤ 0.05) in the dehydrated vocal folds. These are mainly involved with mitochondrial translation and metabolism. The downregulation of proteins involved in mitochondrial metabolism in the vocal folds suggests a mechanism to prevent oxidative stress associated with systemic dehydration. SIGNIFICANCE: Voice disorders affect different population demographics worldwide with one in 13 adults in the United States reporting voice problems annually. Vocal fold systemic hydration is clinically recognized for preventing and treating voice problems and depends on optimal body hydration primarily achieved by water intake. Herein, we use the rabbit as a translatable animal model, and furosemide as a translatable method of systemic dehydration, to reveal a comprehensive proteomic profile of vocal fold mucosa and muscle in response to systemic dehydration. The significant subset of proteins differentially regulated due to furosemide-induced dehydration offer novel insights into the molecular mechanisms of systemic dehydration in the vocal folds. These findings also deepen our understanding of changes to tissue biology after diuretic administration.

Oral Ondansetron Administration in Children Seeking Emergency Department Care for Acute Gastroenteritis: A Patient-Level Propensity-Matched Analysis

STUDY OBJECTIVE

This study aimed to explore oral ondansetron usage and impact on outcomes in clinical practice.

METHODS

This observational study was a planned secondary analysis of 2 trials conducted in 10 US and 6 Canadian institutions between 2014 and 2017. Children 3 to 48 months old with gastroenteritis and ≥3 episodes of vomiting in the 24 hours preceding emergency department (ED) presentation were included. Oral ondansetron was administered at the discretion of the provider. The principal outcomes were intravenous fluid administration and hospitalization at the index visit and during the subsequent 72 hours and diarrhea and vomiting frequency during the 24 hours following the ED visit.

RESULTS

In total, 794 children were included. The median age was 16.0 months (interquartile range 10.0 to 26.0), and 50.1% (398/794) received oral ondansetron. In propensity-adjusted analysis (n=528), children administered oral ondansetron were less likely to receive intravenous fluids at the index visit (adjusted odds ratio [aOR] 0.50; 95% confidence interval [CI] 0.29 to 0.88). There were no differences in the frequencies of intravenous fluid administration within the first 72 hours (aOR 0.65; 95% CI 0.39 to 1.10) or hospitalization at the index visit (aOR 0.31; 95% CI 0.09 to 1.10) or the subsequent 72 hours (aOR 0.52; 95% CI 0.21 to 1.28). Episodes of vomiting (aRR 0.86; 95% CI 0.63 to 1.19) and diarrhea (aRR 1.11; 95% CI 0.93 to 1.32) during the 24 hours following ED discharge also did not differ.

CONCLUSION

Among preschool-aged children with gastroenteritis seeking ED care, oral ondansetron administration was associated with a reduction in index ED visit intravenous fluid administration; it was not associated with intravenous fluids administered within 72 hours, hospitalization, or vomiting and diarrhea in the 24 hours following discharge.

Point-of-Care Ultrasound Training in Pediatric Residency: A National Needs Assessment

BACKGROUND AND OBJECTIVES

As point-of-care ultrasound (POCUS) evolves into a standard tool for the care of children, pediatric residency programs need to develop POCUS training programs. Few POCUS training resources exist for pediatric residents, and little is known about POCUS training in pediatric residencies. We aim to describe pediatric residency leadership perspectives regarding the value of POCUS and to elucidate the current state of POCUS training in pediatric residency programs.

METHODS

A group of pediatric educators and POCUS experts developed a novel survey followed by cognitive interviews to establish response-process validity. The survey was administered electronically to pediatric residency associate program directors between December 2019 and April 2020. Program characteristics, including region, setting, and size, were used to perform poststratification for analyses. We performed comparative analyses using program and respondent characteristics.

RESULTS

We achieved a 30% (58 of 196) survey response rate. Although only a minority of respondents (26%) used POCUS in clinical practice, a majority (56%) indicated that all pediatric residents should be trained in POCUS. A majority of respondents also considered 8 of 10 POCUS applications important for pediatric residents. Only 37% of programs reported any POCUS training for residents, primarily informal bedside education. Most respondents (94%) cited a lack of qualified instructors as a barrier to POCUS training.

CONCLUSIONS

Most pediatric residency programs do not provide residents with POCUS training despite its perceived value and importance. Numerous POCUS applications are considered important for pediatric residents to learn. Future curricular and faculty development efforts should address the lack of qualified POCUS instructors.

Point-of-care ultrasound to assess volume status and pulmonary oedema in malaria patients

PURPOSE

Fluid management is challenging in malaria patients given the risks associated with intravascular fluid depletion and iatrogenic fluid overload leading to pulmonary oedema. Given the limitations of the physical examination in guiding fluid therapy, we evaluated point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) and lungs as a novel tool to assess volume status and detect early oedema in malaria patients.

METHODS

To assess the correlation between IVC and lung ultrasound (LUS) indices and clinical signs of hypovolaemia and pulmonary oedema, respectively, concurrent clinical and sonographic examinations were performed in an observational study of 48 malaria patients and 62 healthy participants across age groups in Gabon.

RESULTS

IVC collapsibility index (CI) ≥ 50% on enrolment reflecting intravascular fluid depletion was associated with an increased number of clinical signs of hypovolaemia in severe and uncomplicated malaria. With exception of dry mucous membranes, IVC-CI correlated with most clinical signs of hypovolaemia, most notably sunken eyes (r = 0.35, p = 0.0001) and prolonged capillary refill (r = 0.35, p = 0.001). IVC-to-aorta ratio ≤ 0.8 was not associated with any clinical signs of hypovolaemia on enrolment. Among malaria patients, a B-pattern on enrolment reflecting interstitial fluid was associated with dyspnoea (p = 0.0003), crepitations and SpO₂ ≤ 94% (both p < 0.0001), but not tachypnoea (p = 0.069). Severe malaria patients had increased IVC-CI (p < 0.0001) and more B-patterns (p = 0.004) on enrolment relative to uncomplicated malaria and controls.

CONCLUSION

In malaria patients, POCUS of the IVC and lungs may improve the assessment of volume status and detect early oedema, which could help to manage fluids in these patients.

Comparing Pediatric Gastroenteritis Emergency Department Care in Canada and the United States

BACKGROUND

Between-country variation in health care resource use and its impact on outcomes in acute care settings have been challenging to disentangle from illness severity by using administrative data.

