Hydration In Children Research Articles

Postoperative Hydration in Children Using Intermittent Boluses of Balanced Salt Solution: Results of a Randomized Control Trial

BackgroundPostoperative maintenance fluids are traditionally provided via hypotonic dextrose containing fluids administered intravenously by continuous infusion. We hypothesized that scheduled weight-based boluses of balanced salt solution would be more physiologic, reduce fluid volumes, and improve patient comfort. MethodsAs part of an IRB-approved randomized controlled trial (Boluses of Ringer's in Surgical Kids, BRiSK), we randomized patients aged 1–21 years undergoing elective abdominal or thoracic surgery to post-operatively receive weight-based D50.45NS+20mEq/L KCl at a continuous rate or intermittent boluses of Lactated Ringer's solution until oral liquid toleration. Patients with nephropathy, diabetes, or receiving parenteral nutrition were excluded. We analyzed electrolytes, urine output, fluid volume, and adverse events. ResultsWe enrolled and randomized 60 patients: 29 to continuous fluids and 31 to bolus fluids. One patient from the bolus group dropped out. No patients crossed over due to difficulties with application of the bolus protocol. There were no baseline differences between groups with a mean age of 12.6 ± 1.4yr and weight of 50.9 ± 7.2 kg. There were no serious adverse events or electrolyte disturbances in either group. Patients in the bolus group received significantly less total fluid than those in the continuous group (0.43 mL/kg/h vs 1.1 mL/kg/h, p < 0.001) with no difference in urine output [1.4 ± 0.2 mL/kg/h vs 1.6 ± 0.3 mL/kg/h, p = 0.211]. There were two episodes of mild hypoglycemia in the bolus group compared to seven episodes of mild hyperglycemia in the continuous group. ConclusionsAdministration of post-operative intravenous fluids as boluses of balanced salt solution is feasible, safe, and results in significantly less fluid administered compared to a traditional continuous protocol. Level of EvidenceII.

Clinical Presentation and Severity of SARS-CoV-2 Infection Compared to Respiratory Syncytial Virus and Other Viral Respiratory Infections in Children Less than Two Years of Age

The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the implementation of restrictive measures led to a dramatic reduction in respiratory syncytial virus (RSV) occurrence together with rare and mild bronchiolitis induced by SARS-CoV-2. We described the respiratory picture of SARS-CoV-2 infection and evaluated the frequency and the severity of SARS-CoV-2 bronchiolitis comparing it with other respiratory viral infections in children less than two years of age. The severity of respiratory involvement was evaluated based on the need for oxygen therapy, intravenous hydration, and the length of hospital stay. A total of 138 children hospitalized for respiratory symptoms were enrolled: 60 with SARS-CoV-2 and 78 with RSV. In the group of SARS-CoV-2-infected children, 13/60 (21%) received a diagnosis of co-infection. Among the enrolled children, 87/138 (63%) received a diagnosis of bronchiolitis. The comparative evaluation showed a higher risk of the need for oxygen therapy and intravenous hydration in children with RSV infection and co-infection compared to children with SARS-CoV-2 infection. In the children with a diagnosis of bronchiolitis, no differences in the main outcomes among the groups were observed. Although children with SARS-CoV-2 infection have less severe respiratory effects than adults, the pediatrician should pay attention to bronchiolitis due to SARS-CoV-2, which could have a severe clinical course in younger children.

Proctoclysis for rehydration in children – A scoping review and a pilot survey among medical doctors

Although proctoclysis (enema) is a historically proven, safe and cost-effective rehydration method that needs little training for users and can effectively replace intravenous hydration in different care settings, it is an uncommon choice for hydration in children with fever and is often missing in official guidelines. To evaluate the usefulness of proctoclysis, this study provides a scoping review of the existing literature. The matched literature was labelled in 5 categories, identifying 6 indication fields that are emphasized in the literature on rectal rehydration. The analysis showed that proctoclysis is mostly used in the context of diagnostic procedures, constipation or in the treatment of a gastrointestinal disease. It is also described as a quick, safe and cost-effective intervention for fluid replacement in emergency, critical care or resource-scarce settings. There are also socio-cultural variations in its use Additionally, we performed a survey on attitudes and experience of medical doctors towards proctoclysis based on a semi-structured questionnaire. In the survey, we analysed the experience of 35 medical doctors from 8 countries. Although we found a general acceptance of enema as beneficial in both hospitalized patients and in home care, doctors expressed the need for more experience with enema and the need for more education materials in order to effectively perform the procedure. Based on our findings, we suggest that further research is necessary examining the attitude towards proctoclysis among parents, nurses and doctors. Enema can have a considerable clinical advantage during home care for gastroenteritis or other infectious diseases with fever to prevent insufficient oral fluid intake resulting in a negative fluid balance. Risks and safety issues are rare and should be considered. However, due to its low level of social acceptability in order to reduce refusal rate, more education is necessary for both medical providers and parents.

