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      Oral Ondansetron for Gastroenteritis in a Pediatric Emergency Department

      , , ,

      New England Journal of Medicine

      Massachusetts Medical Society

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          Abstract

          Vomiting limits the success of oral rehydration in children with gastroenteritis. We conducted a double-blind trial to determine whether a single oral dose of ondansetron, an antiemetic, would improve outcomes in children with gastroenteritis. We enrolled 215 children 6 months through 10 years of age who were treated in a pediatric emergency department for gastroenteritis and dehydration. After being randomly assigned to treatment with orally disintegrating ondansetron tablets or placebo, the children received oral-rehydration therapy according to a standardized protocol. The primary outcome was the proportion who vomited while receiving oral rehydration. The secondary outcomes were the number of episodes of vomiting and the proportions who were treated with intravenous rehydration or hospitalized. As compared with children who received placebo, children who received ondansetron were less likely to vomit (14 percent vs. 35 percent; relative risk, 0.40; 95 percent confidence interval, 0.26 to 0.61), vomited less often (mean number of episodes per child, 0.18 vs. 0.65; P<0.001), had greater oral intake (239 ml vs. 196 ml, P=0.001), and were less likely to be treated by intravenous rehydration (14 percent vs. 31 percent; relative risk, 0.46; 95 percent confidence interval, 0.26 to 0.79). Although the mean length of stay in the emergency department was reduced by 12 percent in the ondansetron group, as compared with the placebo group (P=0.02), the rates of hospitalization (4 percent and 5 percent, respectively; P=1.00) and of return visits to the emergency department (19 percent and 22 percent, P=0.73) did not differ significantly between groups. In children with gastroenteritis and dehydration, a single dose of oral ondansetron reduces vomiting and facilitates oral rehydration and may thus be well suited for use in the emergency department. Copyright 2006 Massachusetts Medical Society.

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          Most cited references 18

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

           O Murphy,  M Gorelick,  K. Shaw (1997)
          To determine the validity and reliability of various clinical findings in the diagnosis of dehydration in children. Prospective cohort study. An urban pediatric hospital emergency department. One hundred eighty-six children ranging in age from 1 month to 5 years old with diarrhea, vomiting, or poor oral fluid intake, either admitted or followed as outpatients. Exclusion criteria included malnutrition, recent prior therapy at another facility, symptoms for longer than 5 days' duration, and hyponatremia or hypernatremia. All children were evaluated for 10 clinical signs before treatment. The diagnostic standard for dehydration was fluid deficit as determined from serial weight gain after treatment. Sixty-three children (34%) had dehydration, defined as a deficit of 5% or more of body weight. At this deficit, clinical signs were already apparent (median = 5). Individual findings had generally low sensitivity and high specificity, although parent report of decreased urine output was sensitive but not specific. The presence of any three or more signs had a sensitivity of 87% and specificity of 82% for detecting a deficit of 5% or more. A subset of four factors-capillary refill >2 seconds, absent tears, dry mucous membranes, and ill general appearance-predicted dehydration as well as the entire set, with the presence of any two or more of these signs indicating a deficit of at least 5%. Interobserver reliability was good to excellent for all but one of the findings studied (quality of respirations). Conventionally used clinical signs of dehydration are valid and reliable; however, individual findings lack sensitivity. Diagnosis of clinically important dehydration should be based on the presence of at least three clinical findings.
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            Is this child dehydrated?

            The ability to assess the degree of dehydration quickly and accurately in infants and young children often determines patient treatment and disposition. To systematically review the precision and accuracy of symptoms, signs, and basic laboratory tests for evaluating dehydration in infants and children. We identified 1561 potential articles by multiple search strategies of the MEDLINE database through PubMed. Searches of bibliographies of retrieved articles, the Cochrane Library, textbooks, and private collections of experts in the field yielded an additional 42 articles. Twenty-six of 1603 reviewed studies contained original data on the precision or accuracy of findings for the diagnosis of dehydration in young children (1 month to 5 years). Two of the 3 authors independently reviewed and abstracted data for estimating the likelihood ratios (LRs) of diagnostic tests. We eliminated 13 of the 26 studies because of the lack of an accepted diagnostic standard or other limitation in study design. The other 13 studies were included in the review. The most useful individual signs for predicting 5% dehydration in children are an abnormal capillary refill time (LR, 4.1; 95% confidence interval [CI], 1.7-9.8), abnormal skin turgor (LR, 2.5; 95% CI, 1.5-4.2), and abnormal respiratory pattern (LR, 2.0; 95% CI, 1.5-2.7). Combinations of examination signs perform markedly better than any individual sign in predicting dehydration. Historical points and laboratory tests have only modest utility for assessing dehydration. The initial assessment of dehydration in young children should focus on estimating capillary refill time, skin turgor, and respiratory pattern and using combinations of other signs. The relative imprecision and inaccuracy of available tests limit the ability of clinicians to estimate the exact degree of dehydration.
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              Development of a clinical dehydration scale for use in children between 1 and 36 months of age.

              To develop a clinical dehydration scale for use in children <3 years of age. Prospective cohort study of children between 1 and 36 months of age who presented to a tertiary pediatric emergency department (ED) with gastroenteritis. Children were weighed and scored for 12 clinical signs, were rehydrated, and then were reweighed and rescored when rehydration was completed. Weight change from pre- to post-rehydration was used to assess criterion validity with independent global assessments of dehydration severity by attending physicians and nurses as measures of construct validity. Formal approaches to item selection and reduction, reliability, discriminatory power, validity, and responsiveness were used. 137 children (median age: 18 months) with gastroenteritis were studied. The final dehydration scale consisted of four clinical characteristics: general appearance, eyes, mucous membranes, and tears. The measurement properties were as follows: validity as assessed by Pearson's correlation coefficient was 0.36 to 0.57; reliability as assessed by the intra-class correlation coefficient was 0.77; discriminatory power as assessed by Ferguson's delta was 0.83; and responsiveness to change as assessed by Wilcoxon signed rank test was significant at P <.01. Clinicians and researchers may consider this four-item, 8-point rating scale, developed using formal measurement methodology, as an alternative to scales developed ad hoc.
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                Author and article information

                Journal
                New England Journal of Medicine
                N Engl J Med
                Massachusetts Medical Society
                0028-4793
                1533-4406
                April 20 2006
                April 20 2006
                : 354
                : 16
                : 1698-1705
                Article
                10.1056/NEJMoa055119
                16625009
                © 2006
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