Comparison of clinical and biochemical markers of dehydration with the clinical dehydration scale in children: a case comparison trial

Heart rate to identify non-febrile children with dehydration and acute kidney injury in emergency department: a prospective validation study

We previously developed and retrospectively validated the estimated percentage of heart rate variation (EHRV) as a predictor of the composite outcome of ≥ 5% dehydration and/or acute kidney injury (AKI) in non-febrile children. The current study aimed to prospectively validate EHRV as a predictor for dehydration or AKI in a different cohort of children attending the Pediatric Emergency Department. From July 2022 to August 2023, 256 pediatric patients aged 0-18 years attending the Pediatric Emergency Department were enrolled. EHRV was calculated as follows: [(HR at admission - 50th percentile of HR for age and sex)/HR at admission] × 100. Dehydration was categorized as < 5% or ≥ 5% fluid deficit. AKI was defined according to KDIGO creatinine criteria. Statistical analyses included receiver-operating characteristic (ROC) curves and logistic regression analysis. Among enrolled patients, 52 had ≥ 5% dehydration, 50 had AKI, and 16 had both conditions. EHRV demonstrated significant predictive ability for both ≥ 5% dehydration (AUROC = 0.71; 95% confidence interval (CI), 0.63-0.78; p < 0.001) and AKI (AUROC = 0.78; 95% CI, 0.71-0.84; p < 0.001). An EHRV > 24.5% was associated with an increased odds ratio (OR), adjusted for confounders, of ≥ 5% dehydration (OR = 3.5; 95% CI, 1.6-8.0; p = 0.003) and AKI (OR = 3.4; 95% CI, 1.6-7.3; p = 0.002). The sensitivity and specificity of this cut-off were 34% and 83% for ≥ 5% dehydration and 36% and 84% for AKI, respectively.

CONCLUSIONS

This study prospectively validates the clinical utility of EHRV in predicting dehydration and AKI in a pediatric emergency care setting. An EHRV > 24.5% could serve as a marker for suspecting dehydration or AKI. Further validation across diverse patient populations and settings is needed.

WHAT IS KNOWN

• An increased heart rate (HR) is a readily detectable sign of dehydration in children. • In a retrospective validation cohort, an estimated HR variation (EHRV) greater than 24.5% compared to the 50th percentile of HR was predictive of ≥ 5% dehydration and/or acute kidney injury (AKI) in non-febrile patients.

WHAT IS NEW

• We prospectively validated the clinical utility of EHRV in predicting dehydration and AKI in a pediatric emergency care setting. • We confirmed that an EHRV greater than 24.5% is associated with increased odds of ≥ 5% dehydration and AKI.

Dehydration associates with lower urinary tract symptoms in progressive multiple sclerosis

BACKGROUND

Lower urinary tract symptoms (LUTS) are common in persons with progressive multiple sclerosis (pwPMS), who may consequently limit their fluid intake. We aimed to investigate the hypothesis that LUTS associate with objective evidence of inadequate hydration status in pwPMS.

METHODS

In this prospective study, 55 pwPMS were studied over 2 years. A 6-monthly first-morning urine specimen was analysed for urinary osmolality and sodium as hydration markers. LUTS symptom severity in three categories (urgency, voiding and discomfort) was assessed and quantified using a questionnaire. Correlation between LUTS severity and hydration was assessed within subjects and between subjects, controlling for age.

RESULTS

Some 274 urine samples with accompanying LUTS data from 55 participants were analysed. Biochemical data showed the expected loss of urine-concentrating capacity with increasing age. Inadequate hydration was observed in 47% of participants. LUTS were very common (87% reported urgency and 89% voiding symptoms). Voiding and discomfort, but not urgency severity, were correlated with hydration markers, both within and between participants.

CONCLUSIONS

LUTS are very common in pwPMS, and associate with inadequate hydration. The causes and consequences of inadequate hydration in MS need further study, since (i) this will focus greater attention on LUTS management in pwPMS and (ii) dehydration has been associated with reversible cognitive dysfunction and physical underperformance.

Perioperative water and electrolyte balance and water homeostasis regulation in children with acute surgery

BACKGROUND

Hospital-acquired hyponatremia remains a feared event in patients receiving hypotonic fluid therapy. Our objectives were to assess post-operative plasma-sodium concentration and to provide a physiological explanation for plasma-sodium levels over time in children with acute appendicitis.

