Admission to hospital with gastroenteritis

Hypoglycaemia was common in acute gastroenteritis in a prospective hospital-based study, but electrolyte imbalances were not

AIM

Using routine blood sampling in a gastroenteritis diagnostic workup is debatable. This study examined the relationship between the severity of acute gastroenteritis and blood test abnormalities.

METHODS

We prospectively enrolled children under five years of age referred for outpatient or inpatient management for gastroenteritis from February 2014 to April 2016. The four study hospitals cared for 30% of Norwegian children. The severity of gastroenteritis was assessed using Vesikari scores. Blood samples were analysed at each hospital.

RESULTS

The 659 children had a median age of 19 months. The rotavirus was found in 314/514 children with stool samples (61%). Severe gastroenteritis, indicated by a Vesikari score of ≥11, was found in 392/549 (71%) with completed scores, but only 40 of 649 (6%) assessed for dehydration were more than 5% dehydrated. None had sodium <130 mmol/L. Glucose of 3.0-3.3 mmol/L was detected in 52/578 (9%) and <3.0 mmol/L in 33/578 (6%). Hypoglycaemia, elevated urea, low bicarbonate and negative base excess were associated with disease severity. The duration of vomiting and the rotavirus infection were associated with hypoglycaemia. Elevated urea, low bicarbonate and negative base excess had high specificities, but low sensitivities.

CONCLUSION

Hypoglycaemia was common in acute gastroenteritis, but major electrolyte disturbances were infrequent.

Socioeconomic status is associated with symptom severity and sickness absence in people with infectious intestinal disease in the UK

BACKGROUND

The burden of infectious intestinal disease (IID) in the UK is substantial. Negative consequences including sickness absence are common, but little is known about the social patterning of these outcomes, or the extent to which they relate to disease severity.

METHODS

We performed a cross-sectional analysis using IID cases identified from a large population-based survey, to explore the association between socioeconomic status (SES) and symptom severity and sickness absence; and to assess the role of symptom severity on the relationship between SES and absence. Regression modelling was used to investigate these associations, whilst controlling for potential confounders such as age, sex and ethnicity.

RESULTS

Among 1164 cases, those of lower SES versus high had twice the odds of experiencing severe symptoms (OR 2.2, 95%CI;1.66-2.87). Lower SES was associated with higher odds of sickness absence (OR 1.8, 95%CI;1.26-2.69), however this association was attenuated after adjusting for symptom severity (OR 1.4, 95%CI;0.92-2.07).

CONCLUSIONS

In a large sample of IID cases, those of low SES versus high were more likely to report severe symptoms, and sickness absence; with greater severity largely explaining the higher absence. Public health interventions are needed to address the unequal consequences of IID identified.

Evaluation of bacteriostatic potency of expired oral paediatric antibiotics and implications on infant health

Introduction

In spite of significant risks, as well as non-clinical importance due to loss of potency, stiff penalties against administration of expired medications are still not appropriately enforced by health policy makers in many developing countries, possibly because of little evidence to support that expired medications are hazardous. The purpose of this study therefore, was to investigate the effect of expiration dates on in vitro bacteriostatic potentials of oral paediatric antibiotics.

Methods

Comparative bacteriostatic potentials of 31 expired and seven corresponding unexpired oral paediatric antibiotics were determined on infantile diarrhoeagenic bacteria, using a modification of agar well-diffusion method.

Results

Verall total percentage in vitro resistance rates against expired and unexpired paediatric antibiotics respectively were - E. coli (≤100% vs. ≤15.9%), Klebsiella pneumoniae (≤100% vs. ≤31.3%), Proteus mirabilis (≤91.7% vs. ≤41.7%) and Staphylococcus aureus (≤100% vs. ≤18.2%). Resistance rates of 45.5-55.8% (sulfamethoxazole + trimethoprim 5), 39.5-63.6% (amoxycillin 6), 46.5-54.5% (cotrimoxazole 7), 37.5-63.6% (ampicillin + cloxacillin 18), and higher resistance rates of ≥75.0-100% were exhibited towards remaining expired antibiotics. Higher total resistance and multiple antibiotic resistance (MAR) rates were also recorded against expired antibiotics (45.2-93.5%) compared to unexpired antibiotics (28.6-57.2%), except for few strains of E. coli and Proteus mirabilis. Furthermore, unexpired paediatric antibiotics exhibited wider zones of inhibition towards the test diarrhoeagenic bacteria (≥25.0 mm diameter).

