I agree with Dale that this is one of the most poorly investigated areas
in all of pediatrics, with surprisingly polar views from one
well-respected institution to the next. If one reads Santosham's data
from the 80's on oral rehydration, the mean "total CO2s" in these
children are in the 15 range and 90 percent or so were managed
successfully with all oral fluids. Nontheless, I agree with Dale that
when you begin to hover near 13 or so, these children do worse. There is
an evolving set of prospective data to support the notion that a low
'bicarb' has some predictive value as well- see Reid et al. Ann Emerg
Med 1996;28;318-323 and Vega et al. Ped Emerg Care 1997;13:179-182.
Other recent studies that suggest that the bicarb is not predictive have
low power and in my estimation, still show a trend suggesting that low
bicarbs are predictive of who will do worse: Teach et al. Clin Pediatr
1997;7:395-400, Hassib N. Arch Dis Child 1998;78:70-71.
The most amazing thing to me is that the "percentage of body weight
lost", or percentage of "dehydration" is the gold standard for most of
these studies. In my experience, this 'dehydration' concept is not very
predictive of who is on the way toward decompensated hypovolemic shock-
arguably the most dangerous of all the complications of gastroenteritis.
Jay Fisher MD
Pediatric Emergency Services
Las Vegas NV
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