Treating AGE in the ED: More ORT and Less IVF

Abstract

Source: Poonai N, Powell EC, Schnadower D, et al. Variables associated with intravenous rehydration and hospitalization in children with acute gastroenteritis: a secondary analysis of 2 randomized clinical trials. JAMA Netw Open. 2021;4(4):e216433. doi:10.1001/jamanetworkopen.2021.6433Investigators from multiple institutions conducted a secondary analysis to identify factors associated with intravenous (IV) fluid administration and hospitalization in children with acute gastroenteritis (AGE). Data were obtained from 2 randomized controlled trials of probiotics in children with AGE-associated diarrhea. Participants were aged 3-48 months and had ≥3 watery stools in the preceding 24 hours of presentation to 1 of 16 emergency departments (EDs) in the US or Canada during the study period of 2013–2017. Demographics, clinical characteristics (eg, frequency of vomiting in the 24 hours pre-ED visit, previous health care visit for the same illness, duration of illness), and treatment received (eg, oral ondansetron, IV fluid administration) were collected from study participants. Dehydration was assessed using the Clinical Dehydration Scale, which is scored from 0-8 and categorized as no dehydration (0), mild to moderate dehydration (1-4), and severe dehydration (5-8).The primary outcomes for this study were: (1) IV rehydration, defined as any crystalloid administered through a peripheral IV line for the purposes of rehydration; and (2) hospitalization, defined as admission to an inpatient unit outside the ED. Investigators assessed the association between these outcomes and demographics, clinical characteristics, use of oral ondansetron, and dehydration scores. Multivariable models were created to test the independent association of these variables with outcomes.There were 1,846 participants included in analysis. The mean age of participants was 19.1 months, and 54.6% were boys. Overall, 13% of participants received IV rehydration, and 3.6% were hospitalized.In multivariable models, administration of oral ondansetron was associated with a significantly lower odds of IV rehydration (OR, 0.21; 95% CI, 0.13, 0.32) and hospitalization (OR, 0.44; 95% CI, 0.21, 0.89). Several variables were significantly associated with increased odds of IV rehydration, including mild to moderate hydration scores (OR, 8.73; 95% CI, 5.81, 13.13), severe dehydration scores (OR, 34.15; 95% CI, 13.45, 86.73), and a prior health care visit with IV rehydration (OR, 4.55; 95% CI, 1.32, 15.72). Several variables also were significantly associated with increased odds of hospitalization, including severe dehydration scores (OR, 53.45; 95% CI, 19.10, 149.57), a prior health care visit with IV rehydration (OR, 10.26; 95% CI, 3.11, 33.86), and duration of vomiting ≥48 hours (OR, 3.21; 95% CI, 1.37, 7.56).The investigators conclude that oral ondansetron use may reduce IV rehydration treatment and hospitalization in children with AGE.Dr Bechtel has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Children commonly present to EDs for evaluation of dehydration due to AGE.1 Despite guidelines recommending oral rehydration therapy (ORT), IV fluids frequently are administered to children with AGE in high-income countries such as the US.2 This likely is because parents of young children choose IV fluids over ORT when given a choice of rehydration therapy in the ED.3 It is important to note that meta-analysis has shown no clinically meaningful differences between ORT and IV fluids in terms of efficacy and safety.4 Furthermore, ondansetron for ORT will not mask illness more severe than AGE (See AAP Grand Rounds. 2010;23[5]:49.)5 Therefore, it would be helpful to know which children with AGE and dehydration likely will fail ORT and need IV fluids.The current authors found that mild to moderate hydration scores, severe dehydration scores, a prior health care visit with IV fluids, and vomiting ≥48 hours were associated with the need for IV fluids and hospitalization. More importantly, the use of oral ondansetron was associated with a reduced need for IV fluids and hospitalization, likely because it facilitated successful ORT. Future study is needed to determine if home use of ondansetron coupled with ORT would prevent an ED visit for dehydration from AGE in the first place.A limitation of the current study is that scores to assess dehydration and/or hydration status in children with AGE may be helpful only for children with moderate to severe dehydration in high-income settings.6 Thus, the applicability of the results of the current study to low- and medium-income countries may be limited.Administration of oral ondansetron to dehydrated children with AGE in the ED may reduce the likelihood for IV fluids and hospitalization.The higher rates of IV rehydration in US EDs as compared to those in Canada, without improved outcomes, may arise both from caregiver expectations and provider preferences.3 This is an opportunity in the US to decrease use of expensive health care resources.7