Gastroenteritis an Evidence Based Approach to Typical Vomiting, Diarrhea, And Dehydration-Copy

December 2004 Volume 1, Number 5

Author

Mark A Hostetler, MD, MPH, FACEP, FAAPAssistant Professor, Department of Pediatrics, and Chief, Section of Emergency Medicine, University Of Chicago, Pritzker School of Medicine—Chicago, IL.

Peer Reviewers

Albert K Nakanishi, MD, MPH, FAAPAssociate Professor of Pediatrics, Saint Louis University School of Medicine, Cardinal Glennon Children’s Hospital—Saint Louis, MO.

Paula J Whiteman, MD, FACEPMedical Director, Pediatric Emergency Medicine, Encino-Tarzana Regional Medical Center; Attending Physician, Cedars-Sinai Medical Center—Los Angeles, CA.

CME Objectives

Upon completing this article, you should be able to:

1. list perceived barriers to the initiation of oral rehydration therapy in the ED;

2. identify physical examination findings that help the emergency physician determine the degree to which a young child is dehydrated; and

3. discuss the indications for oral and intravenous rehydration for dehydrated young children in the ED.

Date of original release: December 31, 2004. Date of most recent review: December 29, 2004. See “Physician CME Information” on back page.

Editor-in-Chief

Lance Brown, MD, MPH, FACEP, Chief, Division of Pediatric Emergency Medicine; Associate Professor of Emergency Medicine and Pediatrics; Loma Linda University Medical Center and Children’s Hospital, Loma Linda, CA.

Editorial Board

Jeffrey R. Avner, MD, FAAP, Professor of Clinical Pediatrics, Albert Einstein College of Medicine; Director, Pediatric Emergency Service, Children’s Hospital at Montefiore, Bronx, NY.

Beverly Bauman, MD, FAAP, FACEP, Assistant Chief, Pediatric Emergency Services, Oregon Health & Sciences University, Portland, OR.

T. Kent Denmark, MD, FAAP, FACEP, Residency Director, Pediatric Emergency Medicine; Assistant Professor, Departments of Emergency Medicine and Pediatrics; Loma Linda University Medical Center and Children’s Hospital, Loma Linda, CA.

Michael J. Gerardi, MD, FAAP, FACEP, Clinical Assistant Professor, Medicine, University of Medicine and Dentistry of New Jersey; Director, Pediatric Emergency Medicine, Children’s Medical Center, Atlantic Health System; Department of Emergency Medicine, Morristown Memorial Hospital.

Ran D. Goldman, MD, Associate Professor, Department of Pediatrics, University of Toronto; Division of Pediatric Emergency Medicine and Clinical Pharmacology and

Toxicology, The Hospital for Sick Children, Toronto.

Martin I. Herman, MD, FAAP, FACEP, Associate Professor, Pediatrics, Division Critical Care and Emergency Services, UT Health Sciences, School of Medicine; Assistant Director Emergency Services, Lebonheur Children’s Medical Center, Memphis TN.

Marilyn P. Hicks, MD, FACEP, Director, Pediatric Emergency Medicine Education, Department of Emergency Medicine, WakeMed, Raleigh, NC; Adjunct Assistant Professor, Department of Emergency Medicine, University of North Carolina, Chapel Hill, Chapel Hill, NC.

Mark A. Hostetler, MD, MPH, Assistant Professor, Department of Pediatrics; Chief, Section of Emergency Medicine; Medical

Director, Pediatric Emergency Department, The University of Chicago, Pritzker School of Medicine, Chicago, IL.

Alson S. Inaba, MD, FAAP, PALS-NF, Pediatric Emergency Medicine Attending Physician, Kapiolani Medical Center for Women & Children; Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu, HI; Pediatric Advanced Life Support National Faculty Representative, American Heart Association, Hawaii & Pacific Island Region.

Andy Jagoda, MD, FACEP, Vice-Chair of Academic Affairs, Department of Emergency Medicine; Residency Program Director; Director, International Studies Program, Mount Sinai School of Medicine, New York, NY.

Brent R. King, MD, FACEP, FAAP, FAAEM, Professor of Emergency Medicine and Pediatrics; Chairman, Department of Emergency Medicine, The University of Texas Houston Medical School, Houston, TX.

Robert Luten, MD, Professor, Pediatrics and Emergency Medicine, University of Florida, Jacksonville, Jacksonville, FL.

Ghazala Q. Sharieff, MD, FAAP, FACEP, FAAEM, Associate Clinical Professor, Children’s Hospital and Health Center/University of California, San Diego; Director of Pediatric Emergency Medicine, California Emergency Physicians.

Gary R. Strange, MD, MA, FACEP, Professor and Head, Department of Emergency Medicine, University of Illinois, Chicago, IL.

EMERGENCY MEDICINE PRACTICE P E D I A T R I C

AN EVIDENCE-BASED APPROACH TO PEDIATRIC EMERGENCY MEDICINE ▲ EMPRACTICE.NET

Gastroenteritis: AnEvidence-Based ApproachTo Typical Vomiting, Diarrhea, And Dehydration Gastroenteritis season is upon us! Your ED and waiting room are overflowing with anxious parents who have brought their children to you with varying degrees of vomiting, diarrhea, and dehydration. The charge nurse is concerned that things are getting backed up. Every parent insists that their child is severely dehydrated and needs intravenous fluids and admission. Many of your strongest nurses, on the other hand, seem to think that almost none of these children needed to be brought to the ED in the first place, and they have started “PO challenges” on just about every child. As you prepare to evaluate the next patient in the to-be-seen rack, you real-ize that the ED really is getting terribly backed up. Whereas “putting in an IV and checking some lytes” seemed reasonable when there were just a few children present-ing with vomiting and diarrhea, you realize it is time to get very serious about the situation. You need to figure out which children truly need intravenous hydration and laboratories checked, which children are appropriate candidates for oral rehydra-tion, and which parents need some quick reassurance and the discharge papers. During inevitable winter nights like this, several questions enter your mind. Are any of those published practice guidelines worth the paper on which they’re printed? If so, do they apply to my patients in my ED? What’s the deal with oral rehydration? Are there any fluids I am not supposed to be using, and if so, why not? How can I reliably identify the dehydrated kids? Are any labs helpful, and if so, in what circumstances? Did I wash my hands after that last patient?

TREATING children for vomiting, diarrhea, and possible dehydration is extremely common in any ED that sees children. Before delving into a

discussion of vomiting and diarrhea, an important definition needs to be pre-sented up front. The word: “gastroenteritis.” The official dictionary definition

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Pediatric Emergency Medicine Practice 2 EBMedPractice.net • December 2004

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Table 1. Differential Diagnosis For Children With Vomiting.

Infancy Childhood Adolescence

Mechanical Gastroesophageal refluxMalrotation with midgut volvulusPyloric stenosisIntussusceptionIncarcerated herniaTracheoesophageal fistula

ConstipationIncarcerated herniaMeckel’s diverticulumBowel obstruction

ConstipationIncarcerated herniaMeckel’s diverticulumBowel obstruction

Inflammatory/Infectious

Necrotizing enterocolitisGastroenteritisSepsisMeningitisPneumoniaOtitis media

Gastritis/GastroenteritisOtitis media AppendicitisPancreatitisHenoch-Schönlein purpuraBiliary tract disease

GastroenteritisAppendicitisHenoch-Schönlein purpuraPancreatitisGastritisBiliary tract disease

Genitourinary Urinary tract infection Urinary tract infection Urinary tract infectionPregnancyTesticular/Ovarian torsion

CNS HydrocephalusIntracranial hemorrhageIntracranial tumor

Migraine headacheHydrocephalusIntracranial hemorrhageIntracranial tumorReye’s syndrome

Migraine headache HydrocephalusIntracranial hemorrhageIntracranial tumorGlaucoma

Metabolic Diabetic ketoacidosisCongenital adrenal hyperplasiaUrea cycle defectsOrganic aciduriasAmino acidopathiesFatty acid oxidation disorders

Diabetic ketoacidosisUrea cycle defectsFatty acid oxidation disorders

Diabetic ketoacidosis

Other/Atypical Occult trauma (abuse)Toxic ingestionsMunchausen by proxy

Sickle cellToxic ingestionsOccult trauma (abuse)Munchausen by proxy

Sickle cellToxic ingestionsOccult trauma (abuse)Munchausen/Munchausen by proxy

*Source: Adapted from Hostetler MA, Bracikowski A. Gastrointestinal Disorders. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medi-cine: Concepts and Clinical Practice, 5th ed. St. Louis, MO: Mosby; 2002:2300.

of “gastroenteritis” is “an acute inflammation of the lining of the stomach and intestines, characterized by anorexia, nausea, diarrhea, abdominal pain, and weakness.”1 The hallmark of gastroenteritis is diarrhea. Because of nausea, most children also have some vomiting as a part of a viral gastroenteritis. Too often clinicians can be overheard using the term “gastroenteritis” as slang for vomiting they think is clinically benign. For practical purposes, “gastroenteri-tis” should only apply to children with nausea or vomiting AND diarrhea. Although there is a very broad differen-tial diagnosis for children exhibiting vomiting without diarrhea (See Table 1), the differential diagnosis narrows substantially when both vomiting and diarrhea are promi-nent symptoms. In most cases in the United States and the developed world, gastroenteritis is caused by self-limited viral infections, and the main concern is dehydration. The language used to describe dehydration in chil-dren is familiar to most pediatricians. Some physicians, however, may not be accustomed to talking about dehy-dration in terms of percentages. In essence, the theoretical ideal is to have a very recent, known preillness weight,

and then to measure a weight on the same scale during the illness to determine the water weight lost due to vomit-ing and diarrhea. This change is usually expressed as a percentage. For example, if a physician knew that a child had a recent weight of 10 kg, has had vomiting and diar-rhea, and now weighs 9 kg, it would be said that the child was 10% dehydrated (1 kg lost divided by the preillness weight of 10 kg). In practice, however, a recent weight is seldom, if ever, known. More commonly, physicians use a combination of signs and symptoms to estimate the broad category of dehydration (ie, none, mild, moderate, severe) and then assign a percentage number that matches this category. For example, the signs and symptoms that are typically seen in children with moderate dehydration are thought to occur in children who are between 5% and 10% dehydrated. This leads physicians to see a child, deter-mine that they are moderately dehydrated, and then say a very precise thing like, “This child is 8% dehydrated.” It has to be recognized that this numeric value is in no way calculated or based on any other numbers, values, or tests. This process can be bewildering and seem almost mystical

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3 Pediatric Emergency Medicine PracticeSeptember 2003 • www.empractice.netDecember 2004 • EBMedPractice.net

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Table 2. Clinical Criteria Commonly Used For Classifying Dehydration Severity.