Kids With Altitude: Acute Mountain Sickness and Changes in Body Mass and Total Body Water in Children Travelling to 3800 m.

We explored the incidence of acute mountain sickness (AMS) and extravascular lung water (ELW) in children in relation to changes in body composition and peripheral blood oxygenation (SpO2) during 1 week of acclimatization to 3800 m. In a prospective cohort study, 10 children (7 female, ages 7-14 y) and 10 sex-matched adults (ages 23-44 y) traveled via automobile from sea level to 3000 m for 2 nights, followed by 4 nights at 3800 m. Each morning, body mass and body water (bioelectrical impedance), SpO2 (pulse oximetry), AMS (Lake Louise Questionnaire), and ELW (transthoracic echocardiography) were measured. No differences were found between children and adults in SpO2 or ELW. At 3800 m 7 of 10 children were AMS+ vs 4 of 10 adults. Among those AMS+ at 3800 m, the severity was greater in children compared to adults (5±1 vs 3 ± 0; P=0.005). Loss of body mass occurred more quickly in children (day 5 vs day 7) and to a greater extent (-7±3% vs -2±2%; P<0.001); these changes were mediated via a larger relative loss in total body water in children than in adults (-6±5% vs -2±2%; P=0.027). Children demonstrated a higher incidence of AMS than adults, with greater severity among those AMS+. The loss of body water and body mass at high altitude was also greater in children, albeit unrelated to AMS severity. In addition to awareness of AMS, strategies to maintain body weight and hydration in children traveling to high altitudes should be considered.

Reaction pattern of the autonomic nervous system to the infusion load in the intensive care in children: a prospective comparative study

INTRODUCTION. The leading role in the water and electrolyte balance in critical conditions belongs to infusion therapy. Hemodynamic stabilization is achieved by fluid bolus with risk of hypervolemia. Non-invasive monitoring in ICU is relevant in children. Cardiointervalography is characterized by nosological non-specificity and high sensitivity to neurohumoral changes. The stress index and spectral analysis allow the assessment of therapeutic efficacy. OBJECTIVES. To study the features of the electrophysiological response to the emergency rehydrate volume in children upon admission to the intensive care unit. MATERIALS AND METHODS. A prospective comparative study was conducted with the participation of 172 patients, the age from 0 to 15 years. There were 71 newborns in the first group (21 surgical cases, 50 somatic ones). The second group enrolled children aged 1 to 15 years, in 40 % of all underwent surgical treatment. The characteristic of the electrophysiological response to the hydration was carried out in an intergroup and interstage comparison in different age and nosological groups. DISCUSSION. The autonomic nervous system response to infusion therapy has not been studied in children of different ages. The stress index and frequency analysis reflect the degree of regulatory systems tension and are promising in intensive care monitoring. RESULTS. In newborns with sensory block, it was expressed by tachycardia (p = 0.02); without block — arterial hypotension (p = 0.000) without chronotropic component. The implementation of sympathetic reactions was suppressed in children in the early postoperative period. In children without surgical treatment, the volume of infusion had a sympatholytic effect. CONCLUSIONS. In the early postoperative period, the electrophysiological response in children was limited. Age-related features of reactions to hydration in children with somatic pathology were revealed. In children, infusion therapy contributed to a cardiovascular economical work; in newborns, it was associated with a breakdown in sympathetic adaptation.

Availability of a Flavored Beverage and Impact on Children's Hydration Status, Sleep, and Mood.

