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Nuzhat S, Alam B, Hasan SMT, Shaima SN, Chisti MJ, Faruque ASG, Das R, Ahmed T. Are young and older children with diarrhea presenting in the same way? PLoS One 2024; 19:e0300882. [PMID: 38739609 PMCID: PMC11090295 DOI: 10.1371/journal.pone.0300882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 03/06/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Diarrhoea is a global health problem. More than a quarter of diarrhoeal deaths occur among children less than five years. Different literatures analyzed presentation and outcomes of less than five diarrhoeal children. The world has made remarkable progress in reducing child mortality. So, older children are growing in number. Our aim was to identify clinical differentials and variations of pathogens among younger (less than five) and older (five to nine years) diarrhoeal children. METHOD Data were extracted from the diarrhoeal disease surveillance system (DDSS) of Dhaka Hospital (urban site) and Matlab Hospital (rural site) of the International Centre for Diarrhoeal Disease Research, Bangladesh for the period of January 2012 to December 2021. Out of 28,781 and 12,499 surveillance patients in Dhaka and Matlab Hospital, 614 (2.13%) and 278 (2.22%) children were five to nine-years of age, respectively. Among under five children, 2456 from Dhaka hospital and 1112 from Matlab hospital were selected randomly for analysis (four times of five to nine years age children, 1:4). RESULTS Vomiting, abdominal pain, and dehydrating diarrhoea were significantly higher in older children in comparison to children of less than five years age (p-value <0.05) after adjusting study site, gender, antibiotic use before hospitalization, diarrhoeal duration < 24 hours, intake of oral rehydration fluid at home, parental education, WASH practice and history of cough. Vibrio. cholerae, Salmonella, and Shigella were the common fecal pathogen observed among older children compared to under five after adjusting for age, gender and study site. CONCLUSION Although percentage of admitted diarrhoeal children with five to nine years is less than under five years children but they presented with critical illness with different diarrhoeal pathogens. These observations may help clinicians to formulate better case management strategies for children of five to nine years that may reduce morbidity.
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Affiliation(s)
- Sharika Nuzhat
- Clinical and Laboratory Services, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - Baharul Alam
- Clinical and Laboratory Services, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - S. M. Tafsir Hasan
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - Shamsun Nahar Shaima
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Clinical and Laboratory Services, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - A. S. G. Faruque
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - Rina Das
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, GA, United States of America
| | - Tahmeed Ahmed
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
- James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Office of the Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
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Octavius GS, Imanuelly M, Wibowo J, Heryadi NK, Widjaja M. Inferior vena cava to aorta ratio in dehydrated pediatric patients: a systematic review and meta-analysis. Clin Exp Pediatr 2023; 66:477-484. [PMID: 37321576 PMCID: PMC10626024 DOI: 10.3345/cep.2022.01445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/31/2023] [Accepted: 02/06/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Dehydration due to acute diarrhea is among the leading causes of mortality. However, advancements in management and technology do not help clinicians differentiate dehydration degrees. Ultrasound using the inferior vena cava to aorta (IVC/ Ao) ratio is a promising noninvasive technique to identify significant pediatric dehydration. PUSPOSE Therefore, this systematic review and meta-analysis aimed to examine the diagnostic parameters of the IVC/Ao ratio for predicting clinically significant dehydration in pediatric patients. METHODS We searched the MEDLINE, PubMed, Cochrane Library, ScienceDirect, and Google Scholar databases for studies of pediatric patients (≤18 years old) who presented with signs and symptoms of dehydration due to acute diarrhea, gastroenteritis, or vomiting. The inclusion criteria were cross-sectional, case-control, cohort, and randomized controlled trial study design and publication in any language. We then conducted a meta-analysis using the midas and metandi commands from Stata software. RESULTS Five studies of 461 patients were included. The combined sensitivity was 86% (95% confidence interval [CI], 79%-91%), while the specificity was 73% (95% CI, 59%-84%). The area under the curve was 0.89 (95% CI, 0.86-0.91). The positive likelihood ratio (LR+) was 3.2 (95% CI, 2.1-5.1) with a 76% posttest probability, while the negative likelihood ratio (LR-) was 0.18 (95% CI, 0.12-0.28) with a 16% posttest probability. The combined negative predictive value was 0.83 (95% CI, 0.75-0.91), while the positive predictive value was 0.75 (95% CI, 0.68-0.82). CONCLUSION The IVC/Ao ratio was insufficient to exclude or confirm significant dehydration in pediatric patients. More studies are needed, especially multicenter, adequately powered diagnostic research, to will help establish the usefulness of the IVC/Ao ratio.
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Affiliation(s)
| | - Michelle Imanuelly
- Department of Pediatrics, Universitas Pelita Harapan, Jakarta, Indonesia
| | - Johan Wibowo
- Department of Pediatrics, Universitas Pelita Harapan, Jakarta, Indonesia
| | | | - Melanie Widjaja
- Department of Pediatrics, Universitas Pelita Harapan, Jakarta, Indonesia
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Kaminecki I, Huang DM, Shipman PC, Gibson RW. Point-of-Care Ultrasonography for the Assessment of Dehydration in Children: A Systematic Review. Pediatr Emerg Care 2023; 39:786-796. [PMID: 37562138 DOI: 10.1097/pec.0000000000003025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
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.
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Point-of-Care Noninvasive Technology for Pediatric Dehydration Assessment. Pediatr Emerg Care 2022:00006565-990000000-00155. [PMID: 36252055 DOI: 10.1097/pec.0000000000002824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
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.
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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. Prehosp Disaster Med 2022; 37:474-479. [PMID: 35611835 DOI: 10.1017/s1049023x22000838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Levine AC, O’Connell KJ, Schnadower D, VanBuren TJM, Mahajan P, Hurley KF, Tarr P, Olsen CS, Poonai N, Schuh S, Powell EC, Farion KJ, Sapien RE, Roskind CG, Rogers AJ, Bhatt S, Gouin S, Vance C, Freedman SB. Derivation of the Pediatric Acute Gastroenteritis Risk Score to Predict Moderate-to-Severe Acute Gastroenteritis. J Pediatr Gastroenterol Nutr 2022; 74:446-453. [PMID: 35129163 PMCID: PMC9203936 DOI: 10.1097/mpg.0000000000003395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Although most acute gastroenteritis (AGE) episodes in children rapidly self-resolve, some children go on to experience more significant and prolonged illness. We sought to develop a prognostic score to identify children at risk of experiencing moderate-to-severe disease after an index emergency department (ED) visit. METHODS Data were collected from a cohort of children 3 to 48 months of age diagnosed with AGE in 16 North American pediatric EDs. Moderate-to-severe AGE was defined as a Modified Vesikari Scale (MVS) score ≥9 during the 14-day post-ED visit. A clinical prognostic model was derived using multivariable logistic regression and converted into a simple risk score. The model's accuracy was assessed for moderate-to-severe AGE and several secondary outcomes. RESULTS After their index ED visit, 19% (336/1770) of participants developed moderate-to-severe AGE. Patient age, number of vomiting episodes, dehydration status, prior ED visits, and intravenous rehydration were associated with MVS ≥9 in multivariable regression. Calibration of the prognostic model was strong with a P value of 0.77 by the Hosmer-Lemenshow goodness-of-fit test, and discrimination was moderate with an area under the receiver operator characteristic curve of 0.68 (95% confidence interval [CI] 0.65-0.72). Similarly, the model was shown to have good calibration when fit to the secondary outcomes of subsequent ED revisit, intravenous rehydration, or hospitalization within 72 hours after the index visit. CONCLUSIONS After external validation, this new risk score may provide clinicians with accurate prognostic insight into the likely disease course of children with AGE, informing disposition decisions, anticipatory guidance, and follow-up care.