Mild (3-5%) Moderate (6-9%) Severe (> 10%)

Mental Status Well-appearing Ill-appearing, non-toxic Lethargic, toxic

Heart rate Normal to increased Tachycardia Marked tachycardia

Breathing Normal Increased Increased, deep

Pulse Normal quality Normal to decr quality Poor quality

Capillary refill Normal (< 2 sec) Normal to sl prolonged (2-4 sec) Markedly prolonged

Perfusion Warm Cool Cold, mottled

Blood pressure Normal Normal Hypotensive

Eyes Normal Slightly sunken Very sunken

Tears Normal Decreased Absent

Mucous Membranes Moist Tacky Very dry

Skin turgor (recoil) Instant recoil Delayed (2 sec) Very prolonged

Urine output Normal to slightly decreased Decreased Minimal

*Source: Adapted as a composite from: WHO, 1995; Gorelick MH, Shaw KN, Murphy KO, 1997; Friedman JN, Goldman RD, Srivastava R, et al, 2004. See references 6, 10, and 11.

Rapid versus Standard RehydrationThere are clinical instances when the rapid administration of fluid, particularly intravenously administered fluid, can be difficult for the patient to tolerate. Certainly, in cases of myocarditis, some congenital heart conditions, brain masses, and cases of diabetic ketoacidosis, physicians will need to individualize fluid administration and be rela-tively cautious with regard to the rapidity and volume of fluid administration. This is not the case for children with gastroenteritis. In the absence of other complicating fac-tors, rapid rehydration, either orally or intravenously, has been found to be safe and effective. This concept is well supported in the available literature.19-23

Laboratory InvestigationsAlthough it is clear that the vast majority of children do not require laboratory studies, current data lack the sensitivity and specificity to guide exactly which patients should be tested.8,24 Rather than being used to diagnose or confirm dehydration, testing is better used to verify that no other abnormalities are present. Disorders of glucose and sodium are particularly important to identify, as these alter management the most. Unfortunately, the literature on when to order laboratory tests is relatively weak.

Epidemiology, Etiology, Pathophysiology

Epidemiology Worldwide, diarrheal disease and dehydration account for as much as one-third of all deaths among infants and children under the age of 5 years.5,12,25 There are more than 1.5 million annual visits among children for vomiting and diarrhea to US EDs resulting in 200,000 hospitaliza-tions and approximately 300 deaths.25-27 In developing countries mortality rates are much higher, and in children under the age of 5 years, there are an estimated 2 million deaths annually.26 Although these numbers remain high,

to physicians not familiar with it. But understanding this practice can be very helpful in allowing physicians with different levels of training and experience to understand each other. In this issue of Pediatric Emergency Medicine PRACTICE, we’ll review an evidence-based approach to the evaluation and management of children with “good old” gastroen-teritis.

Critical Appraisal Of The Literature

Gastroenteritis is one of the most common chief com-plaints encountered in the ED. A wide range of topics related to gastroenteritis and dehydration can be found in the literature, including epidemiology, evaluation, and management.2 The literature consists of a heterogeneous mix of prospective cohorts, retrospective reviews, and ran-domized controlled trials. Although the quality is gener-ally fairly good, both the quality and quantity of pediatric-specific research in this area continue to increase. There is, in addition, an important set of public policy guidelines.3-7

Assessment Of DehydrationOf all the topics in this area, the assessment of dehydration is perhaps the most protean. Selected physical examina-tion findings (general appearance, capillary refill, skin tur-gor/recoil, respiratory pattern) have the highest predictive value, whereas historical features have little or no value.8-11 (See Table 2.)

Enteral versus Intravenous RehydrationAssociated with fewer side effects, lower cost, shorter treatment times, and fewer admissions, enteral rehydra-tion is safe and effective and the preferred treatment for children with mild or moderate dehydration.12-18

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LC even death.15,21,34,35 In order to maintain adequate intravas-cular volume, both glucose and sodium need to be trans-ported across the intestinal membrane in an equimolar fashion.36,37 The degree to which underlying inflammatory changes occur to the bowel mucosa depends on the etio-logic agent. These inflammatory changes result in damage to the intestinal villi, the overall structure of the mucosa, and the overall absorptive capacity of the gastrointestinal tract. Limited absorption results in a greater output of diarrheal fluid and worsening dehydration. Interestingly, fasting, which can occur with the nausea and vomiting of gastroenteritis, actually worsens the capacity of the bowel to absorb fluid. Continued feedings not only slow the progression of dehydration by adding to the overall fluids available to the child’s intravascular space, the presence of the feedings in the bowel lumen promotes mucosal recov-ery and improves fluid absorption.36-38 The primary patho-physiology on which oral rehydration strategies are based revolves around the cotransport of glucose and sodium, and the localized improvement to the bowel mucosa, due to the presence of feedings in the lumen.

Differential Diagnosis

Gastroenteritis, particularly when caused by a virus that sweeps through a community, is a clinical diagnosis. The hallmarks are nausea, vomiting, and diarrhea, with or without signs of dehydration. Fever may be present. The diarrhea is typically watery, and it is unusual to have the stool be positive for blood either grossly or on occult test-ing. Only 10% of gastroenteritis is associated with bloody diarrhea.32 The most common infectious causes of grossly bloody diarrhea include Shigella and enterotoxigenic E. coli 0157:H7, the variant associated with hemolytic uremic syndrome.39 (Table 4.) Severe abdominal pain and altered mental status, in particular, are not seen in typical gas-troenteritis and should prompt the clinician to explore alternative diagnoses. A discussion of alternative diagno-ses is beyond the scope of this review. However, just as the truism “not all that wheezes is asthma” rings true for most clinicians, an analogous “not all that vomits and has diar-rhea is gastroenteritis” should ring similarly true. 40-42 In particular, the differential diagnosis for vomiting is large and must take into consideration a wide variety of factors, especially the patient’s age.43 (See Table 1.) Prehospital Care

Prehospital personnel should follow local EMS protocols for pediatric patients. Initial evaluation and management in the field and during transport should focus on the rapid cardiopulmonary assessment and management of im-paired perfusion with intravenous fluids. Hemodynami-cally stable children with vomiting and diarrhea, normal mental status, and normal perfusion do not require any prehospital interventions, other than transport. ED Evaluation

When presented with a child with vomiting and diar-

Table 3. Infectious Etiologies Identified In Children Admitted For Dehydration.

Description (%)

Viral enteritis NOS* 21.9

Rotavirus 1.9

Salmonella spp. 1.0

Shigella spp. 1.0

Bacterial enteritis NOS* 0.7

Clostridium spp. 0.6

E. coli (pathologic/invasive) 0.5

*Source: Adapted from McConnochie KM, Conners GP, Lu E, Wilson C. See reference 30.†NOS = not otherwise specified‡spp = species

they have been reduced almost by half over the past 2 decades, in large part due to the widespread use of oral rehydration therapy.26,28 Societal costs are significant, with an estimated $1 billion per year in total costs estimated to society for rotaviral disease alone.29 In one study of those patients admitted to the hospital, simple, uncomplicated gastroenteritis accounted for 75% of all cases of admitted dehydration, and of these cases, 51% were estimated to be mildly dehydrated (at least 5% dehydrated), 16% moder-ately dehydrated (approximately 10% dehydrated), and 26% were severely dehydrated (> 10% dehydration).30 The etiologic agents that commonly cause gastroenteritis are highly transmissible (via the fecal-oral route). This ease of transmission most likely explains why cases of gastroen-teritis occur in groups, such as day cares, schools, families, and wider communities.

EtiologyViruses are responsible for up to 80% of all cases of gastro-enteritis, with the remainder being caused by bacteria and parasites.31,32 Common viral etiologies include rotavirus, enteric adenovirus, and Norwalk virus.4,31 Less common entities include calicivirus and astrovirus. Rotavirus ac-counts for approximately one third of all hospitalizations of acute gastroenteritis in children.29 Although much less common than viruses, the most common etiologic agents for bacterial gastroenteritis in the developed world include Campylobacter jejuni, Salmonella spp, Shigella spp, Yersinia enterocolitica, and Escherichia coli species.33 In one popu-lation-based study of children admitted to the hospital with dehydration, an infectious agent was identified in a minority of cases. However, when an etiologic agent was identified, the most common were nonspecific viruses and rotavirus. (See Table 3.)30

Pathophysiology

No matter what the infectious agent is, acute gastroenteri-tis is associated with varying degrees of fluid shifts, with the potential to cause significant dehydration, shock, and

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Table 4. Common Infectious Agents Causing Vomiting And Diarrhea In Children.

Agent Source/Symptoms Antimicrobial Treatment

Campylobacter jejuni Source: contaminated, poorly cooked chicken; un-pasteurized milk; fecal-oral contact.

Symptoms: fever, abdominal pain, diarrhea (occa-sionally bloody). Abdominal pain can mimic that of appendicitis. Mild infection lasts 1-2 days.

Treatment recommendedShortens illness and prevents relapse

E. coli 0157:H7 Source: contaminated, poorly cooked meat, often beef; fecal-oral contact.

Symptoms: diarrhea, which may be bloody and pro-fuse; abdominal pain, which may be severe; nausea and vomiting. Complications including hemolytic-uremic syndrome and renal failure.

Treatment not recommendedMay increase risk of hemolytic-uremic syndrome

Giardia lamblia Source: contaminated water; fecal-oral contact.

Symptoms: explosive, foul-smelling stools associated with excessive flatulence, abdominal distention, and anorexia. Fever is usually absent

Treatment recommended for symptomatic infections

Salmonella spp. Source: Contaminated, poorly cooked food (poultry, eggs, dairy products); fecal-oral contact; reptiles.

Symptoms: abdominal cramps, vomiting and diar-rhea often in association with fever.

Treatment recommended for specific, high-risk patients (very young, very sick, immunocompromised)

Shigella spp. Source: Contaminated food or water; fecal-oral contact.

Symptoms: Symptoms vary from mild diarrhea and no constitutional symptoms to patients with severe crampy abdominal pain, profuse diarrhea that may be bloody, fever, and prostration.