METHODS

Thirteen normonatremic (plasma-sodium ≥135 mmol/L) children (8 males), median age 12.3 (IQR 11.5-13.5) years participated in this prospective observational study (ACTRN12621000587808). Urine was collected and analyzed. Blood tests, including renin, aldosterone, arginine-vasopressin, and circulating nitric oxide substrates were determined on admission, at induction of anesthesia, and at the end of surgery.

RESULTS

On admission, participants were assumed to be mildly dehydrated and were prescribed 50 mL/kg of Ringer's acetate intravenously followed by half-isotonic saline as maintenance fluid therapy. Blood tests, urinary indices, plasma levels of aldosterone, arginine-vasopressin, and net water-electrolyte balance indicated that participants were dehydrated on admission. Although nearly 50% of participants still had arginine-vasopressin levels that would have been expected to produce maximum antidiuresis at the end of surgery, electrolyte-free water clearance indicated that almost all participants were able to excrete net free water. No participant became hyponatremic.

CONCLUSIONS

The use of moderately hypotonic fluid therapy after correction of extracellular fluid deficit is not necessarily associated with post-operative hyponatremia.

IMPACT

Our observations show that in acutely ill normonatremic children not only the composition but also the amount of volume infused influence on the risk of hyponatremia. Our observations also suggest that perioperative administration of hypotonic fluid therapy is followed by a tendency towards hyponatremia if extracellular fluid depletion is left untreated. After correcting extracellular deficit almost all patients were able to excrete net free water. This occurred despite nearly 50% of the cohort having high circulating plasma levels of arginine-vasopressin at the end of surgery, suggesting a phenomenon of renal escape from arginine-vasopressin-induced antidiuresis.

The Association Between Initial Serum Bicarbonate Levels and the Management of Dehydrated Children in the Emergency Department: A Retrospective Review

OBJECTIVES

There is no consensus in the current literature on the relevance of serum bicarbonate levels, cutoff benchmarks and the management of dehydration; therefore, this study aims to explore whether an association can be established between initial serum bicarbonate levels and the subsequent management of children between the ages of 0 to 36 months presenting to the emergency department (ED) with dehydration.

METHODS

The study is a single center, retrospective review of 335 charts of children between 0 and 36 months of age presenting to the ED of an urban academic tertiary hospital between June 2014 and June 2016 with a medical history suggestive of dehydration and documented serum bicarbonate levels during their visits.

RESULTS

A total of 310 charts were analyzed. No significant difference was found between mean serum bicarbonate levels of admitted and discharged patients (18.82 mmol/L vs 18.75 mmol/L; P = 0.89). Children with serum bicarbonate levels below 15 mmol/L were significantly more likely to receive a fluid bolus ( P = 0.00) in the ED but neither the length of stay in the ED ( P = 0.07) nor in the hospital ( P = 0.41) was affected. Bounce backs within 7 days of discharge were not associated with serum bicarbonate levels at first presentation, but rather with a shorter duration of diarrhea ( P = 0.013).

CONCLUSIONS

Initial serum bicarbonate level of dehydrated children does not appear to be associated with the severity of dehydration, vomiting, diarrhea and the patients' management in the ED or the hospital. Initial serum bicarbonate is associated with the decision to administer fluid boluses and potential bounce back.

Impact of rotavirus vaccine implementation on Israeli children: a comparison between pre- and post-vaccination era

BACKGROUND

Worldwide rotavirus vaccination has resulted in a substantial decrease in rotavirus-induced severe gastroenteritis and related hospitalizations among children. Still, the characterization of patients warranting hospitalization needs to be further elucidated. The purpose of the study is to compare the clinical and laboratory features of children hospitalized with acute rotavirus infection before and after the introduction of routine vaccination.

METHODS

This is a retrospective observational study. Participants were pediatric patients who presented to the Bnai Zion Medical Center pediatric emergency department and were diagnosed with rotavirus acute gastroenteritis between 2017 and 2019.

RESULTS

During the pre-vaccination period (2007-2009), 114 infants and young children (median age: 14 months, range: 1-72 months; 59 male, 55 female) were hospitalized for rotavirus-induced acute gastroenteritis with a rate of 11.71 positive rotavirus tests per 1000 emergency room visits. In the post-vaccination period (2012-2019), 168 infants and young children (median age: 17 months, range: 0-84 months; 90 male, 78 female) were hospitalized with a rate of 4.18 positive rotavirus tests per 1000 emergency room visits. There were no statistical differences between the two groups in gender, breast-feeding rates and sibling(s). The proportion of cases with moderate-to-severe dehydration was higher in the post-vaccination children than in the pre-vaccination children.