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Affiliation(s)
- Adam C. Levine
- Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children’s Hospital and Brown University, Providence, RI
| | - Karen J. O’Connell
- Division of Emergency Medicine, Children’s National Hospital, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | - Prashant Mahajan
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Michigan
- Wayne State University, Detroit
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI
| | - Katrina F. Hurley
- Department of Emergency Medicine, IWK Health, Halifax, Nova Scotia, Canada
| | - Phillip Tarr
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Naveen Poonai
- Departments of Pediatrics, Internal Medicine, Epidemiology & Biostatistics, Schulich School of Medicine and Dentistry
- Children’s Health Research Institute, London Health Sciences Centre, London
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, SickKids Research Institute, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth C. Powell
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, IL
| | - Ken J. Farion
- Departments of Pediatrics and Emergency Medicine, University of Ottawa
- Pediatric Emergency Department, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Robert E. Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Cindy G. Roskind
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Alexander J. Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI
| | - Seema Bhatt
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Serge Gouin
- Departments of Pediatric Emergency Medicine & Pediatrics, Université de Montréal, Montréal, Quebec, Canada
| | - Cheryl Vance
- Departments of Pediatrics and Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA
| | - Stephen B. Freedman
- Divisions of Pediatric Emergency Medicine and Gastroenterology, Alberta, Children’s Hospital, Alberta, Canada
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB
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Kamugisha JGK, Lanyero B, Nabukeera-Barungi N, Nambuya-Lakor H, Ritz C, Mølgaard C, Michaelsen KF, Briend A, Mupere E, Friis H, Grenov B. Weight and mid-upper arm circumference gain velocities during treatment of young children with severe acute malnutrition, a prospective study in Uganda. BMC Nutr 2021; 7:26. [PMID: 34140028 PMCID: PMC8212498 DOI: 10.1186/s40795-021-00428-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/01/2021] [Indexed: 11/23/2022] Open
Abstract
Background Weight gain is routinely monitored to assess hydration and growth during treatment of children with complicated severe acute malnutrition (SAM). However, changes in weight and mid-upper arm circumference (MUAC) gain velocities over time are scarcely described. We assessed weight and MUAC gain velocities in 6–59 mo-old children with complicated SAM by treatment phase and edema status. Methods This was a prospective study, nested in a randomized/probiotic trial (ISRCTN16454889). Weight and MUAC gain velocities were assessed by treatment phase and edema at admission using linear mixed-effects models. Results Among 400 children enrolled, the median (IQR) age was 15.0 (11.2;19.2) months, 58% were males, and 65% presented with edema. During inpatient therapeutic care (ITC), children with edema vs no edema at admission had negative weight gain velocity in the stabilization phase [differences at day 3 and 4 were − 11.26 (95% CI: − 20.73; − 1.79) g/kg/d and − 13.09 (95% CI: − 23.15; − 3.02) g/kg/d, respectively]. This gradually changed into positive weight gain velocity in transition and eventually peaked at 12 g/kg/d early in the rehabilitation phase, with no difference by edema status (P > 0.9). During outpatient therapeutic care (OTC), overall, weight gain velocity showed a decreasing trend over time (from 5 to 2 g/kg/d), [difference between edema and non-edema groups at week 2 was 2.1 (95% CI: 1.0;3.2) g/kg/d]. MUAC gain velocity results mirrored those of weight gain velocity [differences were − 2.30 (95% CI: − 3.6; − 0.97) mm/week at week 1 in ITC and 0.65 (95% CI: − 0.07;1.37) mm/week at week 2 in OTC]. Conclusions Weight and MUAC gain velocities among Ugandan children with complicated SAM showed an increasing trend during transition and early in the rehabilitation phase, and a decreasing trend thereafter, but, overall, catch-up growth was prolonged. Further research to establish specific cut-offs to assess weight and MUAC gain velocities during different periods of rehabilitation is needed. Supplementary Information The online version contains supplementary material available at 10.1186/s40795-021-00428-0.
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Affiliation(s)
- Jolly G K Kamugisha
- Mwanamugimu Nutrition Unit, Department of Pediatrics, Mulago National Referral Hospital, P.O. Box 7051, Kampala, Uganda. .,Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark.
| | - Betty Lanyero
- Mwanamugimu Nutrition Unit, Department of Pediatrics, Mulago National Referral Hospital, P.O. Box 7051, Kampala, Uganda
| | - Nicolette Nabukeera-Barungi
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Harriet Nambuya-Lakor
- Mwanamugimu Nutrition Unit, Department of Pediatrics, Mulago National Referral Hospital, P.O. Box 7051, Kampala, Uganda.,Department of Pediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark.,Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Arvo building, Arvo Ylpön katu 34, FIN-33014 Tampere University, Tampere, Finland
| | - Ezekiel Mupere
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark
| | - Benedikte Grenov
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark
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Bennet D, Khorsandian Y, Pelusi J, Mirabella A, Pirrotte P, Zenhausern F. Molecular and physical technologies for monitoring fluid and electrolyte imbalance: A focus on cancer population. Clin Transl Med 2021; 11:e461. [PMID: 34185420 PMCID: PMC8214861 DOI: 10.1002/ctm2.461] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/11/2021] [Accepted: 05/29/2021] [Indexed: 12/23/2022] Open
Abstract
Several clinical examinations have shown the essential impact of monitoring (de)hydration (fluid and electrolyte imbalance) in cancer patients. There are multiple risk factors associated with (de)hydration, including aging, excessive or lack of fluid consumption in sports, alcohol consumption, hot weather, diabetes insipidus, vomiting, diarrhea, cancer, radiation, chemotherapy, and use of diuretics. Fluid and electrolyte imbalance mainly involves alterations in the levels of sodium, potassium, calcium, and magnesium in extracellular fluids. Hyponatremia is a common condition among individuals with cancer (62% of cases), along with hypokalemia (40%), hypophosphatemia (32%), hypomagnesemia (17%), hypocalcemia (12%), and hypernatremia (1-5%). Lack of hydration and monitoring of hydration status can lead to severe complications, such as nausea/vomiting, diarrhea, fatigue, seizures, cell swelling or shrinking, kidney failure, shock, coma, and even death. This article aims to review the current (de)hydration (fluid and electrolyte imbalance) monitoring technologies focusing on cancer. First, we discuss the physiological and pathophysiological implications of fluid and electrolyte imbalance in cancer patients. Second, we explore the different molecular and physical monitoring methods used to measure fluid and electrolyte imbalance and the measurement challenges in diverse populations. Hydration status is assessed in various indices; plasma, sweat, tear, saliva, urine, body mass, interstitial fluid, and skin-integration techniques have been extensively investigated. No unified (de)hydration (fluid and electrolyte imbalance) monitoring technology exists for different populations (including sports, elderly, children, and cancer). Establishing novel methods and technologies to facilitate and unify measurements of hydration status represents an excellent opportunity to develop impactful new approaches for patient care.
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Affiliation(s)
- Devasier Bennet
- Center for Applied NanoBioscience and MedicineThe University of ArizonaCollege of MedicinePhoenixUSA
| | - Yasaman Khorsandian
- Center for Applied NanoBioscience and MedicineThe University of ArizonaCollege of MedicinePhoenixUSA
| | | | | | - Patrick Pirrotte
- Collaborative Center for Translational Mass SpectrometryTranslational Genomics Research InstitutePhoenixUSA
| | - Frederic Zenhausern
- Center for Applied NanoBioscience and MedicineThe University of ArizonaCollege of MedicinePhoenixUSA
- HonorHealth Research InstituteScottsdaleUSA
- Collaborative Center for Translational Mass SpectrometryTranslational Genomics Research InstitutePhoenixUSA
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Levine AC, Barry MA, Gainey M, Nasrin S, Qu K, Schmid CH, Nelson EJ, Garbern SC, Monjory M, Rosen R, Alam NH. Derivation of the first clinical diagnostic models for dehydration severity in patients over five years with acute diarrhea. PLoS Negl Trop Dis 2021; 15:e0009266. [PMID: 33690646 PMCID: PMC7984611 DOI: 10.1371/journal.pntd.0009266] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/22/2021] [Accepted: 02/23/2021] [Indexed: 12/31/2022] Open
Abstract
Diarrheal diseases lead to an estimated 1.3 million deaths each year, with the majority of those deaths occurring in patients over five years of age. As the severity of diarrheal disease can vary widely, accurately assessing dehydration status remains the most critical step in acute diarrhea management. The objective of this study is to empirically derive clinical diagnostic models for assessing dehydration severity in patients over five years with acute diarrhea in low resource settings. We enrolled a random sample of patients over five years with acute diarrhea presenting to the icddr,b Dhaka Hospital. Two blinded nurses independently assessed patients for symptoms/signs of dehydration on arrival. Afterward, consecutive weights were obtained to determine the percent weight change with rehydration, our criterion standard for dehydration severity. Full and simplified ordinal logistic regression models were derived to predict the outcome of none (<3%), some (3-9%), or severe (>9%) dehydration. The reliability and accuracy of each model were assessed. Bootstrapping was used to correct for over-optimism and compare each model's performance to the current World Health Organization (WHO) algorithm. 2,172 patients were enrolled, of which 2,139 (98.5%) had complete data for analysis. The Inter-Class Correlation Coefficient (reliability) was 0.90 (95% CI = 0.87, 0.91) for the full model and 0.82 (95% CI = 0.77, 0.86) for the simplified model. The area under the Receiver-Operator Characteristic curve (accuracy) for severe dehydration was 0.79 (95% CI: 0.76-0.82) for the full model and 0.73 (95% CI: 0.70, 0.76) for the simplified model. The accuracy for both the full and simplified models were significantly better than the WHO algorithm (p<0.001). This is the first study to empirically derive clinical diagnostic models for dehydration severity in patients over five years. Once prospectively validated, the models may improve management of patients with acute diarrhea in low resource settings.