Treatment recommended for all patients

Staphylococcal food poisoning Source: Contaminated food.

Symptoms: abrupt onset nausea, vomiting, abdomi-nal cramping, and diarrhea usually 2-4 hours after eating contaminated food.

Treatment not recommended

Norwalk virus Source: Contaminated food or water; fecal-oral.

Symptoms: Nausea, vomiting, abdominal pain lasting 24-48 hours.


Rotavirus Source: Fecal-oral route.

Symptoms: Foul-smelling profuse, non-bloody, watery diarrhea, most common during the winter months, usually lasting 3-8 days.


Vibrio spp Source: Contaminated water or food.

Symptoms: Profuse “rice water” diarrhea with varying degrees of abdominal cramps and fever (but is most often described as being painless and without fever).

Treatment recommendedResults in prompt eradication

*spp = species

rhea, the main challenge for most emergency physicians is determining the degree of dehydration and the overall severity of illness. The gold standard for the diagnosis of dehydration is the comparison of a recent preillness weight with current weight. It is difficult to conceive of

an instance when an emergency physician would have this information. In lieu of serial weights, emergency physicians must estimate fluid deficits based on surrogate information available in the history, physical examination, and, occasionally, laboratory values.

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LC HistoryThe history may yield important information regarding alternative diagnoses. Important information to explore with the family includes factors such as fever, pain, pres-ence of blood or mucus in the stool, blood or bile in the emesis, headache, trauma, infectious contacts, ingestions, and travel. If the history suggests typical gastroenteritis, the history may help in assessing the trajectory of the illness. This is particularly helpful when evaluating a child who is not currently dehydrated, but may rapidly become so. When assessing for risk of present and future dehydration, physicians may ask about the number and quantity of vomiting or diarrheal episodes as an estimate of ongoing volume loss, the number of wet diapers as a surrogate for urinary output, and the amount and type of oral intake. The number of diapers wet with urine is exceedingly difficult to assess in the context of multiple diapers wet with diarrhea.

Physical ExaminationThe physical examination may also yield important information regarding alternative diagnoses. Abdominal distention or peritoneal signs suggest intra-abdominal di-agnoses other than simple, uncomplicated gastroenteritis. (See Table 1.) Altered mental status carries a wide differ-ential diagnosis as well, including central nervous system, toxicologic, endocrine disorders — such as diabetic ketoacidosis — and metabolic conditions (ie, inborn errors of metabolism). (See The Critically Ill or Comatose Infant: An Organized Approach, Emergency Medicine PRACTICE, Volume 4, Number 10, October 2002.) In cases of gastroenteritis, the physical examination has the highest yield in estimating dehydration. Vital signs should be measured and compared to age-based norms. It is probably prudent to recheck abnormal values. Most infants and young children with gastroenteritis have some degree of tachycardia, tachypnea, and a low-grade fever. Dehydration may be suggested by tachycardia out of proportion to fever, and when an afebrile child is calm. The anterior fontanel is normally flat, but may become sunken as the child becomes dehydrated. The eyes of a dehydrated child may appear sunken in their orbits. Oral mucous membranes can be assessed for dryness. In cases of uncomplicated gastroenteritis, the abdomen is usually soft and nondistended. Bowel sounds are variable and generally unhelpful, as they may be hyperactive, normal, or hypoactive. Rectal exams are rarely indicated.

Estimating Dehydration The signs and symptoms of dehydration are generally imprecise and inaccurate. Common recommendations are based on opinion and dogma, making it very difficult for clinicians to accurately predict the degree of dehydration. Incorrect assessment of dehydration can have important consequences. Failure to recognize or adequately treat dehydration results in increased morbidity and mortality.44 However, it seems that failure to identify seriously dehy-drated children is rarely a problem for most emergency

physicians. Probably more common is the inappropriate diagnosis of dehydration when it is not present. Inappro-priate diagnoses of dehydration can lead to substantial and inappropriate use of health care resources.45 Multiple studies have shown that no single physical finding is sufficiently accurate to determine the degree to which children are dehydrated.8-10,46-48 This should come as no surprise to experienced clinicians, who rarely base deci-sions on a single sign or symptom. Instead, a combination of signs and symptoms is often more helpful and accurate. (See Table 5.) According to a systematic review of the literature, the most useful signs for predicting dehydration in children include abnormal capillary refill time (Likeli-hood Ratio 4.1; 95% confidence interval [CI], 1.7-9.8), skin turgor (or recoil) (LR, 2.5; 95% CI, 1.5-4.2), and respiratory pattern (LR, 2.0; 95% CI, 1.5-2.7).8 Capillary refill is probably best assessed on the distal pad of the fingertip (palmar surface), at the level of the heart, in a warm ambient temperature. Gentle pressure is applied until the capillary bed blanches and is then re-leased. The time elapsed until restoration of normal color represents the capillary refill time, with normal values less than 1.5 to 2 seconds.46 Delayed capillary refill sug-gests peripheral vasoconstriction that can be seen in cold ambient temperatures, as well as dehydration and shock. Although skin turgor has been used to describe dehydra-tion for many years, the actual technique is somewhat less defined. One common method is to simply pinch a small fold of skin from the lateral aspect of the abdominal wall and watch for natural recoil back into normal position. The normal amount of time for the skin to recoil back to normal is unknown. One method of describing skin turgor uses the following categories: normal (instant), delayed (up to 2 seconds), or prolonged (2 seconds or greater).47,48 The child’s resting respiratory pattern should be observed for a period of at least 1 full minute. In a potentially dehy-drated child, hyperpnea (deep, rapid breathing without other signs of respiratory distress) suggests acidemia resulting from inadequate tissue perfusion. In a prospective cohort analysis of 186 children with gastroenteritis, the presence of an increasing number of clinical signs (general condition, quality of radial pulse, quality of respiration, skin elasticity, eyes, tears, mucous membranes, urine output) was associated with increasing levels of dehydration.10 Objective signs of dehydration can be apparent with estimated fluid deficits below 5% (2 signs). The presence of 3 or more signs had a sensitiv-ity of 87% and a specificity of 82% for detecting a deficit of 5% or more, consistent with moderate dehydration.10 Severe dehydration representing an estimated deficit of 10% or greater was associated with the presence of 6 or more signs. Using logistic regression modeling, a subset of 4 clinical findings with similar predictive characteristics was identified: capillary refill > 2 seconds, dry mucous membranes, absent tears, and abnormal general appear-ance. Another group of clinical researchers have recently developed a new 4-item, 8-point dehydration scale (general appearance, eyes, mucous membranes, and tears)

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E, LLCusing a prospective cohort of 137 patients and formal measurement methodology.11 Although there are fewer items, the scale is somewhat more complicated. The results are similar to other studies, including a sensitivity of 74% for mild dehydration, 33% for moderate dehydration, and 70% for severe dehydration.9 Other physical findings, such as lack of tears and sunken eyes, were not strong, inde-pendent predictors of dehydration.9 This is probably due to an absence of objective ways to measure these clinical findings. Urinary output, although frequently described as an important indicator of dehydration, actually occurs early during the course of becoming dehydrated, and has a positive predictive value of only 17% for identifying dehydration.10,49

Diagnostic Studies

Laboratory StudiesIn the vast majority of cases of gastroenteritis, the utility of laboratory studies is limited. There are no gold standards for “confirming” dehydration. Although the literature re-ports over 30 different tests purportedly useful for aiding in the determination of dehydration, none have performed consistently well when applied to determining the severity of dehydration.8,24 In addition, there is significant varia-tion among test ordering in children with gastroenteritis, leading to selection bias in many studies (particularly retrospective studies), and there is no evidence that testing leads to a change in patient outcome or family satisfac-tion.50

Ten Pitfalls To Avoid1. A well-appearing child with no evidence of dehydration gets a "PO challenge" that is given ad lib. The child guzzles the entire 2 containers of apple juice immediately, and shortly thereafter the child vomits, followed by the mother proudly showing you the emesis. The mother and nurse form a united front to insist that the child has confirmed the need for an IV.

The fact that the child vomited is a normal part of the disease process. It only demonstrates that he was given too much to drink too quickly.

2. “I thought vomiting was a contraindication to ORT.”Essentially all patients with gastroenteritis vomit. All atients with mild or moderate dehydration are eligible to receive ORT. The goal with ORT is to start with small amounts of fluid that are able to be absorbed by the gastric mucosa before they are able to be vomited, and then increase as tolerated. Even if vomiting occurs during rehydration, ORT can continue and is often successful.

3. “I didn’t want to use oral rehydration because I thought it would take too long, and putting in an IV would be quicker.”

The data clearly support the use of oral rehydration over intravenous rehydration, with an overall shorter length of stay in the ED and fewer admissions.

4. “I thought moderate dehydration was a contraindication to oral rehydration.”

Oral rehydration is indicated for mild or moderate dehydration.

5. “I know the kid was only 2-months old, but her mom had the stomach flu, too, so I figured she just had the stomach flu as well.”

Not all that vomits is gastroenteritis. Gastroenteritis in very young infants is relatively uncommon. In infants under 3 months of age, gastroenteritis is almost a diagnosis of exclusion.

6. “That 2-month-old looked fairly dry, but I tanked her up pretty good, and I thought she looked great before she left.”

Great care should be taken before sending home very young infants after fluid resuscitation. These young infants have a lower likelihood of having typical gastroenteritis and are more likely to have other causes to their vomiting. These infants also have a higher risk for hypoglycemia due to poor feeding, a high metabolic rate, and low glycogen stores.

7. “I gave the parents old discharge instruction forms, because that’s all I had.”

Older practice patterns, such as withholding all feeds, using dilute formula, or exclusively using clear fluids for days on end, may still be printed on the discharge forms found in some EDs. Patients and families require accurate and updated information. Discharge instructions should include specific information on appropriate rehydration fluids and techniques, as well as on the importance of rapid return to realimentation as soon as possible. Exclusive administration of oral rehydration solutions can be the cause of ongoing diarrhea.

8. “I thought his abdominal pain and tenderness were just related to his gastroenteritis.”

In the absence of typical symptoms, or in the presence of other concerning symptoms, other causes should be excluded (eg, surgical causes, such as acute appendicitis or intussusception).

9. “I though antiemetics were contraindicated in children. Or, they’re too expensive, or have too many side effects.”

