Isotonic is better than hypotonic saline for intravenous rehydration of children with gastroenteritis: a prospective randomised study

Aims

To determine whether the risk of hyponatraemia in children with gastroenteritis receiving intravenous (IV) fluids is decreased by the use of 0.9% saline.

Methods

A prospective randomised study was carried out in a tertiary paediatric hospital. A total of 102 children with gastroenteritis were randomised to receive either 0.9% saline + 2.5% dextrose (NS) or 0.45% saline + 2.5% dextrose (N/2) at a rate determined by their treating physician according to hospital guidelines and clinical judgement. Plasma electrolytes, osmolality, and plasma glucose were measured before (T₀) and 4 hours after (T₄) starting IV fluids, and subsequently if clinically indicated. Electrolytes and osmolality were measured in urine samples. Results were analysed according to whether children were hyponatraemic (plasma sodium <135 mmol/l) or normonatraemic at T₀.

Results

At T₀, mean (SD) plasma sodium was 135 (3.3) mmol/l (range 124–142), with 37/102 (36%) hyponatraemic. At T₄, mean plasma sodium in children receiving N/2 remained unchanged in those initially hyponatraemic (n = 16), but fell 2.3 (2.2) mmol/l in the normonatraemic group. In contrast, among children receiving NS, mean plasma sodium was 2.4 (2.0) mmol/l higher in those hyponatraemic at baseline (n = 21) and unchanged in the initially normonatraemic children. In 16 children who were still receiving IV fluids at 24 hours, 3/8 receiving N/2 were hyponatraemic compared with 0/8 receiving NS. No child became hypernatraemic.

Conclusions

In gastroenteritis treated with intravenous fluids, normal saline is preferable to hypotonic saline because it protects against hyponatraemia without causing hypernatraemia.     

Isotonic is better than hypotonic saline for intravenous rehydration of children with gastroenteritis: a prospective randomised study.

AIMS: To determine whether the risk of hyponatraemia in children with gastroenteritis receiving intravenous (IV) fluids is decreased by the use of 0.9% saline. METHODS: A prospective randomised study was carried out in a tertiary paediatric hospital. A total of 102 children with gastroenteritis were randomised to receive either 0.9% saline + 2.5% dextrose (NS) or 0.45% saline + 2.5% dextrose (N/2) at a rate determined by their treating physician according to hospital guidelines and clinical judgement. Plasma electrolytes, osmolality, and plasma glucose were measured before (T(0)) and 4 hours after (T(4)) starting IV fluids, and subsequently if clinically indicated. Electrolytes and osmolality were measured in urine samples. Results were analysed according to whether children were hyponatraemic (plasma sodium <135 mmol/l) or normonatraemic at T(0). RESULTS: At T(0), mean (SD) plasma sodium was 135 (3.3) mmol/l (range 124-142), with 37/102 (36%) hyponatraemic. At T(4), mean plasma sodium in children receiving N/2 remained unchanged in those initially hyponatraemic (n = 16), but fell 2.3 (2.2) mmol/l in the normonatraemic group. In contrast, among children receiving NS, mean plasma sodium was 2.4 (2.0) mmol/l higher in those hyponatraemic at baseline (n = 21) and unchanged in the initially normonatraemic children. In 16 children who were still receiving IV fluids at 24 hours, 3/8 receiving N/2 were hyponatraemic compared with 0/8 receiving NS. No child became hypernatraemic. CONCLUSIONS: In gastroenteritis treated with intravenous fluids, normal saline is preferable to hypotonic saline because it protects against hyponatraemia without causing hypernatraemia.     

Towards a better oral rehydration fluid

Improvements in characteristics of solutions used for oral rehydration therapy, to provide significant reductions in amount and duration of diarrhea, are expected to contribute to wider use of these fluids. Recent studies suggest that these may come about from reducing the osmolality of the solution, and by providing short chain fatty acids for better fluid absorption from the colon. This article briefly reviews the physiology of intestinal and colonic absorption in diarrhea, and indicates the further studies that are needed to translate the above advances into universal practice for the treatment of diarrhea.     

Neurogenic hypernatremia syndrome in children

Chronic "neurogenic" hypernatremia is the consequence of defective thirst mechanism either alone or in combination with impaired osmoregulation of ADH release. Both the specific receptors and the structures involved in hormonal secretion are localised in the hypothalamic area. "Neurogenic" hypernatremia can be secondary to a hypothalamic lesion of different type (neoplastic, vascular, malformative) or rarely it can be idiopathic. We present three cases: two females 4 and 5 months old, affected by cerebral malformations involving midline structures of the brain (III ventricule, corpus callosum etc.) and a male 4 years old with a idiopathic form. We discuss the relationship between the origin of the cerebral malformations and the ontogeny of the structures involved in the control of the osmolarity. Moreover we have observed that the hypernatremia in associated with hyperlipemia: the pathogenetic hypothesis explaining this abnormality are discussed.     