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Affiliation(s)
- Adam C. Levine
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
| | - Meagan A. Barry
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
| | - Monique Gainey
- Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Sabiha Nasrin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Kexin Qu
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Christopher H. Schmid
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Eric J. Nelson
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, United States of America
| | - Stephanie C. Garbern
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
| | - Mahmuda Monjory
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Rochelle Rosen
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Nur H. Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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10
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Rosengarten L. How to manage the care of the dehydrated child. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2019; 28:1366-1368. [PMID: 31778337 DOI: 10.12968/bjon.2019.28.21.1366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Leah Rosengarten
- Lecturer in Children's Nursing, Department of Health and Life Sciences, University of Northumbria, Newcastle upon Tyne
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11
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Gainey M, Barry M, Levine AC, Nasrin S. Developing a Novel Mobile Health (mHealth) Tool to Improve Dehydration Assessment and Management in Patients with Acute Diarrhea in Resource-Limited Settings. RHODE ISLAND MEDICAL JOURNAL (2013) 2019; 102:36-39. [PMID: 31480818 PMCID: PMC7266095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Dehydration due to diarrhea is one of the main causes of death worldwide, yet no clinical tools for accurately assessing and managing dehydration in patients with acute diarrhea have been created for low- and middle-income countries (LMICs). In 2012, Brown University's Department of Emergency Medicine began partnering with the International Centre for Diarrhoeal Disease, Bangladesh in order to address some of these gaps. Out of this partnership, the DHAKA Score, a clinical diagnostic model for assessing dehydration in children under five years of age with acute diarrhea, was developed. Building upon the success of the DHAKA Study, researchers at both institutions have launched the NIRUDAK Study earlier this year to develop and validate similar age-specific clinical diagnostic models yet shifting the patient population to those over five. Improving diagnostic approaches and fluid management may reduce unnecessary utilization of already limited healthcare resources as well as the morbidity and mortality that occurs due to misdiagnosis.
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Affiliation(s)
- Monique Gainey
- Clinical Research Program Coordinator, Rhode Island Hospital
| | - Meagan Barry
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University
| | | | - Sabiha Nasrin
- Medical Officer, International Centre for Diarrheal Disease, Bangladesh icddr,b
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12
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Caruggi S, Rossi M, De Giacomo C, Luini C, Ruggiero N, Salvatoni A, Salvatore S. Pediatric Dehydration Assessment at Triage: Prospective Study on Refilling Time. Pediatr Gastroenterol Hepatol Nutr 2018; 21:278-288. [PMID: 30345241 PMCID: PMC6182472 DOI: 10.5223/pghn.2018.21.4.278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 04/20/2018] [Accepted: 04/23/2018] [Indexed: 01/02/2023] Open
Abstract
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.
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Affiliation(s)
- Samuele Caruggi
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | - Martina Rossi
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | | | - Chiara Luini
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | - Nicola Ruggiero
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | - Alessandro Salvatoni
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | - Silvia Salvatore
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
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13
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Stenson EK, Punn R, Ramsi M, Kache S. A Retrospective Evaluation of Echocardiograms to Establish Normative Inferior Vena Cava and Aortic Measurements for Children Younger Than 6 Years. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2225-2233. [PMID: 29480561 DOI: 10.1002/jum.14574] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/29/2017] [Accepted: 12/02/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The ability to plot the inferior vena cava (IVC) size on a normal curve for pediatric patients may prove beneficial. First, in patients with normal cardiac anatomy who present in shock, assessing IVC size may be valuable for evaluating the degree of dehydration. Second, in children with heart disease, understanding how a child's IVC size compares to normal could be particularly beneficial for patients with right heart disease. We sought to create normal curves for the IVC and aorta in children younger than 6 years. METHODS Data were gathered from 347 echocardiograms of healthy children younger than 6 years in a retrospective study at a quaternary care children's hospital. From the subcostal long- and short-axis images, maximum diameters in the transverse and longitudinal views were obtained for both the IVC and the aorta. RESULTS Both IVC and aortic dimensions increased in a linear fashion and had excellent correlations with the body surface area, body mass, and height (IVC, r = 0.78-0.81; P < .0001; aorta, r = 0.82-0.86; P < .0001). CONCLUSIONS In children younger than 6 years, the IVC and aorta increase linearly as the children grow. Such normal curves will be beneficial for assessing a pediatric patient's hydration status or right heart function in patients with congenital heart disease.
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Affiliation(s)
- Erin K Stenson
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rajesh Punn
- Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Musaab Ramsi
- Department of Pediatric Critical Care, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Saraswati Kache
- Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California, USA
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14
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Abstract
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.
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15
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Pomorska D, Dziechciarz P, Mduma E, Gidion J, Falszewska A, Szajewska H. Comparison of three dehydration scales showed that they were of limited or no value for assessing small children with acute diarrhoea. Acta Paediatr 2018; 107:1283-1287. [PMID: 29461647 DOI: 10.1111/apa.14284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/27/2017] [Accepted: 02/14/2018] [Indexed: 01/29/2023]
Abstract
AIM We explored the diagnostic accuracy of the clinical dehydration scale (CDS), the World Health Organization (WHO) scale and the Gorelick scale for assessing dehydration in children admitted to a Tanzanian referral hospital. METHODS This was a prospective, observational study, carried out from April 2015 to January 2017 on children aged one month to five years admitted to the hospital with acute diarrhoea lasting less than five days. Before rehydration therapy, each patient's weight was recorded and the degree of dehydration was assessed based on the three scales. The reference standard was the percentage weight change between admission and discharge. The main outcomes were the sensitivity, specificity and positive and negative likelihood ratios (LRs) of the scales. RESULTS Data from 124 eligible patients were available. The CDS showed limited value for ruling in cases with some dehydration (LR 1.9, 95% confidence interval 1.1-2.8), but was of no value in assessing no and moderate to severe dehydration. The WHO and Gorelick scales were of no value in evaluating any degree of dehydration. CONCLUSION The WHO and Gorelick dehydration scales were no use for assessing dehydration in small children, and the CDS was of limited use for predicting cases with some dehydration.