The use of ondansetron, in particular, has been found to be safe and effective, as an adjunct to ORT, to decrease vomiting in patients with severe refractory vomiting.

10. “There is no reason to develop a clinical pathway in our ED.”

Multiple studies have shown that the evaluation and management of dehydration in children using a well-developed clinical pathway is an excellent means of streamlining care, reducing variation, and improving care. Added benefits include reducing admissions, saving money, and improving satisfaction. ▲

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Table 5. Essential Steps Of Oral Rehydration Therapy.

Select an appropriate fluid (see text for a discussion of options)

Estimate the degree to which the child is dehydrated (See Table 2.)

Estimate the fluid deficit

Example: 10 kg child, estimated at 7% dehydrated, has a weight loss of: 0.07 x 10 = 0.7kg Acute weight loss with vomiting and diarrhea is due to water loss (not bone, fat, etc.) Since 1 L water weighs 1kg, 700 ml water weighs 0.7kg. So, estimated total fluid deficit for this child is 700 ml.

Begin oral rehydration at a rate of 5 ml every 5 minutes (use a watch or clock for timing)

Increase the rate of intake as tolerated

Goals include replacing at least 10 ml/kg in the first hour and having the total fluid deficit replaced within 4 hours

of gastroenteritis, even in the presence of severe dehydra-tion.

Treatment

Oral RehydrationOral rehydration therapy (ORT) has been extensively studied. ORT is known to be safe and effective as the treatment of choice for mild and moderate dehydration.57-

60 Morbidity and mortality can be greatly reduced with the use of ORT.12-17,61 Unlike most innovations that are created in the developed world and then implemented in the third world, ORT is an example of “reverse technol-ogy,” whereby an innovation first implemented in third world countries is translated into use in more modern, developed countries. In 1996 an expert panel estimated that the use of ORT alone could decrease hospitalizations by half (100,000/year).61 A subsequent meta-analysis of 16 trials comparing 1545 children found that, for childhood gastroenteritis, ORT is as at least as effective as intrave-nous rehydration, is associated with fewer major adverse events, and results in shorter hospital stays.62 The data are overwhelmingly positive. In terms of implementation, it is probably best to think of ORT as a distinct procedure. (See Table 5.) One of the first issues in initiating ORT involves the selection of the fluid to be used. For 2 decades the World Health Orga-nization recommended an oral rehydration solution (ORS) containing the following: sodium, 90 mmol/L; potassium, 20 mmol/L; chloride, 80 mmol/L; citrate, 10 mmol/L; and glucose, 111 mmol/L. This solution has an osmolarity of 311 mOsm/L. A newer, lower osmolarity version is now recommended and has been shown to reduce the amount of diarrheal output, particularly in cases of cholera. It contains sodium, 75 mmol/L; potassium, 20 mmol/L; chloride, 65 mmol/L; citrate, 10 mmol/L and glucose, 75 mmol/L. This ORS has a total osmolarity of 245 mOsm/L. This lower-osmolarity version has been shown to have im-proved performance with severe diarrheal disease.63 There are a variety of ORS formulations available. (See Table 6.) Two formulations of commercially available ORS — one glucose-based (Pedialyte®, Ross Products Division of Abbott Laboratories) and one rice-based (Infalyte®, Mead

Although an elevated urine specific gravity does oc-cur in dehydration, it occurs very early in the course of the illness — during the time of clinically insignificant fluid losses — is a nonspecific finding, and does not correlate with the overall degree of dehydration.8 Among blood tests, the blood urea nitrogen (BUN) (or the BUN/creati-nine ratio) and bicarbonate concentrations appear to be the most helpful, but only when markedly abnormal.8,24 Given the lack of objective evidence and predictive capa-bilities, laboratory studies should never be required as a means of diagnosing dehydration. A reasonable strategy seems to be using laboratory testing to confirm or verify that there are no gross abnormalities, such as hypoglyce-mia, hyperglycemia, or electrolyte disturbances. It should also be remembered that different means of volume loss (vomiting versus diarrhea) may have varying impact on some of the laboratory studies that are assayed and mea-sured (bicarbonate level), while others, such as the BUN, are independent of how the fluid is lost. Although perhaps convenient to obtain, the data are conflicting regarding laboratory assessments in children for whom intravenous rehydration is planned. Stool studies are seldom indicated.50 In well-appear-ing, previously healthy patients with an acute onset of vomiting and diarrhea, stool studies are unhelpful.52-54 (See Table 4.) Stool testing may be indicated for cases involv-ing recent travel to the third world (suggestive of a higher likelihood of bacterial illness), comorbidity, frankly bloody stool, or diarrhea of 5 days duration, particularly if there is a history of fever.33,39,55 Recent antibiotic use raises the like-lihood of Clostridium difficile infection. Selection criteria to identify children for whom C. difficile testing is indicated are not currently evidence-based. Point-of-Care TestingHypoglycemia may be associated with diarrheal illness, particularly in those who have an altered mental status, are ill appearing, or are in early infancy, and therefore have diminished fat reserves (ie, infants).56

RadiographyThere is no role for routine radiographic imaging in cases

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E, LLCJohnson Nutritional Group) — have been shown to be equally efficacious.18 In at least one study, however, rice-based ORS reduced the failure rate of ORT (measured by the surrogate variable of the rate of initiating intravenous fluid therapy) compared with the use of glucose-based ORS.64 Rice-based ORS appears to be effective at reducing stool volume; however, according to the Cochrane collab-orative review process, this effect is most prominent only in patients with cholera.65 Several points are clear: The WHO and commercially available ORS solutions are the best options, with nearly identical proportions of electro-lyte constituents. Sports drinks contain a higher propor-tion of sugars and lower proportions of sodium, but are typically more palatable to older children. Fruit juices and soda are inappropriate choices as ORS, based on their constituents. This is not to be confused with having a child who is not dehydrated or who is minimally dehydrated drinking what they like. For the purposes of ORS, fruit juices and soda should not be used. Plain water is an inap-propriate choice for ORS, due to the absence of the neces-sary electrolytes and glucose. Young infants given plain water or dilute tea are at risk for developing hyponatremia that may be severe enough to cause seizures. Again, there is little reason to withhold a drink of water from a thirsty, older child, but water should not be used for the specific purposes of rehydration. Despite excellent data supporting the use of ORT and recommendations from well recognized organizations emphasizing the use of ORT for rehydration in mild or moderate dehydration, studies show that ORT is used in less than 30% of the cases of diarrhea in the United States for which it is indicated.61,66,67 This underuse of ORT is as-sociated with unnecessary ED visits and hospitalizations, resulting in direct medical costs of greater than $1 billion per year.61 In another recent survey, nearly one third of pediatric or general emergency physicians indicated that they always used IV rehydration for mild dehydration,

something that clearly goes against all published recom-mendations.68 Even among academic pediatric emergency medicine fellowship directors, who would otherwise be expected to have an evidence-based practice as part of their training program, the rate of ORT usage was low. In one study, only 31% of respondents use ORT for mildly or moderately dehydrated patients.69 The explanation for the limited implementation of ORT is not entirely clear. Reasons cited for failing to initi-ate ORT when it is indicated include: extended length of stay in the ED, increased staff time to implement ORT, concerns over patient satisfaction, and potential failure rates.70 However, in a study designed specifically to ad-dress these commonly reported barriers to using ORT, results indicated that ORT performed better than IV therapy on all outcomes that were previously considered to be barriers: length of ED stay, mean staff time, treatment failure, rate of relapse, and satisfaction.70

For whatever reasons, ORT remains underutilized for the treatment of dehydration in the United States, both at home and in the ED, despite multiple clinical trials verifying its clinical efficacy and safety. The WHO has for-mulated, endorsed, and perfected the exact composition for premade packets of ORS, and these packets are quite inexpensive (approximately $0.55 per packet). These pow-dered formulations have been found to be safe and effec-tive when combined with potable water, and they are very easy to use.71,72 Commercial variations are now produced and available in the United States. They can be purchased from Jianas Brothers (Kansas City, MO), Cera Products (Jessup, MD), and Pharmacia & Upjohn, Inc (Peapack, NJ). Other ORS formulations are commercially available, fla-vored, and are come in premixed and prepackaged bottles at a cost of between $2 and $9 per liter. These formulations are readily available in any grocery or convenience store, but they are of course significantly more costly than the

Table 6. Constituent Components & Recommendations For Oral Rehydration Solutions (ORS).

Osmolality(mOsm/kg)

Glucose(mmol/L)

Sodium(mmol/L)

Potassium(mmol/L)

Recommendation as an ORS

WHO 331 111 90 20 Recommended for all ages

Low-Osmolarity WHO

245 75 75 20 Recommended for all ages

Commercial ORS(ie, Pedialyte®)

250 130 45 20 Recommended for all ages

Sports Drink(ie, Gatorade®)

330 255 20 3 Not recommended for children younger than 2 years of age

Cola 500 700 2 0.1 Not recommended

7-Up® 388 500 4 0 Not recommended

Orange juice 687 680 1 486 Not recommended

Apple juice 694 690 0 27 Not recommended

*Source: Adapted from Sandhu BK; European Society of Pediatric Gastroenterology, Hepatology and Nutrition Working Group on Acute Diarrhoea. See reference 17.

Continued on page 12

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NO➤

NO

➤

The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III: May be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

Copyright ©2004 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any for-mat without written consent of EB Practice, LLC.

Clinical signs of dehydration?

Administer 20 ml/kg normal saline boluses until perfusion is ad-equate (and child is no longer in physiologic shock). (Class II)Admit to Pediatric Inten-sive Care Unit. (Transfer according to local resources.) (Class II)

1.

2.

NO

➤

➤Discharge home with appropriate discharge instructions. (See Sample Discharge Instructions on next page.)

Follow up with primary care physician

Admit to basic pediatric ward bed or to observation unit. (Class II)

Dehydration resolved and patient tolerating oral fluids?YES

➤

YES

Option 1If oral rehydration failed due to persistent vomiting, initiate intravenous rehydration and then reassess for dehydration. (Class II)

Option 2If oral rehydration failed due to persistent vomiting, may administer antiemetic (eg, ondansetron) and reattempt oral hydration. Reassess for dehydration. (Class II)

NO➤

➤YES

➤

Clinical Pathway: Evaluation And Management Of Dehydration Due To Gastroenteritis In Children Over 3 Months Of Age

Is the dehydration severe?➤YES

Option 1Oral rehydration therapy. (Class II)

Option 2Intravenous rehydration; then assess whether patient is tolerating oral fluids. (Class II)

Option 3Nasogastric rehydration (Class III);

Then, reassess for dehydration.