METHODS

We conducted a preplanned analysis employing patient-level emergency department (ED) data from children enrolled in 2 previously conducted clinical trials. Participants aged 3 to <48 months with <72 hours of gastroenteritis were recruited in pediatric EDs in the United States (N = 10 sites; 588 participants) and Canada (N = 6 sites; 827 participants). The primary outcome was an unscheduled health care provider visit within 7 days; the secondary outcomes were intravenous fluid administration and hospitalization at or within 7 days of the index visit.

RESULTS

In adjusted analysis, unscheduled revisits within 7 days did not differ (adjusted odds ratio [aOR]: 0.72; 95% confidence interval (CI): 0.50 to 1.02). At the index ED visit, although participants in Canada were assessed as being more dehydrated, intravenous fluids were administered more frequently in the United States (aOR: 4.6; 95% CI: 2.9 to 7.1). Intravenous fluid administration rates did not differ after enrollment (aOR: 1.4; 95% CI: 0.7 to 2.8; US cohort with Canadian as referent). Overall, intravenous rehydration was higher in the United States (aOR: 3.8; 95% CI: 2.5 to 5.7). Although hospitalization rates during the 7 days after enrollment (aOR: 1.1; 95% CI: 0.4 to 2.6) did not differ, hospitalization at the index visit was more common in the United States (3.9% vs 2.3%; aOR: 3.2; 95% CI: 1.6 to 6.8).

CONCLUSIONS

Among children with gastroenteritis and similar disease severity, revisit rates were similar in our 2 study cohorts, despite lower rates of intravenous rehydration and hospitalization in Canadian-based EDs.

Recommendations for clinical research in children presenting to primary care out-of-hours services: a randomised controlled trial with parallel cohort study

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.

Sucralfate as an Adjunct to Analgesia to Improve Oral Intake in Children With Infectious Oral Ulcers: A Randomized, Double-Blind, Placebo-Controlled Trial

STUDY HYPOTHESIS

We hypothesized that sucralfate along with oral analgesics (acetaminophen or ibuprofen) administered in the emergency department leads to a clinically significant improvement in oral intake in children with acute infectious oral ulcers.

METHODS

This was a randomized, double-blind, placebo-controlled trial of sucralfate versus placebo conducted between 2017 and 2018 in an urban pediatric emergency department. Children aged 6 months to 5 years with acute, infectious oral ulcers and poor oral intake received either acetaminophen at 15 mg/kg or ibuprofen at 10 mg/kg and were then randomized to receive sucralfate at 20 mg/kg per dose up to 1 g or a placebo solution. The primary outcome was oral fluid intake within 60 minutes of medication administration. The secondary outcomes were repeat ED visits, length of stay in ED, intravenous hydration rate, admission rate, adverse event rate, and emergency physician's determination of the adequacy of oral intake.

RESULTS

One hundred subjects with mild dehydration (clinical dehydration score of 1) and a median age of 1.38 years were enrolled and analyzed (49 in the sucralfate group and 51 in the placebo group). Oral intake 1 hour after drug administration was similar in both the groups: the median intake in the sucralfate group was 9.7 mL/kg and 10.7 mL/kg in the placebo group (difference -1 mL/kg; 95% confidence interval [CI] -2.0 to 4.8). According to the emergency physician's report, the secondary outcomes were significant only for adequate oral intake: 71% in the sucralfate group versus 88% in the placebo group (difference -16.8%; 95% CI -32.2 to -1.4).

CONCLUSION

Sucralfate as an adjunct to oral analgesics was not superior to placebo in improving oral intake in children with acute oral infectious ulcers.

Variables Associated With Intravenous Rehydration and Hospitalization in Children With Acute Gastroenteritis: A Secondary Analysis of 2 Randomized Clinical Trials

IMPORTANCE

Despite guidelines endorsing oral rehydration therapy, intravenous fluids are commonly administered to children with acute gastroenteritis in high-income countries.

OBJECTIVE

To identify factors associated with intravenous fluid administration and hospitalization in children with acute gastroenteritis.

DESIGN, SETTING, AND PARTICIPANTS

This study is a planned secondary analysis of the Pediatric Emergency Research Canada (PERC) and Pediatric Emergency Care Applied Research Network (PECARN) probiotic trials. Participants include children aged 3 to 48 months with 3 or more watery stools in 24 hours between November 5, 2013, and April 7, 2017, for the PERC study and July 8, 2014, and June 23, 2017, for the PECARN Study. Children were from 16 pediatric emergency departments throughout Canada (6) and the US (10). Data were analyzed from November 2, 2018, to March 16, 2021.

EXPOSURES

Sex, age, preceding health care visit, distance between home and hospital, country (US vs Canada), frequency and duration of vomiting and diarrhea, presence of fever, Clinical Dehydration Scale score, oral ondansetron followed by oral rehydration therapy, and infectious agent.

MAIN OUTCOMES AND MEASURES

Intravenous fluid administration and hospitalization.

RESULTS

This secondary analysis of 2 randomized clinical trials included 1846 children (mean [SD] age, 19.1 [11.4] months; 1007 boys [54.6%]), of whom 534 of 1846 (28.9%) received oral ondansetron, 240 of 1846 (13.0%) received intravenous rehydration, and 67 of 1846 (3.6%) were hospitalized. The following were independently associated with intravenous rehydration: higher Clinical Dehydration Scale score (mild to moderate vs none, odds ratio [OR], 8.73; 95% CI, 5.81-13.13; and severe vs none, OR, 34.15; 95% CI, 13.45-86.73); country (US vs Canada, OR, 6.76; 95% CI, 3.15-14.49); prior health care visit with intravenous fluids (OR, 4.55; 95% CI, 1.32-15.72); and frequency of vomiting (per 5 episodes, OR, 1.66; 95% CI, 1.39-1.99). The following were independently associated with hospitalization: higher Clinical Dehydration Scale score (mild to moderate vs none, OR, 11.10; 95% CI, 5.05-24.38; and severe vs none, OR, 23.55; 95% CI, 7.09-78.25) and country (US vs Canada, OR, 3.37; 95% CI, 1.36-8.40). Oral ondansetron was associated with reduced odds of intravenous rehydration (OR, 0.21; 95% CI, 0.13-0.32) and hospitalization (OR, 0.44; 95% CI, 0.21-0.89).

CONCLUSIONS AND RELEVANCE

Intravenous rehydration and hospitalization were associated with clinical evidence of dehydration and lack of an oral ondansetron-supported oral rehydration period. Strategies focusing on oral ondansetron administration followed by oral rehydration therapy in children with dehydration may reduce the reliance on intravenous rehydration and hospitalization.