CONCLUSIONS

Rates of rotavirus-attributed acute gastroenteritis hospitalizations declined from the pre- to the post-vaccination period. Higher rates of dehydration were found in the post-vaccination children. Ongoing surveillance is warranted to better understand the implications of the vaccine.

How to interpret symptoms, signs and investigations of dehydration in children with gastroenteritis

Dehydration is a significant cause of morbidity and mortality in children worldwide. Infants and young children are vulnerable to dehydration, and clinical assessment plays a pivotal role in their care. In addition, laboratory investigations can, in some children, be helpful when assessing the severity of dehydration and for guiding rehydration treatment. In this interpretation, we review the current literature and provide an evidence-based approach to recognising and managing dehydration in children.

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.

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.

Elevated Serum Uric Acid in Benign Convulsions with Mild Gastroenteritis in Children

Background and Purpose

To identify whether serum uric acid levels are significantly higher in patients with benign convulsion associated with mild gastroenteritis (CwG) than in patients with acute gastroenteritis.

Methods

This retrospective study compared the serum levels of uric acid between CwG, acute gastroenteritis, and febrile seizure after correcting for the varying degree of mild dehydration using serum HCO₃⁻ levels. We also compared the serum uric acid levels between patients with CwG and febrile seizures in order to exclude the effect of seizures on uric acid.

Results

This study included 154 CwG patients (age range 0.73–3.19 years), 2,938 patients with acute gastroenteritis, and 154 patients with febrile seizure. The serum uric acid level was significantly higher in CwG patients than in patients with acute gastroenteritis [9.79±2.16 mg/dL vs. 6.04±2.3 mg/dL (mean±SD), p<0.001]. This difference was also significant after correcting for dehydration. The serum uric acid level was significantly higher in CwG patients than in dehydration-corrected acute gastroenteritis patients (9.79±2.16 mg/dL vs. 6.67±2.48 mg/dL, p<0.001). The serum uric acid level was not elevated in patients with febrile seizure.

Conclusions

We have confirmed that serum uric acid is elevated in CwG patients even after correcting for their dehydration status, and that this was not a postictal phenomenon. Highly elevated serum uric acid in CwG could be a useful clinical indicator of CwG in patients with acute gastroenteritis.

Pediatric Dehydration Assessment at Triage: Prospective Study on Refilling Time

PURPOSE

Dehydration is a paediatric medical emergency but there is no single standard parameter to evaluate it at the emergency department. Our aim was to evaluate the reliability and validity of capillary refilling time as a triage parameter to assess dehydration in children.

METHODS

This was a prospective pilot cohort study of children who presented to two paediatric emergency departments in Italy, with symptoms of dehydration. Reliability was assessed by comparing the triage nurse's measurements with those obtained by the physician. Validity was demonstrated by using 6 parameters suggestive of dehydration. Comparison between refilling time (RT) and a validated Clinical Dehydration Score (CDS) was also considered. The scale's discriminative ability was evaluated for the outcome of starting intravenous rehydration therapy by using a receiver operating characteristic (ROC) curve.

RESULTS

Participants were 242 children. All nurses found easy to elicit the RT after being trained. Interobserver reliability was fair, with a Cohen's kappa of 0.56 (95% confidence interval [CI], 0.41 to 0.70). There was a significant correlation between RT and weight loss percentage (r-squared=-0.27; 95% CI, -0.47 to -0.04). The scale's discriminative ability yielded an area under the ROC curve (AUC) of 0.65 (95% CI, 0.57 to 0.73). We found a similarity between RT AUC and CDS-scale AUC matching the two ROC curves.

CONCLUSION

The study showed that RT represents a fast and handy tool to recognize dehydrated children who need a prompt rehydration and may be introduced in the triage line-up.