Dehydration resolved and patient tolerating oral fluids?

➤

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11 Pediatric Emergency Medicine PracticeDecember 2004 • EBMedPractice.net

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Sample Discharge Instructions

How to Prevent Your Child from Becoming DehydratedUse plenty of oral rehydration fluids.Acceptable fluids include:

Over-the-counter oral rehydration solutions (Pedialyte®, Infalyte®, Rehydralyte®).If necessary, you may add a small amount of your child’s favorite flavoring or juice to the oral rehydration solution, if that increases the child’s interest in drinking the oral rehydra-tion solution.Freezer rehydration popsicles (do not use regular popsicles – they are mainly just pure sugar and do not contain the necessary salts and electrolytes).

Do not use:Pure juices – they have too much sugar and can cause worsening diarrhea.Plain water – does not have any sugar or salts and can cause electrolyte changes. Be espe-cially careful about giving plain water to small babies, as it can sometimes cause changes resulting in seizures.Soda – they are also just water and sugar and have the wrong concentration of salts and electrolytes.

If your child is vomiting, start with small amounts of oral rehydration fluid. Give 1 teaspoon (or 5cc in syringe) every 5 minutes, and then increase gradually, as tolerated by your child.

You should return to your child’s normal diet as soon as possibleYou do not need to stop milk or formula products.You may continue breastfeeding.You can still expect to see some vomiting and diarrhea. That is part of the normal disease process. Your child still needs to continue to receive adequate nutrition.

Signs of DehydrationYour child may appear less active, sleepy, or lethargic.Your child cries, but has no tears.Decreased frequency of urination, or wetting diapersSunken eyesCool, clammy skinIf these appear, you need to increase the amount and frequency of the oral rehydration solution you are giving and speak with your doctor or clinic for a follow-up appointment.

You should return to the ED if your child:Appears very sleepy, lethargic, or is difficult to arouse.Has not urinated or wet a diaper in 8 hours.Appears to be breathing either very fast, or has very deep and slow breathing.If the vomiting or diarrhea becomes bloody.If your child’s abdomen becomes distended or appears to be tender or painful to the touch.

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WHO packets. Due to the relatively high cost, parents may be deterred from obtaining appropriate ORS. In at least 1 case report, lack of access to appropriate ORS was cited as the specific cause for hypernatremia in an infant.73 Parents who used both WHO-ORS packets and commercially pre-pared ORS preferred the WHO-ORS.71 In another study, providing ORS during office visits increased their use and decreased subsequent unscheduled office visits.74 Provid-ing good anticipatory guidance during ED visits will not only provide quality care during that visit, but also for all future visits.

Intravenous RehydrationNot all patients are good candidates for oral rehydration. Patients in shock clearly require resuscitation with intrave-nous (IV) fluids. Patients whose dehydration falls into the severe category, or in whom oral rehydration attempts are failing, also benefit from an initial bolus of IV rehydration. Patients repeatedly vomiting despite appropriate attempts at ORT also require IV therapy. Interestingly, IV rehydra-tion in the ED leading to discharge home is a relatively new concept. Debate continues as to how quickly the fluids should be given.75 To somewhat oversimplify; fluid replacement therapy in children has historically been a process of calculat-ing the fluid deficit and then replacing this volume of fluid over an extended time, commonly 24 hours or more.15,21,34,35,76-78 More recent developments include a “rapid” rehydration approach, which recommends giving

IV fluids relatively rapidly over a matter of a few hours, and then switching to oral fluids as soon as possible. This alternative “rapid” approach has gained increasing favor, and in the absence of any other complicating factors (ce-rebral edema, altered mental status, comorbidity, or other atypical presentation), has been found to be both safe and effective.19-23 With this approach, various investigators have used anywhere from 20-60 ml/kg over 1-3 hours, fol-lowed by institution of ORS.19-23 Using a clinical pathway that included rapid oral and IV rehydration resulted in a reduction in admissions for moderately dehydrated children — from 96.3% to 55.8% — and the number of chil-dren discharged in 8 hours or less improved from 4% to 44%, compared to prior to the intervention.23 In a compar-ative trial of rapid oral and intravenous rehydration, the oral rehydration group performed slightly better in terms of weight gain, reintroduction of feedings, and reduction of diarrhea.79 According to a study to evaluate actual time required to treat dehydration, the mean IV treatment time was 5.4 hours, significantly longer than the mean time for treating other patients (1.2 hours).80

The initial fluid choice for rehydration should be isotonic and dextrose-free. Normal saline or lactate ringers are reasonable choices, given 40 mL/kg over 1-2 hours, followed by ORS and realimentation as tolerated. There are a couple of caveats. Patients in the mild or moderate category with routine gastroenteritis and no other compli-cating factors should be able to receive 40 mL/kg without any contraindication. Infants are at slightly greater risk of developing clinically important imbalances in serum glucose and sodium. It has been recommended that young

Continued from page 9

Develop a multidisciplinary clinical guideline for use in your department that can be initiated at triage and continued throughout the patient’s course from their emergency stay to discharge. Using a clinical pathway can have dramatic effects. At the Children’s Hospital of Westmead in Australia, the institution of an ED clinical pathway for dehydration-rehydration resulted in a reduction in the rate of admissions for moderately dehydrated children, from 96.3% to 55.8%, and the number discharged in 8 hours or less was 44.2%, compared to only 3.7% prior to the intervention.23 In a similar study at the Children’s Hospital Medical Center in Cincinnati, the length of ED stay and percentage of patients requiring admission also decreased following implementation of an evidence-based acute gastroenteritis guideline.102,103

The guideline should take into consideration the key assessment parameters, as described in the physical examination section, and allow for consistent usage of language and parameters commonly used. Ensure that all stakeholders are involved in the development and

acceptance of the guideline. Once developed and approved, it is essential that all caregivers are inserviced and that the guideline becomes adopted into routine practice. It should also become part of routine orientation for new nurses, medical students and residents. It is also helpful to perform quality improvement studies to evaluate performance of the intervention. This can be accomplished in terms of patient outcomes, such as length of stay, percent admissions, return visits (treatment failures), and satisfaction. Referring physicians should also be apprised of the changes, and their satisfaction can also be tracked. Patients without clinical evidence of dehydration do not need any intervention and do not benefit by attempts at “PO trials” or laboratory evaluations. Patients with mild to moderate dehydration are appropriate for oral rehydration therapy (ORT). Patients with severe dehydration should have an intravenous line inserted, and rapid intravenous rehydration. Laboratory testing is best reserved for patients under the age of 3 to 6 months, those with severe dehydration, and those with atypical features. ▲

Cost- And Time-Effective Strategies For Managing Vomiting And Diarrhea In Children

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E, LLCinfants should have somewhat more liberal laboratory testing and more frequent laboratory rechecks when un-dergoing IV rehydration. Isotonic fluid (eg, normal saline) for initial rehydration is well tolerated, even in the case of hypernatremia.15,21,78 Hypotonic fluids (eg, 0.45% saline or 0.2% saline) should be avoided, as they have higher rates of adverse events, including fatal outcomes.81 In addition, in patients with hypernatremia specifically, they should be switched to ORS as soon as possible, as the rate of seizures related to sodium disturbances are much lower when ORS is added to IV rehydration.13,82,83 Once intravascular volume has been replenished (ie, once the patient has been rehydrated), the patient can be converted, either orally or intravenously, to a solution that contains some form of dextrose. Nasogastric RehydrationIn a study comparing rapid nasogastric and IV rehydra-tion in pediatric patients, children received 50 mL/kg over a 3-hour period. Results indicated that both were safe, efficacious, and cost-effective alternatives to the standard treatment for moderate dehydration in otherwise uncom-plicated pediatric patients.84 Probably few physicians have tried to convince families to have their child undergo a na-sogastric tube being placed instead of an IV. How success-ful physicians are in convincing families to try nasogastric rehydration remains unexplored.

RealimentationThere are significant nutritional advantages to continu-ing feeding during episodes of acute gastroenteritis. In addition, the early initiation of feeding improves gastro-intestinal structure and function and hastens intestinal recovery.36 Early realimentation is associated with reduced duration of illness and improved weight gain.36,56,85 Follow-ing rehydration, realimentation should therefore be started as soon as possible using an age-appropriate diet. The ap-proach is simple and straightforward. The feeding should be with the same foods or formula or breast milk the child

had been taking prior to the illness. In addition, there is no evidence that removing milk from the diet, or recommend-ing the routine dilution of milk during or following oral rehydration therapy is necessary or helpful.36,86 Breast milk is similarly well tolerated and should not be restricted. Breast-fed infants with diarrhea should continue nursing. Given traditional approaches to gastroenteritis, including avoiding feedings altogether, it may be difficult to con-vince parents that early or continued feeding is beneficial, may decrease stool output, shorten duration of illness, and improve nutrition for the child, but every attempt should be made to do so.

MedicationsAntiemeticsMost patients do well with oral rehydration alone. Oc-casionally vomiting is quite severe, and antiemetics may be helpful in getting control of the situation. In such cases, administration of antiemetics may be helpful as an adjunct to suppress vomiting and promote successful ORT. Al-though antiemetics are commonly used in adults, clinical experiences with antiemetics in children have historically included side-effect profiles with unacceptably high rates of sedation, extrapyramidal effects, and, rarely, seizures. Newer agents, such as ondansetron, a 5-HT3 receptor antagonist, heralded great promise as being highly effec-tive with few side effects. In ED settings, ondansetron has been found to be safe and effective at decreasing vomiting and the need for admission.87,88 Although early experience demonstrated success, concerns remained regarding the high cost. The estimated cost of ondansetron is $26 per 4-mg vial. In comparison, the average cost per hospitaliza-tion is $1900, excluding ED charges, and the estimated number needed to treat is 8.5.87 In other words, for every 8.5 children treated with ondansetron for gastroenteritis, 1 hospitalization would be prevented. Combining these re-sults, ondansetron is cost-effective in reducing the need for admissions in children with severe vomiting.87-89 Although not specifically addressed in these relatively small studies, ondansetron could be expected to be most cost-effective if used either for patients receiving IV therapy or those most at risk for admission, (ie, those with refractory vomiting). These two groups would be most likely to benefit from the therapy.