TRIAL REGISTRATION

ClinicalTrials.gov Identifiers: NCT01853124 (PERC) and NCT01773967 (PECARN).

The utility of ketones at triage: a prospective cohort study

OBJECTIVE

To establish the relationship between serum point-of-care (POC) ketones at triage and moderate-to-severe dehydration based on the validated Gorelick Scales.

DESIGN, SETTING AND PATIENTS

Prospective unblinded study from April 2016 to February 2017 in a paediatric emergency department. Patients aged 1 month to 5 years, with vomiting and/or diarrhoea and/or decreased intake with signs of moderate or severe dehydration or clinical concern for hypoglycaemia were eligible.

MAIN OUTCOME MEASURES

The primary outcome was to describe the relationship between triage POC ketones to the two Gorelick Scales. Secondary outcomes were to examine the response of ketone levels to fluid/glucose administration and patient disposition.

RESULTS

One-hundred and ninety-eight patients were included; median age 1.8 years. The median triage ketones were 4.6 (IQR 2.8-5.6) mmol/L. A weak correlation was identified between triage ketones and the 10-point Gorelick Scale (Spearman's ρ=0.217, p=0.002), however no correlation between triage ketones and the 4-point Gorelick Scale was identified. Those admitted had median triage ketones of 5.2 (IQR 4-6) mmol/L and repeat ketones of 4.6 (IQR 3.3-5.7) mmol/L compared with 4.2 (IQR 2.4-5.3) mmol/L and 2.9 (IQR 1.6-4.2) mmol/L in those discharged home.

CONCLUSION

No correlation between triage POC ketones and the 4-point Gorelick Scale was established. POC ketones at triage have poor accuracy for predicting hospital admission. The elevated profile of POC ketones in non-diabetic children with acute illness suggests a potential target of tailored treatments for further research.

Reviewing the current methods of assessing hydration in athletes

Background

Despite a substantial body of research, no clear best practice guidelines exist for the assessment of hydration in athletes. Body water is stored in and shifted between different sites throughout the body complicating hydration assessment. This review seeks to highlight the unique strengths and limitations of various hydration assessment methods described in the literature as well as providing best practice guidelines.

Main body

There is a plethora of methods that range in validity and reliability, including complicated and invasive methods (i.e. neutron activation analysis and stable isotope dilution), to moderately invasive blood, urine and salivary variables, progressing to non-invasive metrics such as tear osmolality, body mass, bioimpedance analysis, and sensation of thirst. Any single assessment of hydration status is problematic. Instead, the recommended approach is to use a combination, which have complementary strengths, which increase accuracy and validity. If methods such as salivary variables, urine colour, vital signs and sensation of thirst are utilised in isolation, great care must be taken due to their lack of sensitivity, reliability and/or accuracy. Detailed assessments such as neutron activation and stable isotope dilution analysis are highly accurate but expensive, with significant time delays due to data analysis providing little potential for immediate action. While alternative variables such as hormonal and electrolyte concentration, bioimpedance and tear osmolality require further research to determine their validity and reliability before inclusion into any test battery.

Conclusion

To improve best practice additional comprehensive research is required to further the scientific understanding of evaluating hydration status.

Unraveling the molecular pathobiology of vocal fold systemic dehydration using an in vivo rabbit model

Vocal folds are a viscoelastic multilayered structure responsible for voice production. Vocal fold epithelial damage may weaken the protection of deeper layers of lamina propria and thyroarytenoid muscle and impair voice production. Systemic dehydration can adversely affect vocal function by creating suboptimal biomechanical conditions for vocal fold vibration. However, the molecular pathobiology of systemically dehydrated vocal folds is poorly understood. We used an in vivo rabbit model to investigate the complete gene expression profile of systemically dehydrated vocal folds. The RNA-Seq based transcriptome revealed 203 differentially expressed (DE) vocal fold genes due to systemic dehydration. Interestingly, function enrichment analysis showed downregulation of genes involved in cell adhesion, cell junction, inflammation, and upregulation of genes involved in cell proliferation. RT-qPCR validation was performed for a subset of DE genes and confirmed the downregulation of DSG1, CDH3, NECTIN1, SDC1, S100A9, SPINK5, ECM1, IL1A, and IL36A genes. In addition, the upregulation of the transcription factor NR4A3 gene involved in epithelial cell proliferation was validated. Taken together, these results suggest an alteration of the vocal fold epithelial barrier independent of inflammation, which could indicate a disruption and remodeling of the epithelial barrier integrity. This transcriptome provides a first global picture of the molecular changes in vocal fold tissue in response to systemic dehydration. The alterations observed at the transcriptional level help to understand the pathobiology of dehydration in voice function and highlight the benefits of hydration in voice therapy.

Reduction in Resources and Cost for Gastroenteritis Through Implementation of Dehydration Pathway

OBJECTIVES

Management decisions for patients with gastroenteritis affect resource use within pediatric emergency departments (EDs), and algorithmic care using evidence-based guidelines (EBGs) has become widespread. We aimed to determine if the implementation of a dehydration EBG in a pediatric ED resulted in a reduction in intravenous (IV) fluid administration and the cost of care.

METHODS

In a single-center quality improvement initiative between 2010 and 2016, investigators aimed to decrease the percentage of patients with gastroenteritis who were rehydrated with IV fluids. The EBG assigned the patient a dehydration score with subsequent rehydration strategy on the basis of presenting signs and symptoms. The primary outcome was proportion of patients receiving IV fluid, which was analyzed using statistical process control methods. The secondary outcome was cost of the episode of care. Balancing measures included ED length of stay, admission rate, and return visit rate within 72 hours.

RESULTS

A total of 7145 patients met inclusion criteria with a median age of 17 months. Use of IV fluid decreased from a mean of 15% to 9% postimplementation. Average episode of care-related health care costs decreased from $599 to $410. For our balancing measures, there were improvements in ED length of stay, rate of admission, and rate of return visits.

CONCLUSIONS

Implementation of an EBG for patients with gastroenteritis led to a decrease in frequency of IV administration, shorter lengths of stay, and lower health care costs.

Trends and Variation in Care and Outcomes for Children Hospitalized With Acute Gastroenteritis

OBJECTIVES

Assess trends in inpatient acute gastroenteritis (AGE) management across children's hospitals and identify elements of AGE management associated with resource use.