The Use and Interpretation of Sodium Concentrations in Casual (Spot) Urine Collections for Population Surveillance and Partitioning of Dietary Iodine Intake Sources

In 2013, the World Health Organization (WHO) called for joint surveillance of population salt and iodine intakes using urinary analysis. 24-h urine collection is considered the gold standard for salt intake assessment, but there is an emerging consensus that casual urine sampling can provide comparable information for population-level surveillance. Our review covers the use of the urinary sodium concentration (UNaC) and the urinary iodine concentration (UIC) from casual urine samples to estimate salt intakes and to partition the sources of iodine intakes. We reviewed literature on 24-h urinary sodium excretion (UNaE) and UNaC and documented the use of UNaC for national salt intake monitoring. We combined information from our review of urinary sodium with evidence on urinary iodine to assess the appropriateness of partitioning methods currently being adapted for cross-sectional survey analyses. At least nine countries are using casual urine collection for surveillance of population salt intakes; all these countries used single samples. Time trend analyses indicate that single UNaC can be used for monitoring changes in mean salt intakes. However; single UNaC suffers the same limitation as single UNaE; i.e., an estimate of the proportion excess salt intake can be biased due to high individual variability. There is evidence, albeit limited, that repeat UNaC sampling has good agreement at the population level with repeat UNaE collections; thus permitting an unbiased estimate of the proportion of excess salt intake. High variability of UIC and UNaC in single urine samples may also bias the estimates of dietary iodine intake sources. Our review concludes that repeated collection, in a sub-sample of individuals, of casual UNaC data would provide an immediate practical approach for routine monitoring of salt intake, because it overcomes the bias in estimates of excess salt intake. Thus we recommend more survey research to expand the evidence-base on predicted-UNaE from repeat casual UNaC sampling. We also conclude that the methodology for partitioning the sources of iodine intake based on the combination of UIC and UNaC measurements in casual urine samples can be improved by repeat collections of casual data; which helps to reduce regression dilution bias. We recommend more survey research to determine the effect of regression dilution bias and circadian rhythms on the partitioning of dietary iodine intake sources.

Gastroduodenal Perforation and Ulcer Associated With Rotavirus and Norovirus Infections in Japanese Children: A Case Report and Comprehensive Literature Review

Race, young age, male gender, severe dehydration, metabolic acidosis, drowsiness/unconsciousness and shock are associated with gastroduodenal perforation/ulcer (GDPU) in childhood rotaviruses and noroviruses gastroenteritis. Awareness of the risk of GDPU prevents lethal outcome in these common infections among young children.

Background. There is no literature review on gastroduodenal perforation or ulcer (GDPU) with rotavirus (RV) and norovirus (NoV) gastroenteritis.

Methods. Pediatric cases of GDPU or upper gastrointestinal bleeding with RV and NoV gastroenteritis were searched from September 1974 until October 2015 using PubMed, Google for English, other-language-publications, and Ichushi (http://www.jamas.or.jp) for Japanese-language publications. All reports confirming GDPU or upper gastrointestinal bleeding with RV and NoV gastroenteritis were eligible for inclusion in the study. In addition, clinical characteristics were reviewed.

Results. A boy with duodenal ulcer (DU) and NoV gastroenteritis was described. There were 32 GDPU cases (23 RVs and 9 NoVs cases), including our case; with the exception of 1 case, all were Japanese. Mean age, male/female ratio, and symptoms' duration before admission were 21.6 months, 2.2, and 4.0 days, respectively. Vomiting was the most common symptom, followed by diarrhea, lethargy, fever, abdominal distension, and convulsion. Dehydration, hematemesis, melena, drowsiness or unconsciousness, shock, metabolic acidosis, leukocytosis, anemia, positive C-reactive protein, high blood urea nitrogen, and hyponatremia commonly occurred. Helicobacter pylori was a minor cause of GDPU. Duodenal (DP) or gastric perforation (GP) developed in 14 cases (10 DP/RVs, 1 GP/RV, and 3 DP/NoVs). Duodenal ulcer or gastric ulcer (GU) developed in 18 cases (10 DU/RVs, 4 DU/NoVs, 1 GU/RV, 1 GU + DU/NoV, and 2 upper gastrointestinal bleeding/RVs). The predominant perforation or ulcer site was in the duodenum. With the exception of 2 deaths from DU, all cases recovered.

Conclusions. Race, young age, male, severe dehydration, metabolic acidosis, drowsiness and unconsciousness, and shock may be potential risk factors of GDPU associated with RV and NoV gastroenteritis. Limitation of this descriptive study warrants further investigations to determine the risk factors in these infections that could be associated with GDPU.