Antidiarrheal AgentsIn the past, agents such as loperamide and diphenoxylate were used in the treatment of patients with acute diar-rhea. Although the agents may slow intestinal transit time, concern remains regarding adverse events, such as ileus, abdominal distention, and sedation. These agents are no longer recommended in the routine treatment of gastroen-teritis in infants and young children.90

Bismuth Salts Bismuth subsalicylate (most commonly seen in products such as Pepto-Bismol®) is a common constituent in many antidiarrheal medications available over the counter.

Medicolegal IssuesAlthough risks exist, even when least expected, medicolegal risk can be incurred in a variety of ways. Issues or problems may arise with any of the following:

The severely illThose with abnormal vital signsInfants under the age of 3 to 6 monthsFailing to include other diagnostic possibilities when the case presentation does not match classic gastroenteritis or includes other symptoms (abdominal distention, headache, neurologic symptoms)Failure to appreciate the potential for decompensation, preexisting disease, or comorbidities

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Key Points For Managing Vomiting And Diarrhea In Children• Most children are not clinically dehydrated and do not require “PO trials” in order to “prove they can tolerate PO” prior to discharge.

• Oral rehydration using an appropriate oral rehydration solution (ORS) is the preferred method.

• Rehydration should be performed rapidly (over less than 4 hours).

• Once started, rehydration is continued in the ED and then continued at home by the parents/guardians.

• Successful ORT involves several phases:Rehydration1.

Maintenance and prevention of dehydrationRealimentation

• Laboratory testing is seldom necessary.

• Medications are usually not necessary.

• Following rehydration, rapid realimentation involves using an age-appropriate, unrestricted diet that should begin as soon as possible.

Both formula- and breastfed infants should be started back on their usual feedings as soon as possible. Partial dilution of formula and restriction of lactose are not necessary.

2.3.

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Despite its widespread use in the treatment of diarrhea, its mechanism of action is still incompletely understood. The literature indicates that possible mechanisms of action include a direct antimicrobial effect, binding and inactiva-tion of enterotoxins, prevention of attachment of microor-ganisms to the intestinal mucosa, and a direct antisecre-tory effect. Data suggest that products containing bismuth subsalicylate are a safe and effective adjunct to standard ORT for infants and children with gastroenteritis. These products result in decreased duration of diarrhea, amount of stool output, and length of hospitalization.90,91 However, due to new labeling requirements by the Food and Drug Administration, pediatric dosing will no longer appear on antidiarrheal drugs containing bismuth subsalicylate.92 Presumably, this is due to concerns over the rare devel-opment of Reye’s syndrome in febrile children who take aspirin-like products.

Antimicrobial TherapyThe use of empiric antibiotics is not recommended. Most cases of gastroenteritis are due to viruses, and therefore the children will not benefit from antibiotics. Although there is a select group of bacterial entities in which anti-microbial therapy is recommended, even most bacterial gastroenteritis does not require or benefit from antibiotic treatment.93,94 (See Table 4.) This is because antimicrobial therapy may prolong the course of the illness in some cases and has been associated with increased rates of other complications.95

Special Circumstances

Clinical guidelines are intended for previously healthy patients with classic, uncomplicated gastroenteritis. Care must be individualized for other children. In particular, patients with known or suspected underlying cardiovas-cular, renal, endocrine, or central nervous system dis-eases who may be at risk for significant fluid overload or

cardiovascular decompensation should not undergo rapid rehydration.

Controversies/Cutting Edge

One area of controversy involves the use of a “PO chal-lenge” before discharging patients from the ED. There is no literature to support the practice of trials of drinking fluids prior to discharge to home. This “time-honored” approach is wide open for study and cannot be recom-mended based on the available evidence. Although oral rehydration has been well supported and has very good supporting evidence, the routine use of oral rehydration therapy in the ED remains controversial. These perceived barriers have been discussed above. (See Treatment, Oral Rehydration on page 8.) Most clinicians agree that more emphasis should be placed on oral rehy-dration and the prevention of dehydration, rather than on intravenous rehydration. In many ways, this may just be “lip service.” Although multiple experts have been advo-cating for the increased use of enteral rehydration for over 30 years as the preferred treatment for the acute replace-ment of fluid and electrolyte losses, the widespread use of this simple technology still seems to elude most practitio-ners. Racecadotril, an enkephalinase inhibitor with anti-secretory and antidiarrheal properties, has been tested for use in children. Data suggest that when compared to placebo, racecadotril lowers stool output by up to 50% in patients with profuse, watery diarrhea.96,97 Racecadotril appears to be well tolerated and may prove to be a useful adjuvant to standard oral rehydration therapy in infants and children with acute gastroenteritis, particularly those with severe diarrheal illnesses, such as those caused by ro-tavirus. Currently, however, it has not gained widespread use in the United States. There are some limited data to suggest that lactobacil-lus therapy may have some usefulness in acute infectious

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E, LLCdiarrhea in children; however, its effect seems to be fairly small, and it has failed to gain any widespread acceptance in the United States.98,99

Disposition

Children who demonstrate no evidence of dehydration should be discharged with instructions on how to recog-nize and prevent dehydration. (See Sample Discharge In-structions on page 11.) In terms of discharge instructions, handing out preprinted instruction sheets alone is not sufficient. Discharge instructions must be designed to be culturally sensitive and related at basic cognitive levels for the populations being served. They must also be readily available in all languages appropriate for the population of patients seen in the catchment area of the ED. Both inac-curate information and improper instructions are potential causes for significant error and patient harm.100

Parents of infants with gastroenteritis and dehydra-tion need, at minimum, both verbal and written instruc-tions in the use of ORS. Those receiving ORT in the ED, will not only see ORT, but will also actually participate in the process. Parents and caregivers vary in their precon-ceived notions and their ability to understand and retain information.101 Patients with severe dehydration should receive rapid IV rehydration, followed by ORT. Patients should be reassessed after initial therapy to determine response and ability to proceed to realimentation and discharge. The data are unclear regarding specific admis-sion criteria, either to the pediatric intensive care unit or to the pediatric ward.17,30 Although evidence-based admis-sion criteria have not been fully developed, it is probably prudent to admit children with any of the following: ill appearance, atypical presentation, age less than 3 months, high probability of outpatient failure (eg, high ongoing losses, social reasons, complications), comorbid condi-tions, and failure of ED rehydration.

Summary

Gastroenteritis is a common pediatric complaint. Whereas dehydration has the potential to become a sequela of the disease process, it does not always occur. Dehydration, by itself, is not an indication for IV rehydration or hospital-ization. Oral rehydration is the preferred therapy for mild and moderate dehydration, and intravenous therapy is best reserved for refractory moderate or severe dehydra-tion. A simple approach to the ED management of these patients, focusing on objective dehydration assessment and ORS, can greatly streamline care. Optimal nutritional therapy, with continued feeding during illness, should be considered of paramount importance in the overall management of acute gastroenteritis. Involving all care providers, including parents, nurses, and primary care physicians, in a coordinated process of rehydration will result in the greatest likelihood of success in managing these all too common cases. ▲

Calculating And Replacing Fluid Deficits

“I’ve given a couple of 20 ml/kg boluses of normal saline. Now what?!?”

One area of interest to many emergency physicians is the management of dehydrated children over many hours. At times, primarily due to hospital overcrowding, emergency physicians find that their pediatric referral hospitals are unable to accept transfers for prolonged periods, or admit-ted children spend hours (if not days) in the ED before being moved up into a hospital bed. Alternatively, it is becoming more common for children with typical gastro-enteritis to be admitted to 23-hour observation units and managed by emergency physicians. In order to help emer-gency physicians in these circumstances, this brief section will provide the details of how to calculate and replace fluid deficits over 24 hours.

Example

A 2-year-old boy weighing 12 kg has persistent vomiting and copious watery diarrhea. A trial of oral rehydration has failed due to unremitting vomiting, even after the administration of an oral dissolving table of ondansetron. The boy is moderately dehydrated (See Table 2). The boy receives a 250 ml (20.8 ml/kg) bolus of normal saline. The vomiting persists. After deciding to admit the child to the observation unit, the emergency physician also decides to calculate the fluid deficit and replace the fluid deficit over 24 hours. Remember that 1 L of water weighs 1 kg.

Step 1 - Calculate the total fluid deficit

If you assume that the child is in the more severe part of the moderate dehydration category, then this would suggest that the child is around 8% or 9% dehydrated. For ease of calculation, selecting 10% as “overhydrating” a child by 1% or 2% shouldn’t have a negative effect on a previously healthy child. So, if a 12-kg child is thought to have lost 10% of their body weight, this would be 1.2 kg. If this is all water-weight loss (which it is), this would be 1.2 L, or 1,200 ml.

Step 2 - Calculate the hourly rate and “front load”

Replace the first half of the fluid deficit over the first 8 hours and the second half of the fluid deficit over the next 16 hours. So, 1,200 ml divided by 2 = 600 ml. Giving 600 ml over 8 hours = 75 ml per hour. For the next 16 hours, the rate would be 38 ml per hour (600 ml divided by 16 = 37.5).

Step 3 - Pick a fluid

Unless the child is an infant in the first few months of life, a reasonable choice is D5 0.45NS, with 20 mEq KCl per liter. For the younger infants, D5 0.2NS with 20 mEq KCl per liter is typically chosen.

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D5 0.45NS with 20 mEq KCl per liter at 75 ml/hour IV for the first 8 hours, and then 38 ml/hour for the next 16 hours.

Dosing Ondansetron

Since the use of ondansetron is off-label, emergency physicians may have difficulty finding information about the dosing of ondansetron for use in the setting of gas-troenteritis. In the study by Ramsook et al,88 the authors administered the oral solution every 8 hours and gave 1.6 mg per dose for children 6 to 12 months of age, 3.2 mg to children 1 to 3 years of age, and 4 mg to children 4 to 12 years of age. Reeves et al87 administered 0.15 mg/kg of the intravenous preparation, up to a maximum of 8 mg in a single dose. The oral dissolving tablets (ODT) are available in 4-mg and 8-mg preparations. For this reason, it may be reasonable to dose ondansetron as follows:

Infants and Toddlers — 2 mg (1/2 a 4-mg ODT)Young School Aged Children — 4 mg Older Children and Adolescents — 8 mg.

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The find-ings of a large, prospective, randomized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each refer-ence, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in the paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the refer-ence.