METHODS

We examined inpatient stays for children 6 months to 18 years hospitalized with AGE from 2009 to 2018 using the Pediatric Health Information System database. We characterized demographics, hospital-level resource use (ie, medications, laboratories, and imaging), and outcomes (ie, cost per case, 14-day revisit rates, and length of stay [LOS]). We compared demographic characteristics and resource use between 2009 to 2013 and 2014 to 2018 using χ² and Wilcoxon rank-sum tests. We grouped hospitals on the basis of 2009 use of each resource and trended use over time using logistic regression. Annual change in mean cost and LOS were estimated by using models of log-transformed data.

RESULTS

Across 32 354 hospitalizations at 38 hospitals, there was a high use of electrolyte testing (85.4%) and intravenous fluids (84.1%) without substantial changes over time. There were significant reductions in the majority of laboratory, medication, and imaging resources across hospitals over the study period. The most notable reductions were for rotavirus and stool testing. Many hospitals saw a decrease in LOS, with only 3 noting an increased revisit rate. Reductions in cost per case over time were most associated with decreases in imaging, laboratory testing, and LOS.

CONCLUSIONS

Significant variation in resource use for children hospitalized with AGE coupled with high use of resources discouraged in AGE guidelines highlights potential opportunities to improve resource use that may be addressed in future AGE guidelines and quality improvement initiatives.

Acute Infectious Diarrhea and Gastroenteritis in Children

PURPOSE OF REVIEW

We aimed to summarize the most current evidence on the main aspects of the diarrheal diseases in children. The following key elements were addressed: definitions, etiology, pathogenesis, diagnosis, dietary management, pharmacological treatments, and prevention. We covered the following questions: What are the most important clinical and laboratory features of the disease? What are the best approaches for the dietary management? What is the best way to classify the hydration status, and to prevent and treat the dehydration? What are the most effective and safe interventions for reducing the diarrhea and vomiting?

RECENT FINDINGS

Diarrheal diseases are one of the most common diseases in childhood. The most common cause is rotavirus. A key element in the approach of a child with diarrhea is determining their hydration status, which determines the fluid management. Laboratory tests are nor routinely required, as most of the cases, they do not affect the management and it should be indicated only in selected cases. Several treatments have been studied to reduce the duration of the diarrhea. Only symbiotics and zinc have shown to be effective and safe with high certainty on the evidence. Rest of the interventions although seem to be effective have low to very low quality of the evidence. The only effective and safe antiemetic for controlling vomiting is ondansetron. A list of antimicrobials indications according to the identified microorganisms is provided. We summarized the most current evidence on diagnosis, management, and prevention of diarrhea in children. More research is needed in some areas such as dehydration scales, rehydration management, antidiarrheals, and antibiotic treatments.

Oral Ondansetron Administration to Dehydrated Children in Pakistan: A Randomized Clinical Trial

BACKGROUND

Ondansetron is an effective antiemetic employed to prevent vomiting in children with gastroenteritis in high-income countries; data from low- and middle-income countries are sparse.

METHODS

We conducted a randomized, double-blind, placebo-controlled superiority trial in 2 pediatric emergency departments in Pakistan. Dehydrated children aged 6 to 60 months with ≥1 diarrheal (ie, loose or liquid) stool and ≥1 vomiting episode within the preceding 4 hours were eligible to participate. Participants received a single weight-based dose of oral ondansetron (8-15 kg: 2 mg; >15 kg: 4 mg) or identical placebo. The primary outcome was intravenous administration of ≥20 mL/kg over 4 hours of an isotonic fluid within 72 hours of random assignment.

RESULTS

All 918 (100%) randomly assigned children completed follow-up. Intravenous rehydration was administered to 14.7% (68 of 462) and 19.5% (89 of 456) of those administered ondansetron and placebo, respectively (difference: -4.8%; 95% confidence interval [CI], -9.7% to 0.0%). In multivariable logistic regression analysis adjusted for other antiemetic agents, antibiotics, zinc, and the number of vomiting episodes in the preceding 24 hours, children administered ondansetron had lower odds of the primary outcome (odds ratio: 0.70; 95% CI, 0.49 to 1.00). Fewer children in the ondansetron, relative to the placebo group vomited during the observation period (difference: -12.9%; 95% CI, -18.0% to -7.8%). The median number of vomiting episodes (P < .001) was lower in the ondansetron group.

CONCLUSIONS

Among children with gastroenteritis-associated vomiting and dehydration, oral ondansetron administration reduced vomiting and intravenous rehydration use. Ondansetron use may be considered to promote oral rehydration therapy success among dehydrated children in low- and middle-income countries.

A prospective comparative study of children with gastroenteritis: emergency department compared with symptomatic care at home

Little is known about the epidemiology and severity of gastroenteritis among children treated at home. We sought to compare illness severity and etiology between children brought for emergency department (ED) care to those managed at home (i.e., community). Prospective cohort study of children enrolled between December 2014 and December 2016 in two pediatric EDs in Alberta, Canada along with children treated at home after telephone triage (i.e., community). Primary outcomes were maximal frequency of vomiting and diarrhea in the 24-h pre-enrollment period; secondary outcomes included etiologic pathogens, dehydration severity, future healthcare visits, and treatments provided. A total of 1613 patients (1317 ED, 296 community) were enrolled. Median maximal frequency of vomiting was higher in the ED cohort (5 (3, 10) vs. 5 (2, 8); P < 0.001). Proportion of children with diarrhea and its 24-h median frequency were lower in the ED cohort (61.3 vs. 82.8% and 2 (0, 6) vs. 4 (1, 7); P < 0.001, respectively). In regression analysis, the ED cohort had a higher maximum number of vomiting episodes pre-enrollment (incident rate ratio (IRR) 1.25; 95% CI 1.12, 1.40) while the community cohort had higher maximal 24-h period diarrheal episodes (IRR 1.20; 95% CI 1.01, 1.43). Norovirus was identified more frequently in the community cohort (36.8% vs. 23.6%; P < 0.001). Children treated in the ED have a greater number of vomiting episodes; those treated at home have more diarrheal episodes. Norovirus is more common among children treated symptomatically at home and thus may represent a greater burden of disease than previously thought.