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Affiliation(s)
- Dominika Pomorska
- Department of Paediatrics and Clinical Decisions Unit; The Medical University of Warsaw; Warsaw Poland
| | - Piotr Dziechciarz
- Department of Paediatrics; The Medical University of Warsaw; Warsaw Poland
| | - Esto Mduma
- Haydom Global Health Institute; Haydom Tanzania
| | - Joshua Gidion
- Department of Paediatrics; Haydom Lutheran Hospital; Haydom Tanzania
| | - Anna Falszewska
- Department of Paediatrics; The Medical University of Warsaw; Warsaw Poland
| | - Hania Szajewska
- Department of Paediatrics; The Medical University of Warsaw; Warsaw Poland
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Bilal S, Nelson E, Meisner L, Alam M, Al Amin S, Ashenafi Y, Teegala S, Khan AF, Alam N, Levine A. Evaluation of Standard and Mobile Health-Supported Clinical Diagnostic Tools for Assessing Dehydration in Patients with Diarrhea in Rural Bangladesh. Am J Trop Med Hyg 2018; 99:171-179. [PMID: 29761756 DOI: 10.4269/ajtmh.17-0648] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Saadiyah Bilal
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Eric Nelson
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida
| | - Lars Meisner
- Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Mahfuj Alam
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Saad Al Amin
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Yokabed Ashenafi
- Brown University School of Public Health, Providence, Rhode Island
| | | | - Al Fazal Khan
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Nur Alam
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Adam Levine
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island
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17
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Falszewska A, Szajewska H, Dziechciarz P. Diagnostic accuracy of three clinical dehydration scales: a systematic review. Arch Dis Child 2018; 103:383-388. [PMID: 29089317 DOI: 10.1136/archdischild-2017-313762] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/23/2017] [Accepted: 09/26/2017] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Anna Falszewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Piotr Dziechciarz
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
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18
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Wang SSY, Tang GWG, Williams G. Pulsus trigeminy and electrolyte derangements: a forgotten primary care presentation. J Prim Health Care 2018; 10:348-351. [DOI: 10.1071/hc18052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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19
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Abstract
The survival of a child with severe volume depletion at the emergency department depends on the competency of the first responder to recognize and promptly treat hypovolemic shock. Although the basic principles on fluid and electrolytes therapy have been investigated for decades, the topic remains a challenge, as consensus on clinical management protocol is difficult to reach, and more adverse events are reported from fluid administration than for any other drug. While the old principles proposed by Holliday and Segar, and Finberg have stood the test of time, recent systematic reviews and meta-analyses have highlighted the risk of hyponatraemia, and hyponatraemic encephalopathy in some children treated with hypotonic fluids. In the midst of conflicting literature on fluid and electrolytes therapy, it would appear that isotonic fluids are best suitable for the correction of hypotonic, isonatraemic, and hypernatraemic dehydration. Although oral rehydration therapy is adequate to correct mild to moderate isonatraemic dehydration, parenteral fluid therapy is safer for the child with severe dehydration and those with changes in serum sodium. The article reviews the pathophysiology of water and sodium metabolism and, it uses the clinical case examples to illustrate the bed-side approach to the management of three different types of dehydration using a pre-mixed isotonic fluid solution (with 20 or 40 mmol/L of potassium chloride added depending on the absence or presence of hypokalemia, respectively). When 3% sodium chloride is unavailable to treat hyponatraemic encephalopathy, 0.9% sodium chloride becomes inevitable, albeit, a closer monitoring of serum sodium is required. The importance of a keen and regular clinical and laboratory monitoring of a child being rehydrated is emphasized. The article would be valuable to clinicians in less-developed countries, who must use pre-mixed fluids, and who often cannot get some suitable rehydrating solutions.
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Affiliation(s)
- Emmanuel Ademola Anigilaje
- Nephrology Unit, Department of Paediatrics, College of Health Sciences, University of Abuja, Abuja, Nigeria
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20
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Hall JE, Huynh PP, Mody AP, Wang VJ. Clinical Utility of Noninvasive Method to Measure Specific Gravity in the Pediatric Population. J Emerg Med 2017; 54:440-446. [PMID: 29246433 DOI: 10.1016/j.jemermed.2017.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/10/2017] [Accepted: 11/18/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clinicians rely on any combination of signs and symptoms, clinical scores, or invasive procedures to assess the hydration status in children. Noninvasive tests to evaluate for dehydration in the pediatric population are appealing. OBJECTIVE The objective of our study is to assess the utility of measuring specific gravity of tears compared to specific gravity of urine and the clinical assessment of dehydration. METHODS We conducted a prospective cohort convenience sample study, in a pediatric emergency department at a tertiary care children's hospital. We approached parents/guardians of children aged 6 months to 4 years undergoing transurethral catheterization for evaluation of urinary tract infection for enrollment. We collected tears and urine for measurement of tear specific gravity (TSG) and urine specific gravity (USG), respectively. Treating physicians completed dehydration assessment forms to assess for hydration status. RESULTS Among the 60 participants included, the mean TSG was 1.0183 (SD = 0.007); the mean USG was 1.0186 (SD = 0.0083). TSG and USG were positively correlated with each other (Pearson Correlation = 0.423, p = 0.001). Clinical dehydration scores ranged from 0 to 3, with 87% assigned a score of 0, by physician assessment. Mean number of episodes of vomiting and diarrhea in a 24-hour period were 2.2 (SD = 3.9) and 1.5 (SD = 3.2), respectively. Sixty-two percent of parents reported decreased oral intake. CONCLUSION TSG measurements yielded similar results compared with USG. Further studies are needed to determine if TSG can be used as a noninvasive method of dehydration assessment in children.
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Affiliation(s)
- Jeanine E Hall
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Pauline P Huynh
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ameer P Mody
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Vincent J Wang
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California
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Sheridan DC, Baker SD, Kayser SA, Jones D, Hansen ML. Variability of Capillary Refill Time among Physician Measurements. J Emerg Med 2017; 53:e51-e57. [PMID: 28941555 DOI: 10.1016/j.jemermed.2017.06.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 06/07/2017] [Accepted: 06/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The assessment of capillary refill time (CRT) is a common physical examination technique. However, despite its importance and its widespread use, there is little standardization, which can lead to inaccurate assessments. OBJECTIVE In this article, we assessed how different physicians estimate CRT. We hypothesized that when different physicians are presented with the same recordings of CRT, clinicians will, on average, provide different CRT estimates. METHODS Using recordings of different fingertip compressions, physicians assessed and documented when capillary refill had returned to normal. Videos were recorded of the fingertips only, with no other identifying markers or subject characteristics provided. Videos were shown at one-quarter speed to allow time for recognition and response to the capillary refill. The primary outcome was physician estimates of CRT for each video recording. RESULTS An analysis of variance regression revealed significant differences in physician estimates of CRT when examining the same CRT videos from 34 subjects. Further regression analyses reveal the importance of controlling for the physician that is examining the patient when predicting a patient's CRT. CONCLUSIONS Results indicate that some physicians gave, on average, slower CRT estimates, whereas others gave, on average, faster CRT estimates. Objective approaches and innovations in assessment of capillary refill have the potential to increase the diagnostic accuracy of this important clinical examination finding.
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Affiliation(s)
- David C Sheridan
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Steven D Baker
- Research and Development, Welch Allyn Inc., Beaverton, Oregon
| | - Susan A Kayser
- Research and Development, Hill-Rom Holdings Inc., Batesville, Indiana
| | - David Jones
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Matthew L Hansen
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
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22
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Falszewska A, Dziechciarz P, Szajewska H. Diagnostic accuracy of clinical dehydration scales in children. Eur J Pediatr 2017; 176:1021-1026. [PMID: 28573405 DOI: 10.1007/s00431-017-2942-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/18/2017] [Accepted: 05/22/2017] [Indexed: 12/22/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Anna Falszewska
- Department of Paediatrics, The Medical University of Warsaw, Zwirki i Wigury 63A, 02-091, Warsaw, Poland
| | - Piotr Dziechciarz
- Department of Paediatrics, The Medical University of Warsaw, Zwirki i Wigury 63A, 02-091, Warsaw, Poland
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Zwirki i Wigury 63A, 02-091, Warsaw, Poland.
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Investigation of the feasibility of non-invasive optical sensors for the quantitative assessment of dehydration. Med Eng Phys 2017; 48:181-187. [PMID: 28734875 DOI: 10.1016/j.medengphy.2017.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 03/07/2017] [Accepted: 06/20/2017] [Indexed: 11/21/2022]
Abstract
This study explores the feasibility of prospectively assessing infant dehydration using four non-invasive, optical sensors based on the quantitative and objective measurement of various clinical markers of dehydration. The sensors were investigated to objectively and unobtrusively assess the hydration state of an infant based on the quantification of capillary refill time (CRT), skin recoil time (SRT), skin temperature profile (STP) and skin tissue hydration by means of infrared spectrometry (ISP). To evaluate the performance of the sensors a clinical study was conducted on a cohort of 10 infants (aged 6-36 months) with acute gastroenteritis. High sensitivity and specificity were exhibited by the sensors, in particular the STP and SRT sensors, when combined into a fusion regression model (sensitivity: 0.90, specificity: 0.78). The SRT and STP sensors and the fusion model all outperformed the commonly used "gold standard" clinical dehydration scales including the Gorelick scale (sensitivity: 0.56, specificity: 0.56), CDS scale (sensitivity: 1.0, specificity: 0.2) and WHO scale (sensitivity: 0.13, specificity: 0.79). These results suggest that objective and quantitative assessment of infant dehydration may be possible using the sensors investigated. However, further evaluation of the sensors on a larger sample population is needed before deploying them in a clinical setting.