Conclusion

This study provided preliminary microbiological results on the appreciable reduction in in vitro bacteriostatic potentials, as well as higher resistance and multiple antibiotic resistance rates among expired oral paediatric antibiotics on infantile diarrhoeagenic bacteria. Apart from less-efficacy, administration of expired antibiotics can lead to increased antibiotic resistance and clinical treatment failure, as well as adverse drug reactions.

Prebiotics in healthy infants and children for prevention of acute infectious diseases: a systematic review and meta-analysis

Prebiotics, defined as nondigestible dietary ingredients resistant to gastric acidity and fermented by the intestinal flora, are used to positively influence the composition of intestinal flora, thereby promoting health benefits. The objective of this systematic review was to assess the efficacy of prebiotics in the prevention of acute infectious diseases in children. A systematic literature search was conducted using the Ovid Medline, Scopus, Web of Science, and Cochrane Library's Central databases. Finally, five randomized controlled trials, all of them investigating infants and children 0-24 months of age, were included in the review. Pooled estimates from three studies revealed a statistically significant decrease in the number of infectious episodes requiring antibiotic therapy in the prebiotic group as compared with the placebo group (rate ratio 0.68; 95% confidence interval 0.61-0.77). Studies available indicate that prebiotics may also be effective in decreasing the rate of overall infections in infants and children 0-24 months of age. Further studies in the age group 3-18 years are required to determine whether prebiotics can be considered for the prevention of acute infectious diseases in the older pediatric population.

Erkrankungen und Therapieformen des unteren Gastrointestinaltrakts

Duodenalatresien sind Hemmungsfehlbildungen und können proximal oder distal der Papilla Vateri entstehen, wobei die präpapillären Obstruktionen selten sind. Grundsätzlich kann zwischen einer Membranatresie und einer Defektatresie unterschieden werden. Die Unterscheidung beruht nicht nur auf embryologischen Gesichtspunkten, sondern hat auch eine klinische Bedeutung: Bei der Membranatresie kann die quergestellte, partiell offene oder geschlossene Membran weit in den distalen Duodenalanteil reichen („Windsackphänomen“), was zu diagnostischen und auch intraoperativen Problemen führen kann. Ein Pancreas anulare findet sich bei etwa 20 % aller Patienten mit Duodenalatresie.

The challenges of managing severe dehydrating diarrhoea in a resource-limited setting

Diarrhoea remains one of the most common causes of childhood deaths worldwide despite the widespread use of oral rehydration solution (ORS). The vast majority of the nearly 2 million diarrhoeal deaths occurring annually in children under five years of age are in south Asia and sub-Saharan Africa. Signs of critical illness in severely dehydrated children are poorly recognised, and although considerable efforts have gone into establishing the management of diarrhoeal disease in general, there is surprisingly little understanding of the aetiology, metabolic processes and risk factors for the very high mortality associated with severe dehydrating diarrhoea (SDD). We suggest that in many resource-poor settings, the degree of fluid requirement as well as the prevalence of electrolyte disturbances are seriously under-recognised and may be contributing significantly to mortality. The heterogeneity of children with SDD renders the generic 'one size fits all' approach to fluid and electrolyte management in these critically ill children inadequate. In this review we will highlight SDD as an important target for research in resource-limited settings, and emphasise the need to re-evaluate the efficacy of prevailing intravenous fluid protocols in well conducted multi-centre interventional trials.

Gastroenteritis in children

INTRODUCTION

Acute gastroenteritis results from infection of the gastrointestinal tract, most commonly with a virus. It is characterised by rapid onset of diarrhoea with or without vomiting, nausea, fever, and abdominal pain. Diarrhoea is defined as the frequent passage of unformed, liquid stools. Regardless of the cause, the mainstay of management of acute gastroenteritis is provision of adequate fluids to prevent and treat dehydration.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent acute gastroenteritis in children? What are the effects of treatments for acute gastroenteritis in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 42 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review, we present information relating to the effectiveness and safety of: rotavirus vaccines for the prevention of gastroenteritis; enteral rehydration solutions (oral or gastric), lactose-free feeds, loperamide, probiotics, and zinc for the treatment of gastroenteritis; and ondansetron for the treatment of vomiting.