Hyponatremia in infants with community-acquired infections on hospital admission

Acute moderate to severe gastroenteritis is traditionally associated with hypernatremia but recent observations suggest that hypernatremia is currently less common than hyponatremia. The latter has sometimes been documented also in children with acute community-acquired diseases, such as bronchiolitis and pyelonephritis. We investigated the prevalence of dysnatremia in children with acute moderate severe gastroenteritis, bronchiolitis and pyelonephritis. This prospective observational study included 400 consecutive previously healthy infants ≥4 weeks to ≤24 months of age (232 males and 168 females): 160 with gastroenteritis and relevant dehydration, 160 with moderate-severe bronchiolitis and 80 with pyelonephritis admitted to our emergency department between 2009 and 2017. Circulating sodium was determined by means of direct potentiometry. For analysis, the Kruskal-Wallis test and the Fisher’s exact test were used. Hyponatremia was found in 214 of the 400 patients. It was common in gastroenteritis (43%) and significantly more frequent in bronchiolitis (57%) and pyelonephritis (68%). Patients with hyponatremia were significantly younger than those without hyponatremia (3.9 [1.6–13] versus 7.5 [3.4–14] months). The gender ratio was similar in children with and without hyponatremia. Hyponatremia was associated with further metabolic abnormalities (hypokalemia, hyperkalemia, metabolic acidosis or metabolic alkalosis) in gastroenteritis (71%) and pyelonephritis (54%), and always isolated in bronchiolitis. In conclusion, hyponatremia is common at presentation among previously healthy infants with gastroenteritis, bronchiolitis or pyelonephritis. These data have relevant consequences for the nutrition and rehydration management in these conditions.

Performance of commercial tests for molecular detection of Shiga toxin-producing Escherichia coli (STEC): a systematic review and meta-analysis protocol

INTRODUCTION

Rapid detection of Shiga toxin-producing Escherichia coli (STEC) enables appropriate treatment. Numerous commercially available molecular tests exist, but they vary in clinical performance. This systematic review aims to synthesise available evidence to compare the clinical performance of enzyme immunoassay (EIA) and nucleic acid amplification tests (NAATs) for the detection of STEC.

METHODS AND ANALYSIS

The following databases will be searched employing a standardised search strategy: Medline, Embase, Cochrane CENTRAL Register of Controlled Trials, Cochrane Database of Systematic Reviews, PubMed, Scopus and Web of Science. Grey literature will be searched under advice from a medical librarian. Independent reviewers will screen titles, abstracts and full texts of retrieved studies for relevant studies. Data will be extracted independently by two reviewers, using a piloted template. Quality Assessment of Diagnostic Accuracy Studies-2 will be employed to assess the risk of bias of individual studies, and the quality of evidence will be assessed with the Grading of Recommendations Assessment, Development and Evaluation approach. A bivariate random-effects model will be used to meta-analyse the sensitivity and specificity of commercial STEC diagnostic tests, and a hierarchical summary receiver operator characteristic curve will be constructed. Studies of single test accuracy of EIA and NAATs and studies of comparative accuracy will be analysed separately.

ETHICS AND DISSEMINATION

Ethics approval was not required for this systematic review and meta-analysis. Findings will be disseminated in conferences, through a peer-reviewed journal and via personal interactions with relevant stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42018099119.

Pediatric Referrals to an Emergency Department From Urgent Care Centers

OBJECTIVE

The aims of this study were to describe pediatric emergency department (ED) referrals from urgent care centers and to determine the percentage of referrals considered essential and serious.

METHODS

A prospective study was conducted between April 2013 and April 2015 on patients younger than 21 years referred directly to an ED in central Pennsylvania from surrounding urgent care centers. Referrals were considered essential or serious based on investigations/procedures performed or medications/consultations received in the ED.

RESULTS

Analysis was performed on 455 patient encounters (mean age, 8.7 y), with 347 (76%) considered essential and 40 (9%) considered serious. The most common chief complaints were abdominal pain (83 encounters), extremity injury (76), fever (39), cough/cold (29), and head/neck injury (29). Thirty-three percent of the patients received laboratory diagnostic investigations (74% serum, 56% urine), and 52% received radiologic investigations (67% x-ray, 17% computed tomography scan, 13% ultrasound, 11% magnetic resonance imaging). Forty-four percent of the patients received a procedure, with the most common being intravenous (IV) placement (66%); reduction, casting, or splinting of extremity fracture/dislocation (18%); and laceration repair (14%). The most common medications administered were IV fluids (33%), oral analgesics (30%), and IV analgesics (26%). Eighty-three percent of the patients were discharged home, 12% were hospitalized, and 4% had emergent surgical intervention. The most common primary diagnoses were closed extremity fracture (60 encounters), gastroenteritis (42), brain concussion (28), upper respiratory infection (24), and nonsurgical, unspecified abdominal pain (24).

CONCLUSIONS

Many ED referrals directed from urgent care centers in our sample were considered essential, and few were considered serious. Urgent care centers should develop educational and preparedness strategies based on the epidemiology of emergencies that may occur.

Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis

BACKGROUND

Gastroenteritis accounts for approximately 1.7 million visits to the emergency department (ED) by children in the United States every year. Data to determine whether the use of probiotics improves outcomes in these children are lacking.

METHODS

We conducted a randomized, double-blind trial involving 886 children 3 to 48 months of age with gastroenteritis who presented to six pediatric EDs in Canada. Participants received a 5-day course of a combination probiotic product containing Lactobacillus rhamnosus R0011 and L. helveticus R0052, at a dose of 4.0×10⁹ colony-forming units twice daily or placebo. The primary outcome was moderate-to-severe gastroenteritis, which was defined according to a post-enrollment modified Vesikari scale symptom score of 9 or higher (scores range from 0 to 20, with higher scores indicating more severe disease). Secondary outcomes included the duration of diarrhea and vomiting, the percentage of children who had unscheduled physician visits, and the presence or absence of adverse events.

RESULTS

Moderate-to-severe gastroenteritis within 14 days after enrollment occurred in 108 of 414 participants (26.1%) who were assigned to probiotics and 102 of 413 participants (24.7%) who were assigned to placebo (odds ratio, 1.06; 95% confidence interval [CI], 0.77 to 1.46; P=0.72). After adjustment for trial site, age, detection of rotavirus in stool, and frequency of diarrhea and vomiting before enrollment, trial-group assignment did not predict moderate-to-severe gastroenteritis (odds ratio, 1.06; 95% CI, 0.76 to 1.49; P=0.74). There were no significant differences between the probiotic group and the placebo group in the median duration of diarrhea (52.5 hours [interquartile range, 18.3 to 95.8] and 55.5 hours [interquartile range, 20.2 to 102.3], respectively; P=0.31) or vomiting (17.7 hours [interquartile range, 0 to 58.6] and 18.7 hours [interquartile range, 0 to 51.6], P=0.18), the percentages of participants with unscheduled visits to a health care provider (30.2% and 26.6%; odds ratio, 1.19; 95% CI, 0.87 to 1.62; P=0.27), and the percentage of participants who reported an adverse event (34.8% and 38.7%; odds ratio, 0.83; 95% CI, 0.62 to 1.11; P=0.21).