Normal cerebrospinal fluid values in children: another look

Cerebrospinal fluid samples sterile for virus and bacteria from 371 patients who had no evidence of CNS pathology were examined. The patients were divided into five age categories. The white blood cell polymorphonuclear, and mononuclear cell counts were evaluated. The frequency distributions for these cell counts were markedly skewed, so values were calculated as percentiles for each age group. WBC values were highest for CSF obtained from patients in younger age categories, but 25% of patients from all age categories had two or three WBCs in their CSF. Patients from all but the 3- to 6-month category had three polymorphonuclear cells in their CSF 5% of the time. There was no significant difference in CSF WBC count between patients who had seizures and those who did not. Knowledge of normal values in different age groups is needed for the interpretation of CSF findings, but it should be used in conjunction with other clinical and laboratory findings.     

Inhaled corticosteroid therapy is safe in tuberculin-positive asthmatic children

BACKGROUND: Although treatment with oral corticosteroids can cause reactivation of latent Mycobacterium tuberculosis (TB) infection in purified protein derivative (PPD)-positive individuals with no evidence of clinical disease, little is known about the effects of inhaled corticosteroids in this respect. OBJECTIVE: This study was undertaken to assess whether inhaled corticosteroid (CS) therapy reactivates latent TB infection in PPD-positive asthmatic children. METHOD: We studied 32 PPD skin test-positive (> or =10 mm) children [age (mean +/- SD), 7.9 +/- 4.1 years] with no family history and no evidence of TB infection on chest radiograms who were receiving inhaled budesonide for the treatment of asthma. They were further evaluated with thorax computed tomography (CT) and erythrocyte sedimentation rate and closely observed for an additional 9 months. RESULTS: At enrollment the mean diameter of PPD reaction was 12.8 +/- 2.7 mm. The mean duration of inhaled CS treatment and the mean cumulative CS dose were 9.8 +/- 7.6 months and 275 +/-199 mg, respectively. Thorax CT studies revealed mediastinal lymph nodes in 7 of the 32 patients. There was no significant difference between children with and without mediastinal lymph nodes according to age, gender, size of PPD skin testing, erythrocyte sedimentation rate and duration and cumulative CS dose of inhaled budesonide therapy before study. A second thorax CT was obtained 9 months later in those 7 patients with lymphadenopathy (additional mean cumulative CS dose, 222.57 mg). There was no change in the size of their lymph nodes. CONCLUSION: Long term inhaled budesonide therapy appears to be safe in PPD-positive asthmatic children.     

Oral rehydration in gastroenteritis in children

Oral rehydration is an ideal form of treatment of gastroenteritis in India both in large hsopitals and in rural health centers where adequate facilities and trained personnel are lacking. This paper concerns a study of oral rehydration in 30 patients (aged 17 days to 5 years) admitted to the Children's Ward (of Goa Medical College between April to August 1972) for gastroenteritis and 210 children who were treated in the Outpatients' Dept. (Ta 1). Tables 2 and 3 show the complaints on admission and clinical signs of the disorder. Fluid replacement was divided into 2 phases. Intravenous fluid thera was administered to all children admitted in shock. Rehydration was started in all cases without shock and was maintained with orally administered glucose electrolyte solution. 12 patients had severe dehydration, 9 moderate and 9 mild. Table 5 details the control of diarrhea while Table 6 details the amount oral fluids given to different age groups and to patients with varying degrees of dehydration. 2 patients (3- and 5- month old females) developed paralytic ileus that led to their deaths. Paralytic ileus is a grave complication with a high mortality rate. It can be prevented by early and adequate administration of potassium. It is possible that some of the 210 outpatients in this study had transient diarrhea, cured themselves of it or took electrolytes which prevented complications from developing. The practice of dispensing "salts" to outpatient appear promising and should be encouraged.     

Oral rehydration therapy in severely malnourished children with diarrheal dehydration

Fifty patients of grade III & IV malnutrition with diarrhoeal dehydration were rehydrated using the WHO recommended ORS. Serum sodium and potassium levels were estimated at admission and 24 hours later. Forty seven patients were successfully rehydrated orally. In 7 patients the level of dehydration at initial assessment was overestimated. Periorbital edema developed in 25.5% of the patients rehydrated. No patient had cardiac failure or convulsions during therapy. Though persistent hyponatremia and hypokalemia were found in 10.6% and 19.15% cases respectively after rehydration, the incidence decreased as compared to the pre-hydration levels and was comparable to that found in malnourished children without diarrhea who served as controls in the present study. Oral rehydration was discontinued in three patients due to development of excessive vomiting in one case and paralytic ileus in two. Thus WHO ORS can be used safely in children with severe malnutrition but constant monitoring is required.     

Urinary incontinence in children: botulinum toxin is a safe and effective treatment option

Purpose  

This study’s aim was to assess the use of intravesical injection of botulinum neurotoxin type A (BoNT-A) as a treatment of overactive bladder (OAB) in children.     

Measurement of cerebrospinal fluid protein is unnecessary in children with leukemia

To determine the incidence and importance of abnormal cerebrospinal fluid (CSF) protein in children with acute leukemia, we performed a retrospective chart review. On 160 pediatric patients a total of 2,172 LPs were performed (median per patient = 15; range 1-38). Overall, 314 (14%) of CSF protein measurements were abnormal: 141 (7%) were abnormally low (<15 mg/dL) and 158 (7%) were abnormally high (>45 mg/dL). In no case did an abnormal CSF protein impact patient management. We conclude that routine measurement of CSF protein is not indicated in children with acute leukemia.