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Andrews JR, Leung DT, Ahmed S, Malek MA, Ahmed D, Begum YA, Qadri F, Ahmed T, Faruque ASG, Nelson EJ. Determinants of severe dehydration from diarrheal disease at hospital presentation: Evidence from 22 years of admissions in Bangladesh. PLoS Negl Trop Dis 2017; 11:e0005512. [PMID: 28448489 PMCID: PMC5423662 DOI: 10.1371/journal.pntd.0005512] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 05/09/2017] [Accepted: 03/20/2017] [Indexed: 11/19/2022] Open
Abstract
Background To take advantage of emerging opportunities to reduce morbidity and mortality from diarrheal disease, we need to better understand the determinants of life-threatening severe dehydration (SD) in resource-poor settings. Methodology/findings We analyzed records of patients admitted with acute diarrheal disease over twenty-two years at the International Centre for Diarrhoeal Disease Research, Bangladesh (1993–2014). Patients presenting with and without SD were compared by multivariable logistic regression models, which included socio-demographic factors and pathogens isolated. Generalized additive models evaluated non-linearities between age or household income and SD. Among 55,956 admitted patients, 13,457 (24%) presented with SD. Vibrio cholerae was the most common pathogen isolated (12,405 patients; 22%), and had the strongest association with SD (AOR 4.77; 95% CI: 4.41–5.51); detection of multiple pathogens did not exacerbate SD risk. The highest proportion of severely dehydrated patients presented in a narrow window only 4–12 hours after symptom onset. Risk of presenting with SD increased sharply from zero to ten years of age and remained high throughout adolescence and adulthood. Adult women had a 38% increased odds (AOR 1.38; 95% CI: 1.30–1.46) of SD compared to adult men. The probability of SD increased sharply at low incomes. These findings were consistent across pathogens. Conclusions/significance There remain underappreciated populations vulnerable to life-threatening diarrheal disease that include adult women and the very poor. In addition to efforts that address diarrheal disease in young children, there is a need to develop interventions for these other high-risk populations that are accessible within 4 hours of symptom onset. To best help patients with diarrheal disease, we need to better understand what causes patients to tip from mild disease to severe disease. In this study, we analyzed records of patients presenting to one of the largest hospitals in the world dedicated to the management of diarrheal diseases. Patients with and without severe dehydration (SD) were compared at multiple-levels. We found that: (i) Patients presented with SD after only 4 to 12 hours of symptoms. (ii) The risk of presenting with SD was higher in older children and adult women; suggesting that people might seek help differently based on age and gender. (iii) The extreme poor had a dramatically increased risk of presenting with SD. In summary, these findings highlight the need for rapid interventions that target older children and adult women in addition to ongoing efforts focused on young children.
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Affiliation(s)
- Jason R. Andrews
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Daniel T. Leung
- Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- Division of Microbiology and Immunology, Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Shahnawaz Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammed Abdul Malek
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Dilruba Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Yasmin Ara Begum
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Firdausi Qadri
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu Syed Golam Faruque
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Eric J. Nelson
- Emerging Pathogens Institute and Child Health Research Institute, Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL, United States of America
- Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States of America
- * E-mail:
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Clinical Practice Guideline for the Treatment of Pediatric Acute Gastroenteritis in the Outpatient Setting. J Pediatr Health Care 2016; 30:610-616. [PMID: 27268427 DOI: 10.1016/j.pedhc.2016.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 04/08/2016] [Accepted: 04/21/2016] [Indexed: 11/20/2022]
Abstract
Acute gastroenteritis (AGE) is a common illness in childhood that usually can be treated in the outpatient setting. Inaccurate assessment or delayed treatment of AGE can lead to an increased risk for invasive interventions. A literature search was conducted using PubMed, CINAHL Plus, the Cochrane Library, and Embase. Results of the query were refined to narrow the focus of relevant studies for the provider caring for dehydrated children in the outpatient setting. Use of clinical dehydration scales to assess the level of dehydration and early initiation of oral rehydration therapy promote optimal patient outcomes. Oral rehydration therapy remains the best means of rehydrating, and ondansetron is a safe and effective adjunct to help children with persistent vomiting. The purpose of this practice guideline is to identify best practices for AGE in children older than 6 months with symptoms for less than 7 days who are being cared for in the outpatient setting.
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Na(+), K(+), Cl(-), acid-base or H2O homeostasis in children with urinary tract infections: a narrative review. Pediatr Nephrol 2016; 31:1403-9. [PMID: 26701834 DOI: 10.1007/s00467-015-3273-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 11/06/2015] [Accepted: 11/09/2015] [Indexed: 10/22/2022]
Abstract
Guidelines on the diagnosis and management of urinary tract infections in childhood do not address the issue of abnormalities in Na(+), K(+), Cl(-) and acid-base balance. We have conducted a narrative review of the literature with the aim to describe the underlying mechanisms of these abnormalities and to suggest therapeutic maneuvers. Abnormalities in Na(+), K(+), Cl(-) and acid-base balance are common in newborns and infants and uncommon in children of more than 3 years of age. Such abnormalities may result from factitious laboratory results, from signs and symptoms (such as excessive sweating, poor fluid intake, vomiting and passage of loose stools) of the infection itself, from a renal dysfunction, from improper parenteral fluid management or from the prescribed antimicrobials. In addition, two transient renal tubular dysfunctions may occur in infants with infectious renal parenchymal involvement: a reduced capacity to concentrate urine and pseudohypoaldosteronism secondary to renal tubular unresponsiveness to aldosterone that presents with hyponatremia, hyperkalemia and acidosis. In addition to antimicrobials, volume resuscitation with an isotonic solution is required in these children. In secondary pseudohypoaldosteronism, isotonic solutions (such as 0.9 % saline or lactated Ringer) correct not only the volume depletion but also the hyperkalemia and acidosis. In conclusion, our review suggests that in infants with infectious renal parenchymal involvement, non-renal and renal causes concur to cause fluid volume depletion and abnormalities in electrolyte and acid-base balance, most frequently hyponatremia.
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Levine AC, Glavis-Bloom J, Modi P, Nasrin S, Atika B, Rege S, Robertson S, Schmid CH, Alam NH. External validation of the DHAKA score and comparison with the current IMCI algorithm for the assessment of dehydration in children with diarrhoea: a prospective cohort study. LANCET GLOBAL HEALTH 2016; 4:e744-51. [PMID: 27567350 DOI: 10.1016/s2214-109x(16)30150-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 06/23/2016] [Accepted: 07/01/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dehydration due to diarrhoea is a leading cause of child death worldwide, yet no clinical tools for assessing dehydration have been validated in resource-limited settings. The Dehydration: Assessing Kids Accurately (DHAKA) score was derived for assessing dehydration in children with diarrhoea in a low-income country setting. In this study, we aimed to externally validate the DHAKA score in a new population of children and compare its accuracy and reliability to the current Integrated Management of Childhood Illness (IMCI) algorithm. METHODS DHAKA was a prospective cohort study done in children younger than 60 months presenting to the International Centre for Diarrhoeal Disease Research, Bangladesh, with acute diarrhoea (defined by WHO as three or more loose stools per day for less than 14 days). Local nurses assessed children and classified their dehydration status using both the DHAKA score and the IMCI algorithm. Serial weights were obtained and dehydration status was established by percentage weight change with rehydration. We did regression analyses to validate the DHAKA score and compared the accuracy and reliability of the DHAKA score and IMCI algorithm with receiver operator characteristic (ROC) curves and the weighted κ statistic. This study was registered with ClinicalTrials.gov, number NCT02007733. FINDINGS Between March 22, 2015, and May 15, 2015, 496 patients were included in our primary analyses. On the basis of our criterion standard, 242 (49%) of 496 children had no dehydration, 184 (37%) of 496 had some dehydration, and 70 (14%) of 496 had severe dehydration. In multivariable regression analyses, each 1-point increase in the DHAKA score predicted an increase of 0·6% in the percentage dehydration of the child and increased the odds of both some and severe dehydration by a factor of 1·4. Both the accuracy and reliability of the DHAKA score were significantly greater than those of the IMCI algorithm. INTERPRETATION The DHAKA score is the first clinical tool for assessing dehydration in children with acute diarrhoea to be externally validated in a low-income country. Further validation studies in a diverse range of settings and paediatric populations are warranted. FUNDING National Institutes of Health Fogarty International Center.