1. Dorland WA. Dorland’s Illustrated Medical Dictionary. 30th Edition. Phila-delphia, Pa: WB Saunders Company; 2003:758.

2.* Finberg L. The early history of the treatment of dehydration. Arch Pedi-atr Adolesc Med 1998;152:71-73. (Review)

3. No authors listed. Clinical policy: critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med 2000;36(4):406-415. (Clinical policy)

4. Parashar U, Quiroz ES, Mounts AW, et al. “Norwalk-like viruses”: public health consequences and outbreak management. MMWR Recomm Rep 2001 Jun 1:50(RR-9);1-17. (Review)

5.* No authors listed. Practice parameter: the management of acute gastro-enteritis in young children. American Academy of Pediatrics, Provi-sional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics 1996 Mar;97(3):424-435. (Practice guideline)

6. World Health Organization. The treatment of diarrhoea. A manual for physicians and other senior health workers. 1995. Available at: http://www.who.int/child-adolescent-health/New_Publications/CHILD_HEALTH/WHO_FCH_CAH_03.7.pdf. Accessed December 30, 2004. (Policy/Guideline)

7. Guerrant RL, Van Gilder T, Steiner TS, et al. Infectious Diseases Society of America. Practice guidelines for the management of infectious diar-rhea. Clin Infect Dis 2001 Feb 1;32(3):331-351. (Practice guideline)

8.* Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA 2004;291(22):2746-2754. (Review)

9.* Duggan C, Refat M, Hashem M, et al. How valid are clinical signs of dehydration in infants? J Pediatr Gastroenterol Nutr 1996;22:56-61. (Prospective cohort; 135 patients)

10.* Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics 1997;99(5):e6. (Prospective cohort; 186 patients)

11. Friedman JN, Goldman RD, Srivastava R, et al. Development of a clini-cal dehydration scale for use in children between 1 and 36 months of age. J Pediatr 2004;145:201-207. (Prospective cohort; 137 patients)

12. Duggan C, Santosham M, Glass RI. The management of acute diarrhea in children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 1992;41(RR-16):1-20. (Review)

13.* Sharifi J, Ghavami F, Nowrouzi Z, et al. Oral versus intravenous rehy-dration therapy in severe gastroenteritis. Arch Dis Child 1985;60:856-60. (Prospective, randomized; 470 patients)

14. Issenman RM, Leung AK. Oral and intravenous rehydration of children. Can Fam Physician 1993;39:2129-2136. (Prospective; 42 patients)

15. Holliday M. The evolution of therapy for dehydration: should deficit therapy still be taught? Pediatrics 1996;98:171-177. (Review)

16. Rahman O, Bennish ML, Alam AN, et al. Rapid intravenous rehydra-tion by means of a single polyelectrolyte solution with or without dextrose. J Pediatr 1988;113:654-660. (Prospective, randomized; 67 patients)

17. Sandhu BK; European Society of Pediatric Gastroenterology, Hepatol-ogy and Nutrition Working Group on Acute Diarrhoea. Practical guidelines for the management of gastroenteritis in children. J Pediatr Gastroenterol Nutr 2001;33(Suppl 2):S36-S39). (Review/Guideline)

18. Cohen MB, Mezoff AG, Laney DW Jr, et al. Use of a single solution for oral rehydration and maintenance therapy of infants with diarrhea and mild to moderate dehydration. Pediatriacs 1995;95:639-645. (Pro-spective randomized trial; 60 patients)

19.* Reid SR, Bonadio WA. Outpatient rapid intravenous rehydration to correct dehydration and resolve vomiting in children with acute gas-troenteritis. Ann Emerg Med 1996;28(3):318-323. (Prospective cohort; 58 patients)

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45. MacKenzie A, Barnes G, Shann F. Clinical signs of dehydration in chil-dren. Lancet 1989;2(8663);605-607. (Retrospective 102 patients)

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48. Saavedra JM, Harris GD, Li S, et al. Capillary refilling (skin turgor) in the assessment of dehydration. Am J Dis Child 1991;145(3):296-298. (Prospective cohort; 32 patients)

49. Choi SW, Park CH, Silva TM, et al. To culture or not to culture: fecal lactoferrin screening for inflammatory bacterial diarrhea. J Clin Mi-crobiol 1996 Apr;34(4):928-932. (Retrospective, cost-benefit analysis; 55 patients)

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52. Fine KD, Ogunji F, George J, et al. Utility of a rapid fecal latex agglutina-tion test detecting the neutrophil protein, lactoferrin, for diagnosing inflammatory causes of chronic diarrhea. Am J Gastroenterol 1998 Aug;93(8):1300-1305. (Non-random sample; 103 patients)

53. Huicho L, Garaycochea V, Uchima N, et al. Fecal lactoferrin, fecal leukocytes and occult blood in the diagnostic approach to childhood invasive diarrhea. Pediatr Infect Dis J 1997 Jul;16(7):644-647. (Prospec-tive; 125 patients with diarrhea)

54. Kane SV, Sandborn WJ, Rufo PA, et al. Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation. Am J Gastroenterol 2003 Jun;98(6):1309-1314. (Prospective, comparative; 215 patients)

55. Thielman NM, Guerrant RL. Clinical practice. Acute infectious diarrhea. N Engl J Med 2004 Jan 1;350(1)38-47. (Review)

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57. Santosham M, Daum RS, Dillman L, et al. Oral rehydration therapy of infantile diarrhea: a controlled study of well-nourished chil-dren hospitalized in the United States and Panama. N Engl J Med 1982;306:1070-1076. (Randomized controlled trial; 146 patients)

58. Santosham M, Burns B, Nadkarni V, et al. Oral rehydration therapy for acute diarrhea in ambulatory children in the United States: a double blind comparison of four different solutions. Pediatrics 1985;76(2):159-166. (Randomized controlled trial; 140 patients)

59. Listernick R, Zieserl E, Davis AT. Outpatient oral rehydration of infants in the United States. Am J Dis Child 1986;140(3):211-215. (Randomized controlled trial; 29 patients)

60. Tamer AM, Friedman LB, Maxwell SR, et al. Oral rehydration of infants in a large urban U.S. medical center. J Pediatr 1985;107(1):14-19. (Ran-domized controlled trial; 100 patients)

61.* Santosham M, Keenan EM, Tulloch J, et al. Oral rehydration therapy for diarrhea: an example of reverse transfer of technology. Pediatrics 1997;100(5):E10.

62. Fonseca BK, Holdgate A, Craig JC. Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of random-ized controlled trials. Arch Pediatr Adolesc Med 2004;158(5):483-490. (Meta-analysis)

63. Hahn S, Kim Y, Garner P. Reduced osmolarity oral rehydration solu-tion for treating dehydration due to diarrhea in children: systematic review. BMJ 2001;323(7304):81-85. (Meta-analysis)

64. Maulen-Radovan I, Gutierrez-Castrellon P, Hashem M, et al. Safety and

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65. Fontaine O, Gore SM, Pierce NF. Rice-based oral rehydration solution for treating diarrhea. Cochrane Database Syst Rev 2000;(2):CD001264. (Meta-analysis)

66. Snyder JD. Use and misuse of oral therapy for diarrhea: comparison of US practices with American Academy of Pediatrics recommenda-tions. Pediatrics 1991;87(1):28-33. (Review)

67.* Reis EC, Goepp JG, Katz S, et al. Barriers to use of oral rehydration therapy. Pediatrics 1994;93(5):708-711. (Survey; 104 respondents)

68. Ozuah PO, Avner JR, Stein RE. Oral rehydration, emergency physicians, and practice parameters: a national survey. Pediatrics 2002;109(2):259-261. (National survey; 176 physicians)

69. Conners GP, Barker WH, Mushlin AI, et al. Oral versus intravenous: rehydration preferences of pediatric emergency medicine fellow-ship directors. Pediatr Emerg Care 2000;16(5):335-338. (Survey; 60 respondents)

70.* Atherly-John YC, Cunningham SJ, Crain EF. A randomized trial of oral vs intravenous rehydration in a pediatric emergency depart-ment. Arch Pediatr Adolesc Med 2002;156(12):1240-1243. (Prospective randomized trial; 34 patients)

71. Ladinsky M, Duggan A, Santosham M, et al. The World Health Organi-zation oral rehydration solution in US pediatric practice: a random-ized trial to evaluate parent satisfaction. Arch Pediatr Adolesc Med 2000;154(7):700-705. (Prospective randomized trial; 91 families)

72. Meyers A, Sampson A, Saladino R, et al. Safety and effectiveness of homemade and reconstituted packet cereal-based oral rehydration solutions: a randomized clinical trial. Pediatrics 1997;100(5):E3. (Pro-spective, randomized; 203 patients)

73. Meyers A, Siegel B, Vinci R. Economic barriers to the use of oral rehy-dration therapy. JAMA 1991;265(13):1724-1725. (Case report)

74. Duggan C, Lasche J, McCarty M, et al. Oral rehydration solution for acute diarrhea prevents subsequent unscheduled follow-up visits. Pe-diatrics 1999;104(3):e29. (Prospective randomized trial; 479 patients)

75. Rosenstein BJ, Baker MD. Pediatric outpatient intravenous rehydration. Am J Emerg Med 1987;5(3):183-186. (Prospective cohort; 68 patients)

76. Feld LG, Kaskel FJ, Schoeneman MJ. The approach to fluid and electro-lyte therapy in pediatrics. Adv Pediatr 1988;35:497-535. (Review)

77. De Bruin WJ, Greenwald BM, Notterman DA. Fluid resuscitation in pediatrics. Crit Care Clin 1992;8(2):423-438. (Review)

78. Adrogue H, Madias N. Hypernatremia. N Engl J Med 2000;342(20):1493-1499. (Review)

79. Vesikari T, Isolauri E, Baer M. A comparative trial of rapid oral and intravenous rehydration in acute diarrhea. Acta Paediatr Scand 1987;76(2):300-305. (Prospective, randomized; 37 patients)

80.* Bender BJ, Ozuah PO. Intravenous rehydration for gastroenteritis: how long does it really take? Pediatr Emerg Care 2004 Apr;20(4):215-218. (Prospective case series; 549 patients)

81. Jackson J, Bolte RG. Risks of intravenous administration of hypotonic fluids ofr pediatric patients in ED and prehsopital settings: let’s remove the handle from the pump. Am J Emerg Med 2000;18(3):269-270. (Case report)