Euhydration remains a challenge in children due to lack of access and unpalatability of water and to other reasons. The purpose of this study was to determine if the availability/access to a beverage (Creative Roots®) influences hydration in children and, therefore, sleep quality and mood. Using a crossover investigation, 46 participants were randomly assigned to a control group (CON) or an intervention group and received Creative Roots® (INT) for two-week periods. We recorded daily first morning and afternoon urine color (Ucol), thirst perception, and bodyweight of the two groups. Participants reported to the lab once per week and provided first morning urine samples to assess Ucol, urine specific gravity (USG), and urine osmolality (Uosmo). Participants also completed the questionnaires Profile of Mood States-Adolescents (POMS-a) and Pittsburgh Sleep Quality Index (PSQI). Dependent t-tests were used to assess the effects of the intervention on hydration, mood, and sleep quality. Uosmo was greater and Ucol was darker in the control group (mean ± SD) [Uosmo: INT = 828 ± 177 mOsm·kg−1, CON = 879 ± 184 mOsm·kg−1, (p = 0.037], [Ucol:INT = 5 ± 1, CON = 5 ± 1, p = 0.024]. USG, POMS-a, and PSQI were not significant between the groups. At-home daily afternoon Ucol was darker in the control group [INT = 3 ± 1, CON = 3 ± 1, p = 0.022]. Access to Creative Roots® provides a small, potentially meaningful hydration benefit in children. However, children still demonstrated consistent mild dehydration based on Uosmo, despite consuming the beverage.

13 Evaluating Potential Overuse of Intravenous Hydration in Patients Hospitalized with Bronchiolitis

Abstract Background Bronchiolitis is the primary cause of hospitalization in children during the first year of life. Respiratory support and hydration are the two pillars of management. Practice guidelines for bronchiolitis (NICE and CPS) recommend nasogastric (NG) hydration before intravenous (IV) fluids if oral hydration cannot be maintained. However, IV hydration remains the primary mode of hydration at our tertiary care pediatric centre. Objectives This is a resource stewardship project aiming to evaluate the baseline use of IV versus NG hydration in children 0-15 months hospitalized for bronchiolitis and requiring supplemental hydration. The secondary objective is to evaluate potential barriers to NG hydration for these children. Design/Methods Data was collected retrospectively for the 2017-2018 bronchiolitis season. A survey was sent to all the pediatric emergency (ED) physicians and nurses, pediatric hospitalists, ED fellows, pediatric residents and ward nurses. Results Among eligible patients (n=95), IV hydration was prescribed 52% of the time, compared to 48% NG hydration. Ninety-six percent (47/49) of IV hydration was initiated in the ED, while only 4% (2/49) was initiated on the ward. Among patients who began receiving hydration in the ED (80/95, or 84%), 41% (33/80) were hydrated via NG and 59% (47/80) by IV. In the survey, while 92% (57/62) of responding physicians claimed to be aware of national guidelines for bronchiolitis, only 67% (42/62) said that NG was the recommended mode of hydration. Among ED practitioners, 56% (19/34) were up-to-date on the recommendation. Two-thirds of all respondents (physicians and nurses) felt that NG hydration would be more acceptable to parents. Among nurses, 84% (38/45) felt that IV installation was a longer procedure to complete. Despite the existence of a local order set indicating NG hydration as the preferred hydration method, only 64% (40/62) of physicians were aware of its existence, and only 23% of these (9/40) actually use the guideline. Main reasons of disuse included forgetting the guideline exists and it not being easily available. In contrast, 93% of nurses were aware of the local guideline. Conclusion Intravenous hydration is overused among patients hospitalized with bronchiolitis at our centre, and the ED is the main setting where this occurs. There is a discrepancy between physicians’ theoretical knowledge of hydration guidelines and the application of these in reality. Barriers to the use of NG hydration can be amenable to a quality improvement (QI) intervention targeting improved knowledge and use of our local guideline, and this will be our focus going forward.

Early versus delayed postoperative oral hydration in children following general anesthesia: a prospective randomized trial

BackgroundOral hydration has typically not been administered for between 4 and 6 h postoperative for children’s safety in China. But children are more likely to suffer from apnea, crying and agitation, wound bleeding, and other complications during the post-anesthesia recovery period because of thirsty and fear. This Prospective, randomized study sought to assess the compare the early and late oral hydration (EOH and DOH, respectively) in children following general anesthesia, with the goal of assessing relative safety and tolerability and thereby improving patient comfort.MethodsA total of 2000 children corresponding to the American Society of Anesthesiology (ASA) I-III were randomized into an EOH group (n = 1000) and a DOH group (n = 1000). For the former group, children were administered a small amount of drinking water following recovery of the swallowing reflex, and children’s vital signs were monitored for 20 min in a postanesthesia care unit (PACU). DOH group patients received water at 4 h following general anesthesia). All patients underwent monitoring to assess their thirst, satisfaction, oropharyngeal discomfort, nausea, and vomiting.ResultsComplete data were collected from a total of 1770 patients (EOH = 832, DOH = 938) and was compared via chi-squared and t-tests as appropriate. There was no hypoxemia in either group, nor did the incidence of nausea and vomiting differ between the two groups (P > 0.05). The thirst score of the EOH group was significantly decreased relative to the DOH group in the children over 5 years old after drinking for 10 to 20 min (P < 0.05).ConclusionsFor children undergoing general anesthesia, a small amount of drinking water in the early stages of recovery will not increase the incidence of nausea, vomiting, or hypoxemia, but will decrease thirst and improve satisfaction. It is important, however, that medical staff carefully monitor the swallowing reflex and vital signs of all children.Trial registrationThis study was registered on the Chinese Clinical Trial Registry (ChiCTR-IOR-16008197) (http://www.chictr.org.cn/index.aspx. On April 2, 2016 the first patients was enrolled and on March 31, 2016 the trial was registered).

