No abstract

Diabetic ketoacidosis (DKA) is a preventable life-threatening complication of type 1 diabetes. Fluids form a crucial component of DKA therapy, goals being the restoration of intravascular, interstitial and intracellular compartments. Hydration reduces hyperglycemia by decreased counter-regulatory hormones, enhanced renal glucose clearance and augmented insulin sensitivity. However, for the last several decades, fluids in DKA have been subject of intense debate owing to their possible role in causation of cerebral edema (CE). Rehydration protocols have been modified to prevent major osmotic shifts, correct electrolyte imbalances and avoid cerebral or pulmonary edema. In DKA, a conservative deficit assumption ranging from 6.5% to 8.5% is preferred. Normal saline (0.9%) has been the traditional fluid of choice, for both, volume resuscitation and deficit replacement in DKA. However, the risk of AKI with its liberal chloride content remains a contentious issue. On the other hand, balanced crystalloids with restricted chloride content need more exploration in children with DKA, both with respect to DKA resolution and AKI. Although fluids are an integral part of DKA management, a fine balance is needed to avoid under-hydration or over-hydration during DKA management. In this narrative review, we discuss the current perspectives on fluids in pediatric DKA.

Nutrition in pediatric acute respiratory distress syndrome (PARDS) is an essential aspect of therapy, with potential to modify outcomes. The gut is slowly establishing its place as the motor of critical illness, and the 'gut-lung' axis has been shown to be in play in the systemic inflammatory response. Thus, utilizing the gut to modify outcomes in PARDS is an exciting prospect. PARDS is associated with high mortality in low-and middle-income countries (LMIC), where malnutrition is also prevalent and may worsen during hospital stay. Mortality may be higher in this subgroup of patients. At present, the gold standard to estimate resting energy expenditure (REE) in critically ill children is indirect calorimetry. However, it is a cumbersome and expensive procedure, as a result of which its routine practice is limited to very few units across the world. Therefore, predictive equations, which may under-or over-estimate REE, are relied upon to approximate calorie and protein needs of children with PARDS. Despite having target calorie and protein requirements, studies have found that a large proportion of critically ill children do not achieve these levels even at the end of a week in pediatric intensive care unit (PICU). The preferred mode of nutrition delivery is enteral, and if possible, early enteral nutrition (EEN). Immunonutrition has been a lucrative subject of research, and while there have been some strides, no therapy has yet conclusively demonstrated benefit in terms of mortality or reduced length of stay in PICU or the hospital. Probable immunonutrients in PARDS include omega-3 fatty acids, arginine, glutamine and vitamin D, though none are a part of any recommendations yet.

Abdominal pain is one of the common symptoms reported by children in urgent care clinics. While most children tend to have self-limiting conditions, the treating pediatrician should watch out for underlying serious causes like intestinal obstruction and perforation peritonitis, which require immediate referral to an emergency department (ED). Abdominal pain may be secondary to surgical or non-surgical causes, and will differ as per the age of the child. The common etiologies for abdominal pain presenting to an urgent care clinic are acute gastro-enteritis, constipation and functional abdominal pain; however, a variety of extra-abdominal conditions may also present as abdominal pain. Meticulous history taking and physical examination are the best tools for diagnosis, while investigations have a limited role in treating benign etiologies.

To analyze the clinical features associated with the need for mechanical ventilation (MV) in children with Guillain-Barré syndrome (GBS).