Gastroenteritis in children

INTRODUCTION

Acute gastroenteritis results from infection of the gastrointestinal tract, most commonly with a virus. It is characterised by rapid onset of diarrhoea with or without vomiting, nausea, fever, and abdominal pain. Diarrhoea is defined as the frequent passage of unformed, liquid stools. Regardless of the cause, the mainstay of management of acute gastroenteritis is provision of adequate fluids to prevent and treat dehydration.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent acute gastroenteritis in children? What are the effects of treatments for acute gastroenteritis in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 20 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review, we present information relating to the effectiveness and safety of: rotavirus vaccines for the prevention of gastroenteritis; enteral rehydration solutions (oral or gastric), lactose-free feeds, and loperamide for the treatment of gastroenteritis; and ondansetron for the treatment of vomiting.

Pre-admission therapy for childhood acute diarrhoea--a hospital-based study

Acute gastroenteritis (AGE) is a common illness among infants and children contributing to significant mortality and morbidity. As such, appropriate treatment received prior to hospital admission is of utmost importance. This retrospective observational study aimed to determine preadmission management in paediatric patients prior to hospital admission. Two hundred and twenty-two case notes of paediatric AGE patients were reviewed over a 12-month period. One hundred and fifty-four patients received medications prior to admission with 143 (92.9%) patients received known classes of medications. Antipyretic agents were the most commonly prescribed (69.2%), followed by antibiotics (38.5%), anti-emetics (35.7%), oral rehydration salts (29.4%) and antidiarrhoeals (28.0%). The mean duration of stay in hospital was slightly shorter in patients, who received prior medications than those who did not (2.22 vs. 2.32 days respectively). Seventy per cent of children admitted for AGE were treated suboptimally prior to hospital admission with oral rehydration salts being largely under-utilized, despite their proven efficacy and safety. Sex, race and age had no influence on the type of preadmission treatment. A greater effort should be made to educate the general public in the appropriate treatment of AGE.

Anemia as a risk factor for infectious diseases in infants and toddlers: results from a prospective study

Anemia due to iron deficiency is the most prevalent form of micronutrient malnutrition in the world, however, the causal relationship between anemia and infection remains unclear. We examined prospectively, the association between anemia and infection among Bedouin infants. We recruited 293 families and newborns from the Bedouin population, which is ongoing major lifestyle changes, during the periods of 1989-1992 and 1994-1997 and followed them to age 18 months. The number of diarrhea and respiratory disease episodes as well as total days of diarrhea were ascertained weekly. Hemoglobin levels were obtained at age 6 months. Additional data on feeding practices, environmental, household and demographic characteristics were obtained throughout the 18 months. Diarrhea before 6 months of age was found to be a risk factor for diarrhea after that age. After controlling for early morbidity < 6 months, anemia (Hb < 11 g/dl) at 6 months was an independent risk factor for diarrhea and respiratory illness from 7 to 18 months of age. This associations remained significant even after controlling, in addition, for environmental and socio-economic factors. In the multivariable models, anemia at age 6 months increased the risk for diarrhea after that age by 2.9-fold (95% confidence interval 1.6 - 5.3; p = 0.001) and that of respiratory disease by 2-fold (1.1 - 3.7; p = 0.03). Our findings suggest that anemia may increase the rates of infections in toddlers. The possibility that reducing anemia in infants may be a preventive measure to lower disease burden from infectious disease in this and other vulnerable populations should be tested in further studies.

Estimating hospital admissions due to rotavirus gastroenteritis from hospital episode statistics

OBJECTIVES

To determine the proportion of hospital admissions, in children < 5 years old, coded for intestinal infectious disease or non-infectious gastroenteritis, using ICD-10 codes, that were due to rotavirus infection. To assess how many children admitted with rotavirus gastroenteritis were given the specific ICD-10 code (A080) for this disease.