Characterizing Dietary and Physical Activity Patterns in Relation to Hydration Among Pre-Adolescent Children

Abstract Objectives The aim of this study was to characterize food and fluid consumption as well as and physical activity patterns in children in relation to ad libitum hydration. Methods Child participants aged 9–11 years (N = 55, 28 females) reported beverage consumption with a 7-day fluid diary. Overall diet was reported using a 7-day diet record and analyses were run using the Nutritional Data System for Research (NDSR). Physical activity was assessed with hip worn accelerometers (Actigraph wGT3x+, Pensacola, FL) over 7 days and aerobic fitness was measured with a VO2 max test. Body composition was assessed with dual energy x-ray absorptiometry (DXA). Urine was collected over a 24hr period and was analyzed separately with a refractometer and freezing point depression for specific gravity (USG) and osmolality (UOsm), respectively. Results Children reported ad libitum consumption of 1645 ± 856 mL of total fluid per day, which was comprised of 37% plain water and 12% milk. The remaining 51% was composed of juice, carbonated, sports, fruit, and caffeinated beverages. Mean 24 h UOsm was 780 ± 250 mOsm/kg and USG was 1.019 ± 0.007. Activity data showed participants spent 52 minutes of MVPA/day. Partial correlations, adjusting for VO2 max, % body fat, sex, energy intake, and accelerometer wear time per day, revealed relationships between plain water consumption and USG (r = −0.32, P = 0.05). USG was related to sedentary activity/day (r = −0.37, P = 0.03); however, there were no other relationships between physical activity and urine hydration markers or plain water intake (all p's &amp;gt; 0.05). Total healthy eating index score (HEI) was not related to plain water intake (r = 0.16, P = 0.34) but trended with UOsm (r = −0.30, P = 0.07). Further, UOsm was inversely correlated with the specific HEI subcomponents of higher vegetable (Rho = −0.32, P = 0.02) and lower saturated fat (Rho = −0.28, P = 0.04) consumption. Conclusions Water consumption in children was below recommendations, and fruit drinks, carbonated drinks, and juice comprised a significant proportion of beverages consumed. Higher water consumption was correlated with lower urine concentration, providing additional support for the importance of water for hydration in children. Finally, hydration was not related to weight status, % body fat, or habitual physical activity. Funding Sources Danone Research, Palaiseau, France.

Physical activity and sedentary behavior impacts on dietary water intake and hydration status in Spanish schoolchildren: A cross-sectional study.

BackgroundThe importance of maintaining an adequate hydration status and the complexity of the water balance make it necessary to study the lifestyle factors that can influence or modify these variables. The aim of this study was to evaluate the hydration status and dietary water intake for a sample of Spanish schoolchildren from 7 to 12 years old and their associations with physical activity (PA) and sedentary behaviors.MethodsA total of 242 schoolchildren was studied (49.17% females). A 24-hour urine sample was collected from each child, and the urine volume and osmolality were measured to estimate the hydration status (adequate hydration ≤800 mOsm/kg). In addition, a 3-day dietary record was completed to evaluate their water intake according to EFSA parameters. Dietary information was processed with DIAL software, and a statistical analysis was performed using SPSS. Student's t-test was used to study the normal variables, and the Mann-Whitney U test was used for those that were not normal. In the case of the categorical variables, the Z and Chi-Square proportions tests were used. The Bonferroni test was used to adjust the values in multiple comparisons. To evaluate the influence of these lifestyles on the urine osmolality, a 2-way ANOVA and an odds ratio were used.ResultsA total of 48.3% of the sample presented an adequate hydration status, and the percentage was significantly higher in females (p = 0.003). Only 20.9% showed an adequate intake of dietary water. The lifestyle influence reveals that more inactive and non-sedentary schoolchildren were adequately hydrated (p = 0.008). PA (practice ≥1 h/day) was associated with a higher risk of having an inadequate hydration status, even when accounting for sex and other lifestyle factors (OR = 1.753(1.006–3.054), p = 0.048).ConclusionsApproximately half of the participants presented an inadequate hydration status (which was higher in males than in females). PA (practice ≥1 h/day) was associated with a higher risk of inadequate hydration. This fact highlighted the importance of raising awareness about hydration in children, especially in ones who are more active.

