Performance of clinical signs in the diagnosis of dehydration in children with acute gastroenteritis

Validity Analysis on the Findings of Dehydration in 2 to 24-Month-Old Children With Acute Diarrhea

OBJECTIVE

The most common cause of diarrheal mortality in children is dehydration. In this study, we aimed to assess the validity (sensitivity and specificity) of history and the clinical and laboratory findings in in the diagnosis of dehydration in children younger than 2 years with acute diarrhea.

METHODS

One hundred twenty-six 2 to 24-month-old children with acute diarrhea, who were admitted to Hacettepe University Ihsan Dogramaci Children's Hospital's Diarrheal Diseases Treatment and Training Unit, were included. The patients were examined on admission for clinical findings of dehydration. Percent weight loss on admission was calculated by using the weight on admission and the weight after the diarrhea resolution and was used as the golden standard for analyzing the validity of clinical and laboratory findings.

RESULTS

Compared with the golden standard, dehydration was overestimated in 13% of the cases and underestimated in 7% when using only the World Health Organization criteria. Dehydrated children had higher diarrheal frequency and longer anuria time. Thirst, weakness, sunken fontanelle, sunken eyes, decreased tears, dry mucous membranes, and dry lip were detected in children with 2% or greater of weight loss. The most valid laboratory findings were low serum pH (<7.30), low bicarbonate (<15 mmol/L), and hyperurisemia (>5.8 mg/dL). In multivariate analysis, physical findings, such as thirst, dry mucous membranes, weakness, sunken eyes, hoarse crying, and low pH, were found to be significant for the diagnosis of dehydration.

CONCLUSIONS

In children with acute diarrhea, diarrheal frequency and last urination time should be asked, thirst, dry mucous membranes, weakness, sunken eyes, and hoarse crying should be examined.

Molecular epidemiology of noroviruses in children under 5 years of age with acute gastroenteritis in Yaoundé, Cameroon

Norovirus is a common cause of acute gastroenteritis (AGE) among children in developing countries. Limited data on the prevalence and genetic variability of norovirus are available in Cameroon, where early childhood mortality due to AGE is common. We tested 902 fecal specimens from children younger than 5 years of age hospitalized with AGE between January 2010 and December 2013. Overall, 76 (8.4%) samples tested positive for norovirus, of which 83% (63/76) were among children below 12 months old. Most of the noroviruses detected were in children infected between July and December of each year. All norovirus-positive specimens were genotyped, with 80% (61/76) being GII.4 (three variants detected). Genotypes GI.2, GI.6, GII.1, GII.2, GII.3, GII.6, GII.16, GII.17, and GII.21 were also detected. Interestingly, GII.4 Sydney and GII.17 Kawasaki viruses were found as early as 2010, years before their emergence globally. This study suggests norovirus is a significant cause of moderate to severe gastroenteritis among young children in Cameroon. The results are important to highlight appropriate prevention and control strategies for reducing the burden of norovirus disease.

Pediatric Dehydration Assessment at Triage: Prospective Study on Refilling Time

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Accuracy of pediatric residents in determination of dehydration in children with gastroenteritis

Objective

The aim of the present study was to determine the accuracy of pediatric residents in diagnosis of dehydration in children with gastroenteritis.

Methods

This was a cross-sectional study in Dr. Sheikh Hospital, affiliated with Mashhad University of Medical Sciences (Mashhad, Iran), in 2016. One hundred fifteen children aged 1 month to 14 years with gastroenteritis were included according to easy sampling. All patients were weighed. Dehydration was scored as mild, moderate and severe by pediatric residents according to Nelson standard table including pulse rate, blood pressure, blood skin supplement, skin turgor, fontanel, mucus membrane, tear respiration and urine output criteria. Patients were rehydrated and reweighed consequently. Percent loss of body weight (PLBW) was calculated and compared with dehydration score. Statistical analysis was performed using SPSS windows program version 19 (SPSS Institute, Inc., Chicago, IL, USA).

Results

Of the115 children, 65 patients were male (56.5%) with the median age of 14.5 months. The Kendall's tau-b and Spearman correlation coefficient for residents' estimation and PLBW were 0.18 and 0.23 respectively (p=0.01 and 0.12 respectively). The ICC between estimated dehydration and PLBW was 0.47. According to residents' estimation and gold standard, PLBW was 6.76% and 1.33%, respectively. The serum level of sodium, potassium, urea and creatinine were 141.8 mEq/L, 4.6 mEq/L, 34.45 mg/dL and 0.6 mg/dL, respectively.

Conclusion

There is positive but weak correlation between residents' estimation and PLBW in patients with dehydration. It is necessary to enhance the educational level of pediatric residents to increase the accuracy of physical examination and decrease medical errors.

Clinical Utility of Noninvasive Method to Measure Specific Gravity in the Pediatric Population

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.

Transient Neonatal Diabetes Mellitus: A Challenge and Opportunity for Specialized Nursing Care

Transient neonatal diabetes mellitus (TNDM) is a rare disorder, with a reported incidence of approximately 1 in 450,000 live births. It is characterized by insulin-requiring hyperglycemia in the neonatal period. The disease improves by early childhood, but the patient may relapse in later life. Diagnosis is made after genetic testing following presentation with hyperglycemia not conforming to Type 1 or Type 2 diabetes. Management is based on insulin and possible sulfonylurea administration. Three genetically distinct subtypes of TNDM are recognized. Type 1 TNDM is due to overexpression of genes at the 6q24 locus, whereas the 11p15 locus is involved in Type 2 and 3 TNDM. In this article the clinical presentation, management, and genetics of TNDM are discussed, particularly emphasizing the role of the neonatal nurse.

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

Background

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

Methods

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

Results

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

Conclusion

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