METHODS

Sixteen-month prospective, observational study of children < 5 years old, admitted to district general hospital with: acute gastroenteritis (> or =3 loose stools/day), proven rotavirus infection and those coded as intestinal infectious disease or non-infectious gastroenteritis.

RESULTS

Four hundred and twenty children < 5 years old were admitted with acute gastroenteritis. Rotavirus was detected in 170 children's stools. Acute rotavirus gastroenteritis accounted for 81/397 (20%) children coded as having non-infectious gastroenteritis and 32/81 (40%) coded for intestinal infectious disease. Only 18 children were coded for rotavirus gastroenteritis. Potentially preventable rotavirus gastroenteritis occurred in 122 children; 78 coded as non-infectious gastroenteritis (20%) and 26 coded for intestinal infectious disease (34%).

CONCLUSIONS

The proportion of children coded with diarrhoeal diseases and found to have rotavirus is less than previously estimated. Using the specific code for rotavirus infection to estimate hospital admissions would be a gross underestimate. Hospital episode statistics cannot reliably estimate the burden of disease due to rotavirus.

The irritable bowel syndrome has origins in the childhood socioeconomic environment

BACKGROUND

The childhood socioeconomic environment has been linked to adult health status in several studies. However, its role in the pathogenesis of adult irritable bowel syndrome (IBS) remains unknown. We aim to assess the influence of the childhood environment on adult IBS, using data from a New Zealand birth cohort study.

METHODS

The Dunedin birth cohort was assembled in 1972-1973 and has been followed prospectively to age 26 (n = 980). IBS was classified according to both Rome and Manning criteria, using self-reported symptom data obtained at age 26 yr. Childhood social class was used as a proxy measure of the quality of the childhood socioeconomic environment and was assigned according to the highest average socioeconomic (SES) level of either parent from interviews across the first 15 yr of life.

RESULTS

Childhood social class was significantly associated with IBS according to Manning Criteria (p = 0.05) and Rome II Criteria (p = 0.05). The prevailing trend was identical for both measures of IBS in the sex-adjusted models: this trend can be characterized as a general, and near-linear decrease in the odds of IBS across decreasing levels of social class. Contrasts with the reference group were significant on all comparisons for Manning Criteria IBS (high vs upper middle, p = 0.04; lower middle, p = 0.04; low, p = 0.01), and on comparisons involving the two lower social class groups for Rome II Criteria IBS (high vs lower middle, p = 0.03; low, p = 0.03). The associations were attenuated, but not eliminated by further adjustment for adult social class.

CONCLUSIONS

An affluent childhood environment is an independent risk factor for adult IBS.

Epidemiology, clinical course and impact on hospitalization costs of acute diarrhea among hospitalized children in Athens, Greece

The aim of this study was to describe the etiology, morbidity and hospitalization costs associated with acute diarrhea among hospitalized children in Greece. During 1999, 294 hospitalized children (median age 1 y) with acute diarrhea were prospectively studied. Bacterial and viral enteropathogens were detected in 100 (34%) and 37 (12.5%) patients, respectively; 17 (6%) patients had mixed infections. Isolated agents included Salmonella spp. (43 patients; 15%), rotavirus (32; 11%), Campylobacter spp. (26; 9%), enteropathogenic Escherichia coli (16; 5.5%), Shigella spp. (11; 4%), Aeromonas spp. (7; 2.5%), adenovirus (6; 2%), Yersinia enterocolitica (6; 2%), enterohemorrhagic Escherichia coli (2; 0.5%) and Giardia lamblia (1; 0.5%). Of the patients with bacterial infection, 70% were admitted between April and September 1999. A rotavirus-associated peak was noted in March. Patients with a bacterial infection were hospitalized for longer periods than those with viral infections. It is concluded that bacterial enteropathogens account for one-third of admissions due to acute diarrhea among children in Greece and are associated with significant hospitalization costs. Rotavirus is also a frequent cause of acute diarrhea necessitating hospitalization.

[Rehydration modalities for acute diarrhea in hospitalized infants. Impact of a permanent short-stay pediatric observation unit]

OBJECTIVE

To analyze hospital treatment of infants with acute gastroenteritis, especially the variations in modes of rehydration, hospitalization rates and lengths of stay, related to paediatrician permanency with a short-stay observation unit at their disposal.