Study of the serum sodium changes in children between 3 months and 5 years age receiving isotonic maintenance intravenous fluids

Background: Isotonic fluid is now the accepted standard of practice as maintenance intravenous fluids. The use of hypotonic fluids has been associated with electrolyte imbalance which could potentially lead to morbidity and mortality. The aim of this prospective study was to assess whether the use of isotonic fluids causes significant changes in the serum sodium concentration and is associated with any related complications in the age group between 3 months and 5 years. Methods: Serum sodium was measured at 0, 12, 24, and 48 h of commencement of isotonic intravenous fluids. Results were analyzed separately for groups between 3–12 months and 13–60 months. Results: All the children in the study group had sodium levels within normal range before the commencement of intravenous fluids. There was no significant change in the mean sodium levels at 12, 24, and 48 h of commencement of intravenous fluids in the age groups between 3–12 months and 13–60 months. There were no complications noted with the use of isotonic intravenous fluids. Conclusion: Use of isotonic intravenous fluids in the age group between 3 months and 5 years is not associated with significant changes in the serum sodium concentrations or adverse events. Hence, isotonic intravenous fluid can be used safely for maintaining hydration in children.

Quality Improvement Initiative to Increase the Use of Nasogastric Hydration in Infants With Bronchiolitis.

Intravenous (IV) hydration is used primarily in children with bronchiolitis at our institution. Because nasogastric (NG) hydration can provide better nutrition, the goal of our quality improvement (QI) initiative was to increase the rate of NG hydration in eligible children 1 to 23 months old with bronchiolitis by 20% over 6 months. We used Plan-Do-Study-Act cycles to increase the use of NG hydration in eligible children. Interventions included educational and system-based changes and sharing parental feedback with providers. Chart reviews were performed to identify the rates of NG hydration, which were plotted over time in a statistical process control p chart. The balancing measure was the rate of complications in children with NG versus IV hydration. Two hundred and ninety-three children who were hospitalized with bronchiolitis needed supplemental hydration during the QI initiative (January 2016-April 2016). Ninety-one children were candidates for NG hydration, and 53 (58%) received NG hydration. The rates of NG hydration increased from a baseline of 0% pre-QI bronchiolitis season (January 2015-April 2015) to 58% during the initiative. There was no aspiration and no accidental placement of the NG tube into a child's airway. Nine patients (17%) in the NG group had a progression of disease requiring nil per os status, and 6 of these were transferred to the PICU whereas none of those in the IV group were transferred to the PICU. Post-QI initiative, the majority of nurses (63%) and physicians (95%) stated that they are more likely to consider NG hydration in children with bronchiolitis. We successfully increased the rates of NG hydration in eligible children with bronchiolitis by using educational and system-based interventions.

Assessing Hydration in Children: From Science to Practice

Raising children's awareness about their hydration status could be done through a noninvasive biomarker. Urine color (UC) has been validated as a biomarker of hydration in adults and children aged 8-14 years. The aim of this survey was to design and to evaluate the level of understanding and attractiveness of a self-assessment, UC-based hydration tool for children aged 6-11 years. The first phase of the survey consisted of face-to-face interviews during which 84 children identified those graphical elements necessary to understand the hydration message from 6 illustration-based designs containing the UC chart. The graphic elements selected were the basis to create 3 new designs. During the 2nd phase, the level of understanding and attractiveness of these 3 new designs was then evaluated via an online questionnaire by a total of 1,231 children in 3 countries. The design with the highest level of understanding was totally or partially understood by 76% of the participants, independent of age and gender. The levels of understanding, however, differed in the countries. In Indonesia, the levels of understanding of the 3 designs were comparable; whereas in both France (74%) and Mexico (78%), significantly more participants totally and partially understood one of the 3 designs. The levels of attractiveness of the 3 designs were comparable, independent of country, age, and gender. On average, 80% of all participants liked the 3 designs a bit or a lot. Only 14% did not like the designs, and 5% of participants had no opinion regarding attractiveness. These results indicated that three out of four children like and understand the correct hydration message from a strictly illustration-based tool containing the eight-point UC scale.