82. Meyer A. Fluid and electrolyte therapy for children. Curr Opin Pediatr 1994;6:303-309. (Review)

83. Pizarro D, Posada G, Levine M. Hypernatremic diarrheal dehydration treated with “slow” (12-hour) oral rehydration therapy: a preliminary report. J Pediatr 1984;104(2):316-9. (Prospective cohort; 35 patients)

84. Nager AL, Wang VJ. Comparison of nasogastric and intravenous

methods of rehydration in pediatric patients with acute dehydra-tion. Pediatrics 2002;109(4):566-572. (Prospective randomized trial; 92 patients)

85. Brown KH, Gastanaduy AS, Saavedra JM, et al. Effect of continued oral feeding on clinical and nutritional outcomes of acute diarrhea in children. J Pediatr 1988;112(2):191-200. (Prospective, randomized; 128 patients)

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87.* Reeves JJ, Shannon MW, Fleisher GR. Ondansetron decreases vomiting associated with acute gastroenteritis: a randomized, controlled trial. Pediatrics 2002 Apr;109(4):e62. (Prospective, randomized double blind trial; 107 pateints)

88.* Ramsook C, Sahagun-Carreon I, Kozinetz CA, et al. A randomized clin-ical trial comparing oral ondansetron with placebo in children with vomiting from acute gastroenteritis. Ann Emerg Med 2002;39(4):397-403. (Prospective randomized trial; 145 patients)

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91. Figueroa-Quintanilla D, Salazar-Lindo E, Sack RB, et al. A controlled trial of bismuth subsalicylate in infants with acute watery diarrheal disease. N Engl J Med 1993; 328:1653-8. (Randomized, placebo-con-trolled, clinical trial; 275 boys in South America)

92. Pepto-Bismol® Web site. Frequently Asked Questions. Available at: http://www.pepto-bismol.com/faqs.shtml#13. Accessed December 30, 2004.

93. Karras DJ, Ong S, Moran GJ, et al; EMERGEncy ID NET Study Group. Antibiotic use for emergency department patients with acute diar-rhea: Prescribing practices, patient expectations, and patient satisfac-tion. Ann Emerg Med 2003 Dec;42(6):835-842. (Multicenter, prospec-tive; 104 patients)

94. Eidlitz-Marcus T, Cohen YH, Nussinovitch M, et al. Comparative efficacy of two- and five-day courses of ceftriaxone for treatment of severe shigellosis in children. J Pediatr 1993 Nov;123(5):822-824. (Prospective, randomized; 40 patients)

95. Wong CS, Jelacic S, Habeeb RL, et al. The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli 0157:H7 infections. N Engl J Med 2000 Jun 29;342(26):1930-1936. (Prospective cohort; 71 patients)

96. Cezard JP, Duhamel JF, Meyer M, et al. Efficacy and tolerabil-ity of racecadotril in acute diarrhea in children. Gastroenterology 2001;120(4):799-805. (Prospective, randomized; 172 patients)

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100. Crocco AG, Villasis-Keever M, Jadad AR. Two wrongs don’t make a right: harm aggravated by inaccurate information on the Internet. Pediatrics 2002;109(3):522-523. (Case report)

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diarrhea among underserved minority parents/caregivers. Ambul Pediatr 2002 May-Jun;2(3):201-206. (Survey; 219 parents/caregivers of children less than 5 years of age)

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103. Cincinnati Children’s Hospital Medical Center. Evidence-based clini-cal practice guideline for children with acute gastroenteritis (AGE). Cincinnati Children’s Hospital Medical Center; 2001 Apr. (Practice guideline; 118 references)

Physician CME Questions

65. Ondansetron is a safe and effective antiemetic for children with gastroenteritis.

a. Trueb. False

66. Laboratory testing is indicated for most children with gastroenteritis.

a. Trueb. False

67. Children without clinical evidence of dehydration do not need any intervention other than parental education in the ED.

a. Trueb. False

68. Antibiotics are indicated for most children with gastroenteritis.

a. Trueb. False

69. The decision on whether or not to use intravenous rehydration is primarily based on urine specific gravity.

a. Trueb. False

70. Urine output is typically decreased in moderate dehydration.

a. Trueb. False

71. Oral rehydration is indicated for moderately dehy-drated, vomiting, young children.

a. Trueb. False

72. When compared to intravenous therapy, oral rehy-dration therapy leads to longer ED stays.

a. Trueb. False

73. The best fluid for intravenous rehydration in young infants is normal saline.

a. Trueb. False

74. Formula diluted with water until it is half strength should be avoided in treated gastroenteritis.

a. Trueb. False

75. A “PO challenge” is no longer recommended in the routine ED management of gastroenteritis.

a. Trueb. False

76. Nasogastric fluid administration is a viable option for rehydrating children with dehydration due to gastroenteritis.

a. Trueb. False

77. Severe dehydration is a contraindication to oral rehydration therapy.

a. Trueb. False

78. Rectal exams are rarely indicated in the evaluation of children with gastroenteritis.

a. Trueb. False

79. No single physical finding is sufficiently accurate to be used in determining the degree to which a child is dehydrated.

a. Trueb. False

80. Decreased urinary output has a positive predictive of about 90% for identifying dehydration in chil-dren with gastroenteritis.

a. Trueb. False

TM

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Pediatric Emergency Medicine Practice is not affiliated with any pharmaceutical firm or medical device manufacturer.

Direct all editorial or subscription-related questions to EB Practice, LLC: 1-800-249-5770 • Fax: 1-770-500-1316 • Non-U.S. subscribers, call: 1-678-366-7933

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Pediatric Emergency Medicine Practice (ISSN 1549-9650) is published monthly (12 times per year) by EB Practice, LLC, 305 Windlake Court, Alpharetta, GA 30022. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Pediatric Emergency Medicine Practice is a trademark of EB Practice, LLC. Copyright 2004 EB Practice, LLC. All rights reserved. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC. Subscription price: $299, U.S. funds. (Call for international shipping prices.)

Publisher: Robert Williford. Executive Editor: Cheryl Strauss.

Coming in Future Issues:

Unexplained Crying • Accidental Poisoning

This test concludes the August through December 2004semester testing period of Pediatric Emergency Medicine Practice. The answer form for this semester and a return

envelope have been included with this issue. Please refer to the instructions printed on the answer form. All paid

subscribers are eligible to take this test.

Monthly online CME testing is available for subscribers at no extra charge at http://www.empractice.net

Class IAlways acceptable, safeDefinitely usefulProven in both efficacy and ef-fectiveness

Level of Evidence:One or more large prospective stud-ies are present (with rare exceptions)High-quality meta-analysesStudy results consistently positive and compelling

Class IISafe, acceptableProbably useful

Level of Evidence:Generally higher levels of evidenceNon-randomized or retrospective studies: historic, cohort, or case-control studiesLess robust RCTsResults consistently positive

Class IIIMay be acceptablePossibly usefulConsidered optional or alternative treatments

Level of Evidence:Generally lower or intermediate levels of evidence

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Case series, animal studies, consen-sus panelsOccasionally positive results

IndeterminateContinuing area of researchNo recommendations until further research

Level of Evidence:Evidence not availableHigher studies in progressResults inconsistent, contradictoryResults not compelling

Significantly modified from: The Emergency Cardiovascular Care Committees of the American Heart As-sociation and representatives from the resuscitation councils of ILCOR: How to Develop Evidence-Based Guidelines for Emergency Cardiac Care: Quality of Evidence and Classes of Recommenda-tions; also: Anonymous. Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency Cardiac Care Committee and Subcom-mittees, American Heart Association. Part IX. Ensuring effectiveness of com-munity-wide emergency cardiac care. JAMA 1992;268(16):2289-2295.

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Class Of Evidence Definitions

Each action in the clinical pathways section of Pediatric Emergency Medicine

Practice receives a score based on the following definitions.

Target Audience: This enduring material is designed for emergency medicine physicians.

Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.

Date of Original Release: This issue of Pediatric Emergency Medicine Practice was published December 31, 2004. This activity is eligible for CME credit through December 1, 2007. The latest review of this material was December 29, 2004.

Discussion of Investigational Information: As part of the newsletter, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product. Disclosure of Off-Label Usage: In this issue of Pediatric Emergency Medicine Practice the use of ondansetron, as described for the use of nausea and vomiting associated with gastroenteritis, is an off-label use. The labeling for oral preparations of ondansetron, including the ODT Orally Disintegrating Tablets and the Oral Solution marketed under the brand name Zofran®, includes prevention of nausea and vomiting associated with cancer chemotherapy, radiotherapy involving whole body or abdominal irradiation, and postoperative care. The labeling for the intravenous preparation of ondansetron, marketed under the brand name Zofran®, includes prevention of nausea and vomiting associated with cancer chemotherapy and postoperative care.

Faculty Disclosure: In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Hostetler, Dr. Nakanishi, and Dr. Whiteman report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.

Accreditation: Mount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

Credit Designation: Mount Sinai School of Medicine designates this educational activity for up to 4 hours of Category 1 credit toward the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit actually spent in the educational activity. Pediatric Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category 1 credit (per annual subscription). This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for up to 48 AAP Credits. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.

Earning Credit: Two Convenient Methods • Print Subscription Semester Program: Paid subscribers with current and

valid licenses in the United States who read all CME articles during each Pediatric Emergency Medicine Practice six-month testing period, complete the post-test and the CME Evaluation Form distributed with the December and June issues, and return it according to the published instructions are eligible for up to 4 hours of Category 1 credit toward the AMA Physician’s Recogni-tion Award (PRA) for each issue. You must complete both the post-test and CME Evaluation Form to receive credit. Results will be kept confidential. CME certificates will be delivered to each participant scoring higher than 70%.

• Online Single-Issue Program: Paid subscribers with current and valid licenses in the United States who read this Pediatric Emergency Medicine Practice CME article and complete the online post-test and CME Evaluation Form at EMPractice.net are eligible for up to 4 hours of Category 1 credit toward the AMA Physician’s Recognition Award (PRA). You must complete both the post-test and CME Evaluation Form to receive credit. Results will be kept confidential. CME certificates may be printed directly from the Web site to each participant scoring higher than 70%.

Physician CME InformationThis CME enduring material is sponsored by Mount Sinai School of Medicine and has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education. Credit may be obtained by reading each issue and completing the printed post-tests administered in December and June or online single-issue post-tests administered at EBMedPractice.net. TM

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