METHODS

This prospective multicentric study during two rotavirus epidemic periods included 1,187 infants (mean age 10 +/- 6 months) with acute gastroenteritis resulting or not in dehydration. During the first period, 12 volunteer hospitals were included. During the second period, we compared six (among the 12) hospitals where infants were admitted in emergency care or pediatric units without pediatric 24-h permanency, with a pediatric emergency care unit having pediatric permanency with a short-stay observation unit.

RESULTS

During the first period, 32% were dehydrated and 6% had hypovolemic shock on admission. The hospitalization rate was 81%. Only 19% of dehydrated infants had exclusively oral rehydration, and 19% of normohydrated infants had intravenous rehydration. During the second period, the hospitalization rate was 42% in the pediatric emergency care unit (28% in the short-stay unit and 14% in hospitalization units) versus 77% in the six hospitals. In the pediatric emergency care unit as compared to the six hospitals, there were a reduction of 65% of hospitalization days, 58% of intravenous accesses, and 66% of laboratory tests.

CONCLUSION

Our findings suggest that a paediatric permanency with a short-stay observation unit at their disposal improves quality of treatment and is cost-effective.

An evidence and consensus based guideline for acute diarrhoea management

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.

Management of acute gastroenteritis in Europe and the impact of the new recommendations: a multicenter study. The Working Group on acute Diarrhoea of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition

BACKGROUND

The European Society for Paediatric Gasteroenterology, Hepatology and Nutrition (ESPGHAN) issued two sets of recommendations for the treatment of infants with acute gastroenteritis (1992, 1997). The purpose of this multicentre study performed in 29 European countries was to determine how closely current treatment compares with the ESPGHAN recommendations.

METHODS

The outline of the study was based on a questionnaire that addressed the management of a 6-month-old infant with acute gastroenteritis complicated by mild to moderate dehydration. National coordinators circulated the questionnaire to randomly selected primary care physicians and to hospital-based paediatricians.

RESULTS

A total of 2997 questionnaires were returned, of which 1768 were from Western Europe (WE) and 1229 from Central and Eastern Europe (CEE). Eighty-four percent of responding physicians said they would follow the ESPGHAN recommendation to use oral rehydration solution (ORS) for rehydration, with 66% using an ORS containing 60 mmol/l sodium ORS. Only 16% (WE 15%, CEE 19%) would follow the guidelines and use rapid oral rehydration over 3 to 4 hours. Forty-five percent would rehydrate infants in a 3- to 6-hour period (WE 35%, CEE 60%), and 17% (WE 23%, CEE 9%) would extend the rehydration period to 12 to 24 hours. ESPGHAN recommendation of rapid reintroduction of normal feeding after 3 to 4 hours of oral rehydration would be followed by only 21% of responding physicians, and only 43% (WE 46%, CEE 38%) would start feeding with full-strength formula. However, the guideline about continuation of breast-feeding is widely followed (total 77%; WE 78%, CEE 75%). Thirty-six percent (WE 45%, CEE 23%) use a lactose-containing formula after successful oral rehydration. Contrary to the ESPGHAN guideline 35% (WE 30%, CEE 42%) would use a lactose-free formula and 19% (WE 12%, CEE 28%) a lactose and cow's milk protein-free formula. Only 37% (WE 30%, CEE 46%) of responding physicians would follow the recommendation to use ORS to replace ongoing losses from watery diarrhoea.

CONCLUSIONS

The results of the survey suggest that with the exception of recommending ORS for rehydration and continuation of breast-feeding during diarrhoea, a minority of responding European physicians follow the ESPGHAN guidelines for optimal management of children with acute gastroenteritis.

Diagnostic clusters in infants as child health outcomes. Variation among socioeconomic areas in one community

Objectives were to examine geographic variation in rates of infant hospitalization for diagnostic clusters in Monroe County (Rochester), New York and to assess these clusters as indexes of child health. ICD-9 codes were used to cluster all 7,883 hospitalizations of infants (< 24 months) between 1985 and 1991 on the basis of their avoidability. Environmentally sensitive clusters accounted for 63% of admissions. These clusters included environmental, environmental/constitutional, and other infectious disease. Disparities in morbidity between inner city and suburbs were greatest for the environmental cluster, followed by the environmental/constitutional, and other infectious disease clusters. For the constitutional and quality indicator clusters, differences between inner-city and suburban risk were minimal. Environmental interventions may be more important than improved health services to reducing racial and economic disparities in child health. Analysis of morbidity clusters, ascertained from available administrative data bases and aggregated for small geographic areas, may guide child health policy well.