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Affiliation(s)
- Adam C Levine
- Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | | | - Payal Modi
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Sabiha Nasrin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Bita Atika
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Soham Rege
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Sarah Robertson
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| | - Christopher H Schmid
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| | - Nur H Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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Song IK, Kim DH, Kim EH, Lee JH, Kim JT, Kim HS. Efficacy of bioelectrical impedance analysis during the perioperative period in children. J Clin Monit Comput 2016; 31:625-630. [DOI: 10.1007/s10877-016-9881-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 04/15/2016] [Indexed: 01/19/2023]
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Kieser E, Dellimore K, Scheffer C, Visser C, Smith J. Development of diagnostic sensors for infant dehydration assessment using optical methods. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2015:5537-40. [PMID: 26737546 DOI: 10.1109/embc.2015.7319646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Dehydration resulting from acute diarrhea is one of the leading causes of infant mortality in the developing world. Safe assessment of an infant's hydration level is essential to determine appropriate clinical intervention strategies. However, clinical hydration scales, which are the current gold standard for non-invasive hydration assessment, are often unreliable in lower resource settings. This study presents the development and testing of non-invasive, optical sensors for the objective assessment of dehydration based on the quantitative measurement of skin recoil time, capillary refill time and skin temperature. The results obtained have demonstrated the basic feasibility of using optical sensors for the objective assessment of dehydration. However, several challenges must be overcome before these sensors can be applied in a clinical setting.
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Tardini G, Milani GP, Agostoni C, Vianello FA, Arturi E, Peeters GGAM, Grillo P, Celano R, Bertolozzi G, Fossali EF. Poor correlation between bioelectrical impedance analysis and post illness weight gain in gastroenteritis. Acta Paediatr 2015; 104:e417-9. [PMID: 25939457 DOI: 10.1111/apa.13035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 04/11/2015] [Accepted: 04/28/2015] [Indexed: 11/29/2022]
Affiliation(s)
- G Tardini
- Pediatric Emergency Department; Foundation IRCCS Ca' Granda; Ospedale Maggiore Policlinico; Milan Italy
| | - GP Milani
- Pediatric Emergency Department; Foundation IRCCS Ca' Granda; Ospedale Maggiore Policlinico; Milan Italy
| | - C Agostoni
- Department of Pediatrics; Foundation IRCCS Ca' Granda; Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - FA Vianello
- Pediatric Emergency Department; Foundation IRCCS Ca' Granda; Ospedale Maggiore Policlinico; Milan Italy
| | - E Arturi
- Pediatric Emergency Department; Foundation IRCCS Ca' Granda; Ospedale Maggiore Policlinico; Milan Italy
| | - GGAM Peeters
- Pediatric Emergency Department; Foundation IRCCS Ca' Granda; Ospedale Maggiore Policlinico; Milan Italy
| | - P Grillo
- Epidemiology Department; Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
| | - R Celano
- Pediatric Emergency Department; Foundation IRCCS Ca' Granda; Ospedale Maggiore Policlinico; Milan Italy
| | - G Bertolozzi
- Pediatric Emergency Department; Foundation IRCCS Ca' Granda; Ospedale Maggiore Policlinico; Milan Italy
| | - EF Fossali
- Pediatric Emergency Department; Foundation IRCCS Ca' Granda; Ospedale Maggiore Policlinico; Milan Italy
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Levine AC, Glavis-Bloom J, Modi P, Nasrin S, Rege S, Chu C, Schmid CH, Alam NH. Empirically Derived Dehydration Scoring and Decision Tree Models for Children With Diarrhea: Assessment and Internal Validation in a Prospective Cohort Study in Dhaka, Bangladesh. GLOBAL HEALTH: SCIENCE AND PRACTICE 2015; 3:405-18. [PMID: 26374802 PMCID: PMC4570015 DOI: 10.9745/ghsp-d-15-00097] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 07/10/2015] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Diarrhea remains one of the most common and most deadly conditions affecting children worldwide. Accurately assessing dehydration status is critical to determining treatment course, yet no clinical diagnostic models for dehydration have been empirically derived and validated for use in resource-limited settings. METHODS In the Dehydration: Assessing Kids Accurately (DHAKA) prospective cohort study, a random sample of children under 5 with acute diarrhea was enrolled between February and June 2014 in Bangladesh. Local nurses assessed children for clinical signs of dehydration on arrival, and then serial weights were obtained as subjects were rehydrated. For each child, the percent weight change with rehydration was used to classify subjects with severe dehydration (>9% weight change), some dehydration (3-9%), or no dehydration (<3%). Clinical variables were then entered into logistic regression and recursive partitioning models to develop the DHAKA Dehydration Score and DHAKA Dehydration Tree, respectively. Models were assessed for their accuracy using the area under their receiver operating characteristic curve (AUC) and for their reliability through repeat clinical exams. Bootstrapping was used to internally validate the models. RESULTS A total of 850 children were enrolled, with 771 included in the final analysis. Of the 771 children included in the analysis, 11% were classified with severe dehydration, 45% with some dehydration, and 44% with no dehydration. Both the DHAKA Dehydration Score and DHAKA Dehydration Tree had significant AUCs of 0.79 (95% CI = 0.74, 0.84) and 0.76 (95% CI = 0.71, 0.80), respectively, for the diagnosis of severe dehydration. Additionally, the DHAKA Dehydration Score and DHAKA Dehydration Tree had significant positive likelihood ratios of 2.0 (95% CI = 1.8, 2.3) and 2.5 (95% CI = 2.1, 2.8), respectively, and significant negative likelihood ratios of 0.23 (95% CI = 0.13, 0.40) and 0.28 (95% CI = 0.18, 0.44), respectively, for the diagnosis of severe dehydration. Both models demonstrated 90% agreement between independent raters and good reproducibility using bootstrapping. CONCLUSION This study is the first to empirically derive and internally validate accurate and reliable clinical diagnostic models for dehydration in a resource-limited setting. After external validation, frontline providers may use these new tools to better manage acute diarrhea in children.