CONCLUSIONS

In children who presented to the emergency department with gastroenteritis, twice-daily administration of a combined L. rhamnosus-L. helveticus probiotic did not prevent the development of moderate-to-severe gastroenteritis within 14 days after enrollment. (Funded by the Canadian Institutes of Health Research and others; PROGUT ClinicalTrials.gov number, NCT01853124 .).

Assessing Dehydration Employing End-Tidal Carbon Dioxide in Children With Vomiting and Diarrhea

OBJECTIVE

Serum bicarbonate reflects dehydration severity in children with gastroenteritis. Previous work in children receiving intravenous rehydration has correlated end-tidal carbon dioxide (EtCO2) with serum bicarbonate. We evaluated whether EtCO2 predicts weight change in children with vomiting and/or diarrhea.

METHODS

A prospective cohort study was conducted. Eligible children were 3 months to 10 years old and presented for emergency department (ED) care because of vomiting and/or diarrhea. End-tidal carbon dioxide measurements were performed after triage. The diagnostic standard was weight change determined from serial measurements after symptom resolution. A receiver operating characteristic curve was constructed to identify a cut-point to predict 5% or more dehydration.

RESULTS

In total, 195 children were enrolled. Among the 169 (87%) with EtCO2 measurements, the median (interquartile range [IQR]) was 30.4 (27.8 to 33.1). One hundred fifty-eight had repeat weights performed at home; the median (IQR) weight change from ED presentation to well weight was +0.06 (-0.14 to +0.30) or +0.72% (-1.2% to +2.1%). Sixteen percent (25/158) had 3% or more and 4% (6/158) had 5% or more weight gain (ie, percent dehydration). One hundred sixteen (60%) completed home follow-up and had acceptable EtCO2 recordings. Receiver operating curve analysis revealed an area under the curve of 0.34 (95% confidence interval, 0.06 to 0.62) for EtCO2 as a predictor of 5% or more dehydration.

CONCLUSIONS

The limited accuracy of EtCO2 measurement to predict 5% or more dehydration precludes its use as a tool to assess dehydration severity in children. End-tidal carbon dioxide monitoring does not have the ability to identify those children with 5% or more dehydration in a cohort of children with vomiting and/or diarrhea presenting for ED care.

Relationship between enteric pathogens and acute gastroenteritis disease severity: a prospective cohort study

OBJECTIVES

To evaluate the relationship between individual bacterial and viral pathogens and disease severity.

METHODS

Children <18 years with three or more episodes of vomiting and/or diarrhoea were enrolled in two Canadian paediatric emergency departments between December 2014 and August 2016. Specimens were analysed employing molecular panels, and outcome data were collected 14 days after enrolment. The primary outcome was severe disease over the entire illness (symptom onset until 14-day follow-up), quantified employing the Modified Vesikari Scale (MVS) score. The score was additionally analysed in two other time periods: index (symptom onset until enrolment) and follow-up (enrolment until 14-day follow-up).

RESULTS

Median participant age was 20.7 (IQR: 11.3, 44.2) months; 47.4% (518/1093) and 73.4% (802/1093) of participants had index and total MVS scores ≥11, respectively. The most commonly identified pathogens were rotavirus (289/1093; 26.4%) and norovirus (258/1093; 23.6%). In multivariable analysis, severe disease over the entire illness was associated with rotavirus (OR = 9.60; 95%CI: 5.69, 16.19), Salmonella (OR = 6.61; 95%CI: 1.50, 29.17), adenovirus (OR = 2.53; 95%CI: 1.62, 3.97), and norovirus (OR = 1.43; 95%CI: 1.01, 2.01). Pathogens associated with severe disease at the index visit were: rotavirus only (OR = 6.13; 95%CI: 4.29, 8.75), Salmonella (OR = 4.59; 95%CI: 1.71, 12.29), adenovirus only (OR = 2.06; 95%CI: 1.41, 3.00), rotavirus plus adenovirus (OR = 3.15; 95%CI: 1.35, 7.37), and norovirus (OR = 0.68; 95%CI: 0.49, 0.94). During the follow-up period, rotavirus (OR = 2.21; 95%CI: 1.50, 3.25) and adenovirus (OR = 2.10; 95%CI: 1.39, 3.18) were associated with severe disease.

CONCLUSIONS

In children presenting for emergency department care with acute gastroenteritis, pathogens identified were predominantly viruses, and several of which were associated with severe disease. Salmonella was the sole bacterium independently associated with severe disease.

Carotid Flow Time Test Performance for the Detection of Dehydration in Children With Diarrhea

OBJECTIVES

Unstructured clinical assessments of dehydration in children are inaccurate. Point-of-care ultrasound is a noninvasive diagnostic tool that can help evaluate the volume status; the corrected carotid artery flow time has been shown to predict volume depletion in adults. We sought to determine the ability of the corrected carotid artery flow time to identify dehydration in a population of children presenting with acute diarrhea in Dhaka, Bangladesh.

METHODS

Children presenting with acute diarrhea were recruited and rehydrated according to hospital protocols. The corrected carotid artery flow time was measured at the time of presentation. The percentage of weight change with rehydration was used to categorize each child's dehydration as severe (>9%), some (3%-9%), or none (<3%). A receiver operating characteristic curve was constructed to test the performance of the corrected carotid artery flow time for detecting severe dehydration. Linear regression was used to model the relationship between the corrected carotid artery flow time and percentage of dehydration.

RESULTS

A total of 350 children (0-60 months) were enrolled. The mean corrected carotid artery flow time was 326 milliseconds (interquartile range, 295-351 milliseconds). The area under the receiver operating characteristic curve for the detection of severe dehydration was 0.51 (95% confidence interval, 0.42, 0.61). Linear regression modeling showed a weak association between the flow time and dehydration.

CONCLUSIONS

The corrected carotid artery flow time was a poor predictor of severe dehydration in this population of children with diarrhea.