Hospitalizations for infectious diseases in Jewish and Bedouin children in southern Israel

Two different population groups reside in the Negev region of southern Israel and have equal, and free from financial barrier, access to tertiary care at a single regional hospital. The Jewish population has a largely urban and industrialized lifestyle, while the Moslem Bedouins are in transition from their traditional nomadic life to settlement. To examine the differences in morbidity patterns reflected in hospitalizations, the computerized hospitalization records of children <15 years of age, for 1989-1991 were used (n=15,947). Rates of hospitalizations for infectious diseases were significantly higher for Bedouins in comparison to Jews (250 and 121/10,000 child years, respectively, odds ratio (OR): 2.1, 95% confidence interval (CI): 2.0-2.2, p < 0.001). Rates of hospitalization per 10,000 child years in Bedouins and Jews for diarrhea were 114 and 32 (OR: 3.7, 95% CI: 3.3-4.0, p < 0.001), respectively, and for pneumonia 55 and 19 (OR: 2.9, 95% CI: 2.6-3.3, p < 0.001), respectively. In infants the differences were even more pronounced, especially for diarrheal diseases. In Bedouin children infectious diseases were associated with longer hospital stay, more pediatric Intensive Care hospitalizations (OR: 2.7, 95% CI: 1.7-4.5,p < 0.001), and higher in-hospital mortality (OR: 5.7, 95% CI: 2.8-12.2, p < 0.001). Thus, Bedouin children are at higher risks of hospitalizations for infectious diseases in early childhood, as compared to Jewish children. This may reflect the differences in lifestyle, environmental and social conditions of the two populations.

[Evaluation of the ambulatory treatment of acute diarrhea in infants. Réseau interhospitalier d'evaluation des pratigues médicales dans les affections courantes de l'enfant]

BACKGROUND

Gastroenteritis remains a common and expensive illness. Oral rehydration solutions (ORS) have been shown to be effective in the prevention and treatment of dehydration, the prime cause for diarrhea-related morbidity and mortality.

OBJECTIVE

To evaluate the ambulatory management of acute gastroenteritis in infants, and particularly practices concerning oral fluid therapy.

METHODS

This prospective, multicenter study included 326 infants (mean age: 10 +/- 6 months), examined in a hospital for acute gastroenteritis, with or without dehydration.

RESULTS

Before admission, 81% had previously been examined by a practitioner, and 89% of these practitioners had written a prescription. This prescription included ORS in 35% and was not different according to the age of the infant. Pediatricians prescribed ORS more frequently than general practitioners (respectively 58% vs 29%; P < 0.001). The failure rate of ORS prescription was 25% (two parents did not observe, ten children refused to drink, and eight stopped treatment because of vomiting). Lactose-free milks were prescribed in 46% of infants and the observance was 82%. At least one drug was prescribed in 94% of infants, with a mean of 2.6 drugs per infant; one antibiotic was prescribed in 33% of infants. Infants were admitted to hospital without any previous consultation in 18%, on the parents' initiative but after at least one previous medical examination in 52%, and on the physician's initiative in 30%. Thirty-three percent were dehydrated; one infant died and two had sequellae.

CONCLUSION

The use of ORS remains insufficient. Efforts to improve use of ORS should be expanded beyond physician education.

Management of childhood gastroenteritis in the community

OBJECTIVE

To examine general practitioners' (GPs') management of childhood gastroenteritis and their perceptions about barriers to optimal management in the community.

DESIGN

Cross-sectional postal survey in which GPs' self-reported practices were assessed by a paediatric gastroenterologist for compliance with published guidelines.

SETTING

Hunter region of NSW, mid 1994.

PARTICIPANTS

All 422 urban and rural GPs practising in the Hunter region were sent questionnaires; 289 (243 urban and 46 rural) GPs responded.