Xyloglucan for the treatment of acute diarrhea: results of a randomized, controlled, open-label, parallel group, multicentre, national clinical trial

Background

There is a strong rationale for the use of agents with film-forming protective properties, like xyloglucan, for the treatment of acute diarrhea. However, few data from clinical trials are available.

Methods

A randomized, controlled, open-label, parallel group, multicentre, clinical trial was performed to evaluate the efficacy and safety of xyloglucan, in comparison with diosmectite and Saccharomyces in adult patients with acute diarrhea due to different causes.

Patients were randomized to receive a 3-day treatment. Symptoms (stools type, nausea, vomiting, abdominal pain and flatulence) were assessed by a self-administered ad-hoc questionnaire 1, 3, 6, 12, 24, 48 and 72 h following the first dose administration. Adverse events were also recorded.

Results

A total of 150 patients (69.3 % women and 30.7 % men, mean age 47.3 ± 14.7 years) were included (n = 50 in each group). A faster onset of action was observed in the xyloglucan group compared with the diosmectite and S. bouliardii groups. At 6 h xyloglucan produced a statistically significant higher decrease in the mean number of type 6 and 7 stools compared with diosmectite (p = 0.031). Xyloglucan was the most efficient treatment in reducing the percentage of patients with nausea throughout the study period, particularly during the first hours (from 26 % at baseline to 4 % after 6 and 12 h). An important improvement of vomiting was observed in all three treatment groups.

Xyloglucan was more effective than diosmectite and S. bouliardii in reducing abdominal pain, with a constant improvement observed throughout the study. The clinical evolution of flatulence followed similar patterns in the three groups, with continuous improvement of the symptom. All treatments were well tolerated, without reported adverse events.

Conclusions

Xyloglucan is a fast, efficacious and safe option for the treatment of acute diarrhea.

Trial registration

EudraCT number 2014-001814-24 (date: 2014-04-28)

ISRCTN number: 90311828

Empirically Derived Dehydration Scoring and Decision Tree Models for Children With Diarrhea: Assessment and Internal Validation in a Prospective Cohort Study in Dhaka, Bangladesh

INTRODUCTION

Diarrhea remains one of the most common and most deadly conditions affecting children worldwide. Accurately assessing dehydration status is critical to determining treatment course, yet no clinical diagnostic models for dehydration have been empirically derived and validated for use in resource-limited settings.

METHODS

In the Dehydration: Assessing Kids Accurately (DHAKA) prospective cohort study, a random sample of children under 5 with acute diarrhea was enrolled between February and June 2014 in Bangladesh. Local nurses assessed children for clinical signs of dehydration on arrival, and then serial weights were obtained as subjects were rehydrated. For each child, the percent weight change with rehydration was used to classify subjects with severe dehydration (>9% weight change), some dehydration (3-9%), or no dehydration (<3%). Clinical variables were then entered into logistic regression and recursive partitioning models to develop the DHAKA Dehydration Score and DHAKA Dehydration Tree, respectively. Models were assessed for their accuracy using the area under their receiver operating characteristic curve (AUC) and for their reliability through repeat clinical exams. Bootstrapping was used to internally validate the models.

RESULTS

A total of 850 children were enrolled, with 771 included in the final analysis. Of the 771 children included in the analysis, 11% were classified with severe dehydration, 45% with some dehydration, and 44% with no dehydration. Both the DHAKA Dehydration Score and DHAKA Dehydration Tree had significant AUCs of 0.79 (95% CI = 0.74, 0.84) and 0.76 (95% CI = 0.71, 0.80), respectively, for the diagnosis of severe dehydration. Additionally, the DHAKA Dehydration Score and DHAKA Dehydration Tree had significant positive likelihood ratios of 2.0 (95% CI = 1.8, 2.3) and 2.5 (95% CI = 2.1, 2.8), respectively, and significant negative likelihood ratios of 0.23 (95% CI = 0.13, 0.40) and 0.28 (95% CI = 0.18, 0.44), respectively, for the diagnosis of severe dehydration. Both models demonstrated 90% agreement between independent raters and good reproducibility using bootstrapping.

CONCLUSION

This study is the first to empirically derive and internally validate accurate and reliable clinical diagnostic models for dehydration in a resource-limited setting. After external validation, frontline providers may use these new tools to better manage acute diarrhea in children.