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Affiliation(s)
- Adam C Levine
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Payal Modi
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Sabiha Nasrin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Soham Rege
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Chieh Chu
- Brown University School of Public Health, Department of Biostatistics, Providence, RI, USA
| | - Christopher H Schmid
- Brown University School of Public Health, Department of Biostatistics, Providence, RI, USA
| | - Nur H Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Freedman SB, Pasichnyk D, Black KJL, Fitzpatrick E, Gouin S, Milne A, Hartling L. Gastroenteritis Therapies in Developed Countries: Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0128754. [PMID: 26075617 PMCID: PMC4468143 DOI: 10.1371/journal.pone.0128754] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 04/09/2015] [Indexed: 01/27/2023] Open
Abstract
Context Gastroenteritis remains a leading cause of childhood morbidity. Objective Because prior reviews have focused on isolated symptoms and studies conducted in developing countries, this study focused on interventions commonly considered for use in developed countries. Intervention specific, patient-centered outcomes were selected. Data Sources MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, trial registries, grey literature, and scientific meetings. Study Selection Randomized controlled trials, conducted in developed countries, of children aged <18 years, with gastroenteritis, performed in emergency department or outpatient settings which evaluated oral rehydration therapy (ORT), antiemetics, probiotics or intravenous fluid administration rate. Data Extraction The study was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. Data were independently extracted by multiple investigators. Analyses employed random effects models. Results 31 trials (4,444 patients) were included. ORT: Compared with intravenous rehydration, hospitalization (RR 0.80, 95%CI 0.24, 2.71) and emergency department return visits (RR 0.86, 95%CI 0.39, 1.89) were similar. Antiemetics: Fewer children administered an antiemetic required intravenous rehydration (RR 0.40, 95%CI 0.26, 0.60) While the data could not be meta-analyzed, three studies reported that ondansetron administration does increase the frequency of diarrhea. Probiotics: No studies reported on the primary outcome, three studies evaluated hospitalization within 7 days (RR 0.87, 95%CI 0.25, 2.98). Rehydration: No difference in length of stay was identified for rapid vs. standard intravenous or nasogastric rehydration. A single study found that 5% dextrose in normal saline reduced hospitalizations compared with normal saline alone (RR 0.70, 95% CI 0.53, 0.92). Conclusions There is a paucity of patient-centered outcome evidence to support many interventions. Since ORT is a low-cost, non-invasive intervention, it should continue to be used. Routine probiotic use cannot be endorsed at this time in outpatient children with gastroenteritis. Despite some evidence that ondansetron administration increases diarrhea frequency, emergency department use leads to reductions in intravenous rehydration and hospitalization. No benefits were associated with ondansetron use following emergency department discharge.
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Affiliation(s)
- Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
| | - Dion Pasichnyk
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Karen J. L. Black
- Division of Pediatric Emergency Medicine, BC Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eleanor Fitzpatrick
- IWK Health Centre, Emergency Department, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Serge Gouin
- Section of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Andrea Milne
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Hoxha T, Xhelili L, Azemi M, Avdiu M, Ismaili-Jaha V, Efendija-Beqa U, Grajcevci-Uka V. Comparing the Accuracy of the Three Dehydration Scales in Children with Acute Diarrhea in a Developing Country of Kosovo. Mater Sociomed 2015; 27:140-3. [PMID: 26244042 PMCID: PMC4499304 DOI: 10.5455/msm.2015.27.140-143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 04/05/2015] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Teuta Hoxha
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo
| | - Luan Xhelili
- Department of Pediatrics, University Hospital Centre “Mother Teresa”, Tirana, Albania
| | - Mehmedali Azemi
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo
| | - Muharrem Avdiu
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo
| | - Vlora Ismaili-Jaha
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo
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Freedman SB, Vandermeer B, Milne A, Hartling L, Black K, Porter R, Joubert G, Gouin S, Doan Q, Williamson J, Aucoin L, Fitzpatrick E, Jabbour M, Klassen T. Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis. J Pediatr 2015; 166:908-16.e1-6. [PMID: 25641247 DOI: 10.1016/j.jpeds.2014.12.029] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/31/2014] [Accepted: 12/12/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the most accurate, noninvasive method of assessing dehydration. STUDY DESIGN The following data sources were searched: electronic databases, gray literature, scientific meetings, reference lists, and authors of unpublished studies. Eligible studies were comparative outpatient evaluations that used an accepted reference standard and were conducted in developed countries in children aged <18 years with gastroenteritis. Data extraction was completed independently by multiple reviewers before a consensus was made. RESULTS Nine studies that included 1039 participants were identified. The 4-item Clinical Dehydration Scale (CDS), the "Gorelick" score, and unstructured physician assessment were evaluated in 3, 2, and 5 studies, respectively. Bedside ultrasound, capillary digital videography, and urinary measurements were each evaluated in one study. The CDS had a positive likelihood ratio (LR) range of 1.87-11.79 and a negative LR range of 0.30-0.71 to predict 6% dehydration. When combined with the 4-item Gorelick Score, the positive LR was 1.93 (95% CI 1.07-3.49) and negative LR was of 0.40 (95% CI 0.24-0.68). Unstructured dehydration assessment had a pooled positive LR of 2.13 (95% CI 1.33-3.44) and negative LR of 0.48 (95% CI 0.28-0.82) to detect ≥ 5% dehydration. CONCLUSIONS Overall, the clinical scales evaluated provide some improved diagnostic accuracy. However, test characteristics indicate that their ability to identify children both with and without dehydration is suboptimal. Current evidence does not support the routine use of ultrasound or urinalysis to determine dehydration severity.
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Affiliation(s)
- Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea Milne
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Hoxha T, Xhelili L, Azemi M, Avdiu M, Ismaili-Jaha V, Efendija-Beqa U, Grajcevci-Uka V. Performance of clinical signs in the diagnosis of dehydration in children with acute gastroenteritis. Med Arch 2015; 69:10-2. [PMID: 25870468 PMCID: PMC4384849 DOI: 10.5455/medarh.2015.69.10-12] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/11/2014] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Acute evaluation and treatment of children presenting with dehydration represent one of the most common situation in the pediatric emergency department. To identify dehydration in infants and children before treatment, a number of symptoms and clinical signs have been evaluated. The aim of the study was to describe the performance of clinical signs in detecting dehydration in children. METHODS Two hundred children aged 1 month to 5 year were involved in our prospective study. The clinical assessment consisted of the ten clinical signs of dehydration, including those recommended by WHO (World Health Organization), heart rate, and capillary refill time. RESULTS Two hundred patients with diarrhea were enrolled in the study. The mean age was 15.62±9.03 months and 57.5% were male. Of these 121 had a fluid deficit of < 5%, 68 had a deficit of 5 to 9% and 11(5.5%) had a deficit of 10% or more. Patients classified as having no or mild, moderate, and severe dehydration were found to have the following respective gains in percent weight at the end of illness: 2.44±0.3, 6.05± 1.01 and, 10.66± 0.28, respectively. All clinical signs were found more frequently with increasing amounts of dehydration(p<0.001, One-way ANOVA). The median number of findings among subjects with no or mild dehydration (deficit <5%) was 3; among those with moderate dehydration (deficit 5% to 9%) was 6.5 and among those with severe dehydration (deficit >10%) the median was 9 (p<0.0001, Kruskal-Wallis test). Using stepwise linear regression and a p value of <0.05 for entry into the model, a four-variable model including sunken eyes, skin elasticity, week radial pulse, and general appearance was derived. CONCLUSION None of the 10 findings studied, is sufficiently accurate to be used in isolation. When considered together, sunken eyes, decreased skin turgor, weak pulse and general appearance provide the best explanatory power of the physical signs considered.
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Affiliation(s)
- Teuta Hoxha
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo
| | - Luan Xhelili
- Department of Pediatrics, University Hospital Centre "Mother Teresa", Tirana, Albania
| | - Mehmedali Azemi
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo
| | - Muharrem Avdiu
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo
| | - Vlora Ismaili-Jaha
- Pediatric Clinic, University Clinical Center of Kosova, Prishtina, Kosovo
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Abstract
Severe acute malnutrition (SAM) is associated with increased severity of common infectious diseases, and death amongst children with SAM is almost always as a result of infection. The diagnosis and management of infection are often different in malnourished versus well-nourished children. The objectives of this brief are to outline the evidence underpinning important practical questions relating to the management of infectious diseases in children with SAM and to highlight research gaps. Overall, the evidence base for many aspects covered in this brief is very poor. The brief addresses antimicrobials; antipyretics; tuberculosis; HIV; malaria; pneumonia; diarrhoea; sepsis; measles; urinary tract infection; nosocomial Infections; soil transmitted helminths; skin infections and pharmacology in the context of SAM. The brief is structured into sets of clinical questions, which we hope will maximise the relevance to contemporary practice.