RESULTS

Nearly all GPs (97%) recommended clear fluids in the management of childhood gastroenteritis, with 195 (67%) recommending oral electrolyte solution. Management practices were assessed as: optimal, 170 GPs (59%); acceptable, 33 GPs (11%); inappropriate or potentially dangerous, 38 GPs (13%); and too vague to classify, 48 GPs (17%). Multiple logistic regression analysis showed that better management strategies were associated with being younger and practising in rural areas. GPs perceived the main barriers to effective management of gastroenteritis were: inadequate parenting skills, 131 GPs (45%); lack of parental understanding about the illness, 118 GPs (41%); other social problems, 67 GPs (23%); parental anxiety, 57 GPs (20%); and conflicting advice given by others, 42 GPs (15%). Only 33 GPs (11%) identified the taste and 16 (6%) the cost of oral electrolyte solution as major barriers.

CONCLUSIONS

Most GPs reported management of gastroenteritis was acceptable, although not necessarily optimal. GPs need to ensure that parents fully understand the nature of their child's illness and their recommendations for management at home.

Socioeconomic variation in discretionary and mandatory hospitalization of infants: an ecologic analysis

OBJECTIVES

To examine geographic variation in rates of infant hospitalization for diagnoses classified by type of hospitalization decision in Monroe County (Rochester), New York.

METHODS

Study design was cross-sectional and ecologic. International Classification of Diseases (ICD) codes were used to categorize all 7883 hospitalizations for infants (age, <24 months) beyond the newborn period between 1985 and 1991. Postal zip codes defined socioeconomic areas as inner-city, other urban, and suburban for the population at risk. In 1990, inner-city infants included 62% black and 65% Medicaid-covered infants, whereas suburban infants included 3% black and 6% covered by Medicaid. Hospitalization rates were compared among the three socioeconomic areas.

RESULTS

Overall hospitalization rate was 50.3 per 1000 child years. Admissions classified as discretionary accounted for 59% of these, followed by those classified as mandatory, 18%; sometime (congenital heart disease, cleft palate), 15%; discretionary surgery (inguinal hernia, tonsillectomy/adenoidectomy), 6%; and unlikely to need admission, 2%. A stepwise, socioeconomic gradient in hospitalization was found, with rates of 38.1, 51.3, and 82.9 per 1000 child-years, respectively, for suburban, other urban, and inner-city areas. Rates for discretionary, unlikely, and mandatory admissions followed this gradient. Using the odds for hospitalization of suburban infants as the base odds, the odds ratio for discretionary hospitalization for inner-city infants was 2.88 (95% confidence interval [CI], 2.69 to 3. 08) and that for mandatory hospitalization was 2.20 (95% CI, 1.94 to 2.49). In multiple regression analysis, low education level of mothers explained 81% of the variance in discretionary hospitalization rate. Although the per capita rate of hospital care of inner-city infants was more than twofold greater than that for suburban infants, potential for reducing this difference is suggested by the fact that discretionary admissions accounted for 78. 9% of this difference, whereas mandatory admissions accounted for 17. 7% of the difference.

CONCLUSION

The hospitalization rate for inner-city infants is much greater than that for suburban infants. A substantial portion of the difference, namely that attributable to mandatory admissions, reflected higher rates of serious illness. Differences attributable to discretionary admissions may reflect higher rates of serious illness to some extent, but also appear to reflect less effective health services to a substantial degree.

Validity and reliability of clinical signs in the diagnosis of dehydration in children

OBJECTIVE

To determine the validity and reliability of various clinical findings in the diagnosis of dehydration in children.

DESIGN

Prospective cohort study.

SETTING

An urban pediatric hospital emergency department.

PARTICIPANTS

One hundred eighty-six children ranging in age from 1 month to 5 years old with diarrhea, vomiting, or poor oral fluid intake, either admitted or followed as outpatients. Exclusion criteria included malnutrition, recent prior therapy at another facility, symptoms for longer than 5 days' duration, and hyponatremia or hypernatremia.

METHODS

All children were evaluated for 10 clinical signs before treatment. The diagnostic standard for dehydration was fluid deficit as determined from serial weight gain after treatment.