Validation of a urine color scale for assessment of urine osmolality in healthy children

AimUrine color (UC) is a practical tool for hydration assessment. The technique has been validated in adults, but has not been tested in children.PurposeThe purpose of the study was to test the validity of the urine color scale in young, healthy boys and girls, as a marker of urine concentration, investigate its diagnostic ability of detecting hypohydration and examine the ability of children to self-assess UC.MethodsA total of 210 children participated (age: 8–14 years, body mass: 43.4 ± 12.6 kg, height: 1.49 ± 0.13 m, body fat: 25.2 ± 7.8 %). Data collection included: two single urine samples (first morning and before lunch) and 24-h sampling. Hydration status was assessed via urine osmolality (UOsmo) and UC via the eight-point color scale.ResultsMean UC was 3 ± 1 and UOsmo 686 ± 223 mmol kg−1. UC displayed a positive relationship as a predictor of UOsmo (R2: 0.45, P < 0.001). Based on the receiver operating curve, UC has good overall classification ability for the three samples (area under the curve 85–92 %), with good sensitivity (92–98 %) and specificity (55–68 %) for detecting hypohydration. The overall accuracy of the self-assessment of UC in the morning or the noon samples ranged from 67 to 78 %. Further threshold analysis indicated that the optimal self-assessed UC threshold for hypohydration was ≥4.ConclusionsThe classical eight-point urine color scale is a valid method to assess hydration in children of age 8–14 years, either by researchers or self-assessment.

Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children.

Maintenance intravenous fluids are frequently used in hospitalised children who cannot maintain adequate hydration through enteral intake. Traditionally used hypotonic fluids have been associated with hyponatraemia and subsequent morbidity and mortality. Use of isotonic fluid has been proposed to reduce complications. To establish and compare the risk of hyponatraemia by systematically reviewing studies where isotonic is compared with hypotonic intravenous fluid for maintenance purposes in children.Secondly, to compare the risk of hypernatraemia, the effect on mean serum sodium concentration and the rate of attributable adverse effects of both fluid types in children. We ran the search on 17 June 2013. We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), Embase (OvidSP), and ISI Web of Science. We also searched clinical trials registers and screened reference lists. We updated this search in October 2014 but these results have not yet been incorporated. We included randomised controlled trials that compared isotonic versus hypotonic intravenous fluids for maintenance hydration in children. At least two authors assessed and extracted data for each trial. We presented dichotomous outcomes as risk ratios (RR) with 95% confidence intervals (CIs) and continuous outcomes as mean differences with 95% CIs. Ten studies met the inclusion criteria, with a total of 1106 patients. The majority of the studies were performed in surgical or intensive care populations (or both). There was considerable variation in the composition of intravenous fluid, particularly hypotonic fluid, used in the studies. There was a low risk of bias for most of the included studies. Ten studies provided data for our primary outcome, a total of 449 patients in the analysis received isotonic fluid, while 521 received hypotonic fluid. Those who received isotonic fluid had a substantially lower risk of hyponatraemia (17% versus 34%; RR 0.48; 95% CI 0.38 to 0.60, high quality evidence). It is unclear whether there is an increased risk of hypernatraemia when isotonic fluids are used (4% versus 3%; RR 1.24; 95% CI 0.65 to 2.38, nine studies, 937 participants, low quality evidence), although the absolute number of patients developing hypernatraemia was low. Most studies had safety restrictions included in their methodology, preventing detailed investigation of serious adverse events. Isotonic intravenous maintenance fluids with sodium concentrations similar to that of plasma reduce the risk of hyponatraemia when compared with hypotonic intravenous fluids. These results apply for the first 24 hours of administration in a wide group of primarily surgical paediatric patients with varying severities of illness.