Evaluation of Standard and Mobile Health-Supported Clinical Diagnostic Tools for Assessing Dehydration in Patients with Diarrhea in Rural Bangladesh

Diarrhea remains a leading cause of morbidity and mortality in patients worldwide. The objective of this study was to determine the relative inter-rater reliability and usability of standard and Mobile health (mHealth)-supported World Health Organization (WHO) algorithms for dehydration assessment in patients with acute diarrhea in a rural, low-income country hospital. Two nurses blinded to each other's examinations assessed dehydration status on patients soon after hospital arrival using either the standard WHO algorithm printed on a laminated card or an mHealth-supported WHO algorithm downloaded onto a smartphone. The assignment of assessment tool was based on odd or even enrollment date. The inter-rater reliability for dehydration assessment between the two nurses was calculated using Cohen's K statistic for each study group. A total of 496 patients (< 5 years N = 349, > 5 years N = 147) were enrolled in the study; 132 (27%) had some or severe dehydration, and 364 (73%) had no dehydration on arrival. Cohen's K statistic demonstrated greater reliability for the mHealth-supported dehydration assessment (0.59) compared with the standard assessment (0.50) in the overall population (P < 0.0001), as well as in the pediatric (0.43 versus 0.37, P < 0.0001) and adult (0.79 versus 0.57, P < 0.0001) populations individually. This is the first study to show that mHealth can improve the reliability of nursing dehydration assessment in patients with acute diarrhea and the first to report on the reliability of the WHO algorithm in adult patients specifically. Future studies should focus on the impact of mHealth-supported dehydration assessment on patient-centered outcomes and examine its reliability in different settings worldwide.

Diagnostic accuracy of three clinical dehydration scales: a systematic review

OBJECTIVE

To systematically assess the diagnostic accuracy of the Clinical Dehydration Scale (CDS), the WHO Scale and the Gorelick Scale in identifying dehydration in children with acute gastroenteritis (AGE).

DESIGN

Three databases, two registers of clinical trials and the reference lists from identified articles were searched for diagnostic accuracy studies in children with AGE. The index tests were the CDS, WHO Scale and Gorelick Scale, and reference standard was the percentage loss of body weight. The main analysed outcomes were the sensitivity, specificity, positive likelihood ratio (LR) and negative LR.

RESULTS

Ten studies were included. In high-income countries, the CDS provided a moderate-to-large increase in the post-test probability of predicting moderate to severe (≥6%) dehydration (positive LR 3.9-11.79), but it was of limited value for ruling it out (negative LR 0.55-0.71). In low-income countries, the CDS showed limited value both for ruling in and ruling out moderate-to-severe dehydration. In both settings, the CDS showed poor diagnostic accuracy for ruling in or out no dehydration (<3%) or some dehydration (3%-6%). The WHO Scale showed no or limited value in assessing dehydration in children with diarrhoea. With one exception, the included studies did not confirm the diagnostic accuracy of the Gorelick Scale.

CONCLUSION

Limited evidence suggests that the CDS can help in ruling in moderate-to-severe dehydration (≥6%) in high-income settings only. The WHO and Gorelick Scales are not helpful for assessing dehydration in children with AGE.

Pediatric Emergency Research Canada: Origins and Evolution

OBJECTIVE

The objective of the study was to describe the origins, growth, and progress of a national research network in pediatric emergency medicine.

METHODS

The success of Pediatric Emergency Research Canada (PERC) is described in terms of advancing the pediatric emergency medicine agenda, grant funding, peer-reviewed publications, mentoring new investigators, and global collaborations.

RESULTS

Since 1995, clinicians and investigators within PERC have grown the network to 15 active tertiary pediatric emergency medicine sites across Canada. Investigators have advanced the research agenda in numerous areas, including gastroenteritis, bronchiolitis, croup, head injury, asthma, and injury management. Since the first PERC Annual Scientific meeting in 2004, the attendance has increased by approximately 400% to 152 attendees, 65 presentations, and 13 project/investigator meetings. More than $33 million in grant funding has been awarded to the network, and has published 76 peer-reviewed articles. In 2011, PERC's success was recognized with a Top Achievement Award in Health Research from Canadian Institutes of Health Research and the Canadian Medical Association Journal.

CONCLUSIONS

Moving forward, PERC will continue to focus on the creation of new knowledge, the mentorship of new investigators and fellows in developing research projects, and promoting a pediatric emergency medicine-focused research agenda guided by the pooling of expertise from individuals across the nation. Through collaborations with networks across the globe, PERC will continue to strive for the conduct of high-quality, impactful research that improves outcomes in children with acute illness and injury.

Comparison of sonographic inferior vena cava and aorta indexes during fluid administered in children

OBJECTIVES

This prospective, observational study evaluated changes in ultrasound measurements of the inferior vena caval index (IVCI), the aorta diameter/IVC diameter index (Ao/IVCD), and the aorta area/IVC area index (Ao/IVCA) during fluid administration in children requiring intravenous fluid administration.

METHODS

Children who presented to the pediatric emergency department with symptoms of dehydration were enrolled between May 2015 and February 2016. The maximum diameter of the aorta, from inner wall to inner wall, and the long and short axis diameters of IVC were measured using a convex array transducer in the transverse view. Subsequently, we measured the diameter of the IVC at the subxiphoid area during inspiration and expiration in longitudinal view. We calculated IVCI, Ao/IVCD, and Ao/IVCA during administration of 10ml/kg and 20ml/kg normal saline boluses.

RESULTS

IVCI and Ao/IVCA significantly changed immediately after administration of initial 10ml/kg of NS. Ao/IVCA showed significant change during the additional administration of 10ml/kg (total 20ml/kg) normal saline boluses (1.43, IQR 1.12-1.86 vs. 1.08, IQR 0.87-1.45, p value<0.001). No significant changes were observed for IVCI and Ao/IVCD. Ao/IVCA was significantly correlated with the volume of fluid administered. The coefficient between initial and administration of the 10ml/kg normal saline bolus was -0.396 (p value=0.010), and that between the 10ml/kg and 20ml/kg normal saline boluses was -0.316 (p value=0.038).

CONCLUSIONS

Ao/IVCA showed better correlations with the volume of fluid administered than IVCI and Ao/IVCA. Ao/IVCA might be a promising index for assessing the effects of fluid administration.

Diagnostic accuracy of clinical dehydration scales in children

The aim of this study was to evaluate the diagnostic accuracy of the Clinical Dehydration Scale (CDS), the World Health Organization (WHO) scale, and the Gorelick scale for dehydration assessment in children. A prospective, observational study was carried out between October 2014 and December 2016. Eligible participants were children aged 1 month to 5 years with acute diarrhea. After hospital admission, each patient's weight was recorded and the degree of dehydration based on three scales was assessed. The reference standard was the percentage weight change between the discharge and admission weights. The main outcomes were the sensitivity, specificity, positive likelihood ratio (LR), and negative LR. Of 128 children enrolled in the study, complete data were available from 118 patients for analysis. Most of children presented with no or mild dehydration. Only the CDS showed limited value in confirming a diagnosis of dehydration ≥6% (positive LR 3.9, 95% CI 1.1 to 9.1), with no value in ruling it out (negative LR 0.6, 95% CI 0.2 to 0.99).