MAIN RESULTS

Sixty-three children (34%) had dehydration, defined as a deficit of 5% or more of body weight. At this deficit, clinical signs were already apparent (median = 5). Individual findings had generally low sensitivity and high specificity, although parent report of decreased urine output was sensitive but not specific. The presence of any three or more signs had a sensitivity of 87% and specificity of 82% for detecting a deficit of 5% or more. A subset of four factors-capillary refill >2 seconds, absent tears, dry mucous membranes, and ill general appearance-predicted dehydration as well as the entire set, with the presence of any two or more of these signs indicating a deficit of at least 5%. Interobserver reliability was good to excellent for all but one of the findings studied (quality of respirations).

CONCLUSIONS

Conventionally used clinical signs of dehydration are valid and reliable; however, individual findings lack sensitivity. Diagnosis of clinically important dehydration should be based on the presence of at least three clinical findings.

Treatment of acute gastroenteritis: too much and too little care

This paper reviews the health services literature regarding care for gastroenteritis in children. United States health care utilization, use of oral rehydration therapy (ORT), and quality of care considerations are described. The literature suggests that some US children may receive too much care while others may not be getting enough and that physician practices continue to differ from expert recommendations.

Pre-admission management of acute gastroenteritis

OBJECTIVE

Acute gastroenteritis contributes to significant morbidity and need for hospital admission. The current literature suggests outpatient management is often inappropriate. This study examines the pre-admission management of children admitted with acute gastroenteritis to a major children's hospital.

METHODOLOGY

Information was obtained from parental questionnaires and the medical notes for 164 children.

RESULTS

Parents were poorly informed regarding appropriate home management. Over 70% sought professional advice prior to admission, usually from their general practitioner. Although 58% received advice on fluid therapy, an oral rehydration solution was recommended for only 32%, and only 9% actually used one before admission. Advice regarding fluid requirements was usually inadequate. Inappropriate medications were prescribed for 22% of children, including antibiotics (15.4%), antidiarrhoeals (1.2%) and anti-emetics (5.5%). Hospitalized children were generally well nourished with minimal dehydration and electrolyte disturbance.

CONCLUSIONS

Oral rehydration therapy is utilized rarely and medications are over-utilized in home management of gastroenteritis. Education of parents, general practitioners and hospital doctors is essential to optimize outpatient management. The impact of optimal outpatient management on hospital admission rates and morbidity requires formal assessment.

Are all hospital admissions for acute gastroenteritis necessary?

Consecutive hospital admissions of 300 children under 2 years old with gastroenteritis were studied to establish the reasons for the request for admission, treatment practices before admission, and the severity of illness. Symptoms were mostly mild. Inappropriate treatment at home was unusual but 87 (29%) had received none before being admitted. In 66 cases (22%) more than one reason was given for referral and 61 (20%) were referred in part for non-medical reasons. Hospital stay was often longer than necessitated by the severity of the illness alone. Redeployment of resources to fund assessment centres on the paediatric ward and more community nursing teams would allow many more of these children to be nursed safely at home.

Prevalence and first-line treatment of diarrhoeal symptoms in the community

By systematically sampling patient registers in two socio-economically contrasting Scottish urban general practices, 440 households were selected and contracted by a research health visitor who interviewed a household member in 425 of them (response rate = 97%). Information was obtained on the point and period prevalence of diarrhoeal symptoms in all household members (n = 1,335), and on the knowledge, attitudes and behaviour of the respondents. While the point prevalence was low (under 1% of the household members), around 12% were reported to have experienced symptoms in the three-month period prior to the interview, and these were associated with a small but far from negligible loss of time from school or work. There were no significant seasonal differences in prevalence rates, nor were there significant differences between the two practices. Knowledge about appropriate treatment was high, but there was some confusion about the administration of liquids (especially milk) other than water, and a high level of ignorance about the existence and purpose of oral rehydration solutions. These findings have implications for public education about the initial management of acute diarrhoeal symptoms.

Glucose polymers in diarrhoea--risk of hypernatraemia

An infant girl with congenital heart disease was fed glucose polymers as dietary supplements. During an attack of gastroenteritis with severe diarrhoea she developed hypernatraemic dehydration, probably due to the high osmotic load of the glucose polymers. This case illustrates the importance of giving adequate amounts of free water to a child on glucose polymers, especially during excessive fluid loss.