140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial

Use of hypotonic intravenous fluid to maintain hydration in children in hospital has been associated with hyponatraemia, leading to neurological morbidity and mortality. We aimed to assess whether use of fluid solutions with a higher sodium concentration reduced the risk of hyponatraemia compared with use of hypotonic solutions. We did a randomised controlled double-blind trial of children admitted to The Royal Children's Hospital (Melbourne, VIC, Australia) who needed intravenous maintenance hydration for 6 h or longer. With an online randomisation system that used unequal block sizes, we randomly assigned patients (1:1) to receive either isotonic intravenous fluid containing 140 mmol/L of sodium (Na140) or hypotonic fluid containing 77 mmol/L of sodium (Na77) for 72 h or until their intravenous fluid rate decreased to lower than 50% of the standard maintenance rate. We stratified assignment by baseline sodium concentrations. Study investigators, treating clinicians, nurses, and patients were masked to treatment assignment. The primary outcome was occurrence of hyponatraemia (serum sodium concentration <135 mmol/L with a decrease of at least 3 mmol/L from baseline) during the treatment period, analysed by intention to treat. The trial was registered with the Australian New Zealand Clinical Trials Registry, number ACTRN1260900924257. Between Feb 2, 2010, and Jan 29, 2013, we randomly assigned 690 patients. Of these patients, primary outcome data were available for 319 who received Na140 and 322 who received Na77. Fewer patients given Na140 than those given Na77 developed hyponatraemia (12 patients [4%] vs 35 [11%]; odds ratio [OR] 0·31, 95% CI 0·16-0·61; p=0·001). No clinically apparent cerebral oedema occurred in either group. Eight patients in the Na140 group (two potentially related to intravenous fluid) and four in the Na77 group (none related to intravenous fluid) developed serious adverse events during the treatment period. One patient in the Na140 had seizures during the treatment period compared with seven who received Na77. Use of isotonic intravenous fluid with a sodium concentration of 140 mmol/L had a lower risk of hyponatraemia without an increase in adverse effects than did fluid containing 77 mmol/L of sodium. An isotonic fluid should be used as intravenous fluid for maintenance hydration in children. National Health and Medical Research Council, Murdoch Childrens Research Institute, The Royal Children's Hospital, and the Australian and New Zealand College of Anaesthetists.

Randomized controlled trial of treatment expectation and intravenous fluid in pediatric migraine.

(1) The primary objectives were (1) to assess the response to intravenous (IV) fluid in children presenting to the ED with migraine and; (2) to assess the effect of treatment expectation on the response to I. Despite a lack of evidence for the practice, many emergency department (ED) migraine treatment protocols include a bolus of IV fluid. This study assessed the overall response to IV fluid hydration and the effect of expected medication treatment on the pain response among children and adolescents with migraine in an urban ED. A single-blind, randomized parallel arm trial of 10 mL/kg IV 0.9% sodium chloride for children and adolescents aged 5-17 years presenting to a pediatric ED with migraine. Patients were randomized into group A (no expectation of medication in combination with IV fluid) and group B (expectation that medication may be given simultaneously). All participants were treated with standard care following the 30-minute assessment. Forty-seven participants were randomized and 2 were excluded; mean age was 13.3 years and 31 (67.4%) were females. Demographics and baseline characteristics were similar between groups. Overall, there was no statistically significant difference for the primary outcome - change from baseline on the visual analog scale (VAS) at 30 minutes with a mean change of -12.3 mm (standard deviation [SD] 17.9) in group A and -12.7 mm (SD 13.2) in group B (P = .936). The standardized difference between the 2 means (Cohen's d effect size) was low at 0.024 (95% confidence interval [CI] -0.56 to 0.61). Overall, complete headache relief was observed in only 1 participant; 16 of 45 (35.6%; 95% CI 21.8 to 51.2) had a reduction in headache of 33% or more and 8 of 45 (17.8%; 95% CI 6.1 to 29.4%) had a minimum clinical significant difference of 30 mm or more on VAS with 4 in each group. Thirteen of 39 patients with follow-up data (33.3%; 95% CI 19.1 to 50.2%) reported a moderate or severe headache at the 24-hour follow up with no difference between groups; only 3 patients returned to the ED. One participant reported a minor IV-related adverse event. The overall decrease in pain with IV fluid is small and clinically insignificant. Treatment expectation did not significantly influence headache relief at 30 minutes with IV fluid hydration in children or adolescents with migraine in the ED. The average relief of headache with IV fluid alone was small; however, a clinically meaningful response was observed in 17.8%. Recurrence of headache is common in 33% after ED discharge.

Evidence-Based Practice Recommendations for Hydration in Children and Adolescents With Cancer Receiving Intravenous Cyclophosphamide

Hemorrhagic cystitis is a known complication of cyclophosphamide, an antineoplastic agent used to treat a variety of oncologic diseases in children. Hydration can prevent hemorrhagic cystitis; however, use varies in clinical practice. A team was assembled to develop evidence-based practice recommendations to address the following question: in a population of children with cancer, what is the appropriate pre- and posthydration for the administration of different dose levels of intravenous cyclophosphamide to prevent bladder toxicity? The purpose was to identify the appropriate rate, duration, and route of hydration to prevent bladder toxicity with low, intermediate, and high dose cyclophosphamide. After a systematic search of the literature, 15 pieces of evidence were evaluated and used. There is a moderate level of quality evidence related to hydration for high dose cyclophosphamide and very low quality evidence related to intermediate or low dose cyclophosphamide. Three general recommendations were made for hydration associated with cyclophosphamide. There is a need for further research related to the prevention of bladder toxicity in children with cancer receiving cyclophosphamide.