CONCLUSION

In our cohort, the CDS was of limited diagnostic value in ruling in severe dehydration in children with acute gastroenteritis. The WHO and Gorelick scales were not helpful in the assessment of dehydration. What is Known : • Treatment of acute gastroenteritis (AGE) is based on assessing and correcting the degree of dehydration. • Several scales combining various signs and symptoms have been developed, including the Clinical Dehydration Scale (CDS), and the World Health Organization (WHO) scale, and the Gorelick scale. None of these scales is internationally accepted for best accuracy in diagnosing dehydration in children. What is New: • The CDS was of limited diagnostic value in ruling in severe dehydration in children with AGE. • The WHO and Gorelick scales were not helpful in the assessment of dehydration.

Predicting Fluid Responsiveness Using Bedside Ultrasound Measurements of the Inferior Vena Cava and Physician Gestalt in the Emergency Department of an Urban Public Hospital in Sub-Saharan Africa

Background

Bedside inferior vena cava (IVC) ultrasound has been proposed as a non-invasive measure of volume status. We compared ultrasound measurements of the caval index (CI) and physician gestalt to predict blood pressure response in patients requiring intravenous fluid resuscitation.

Methods

This was a prospective study of adult emergency department patients requiring fluid resuscitation. A structured data sheet was used to record serial vital signs and the treating clinician’s impression of patient volume status and cause of hypotension. Bedside ultrasound CI measurements were performed at baseline and after each 500mL of fluid. Receiver operating characteristic (ROC) curve analysis was performed to characterize the relationship between CI and Physician gestalt, and the change in mean arterial pressure (MAP).

Results

We enrolled 364 patients, 52% male, mean age 36 years. Indications for fluid resuscitation were haemorrhage (54%), dehydration (30%), and sepsis (17%). Receiver operating characteristic curve analysis found optimal CI cut-off values of 45%, 52% and 53% to predict a MAP rise of 5, 8 and 10 mmHg per litre of fluid, respectively. The sensitivity and specificity of CI of 50% for predicting a 10mmHg increase in MAP per litre were 88% (95%CI 81–93%) and 73% (95%CI 67–79%), respectively, area under the curve (AUC) = 0.85 (0.81–0.89). The sensitivity and specificity of physician gestalt estimate of volume depletion severity were 68% (95%CI 60–75%) and 86% (95%CI 80–90%), respectively, AUC = 0.83 (95% CI: 0.79–0.87). Those with a baseline CI ≥ 50% (51% of patients) had a 2.8-fold greater fluid responsiveness than those with a baseline CI<50% (p<0.0001).

Conclusion

Ultrasound measurement of the CI can predict blood pressure response among patients requiring intravenous fluid resuscitation and may be useful in early identification of patients who will benefit most from volume resuscitation, and those who will likely require other interventions.

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

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.

Accuracy of Inferior Vena Cava Ultrasound for Predicting Dehydration in Children with Acute Diarrhea in Resource-Limited Settings

Introduction

Although dehydration from diarrhea is a leading cause of morbidity and mortality in children under five, existing methods of assessing dehydration status in children have limited accuracy.

Objective

To assess the accuracy of point-of-care ultrasound measurement of the aorta-to-IVC ratio as a predictor of dehydration in children.

Methods

A prospective cohort study of children under five years with acute diarrhea was conducted in the rehydration unit of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Ultrasound measurements of aorta-to-IVC ratio and dehydrated weight were obtained on patient arrival. Percent weight change was monitored during rehydration to classify children as having “some dehydration” with weight change 3–9% or “severe dehydration” with weight change > 9%. Logistic regression analysis and Receiver-Operator Characteristic (ROC) curves were used to evaluate the accuracy of aorta-to-IVC ratio as a predictor of dehydration severity.

Results

850 children were enrolled, of which 771 were included in the final analysis. Aorta to IVC ratio was a significant predictor of the percent dehydration in children with acute diarrhea, with each 1-point increase in the aorta to IVC ratio predicting a 1.1% increase in the percent dehydration of the child. However, the area under the ROC curve (0.60), sensitivity (67%), and specificity (49%), for predicting severe dehydration were all poor.

Conclusions

Point-of-care ultrasound of the aorta-to-IVC ratio was statistically associated with volume status, but was not accurate enough to be used as an independent screening tool for dehydration in children under five years presenting with acute diarrhea in a resource-limited setting.

Comparing the Accuracy of the Three Dehydration Scales in Children with Acute Diarrhea in a Developing Country of Kosovo

BACKGROUND

Although diarrhea is a preventable disease, it remains the second leading cause of death (after pneumonia) among children aged under five years worldwide. The World Health Organization (WHO) scale, the Gorelick scale, and the Clinical Dehydration Scale (CDS) were created to estimate dehydration status using clinical signs. The purpose of this study is to determine whether these clinical scales can accurately assess dehydration status of children in a developing country of Kosovo.

METHODOLOGY

Children aged 1 month to 5 years with a history of acute diarrhea were enrolled in the study. After recording the data about the patients historical features the treating physician recorded the physical examination findings consistent with each clinical score. Receiver operating characteristic (ROC) curves were constructed to evaluate the performance of the three scales, compared to the gold standard, percent weight change with rehydration. Sensitivity, specificity and likelihood ratios were calculated using the best cut-off points of the ROC curves.

RESULTS

We enrolled 230 children, and 200 children met eligibility criteria. The WHO scale for predicting significant dehydration (≥5 percent weight change) had an area under the curve (AUC) of 0.71 (95% : CI= 0.65-0.77). The Gorelick scales 4- and 10-point for predicting significant dehydration, had an area under the curve of 0.71 (95% : CI=0.63- 0.78) and 0.74 (95% : CI= 0.68-0.81) respectively. Only the CDS for predicting the significant dehydration above ≥6% percent weight change, did not have an area under the curve statistically different from the reference line with an AUC of 0.54 (95% CI = 0.45- 0.63).

CONCLUSION

The WHO dehydration scale and Gorelick scales were fair predictors of dehydration in children with diarrhea. Only the Clinical Dehydration Scale was found not to be a helpful predictor of dehydration in our study cohort.