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Key Words
- Antibiotics,
- Children,
- Diarrhoea,
- HIV,
- Infection,
- Malaria
- Malnutrition,
- Measles,
- Pneumonia,
- Sepsis,
- Tuberculosis,
- Urinary tract infection,
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Falszewska A, Dziechciarz P, Szajewska H. The diagnostic accuracy of Clinical Dehydration Scale in identifying dehydration in children with acute gastroenteritis: a systematic review. Clin Pediatr (Phila) 2014; 53:1181-8. [PMID: 24917533 DOI: 10.1177/0009922814538493] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM To systematically update diagnostic accuracy of the Clinical Dehydration Scale (CDS) in clinical recognition of dehydration in children with acute gastroenteritis. METHODS Six databases were searched for diagnostic accuracy studies in which population were children aged 1 to 36 months with acute gastroenteritis; index test was the CDS; and reference test was post-illness weight gain. RESULTS Three studies involving 360 children were included. Limited evidence showed that in high-income countries the CDS provides strong diagnostic accuracy for ruling in moderate and severe (>6%) dehydration (positive likelihood ratio 5.2-6.6), but has limited value for ruling it out (negative likelihood ratio 0.4-0.55). In low-income countries, the CDS has limited value either for ruling moderate or severe dehydration in or out. In both settings, the CDS had limited value for ruling in or out dehydration <3% or dehydration 3% to 6%. CONCLUSION The CDS can help assess moderate to severe dehydration in high-income settings. Given the limited data, the evidence should be viewed with caution.
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Affiliation(s)
- Anna Falszewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Piotr Dziechciarz
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
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Jauregui J, Nelson D, Choo E, Stearns B, Levine AC, Liebmann O, Shah SP. External validation and comparison of three pediatric clinical dehydration scales. PLoS One 2014; 9:e95739. [PMID: 24788134 PMCID: PMC4008432 DOI: 10.1371/journal.pone.0095739] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 03/28/2014] [Indexed: 11/23/2022] Open
Abstract
Objective To prospectively validate three popular clinical dehydration scales and overall physician gestalt in children with vomiting or diarrhea relative to the criterion standard of percent weight change with rehydration. Methods We prospectively enrolled a non-consecutive cohort of children ≤ 18 years of age with an acute episode of diarrhea or vomiting. Patient weight, clinical scale variables and physician clinical impression, or gestalt, were recorded before and after fluid resuscitation in the emergency department and upon hospital discharge. The percent weight change from presentation to discharge was used to calculate the degree of dehydration, with a weight change of ≥ 5% considered significant dehydration. Receiver operating characteristics (ROC) curves were constructed for each of the three clinical scales and physician gestalt. Sensitivity and specificity were calculated based on the best cut-points of the ROC curve. Results We approached 209 patients, and of those, 148 were enrolled and 113 patients had complete data for analysis. Of these, 10.6% had significant dehydration based on our criterion standard. The Clinical Dehydration Scale (CDS) and Gorelick scales both had an area under the ROC curve (AUC) statistically different from the reference line with AUCs of 0.72 (95% CI 0.60, 0.84) and 0.71 (95% CI 0.57, 0.85) respectively. The World Health Organization (WHO) scale and physician gestalt had AUCs of 0.61 (95% CI 0.45, 0.77) and 0.61 (0.44, 0.78) respectively, which were not statistically significant. Conclusion The Gorelick scale and Clinical Dehydration Scale were fair predictors of dehydration in children with diarrhea or vomiting. The World Health Organization scale and physician gestalt were not helpful predictors of dehydration in our cohort.
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Affiliation(s)
- Joshua Jauregui
- Warren Alpert Medical School Department of Emergency Medicine, Brown University, Providence, Rhode Island, United States of America
- Division of Emergency Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - Daniel Nelson
- Warren Alpert Medical School Department of Emergency Medicine, Brown University, Providence, Rhode Island, United States of America
| | - Esther Choo
- Warren Alpert Medical School Department of Emergency Medicine, Brown University, Providence, Rhode Island, United States of America
| | - Branden Stearns
- Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Adam C. Levine
- Warren Alpert Medical School Department of Emergency Medicine, Brown University, Providence, Rhode Island, United States of America
| | - Otto Liebmann
- Warren Alpert Medical School Department of Emergency Medicine, Brown University, Providence, Rhode Island, United States of America
| | - Sachita P. Shah
- Rhode Island Hospital, Providence, Rhode Island, United States of America
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Affiliation(s)
- Umesh D Parashar
- National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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Levine AC, Munyaneza RM, Glavis-Bloom J, Redditt V, Cockrell HC, Kalimba B, Kabemba V, Musavuli J, Gakwerere M, Umurungi JPDC, Shah SP, Drobac PC. Prediction of severe disease in children with diarrhea in a resource-limited setting. PLoS One 2013; 8:e82386. [PMID: 24349271 PMCID: PMC3857792 DOI: 10.1371/journal.pone.0082386] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 10/29/2013] [Indexed: 12/04/2022] Open
Abstract
Objective To investigate the accuracy of three clinical scales for predicting severe disease (severe dehydration or death) in children with diarrhea in a resource-limited setting. Methods Participants included 178 children admitted to three Rwandan hospitals with diarrhea. A local physician or nurse assessed each child on arrival using the World Health Organization (WHO) severe dehydration scale and the Centers for Disease Control (CDC) scale. Children were weighed on arrival and daily until they achieved a stable weight, with a 10% increase between admission weight and stable weight considered severe dehydration. The Clinical Dehydration Scale was then constructed post-hoc using the data collected for the other two scales. Receiver Operator Characteristic (ROC) curves were constructed for each scale compared to the composite outcome of severe dehydration or death. Results The WHO severe dehydration scale, CDC scale, and Clinical Dehydration Scale had areas under the ROC curves (AUCs) of 0.72 (95% CI 0.60, 0.85), 0.73 (95% CI 0.62, 0.84), and 0.80 (95% CI 0.71, 0.89), respectively, in the full cohort. Only the Clinical Dehydration Scale was a significant predictor of severe disease when used in infants, with an AUC of 0.77 (95% CI 0.61, 0.93), and when used by nurses, with an AUC of 0.78 (95% CI 0.63, 0.93). Conclusions While all three scales were moderate predictors of severe disease in children with diarrhea, scale accuracy varied based on provider training and age of the child. Future research should focus on developing or validating clinical tools that can be used accurately by nurses and other less-skilled providers to assess all children with diarrhea in resource-limited settings.
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Affiliation(s)
- Adam C. Levine
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
- * E-mail:
| | - Richard M. Munyaneza
- Department of Community Health, Rwanda Ministry of Health, Kigali, Kigali Province, Rwanda
| | - Justin Glavis-Bloom
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
| | - Vanessa Redditt
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hannah C. Cockrell
- Watson Institute for International Studies, Brown University, Providence, Rhode Island, United States of America
| | - Bantu Kalimba
- Department of Medicine, Kirehe Hospital, Kirehe, Eastern Province, Rwanda
| | - Valentin Kabemba
- Department of Medicine, Kirehe Hospital, Kirehe, Eastern Province, Rwanda
| | - Juvenal Musavuli
- Department of Medicine, Butaro Hospital, Butaro, Northern Province, Rwanda
| | - Mathias Gakwerere
- Department of Medicine, Butaro Hospital, Butaro, Northern Province, Rwanda
| | | | - Sachita P. Shah
- Division of Emergency Medicine, University of Washington Medical Center, Seattle, Washington, United States of America
| | - Peter C. Drobac
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Research Department, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Eastern Province, Rwanda
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Abstract
The bacterial colonization is defined immediately after birth, through direct contact with maternal microbiota and may be influenced during lactation. There is emerging evidence indicating that quantitative and qualitative changes on gut microbiota contribute to alterations in the mucosal activation of immune system leading to intra- or extra-intestinal diseases. A balance between pathogenic and beneficial microbiota throughout childhood and adolescence is important to gastrointestinal health, including protection against pathogens, inhibition of pathogens, nutrient processing (synthesis of vitamin K), stimulation of angiogenesis, and regulation of host fat storage. Probiotics can promote an intentional modulation of intestinal microbiota favoring the health of the host. This paper is a review about modulation of intestinal microbiota on prevention and adjuvant treatment of pediatric gastrointestinal diseases.
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Roland D, Clarke C, Borland M, Pascoe E. Adequately assessing dehydration: A holy grail of paediatric emergency medicine. Int J Emerg Med 2011; 4:71. [PMID: 22112643 PMCID: PMC3235962 DOI: 10.1186/1865-1380-4-71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 11/24/2011] [Indexed: 11/21/2022] Open
Affiliation(s)
- Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Emergency Department Secretaries c/o Elizabeth Cadman-Moore, Leicester Royal Infirmary, Leicester, LE1 5WW, UK.
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