Oral hydration in children with cerebral palsy

AIM: To investigate whether oral motor performance is determinant for the hydration status and the effect of a supplemental oral fluid supply on salivary osmolality. METHODS: The sample consisted of 99 children with cerebral palsy aged 6 to 13 years old. In this study, children participated in 2-day evaluations: 1st day - baseline: saliva collection, caries experience and oral motor performance evaluations; and 2nd day: saliva collection after supplemental fluid supply. Prior to each evaluation, the participants were trained for saliva collection. Unstimulated whole saliva was collected using cotton roll at baseline, with the amount of fluid usually offered by caregivers, and 48 h after baseline, with as much as twice the normal daily fluid intake previously offered. Salivary osmolality was measured using a freezing point depression osmometer. Caries experience index for decayed, missed and filled teeth (DMFT) was evaluated. According to the Oral Motor Assessment Scale, the children were classified into subfunctional or functional groups. Chi-square, Student's t test and Pearson's correlation coefficient were used. RESULTS: The subfunctional group presented a higher percentage of quadriplegic children (p<0.001), with significantly higher values for caries experience (p<0.001) and salivary osmolality (p<0.001), which did not diminish when supplemental fluid supply was offered, compared with the functional group (p=0.001). CONCLUSIONS: The effectiveness of oral motor performance plays an important role in the hydration status of children with cerebral palsy and those with worse oral motor performance may be at higher risk of oral diseases.

A prospective trial of prophylaxis and treatment (P+T) of acute tumor lysis syndrome (ATLS) with rasburicase (R) and nonalkaline hydration in children and adolescents (C+A) with intermediate- (Group B) and high-risk (Group C) mature B-NHL: A Children's Oncology Group report.

9572 Background: The incidence of TLS and renal insufficiency (RI) in our past study in C+A with Group (GP) C B-NHL P+T with allopurinol and alkaline hydration was 26% and 27%, respectively (Cairo, Blood 2007). R is more effective than allopurinol in rapidly reducing hyperuricemia in C+A at high risk of ATLS. (Goldman/Cairo, Blood 2001). Objectives: To assess the toxicity, incidence of ATLS, RI and assisted renal support (ARS) of R added to COP reduction in C+A with GP B + C B-NHL. Methods: COP was administered as previously described (Cairo, Blood, 2007). R (0.2 mg/kg IV) was generously supplied by sanofi-aventis. Hydration (without sodium bicarbonate) was administered at 3 L/m2/day. Laboratory (LTLS) and Clinical (CTLS) were classified according to the Cairo- Bishop classification (BJH, 2004). Chemotherapy began between 4 and 24 hrs of the day 0 R dose. GFR (ml/min/1.73 m2) was calculated using the pediatric Schwartz formula. Results: Seventy-eight pts were evaluated for response to R with COP including GP B pts (Stage III/IV) that were subdivided into normal (NL < 2XULN) (n=23) and high (HI ≥ 2XULN) (n=20) LDH and 35 GP C pts. Mean and elevated (% pts ≥ 8 mg/dl) initial uric acid (UA mg/dl) were 4.5 ± 2 (8.2%), 9.6 ± 4.6 (47%) and 8.6 ± 5.0 (45%), in the three groups, respectively. 47% pts received optional doses of R prior to day 0 and no SAE were attributed to any R doses. Two/20 (10%) in GP B HI LDH and 4/35 (11%) in GP C presented with RI and required ARS prior to R + COP therapy. The incidence of LTLS was 0%, 25% and 17% and CTLS was 0%, 10%, and 11%, respectively. GFR improved from baseline thru day 7 in all three groups: GP B NL LDH (141 ±29 to 154 ± 34), GP B HI LDH (96 ± 40 to 168 ± 45) and GP C (108 ± 42 to 173 ± 64). Conclusions: R during COP reduction is well tolerated and highly effective in preventing and treating ATLS in C+A with FAB group B (stage III/IV) and C B-NHL. Although R added to COP prevents new onset CTLS and need for ARS, approximately 10% of C+A with GP B HI LDH or GP C B-NHL still present at diagnosis with RI and require ARS. Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration sanofi-aventis sanofi-aventis